Every finding on record at Brentwood Place Two

Based on interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for one (Resident #1) of five residents reviewed for pharmacy services.The facility failed to enter a physicians' order for Nitroglycerin 0.4mg sublingual tablet that was administered to Resident #1 on 06/19/2026. This failure could place residents at risk of not receiving medications as ordered by the physician and a delay in treatment and worsening of their condition.Findings included Review of Face Sheet dated 07/02/2026 reflected Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 was diagnosed with Type 2 Diabetes Mellitus (chronic metabolic disease where the body either resists insulin or doesn't produce enough of it, leading to high blood sugar), Peripheral Vascular Disease (slow, progressive circulation disorder characterized by narrowed, blocked, or weakened blood vessels outside the heart and brain), Chronic Kidney Disease (kidneys are damaged and gradually lose their ability to filter waste and excess fluid from your blood), and history Pulmonary Embolism (life-threatening medical emergency where a blood clot (usually from a deep vein in the legs) travels to the lungs and blocks an artery, stopping blood flow). Review of a Progress Note for Resident #1dated 06/19/2026 revealed Resident complained of chest pain and was assessed and given one dose of nitroglycerin [nitro] 0.4mg. Resident however decided to call 911 while he was being treated. 911 came and took him to ER [sic] [Emergency Room]. NP [Nurse Practitioner], DON and resident's next of kin notified. Review of the Order Summary Report for Resident #1 dated 07/02/2026 reflected there was no order for Nitroglycerin 0.4mg sublingual tablet. Review of the MAR for Resident #1 dated June 2026 reflected there was no order for Nitroglycerin 0.4mg sublingual tablet. In an interview with the DON on 07/02/2026 at 9:13 AM it was revealed Resident #1 recently went out to hospital. The DON stated he was on the phone with the nurse when the paramedics showed up to the facility for Resident #1. The DON stated one dose of nitro had been administered to Resident #1 for chest pain. In an interview with Resident #1 on 07/02/2026 at 9:45 AM it was revealed he had lived in the facility for a month. Resident #1 stated he recently went to the hospital due to having trouble breathing. Resident #1 stated he called 911 himself. Resident #1 stated his nurse called his physician and gave him some medication, but he felt he needed to go to the hospital. Resident #1 did not specify what the medication was that the nurse administered. In an interview with the DON on 07/02/2026 at 10:15 AM it was revealed the facility had an emergency medication kit (e-kit) which LVN A pulled the nitro from to administer to Resident #1. The DON stated a physician's order should have been put into the EHR [Electronic Health Record] as a new order and then the medication would have been signed out by LVN A on the MAR. The DON stated the order was to give the nitro three times, five minutes apart. After the 3rd dose the nurse would call 911 if the chest pain had not resolved. The DON stated he would look to see if he was able to locate the physician's order for the nitro. In an interview with the DON on 07/02/2026 at 10:48 AM it was revealed he was unable to locate a telephone physician's order documented in the EHR. The DON stated he only located the Progress Note where it was indicated Resident #1 received the medication. The DON stated he had begun education with the nurses to ensure physician's orders were transcribed into the EHR when a new order was received. In an interview with LVN A on 07/02/2026 at 11:02 AM it was revealed LVN A explained Resident #1 was sent to the emergency room for evaluation and treatment of chest pain. LVN A stated Resident #1 complained of chest pain, so he contacted the physician and spoke with the NP. NP gave a telephone order for nitro. LVN A stated he had another nurse pull the nitro from the e-kit. LVN A stated he administered one dose of nitro to Resident #1 and Resident #1 called 911 himself. LVN A stated it was normal procedure to enter the telephone order into the EHR but due to the medical emergency and 911 showing up he forgot to go back and enter the information. LVN A stated failing to enter a telephone order could result in a resident potentially missing a prescribed medication. LVN A stated the DON had already contacted him and conducted an education on the procedures of entering a telephone order prior to Investigator calling him. An attempt was made to contact LVN B on 07/02/2026 at 12:17 PM but no message could be left due to the mailbox being full. A text message was sent to LVN B on 07/02/2026 at 12:18 PM requesting a return call. No return call was received prior to the end of the investigation. An attempt was made to contact LVN B on 07/02/2026 at 2:12 PM but no message could be left due to the mailbox being full.NOTE: LVN B was scheduled to work on 07/02/2026. At 2:45 PM LVN B had not arrived at work for her 2:00 PM to 10:00 PM shift. In an interview with the DON on 07/02/2026 at 2:31 PM it was revealed it was the practice of the facility to receive a telephone order from the physician and immediately transcribe the information into the EHR. The DON stated when he spoke with LVN A it was an emergent situation and LVN A hurried to get the telephone order for nitro and forgot to go back and transcribe the telephone order. The DON stated he audited the EHR the following Monday but Resident #1 was discharged from the EHR preventing him from being able to correct the EHR. The DON was asked what the risk of failing to transcribe a telephone order. The DON would not directly answer the question. The DON answer by stating if the nurse did not have an order if the medication was needed in the future the physician would be contacted again and the physician would give the order again. Review of Telephone Orders for Medication dated 01/2025 reflected Purpose: To reduce errors associated with misinterpreted verbal or telephone communication of physician orders. Policy:I. Verbal communication of prescription or medication orders and test results is limited to urgent situations in which immediate written or electronic communication is not feasible. II. Abbreviations should be avoided when an order is given or received. Procedure:I. Receiving A Telephone Order (TO)A. The authorized prescriber identifies self, specifies the resident's name and communicates the order. B. The receiver documents the order immediately on the prescriber form including:i. Date and time order is received;ii. Patient name;iii. Drug name (brand or generic);iv. Strength or concentration;v. Dose;vi. Frequency;vii. Route;viii. Quantity and/or duration;ix. Name of prescriber;x. Signature of order recipients.II. The authorized prescriber must countersign the order within a reasonable timeframe after communicating the order.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food safety for the facility's only kitchen.The facility failed to ensure the holding temperature was below 40 degrees F (Fahrenheit) for pureed potato salad served for lunch on 3/4/26.This failure could place residents at risk for food-borne illness, and food contamination.Findings included:During an observation and interview on 3/4/2026 11:46 a.m., of the lunch service revealed pureed potato salad was at 90 degrees F. (Pureed foods are smooth, lump-free food, made by blending or grinding cooked foods for those with chewing or swallowing difficulties).The Dietary Manager proceeded to scoop out the pureed potato salad to individual portions and prepared about 12-16 small cups, covered them and placed them in the freezer to cool them down further. The Dietary Manager stated the pureed potato salad should be at 41 degrees F and needed to cool down further before serving.During an observation on 3/4/2026 at 12:07 p.m., [NAME] F had started serving lunch for the residents. The Dietary Manger removed the individual potato salad and was getting ready to serve to the residents. The Dietary Manager proceeded to record temperature for the individual portioned pureed potato salad. The temperature of one individual portion cup was 86 degrees F and the temperature of another individual portion cup was 84 degrees F. The Dietary Manager proceeded to hand over the pureed potato salad cup to [NAME] F to serve until this surveyor intervened regarding incorrect holding and serving temperature of cold foods.During an interview on 03/04/2026 4:29 p.m., with the Dietitian stated cold food items, such as pureed potato salad should be held at 41 degrees F or lower. The Dietitian stated if the salad was at a higher temperature after cooking, it needed to be cooled down to 41 degrees F and served over ice during service. She stated serving food at incorrect temperatures posed a risk to residents including the potential for food borne illness and concerns related to palatability.During an interview on 03/05/2026 at 9:19 a.m., with the Dietary Manager, she stated the pureed potato salad should be held and served at 41 F or below. She reported that both the cooks and she were responsible for ensuring food items were held and served at the appropriate temperatures. She explained that [NAME] F had prepared the pureed potato salad on the morning of 03/04/2026 and did not have adequate time to cool it down. The Dietary Manager stated because the lunch meal service was approaching, she decided to portion the pureed potato salad into individual cups to help it cool down faster. She stated she replaced the pureed potato salad with a different food item for residents requiring a pureed diet because the potato salad had not cooled down to 41 F and was not at the correct temperature for service. She stated she knew cold foods must be held and served at 41 F or below, and failure to follow correct holding and serving temperature requirements could result in food borne illness and decreased palatability.In an interview on 03/05/2026 at 9:31 a.m., [NAME] F stated she was the morning cook on 03/04/2026 and prepared the pureed potato salad that morning for lunch service. She stated all cold foods must be held and served at 41 F, and the pureed potato salad had not cooled to the correct temperature for service. She stated that if cold pureed potato salad was not held at the appropriate temperature, it should not be served to residents due to the risk of food borne illness.Record review of the facility's policy titled, Food Temperatures, dated 12/2020 reflected, .Policy: Foods prepared and served in the facility will be served at proper temperatures to ensure food safety . If temperatures do not meet applicable serving temperatures, reheat the product or chill the product to the proper temperature for hot foods of 165 for 15 seconds and chill cold foods to be [less than] 41 .If temperatures are not at acceptable levels and cannot be corrected in time for meal service, and appropriate menu substitution should be implemented.Record review of Food and Drug Administration Food Code, dated 2022, reflected, . (2), the FOOD shall have an initial temperature of 5 C (41 F) or less when removed from cold holding temperature control, or 57 C (135 F) or greater when removed from hot holding temperature control.

Based on observation, record review and interview, the facility failed to ensure the resident had a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 3 of 10 residents restrooms (Resident Restroom [ROOM NUMBER], Resident Restroom [ROOM NUMBER], and Resident Restroom [ROOM NUMBER]) reviewed for hot water, 1 of 10 (Resident Restroom [ROOM NUMBER]) for restroom leaks and 1 of 8 residents (Resident #58) reviewed for bed linens. The facility failed to ensure residents had hot water in Resident Restroom [ROOM NUMBER], Resident Restroom [ROOM NUMBER], and Resident Restroom [ROOM NUMBER] on 3/3/26 and 3/4/26.The facility failed to ensure Resident Restroom [ROOM NUMBER] was free from leaks on 3/3/26 and 3/4/26. The facility failed to ensure Resident #58 was provided with clean and sanitary pillowcase on 3/3/2026. These failures could place residents at risk of exposure to infectious diseases, unsanitary environment and a decline in quality of life. 1 and 2. Record review of Work Orders for the facility reflected concerns with hot water heater on 9/19/25 and 9/23/25. During an observation and interview with residents in Resident Restroom [ROOM NUMBER] on 3/3/26 at 10:30 a.m. revealed the water was not hot in the restroom faucet when the hot water was on for 7 minutes. There were two residents in the room and both revealed they had no hot water and noted the plumbing from the faucet was leaking. During an observation and interview with the resident in Resident Restroom [ROOM NUMBER] on 3/3/26 at 10:34a.m. revealed no hot water form the restroom hot water faucet after 7 minutes of running. The resident residing in the room revealed he had luke warm water but never hot water. During an observation in Resident Restroom [ROOM NUMBER] on 3/3/26 at 10:37 a.m. revealed the water was not hot in the restroom faucets after the hot water was on for 7 minutes. The resident was not present at the time of the observation. Interview with the resident from Resident Restroom [ROOM NUMBER] on 3/4/26 at 10:22 a.m. revealed he had not noticed his hot water in the restroom was not hot. During a confidential group interview with six residents during an undisclosed date and time revealed one resident had no hot water in their restroom faucet and had not had hot water for a long time. The resident revealed he had spoken to the Administrator and nurses about his concern, and it had not been resolved. The resident revealed he had not had hot water since his admission several months ago. During an interview and observation with the Maintenance Director on 03/04/2026 at 2:38 p.m. revealed the following:-Resident Restroom [ROOM NUMBER]'s faucet had a hot water temperature of 78 degrees and the plumbing under the sink was leaking water into a trashcan.-Resident Restroom [ROOM NUMBER] was 75 degrees-Resident Restroom [ROOM NUMBER] was 91 degrees The Maintenance Director revealed the hot water in resident restrooms should have been between 98 degrees and 110 degrees. The Maintenance Director revealed he checked all restroom hot water temperatures first thing every Monday morning and had not had any complaints about hot water. The Maintenance Director revealed there were two halls that used the same water heater and if there were too many showers the restrooms in resident rooms run out of hot water. The Maintenance Director was unable to explain the reason the other resident restrooms had hot water in the same hall, but Resident Restroom [ROOM NUMBER], Resident Restroom [ROOM NUMBER] and Resident Restroom [ROOM NUMBER] did not. The Maintenance Director revealed whenever he received a complaint about hot water, he checked the water heater temperature outside and if it was correct he would inform staff not to use the showers until the water was warm again. The risk to the residents of not having had the correct hot water temperature in their restroom faucets was they could have been exposed to bacteria that could have caused sickness. The Maintenance Director revealed he was unaware of the leak in Resident Restroom [ROOM NUMBER] and would fix it immediately because it could have been an accident hazard. During an interview on 03/05/2026 at 1:21 p.m., the Administrator revealed the Maintenance Director checked faucet temperatures in resident restrooms weekly. The Administrator revealed they repaired issues immediately when they were made aware of issues. The Administrator revealed the facility had gotten a new water heater (2025). The Administrator was unable to explain the reason some restrooms had hot water and others did not. The Administrator revealed he would get with the Regional Maintenance Director on the issue to help determine the cause and correct it. The Administrator revealed the residents having not had the appropriate hot water temperature in the restrooms could affect them because the residents could not perform good hand hygiene in their rooms. Record review of facility's policy Water Temperature revised 8/2020 .the facility ensures water is maintained at temperatures suitable to meet residents' needs. 2.Record review of Resident #58's Quarterly MDS, dated [DATE], reflected Resident #58 was a [AGE] year-old male admitted on [DATE] with pertinent diagnoses of hypertension (high blood pressure), traumatic brain injury (disruption in brain flow), malnutrition, and asthma. He had BIMS of 15 indicating he was cognitively intact. During an observation and interview on 03/03/2026 at 11:04 a.m., Resident #58's pillow on his bed did not have a pillowcase. The pillow was stained with multiple brown spots all over it. Resident #58 revealed he would like a pillowcase and was about a month since he had a pillowcase. He revealed he had informed a staff member about wanting a pillowcase but did not recall which staff member or how long it was since he informed the staff member. He revealed he would not like a new pillow although it was stained. During an observation on 03/04/2026 at 1:44 p.m. , Resident # 58 had no pillowcase for his pillow on his bed. During an interview and observation on 03/04/2026 at 3:54 p.m., the Staffing Coordinator revealed she was filling in as a CNA for Resident #58's hall. The Staffing Coordinator revealed Resident # 58's pillow had no pillowcase on it. The Staffing Coordinator revealed CNAs were usually responsible for making beds and it included putting clean bed sheets and pillowcases on resident's bed. The Staffing Coordinator revealed the risk of the resident not having a pillowcase could result in declining resident's quality of life. During an interview on 03/04/2026 4:20 p.m., CNA A revealed CNAs were responsible for ensuring residents had clean bedsheets and pillowcases. CNA A she revealed was not regularly assigned to Resident #58 and could not state the reason he had not had a pillowcase for almost a month. CNA A revealed she provided Resident #58 with a clean pillowcase just before this interview. During an interview on 03/05/2026 at 12:17 p.m., the DON revealed CNAs were responsible for making beds and providing them with clean linen that included bedsheets, blankets and pillowcases. The DON revealed it was his expectation that Charge Nurses oversaw the CNAs to ensure a home-like environment was maintained in resident's rooms. The DON revealed the risk of not providing pillowcases included possible skin issues and decline in residents' quality of life. During an interview on 03/05/2026 at 2:59 PM, LVN B revealed he worked as a charge nurse on Resident #58's hall. LVN B revealed Resident #58 had not informed him about the missing pillowcase. LVN B revealed CNAs were responsible for providing clean linens to residents, and charge nurses were required to supervise the CNAs. LVN B revealed not having clean linens could result in denying the residents' right to a clean, home-like environment. Review of facility's policy Laundry Services revised on 8/2020 reflected .The Facility employs adequate staff to ensure that linen is kept clean, in good repair, and in sufficient quantities to meet the needs of our patients.

Based on observation, interview, and record review, the facility failed to provide drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration for 3 of 6 residents (Resident #29, Resident #15 and Resident #89) reviewed for hydration. The facility failed to ensure Residents#29 received a drink during lunch service on 3/3/26.The facility failed to ensure Resident #15 received a drink during lunch services on 3/3/26 and 3/4/26.The facility failed to provide Resident #89 drinking water on 3/3/26. These could place residents at risk of discomfort, dehydration, and/or a diminished quality of life. 1. Record review of Resident #29's face sheet, dated 3/5/26, revealed a [AGE] year-old male with an admission of 1/6/25. Resident #29 had the following active diagnoses: need for assistance with personal care, Thiamine Deficiency (condition that causes neurological and cardiovascular disease stemming from malnutrition or chronic alcohol use), hypo-osmolality and hyponatremia (electrolyte disorder linked to fluid retention or excessive loss of fluid) and esophagitis (inflammation or swelling of the esophagus). Record review of Resident #29's Comprehensive MDS Assessment, dated 12/18/25, revealed a BIMs score of 0 which indicated a severe cognitive impairment. The MDS indicated Resident #29 required partial/moderate assistance for eating. Record review of Resident #29's care plan, dated 1/12/2026, reflected, . Resident #29 has potential for dehydration or potential fluid deficit r/t hypo-osmolality and hyponatremia. Resident #29 will be free of symptoms of dehydration and maintain moist mucous (the slippery, wet, inner linings of body cavities and organs such as the nose and mouth).Interventions: Monitor and document intake and output as per facility policy. Date Initiated: 03/08/2025. Monitor/document/report to MD PRN s/sx of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin (a sign where skin, when pinched and released it remains in a raised position instead of snapping back quickly), cracked lips, furrowed tongue(deep grooves on the top surface and sides of the tongue), new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes. Date Initiated: 03/08/2025. During an observation of Resident #29 during lunch service on 3/3/26 at 12:01 p.m., revealed he was served his food and had no drink. At 12:15 p.m. Resident #29 finished his plate of food and still had no drink. The Activities Director was observed asking residents what they wanted to drink and she was passing out drinks. The Activity Director had not approached Resident #29 during meal service. An unidentified staff was observed picking up Resident #29's meal tray at 12:29 p.m. and he continued without a drink. During an attempted interview with Resident #29 on 3/3/26 at 1:05 p.m. revealed resident was unable to answer any questions coherently. 2. Record review of Resident #15's face sheet, dated 3/5/26, revealed a [AGE] year-old male with an admission date of 11/18/25. Resident #15 had the following active diagnoses: Type 2 Diabetes (chronic disorder characterized by high blood sugar resulting from the body's inability to use insulin properly), Lymphedema (swelling typically in the arms and legs caused by a buildup in lymph fluid), acute kidney failure (a sudden rapid loss of kidney function usually occurring within hours or days that causes dangerous waste buildup, fluid imbalance and electrolyte disruption in the blood), unspecified opened wound, right foot and need for assistance with personal care. Record review of Resident #15's quarterly MDS assessment, dated 2/25/26, revealed a BIMs score of 14 (scale of 0-15) which indicated severe cognitive impairment. The MDS revealed Resident #15 required supervision or touch assistance for eating and partial assistance for transfers. During an observation of Resident #15 during lunch service on 3/4/26 at 12:05 p.m., Resident #15 was served his lunch tray without a drink. Several staff were observed serving drinks, however Resident #15 was not offered a drink. At 12:32 p.m., Resident #15 finished his meal and he continued not having a drink. During an observation of Resident #15 during lunch service on 3/4/26 at 12:28 p.m. revealed resident was served his meal tray without a drink. At 12:46 p.m. resident #15 finished his meal and continued not having a drink. 3. Record review of MDS assessment, dated 01/03/2026, reflected Resident #89 was a [AGE] year-old female, readmitted on [DATE], diagnoses included necrotizing fasciitis (Life-threatening flesh-eating bacterial infection that destroys skin, fat, and muscle tissue), Type 2 diabetes (Elevated blood sugar level). Resident #89 had a BIMS score of 15 indicating intact cognitive function, needed supervision/touching assistance with chair/bed-to-chair transfers and occasionally incontinent of urine and bowel. Record review of care plan, dated 05/03/2026, reflected Resident #89 had . impaired visual function . initiated date on 04/14/2025 reflected Resident #89 was high risk for falls related to left below- knee amputation, gait/balance problems. Interventions/tasks. Resident #89 needs a safe environment with: . personal items within reach . During an interview and observation on 03/03/2026 at 10:22 a.m. with Resident #89 reflected resident was lying in her bed, she revealed she had not gotten drinking water that day and the facility staff had not provided her water and ice on a regular basis. Resident #89 revealed at times she drank water off her bathroom sink faucet. It was observed the Resident #89 had an empty water pitcher on her table. Interview and observation on 03/03/2026 at 02:36 p.m. with Resident #89 in her room revealed the staff had not brought her drinking water and the water pitcher was observed empty on her table. Interview on 03/03/2026 at 02:40 p.m. with CNA J revealed he worked on the 400 hall in the afternoon shift. CNA J revealed one of his responsibilities was to provide drinking water and ice to the residents several times during his shift and had not done it that day because he came in late for work. CNA J revealed he had not provided drinking water and ice to Resident #89 yet, he revealed not having had enough water to drink could have led to dehydration among residents. He revealed he had received training and in-service within a month on the topics of importance of hydration and resident rights. During a confidential group interview of 6 residents on an undisclosed date and time revealed the residents had not gotten water and ice at night. They revealed the facility had just gotten a new ice machine and went for 2 to 3 days without ice. They revealed the staff would go to the store for ice but had not got enough. Interview with LVN I on 03/04/2026 at 2:05 p.m. revealed she assisted with passing out meal trays and drinks during breakfast and lunch. LVN I revealed it was the nurses' responsibility to confirm each resident received the appropriate types of liquid for each meal. LVN I revealed the regular drinks were served by staff such as CNAs and Nurses while the thickened liquids were brought out on the trays from the kitchen. LVN I revealed all residents should have always had a drink during each meal whether it was water, juice or coffee. LVN I revealed the risk to the residents of not having received a drink during their meals was dehydration. LVN I revealed the ice machine at the facility was broken for a couple of days in the last month, but the facility always had ice. LVN I revealed when the facility had no ice they would have gone to building 3 or 1 for ice. LVN I revealed the expectation was for residents to have ice water throughout the day. Interview with Dietician K on 03/04/2026 at 2:33 p.m. revealed the standard protocol for serving drinks to residents was the staff served drinks listed on the tray tickets. Dietician K revealed the facility had a dining excellence program in which they should have been serving beverages to the residents ahead of the meal tray. Dietician K revealed every resident should have a drink at every meal and staff should have been offering at least two drinks for each meal. Dietitian K revealed if a resident refused a drink the staff should document it. Dietitian K revealed it was a team effort to ensure all residents received drinks during every meal service. Interview with the Activity Director on 03/05/2026 at 10:10 a.m. revealed she helped with passing out drinks occasionally in the dining room. The Activity Director revealed she would ask residents what they wanted to drink and would check their tickets to confirm they could drink what they were asking for. The Activity Director revealed the expectation was all residents should have gotten drinks at every meal service and should have been provided with more drinks if the residents requested. The Activity Director revealed she could not recall any residents declining drinks for meal service on 3/3/26 or 3/4/26. The Activity Director was unable to state the reason Resident #29 and Resident #15 had not gotten drinks on 3/3/26 or 3/4/26. The Activity Director revealed she believed the risk to the residents of not having gotten any drinks during the meal service was they could have been thirsty or the residents could have had an unfulfilled desire. The Activity Director revealed it was a joint effort to make sure all residents received drinks during meal service. The Activity Director revealed the facility always had ice for the residents' drinks. The Activity Director was unable to state how they ensured they had ice when the icemaker was broken. The Activity Director revealed residents had gotten ice water on the days the machine was broken. Interview with the Dietary Manager on 03/05/2026 at 10:26 a.m. revealed residents who needed thickened liquid beverages got them on their food tray from the kitchen; however, the other beverages were offered to the residents from the beverage cart. The Dietary Manager revealed beverages were passed out by staff to residents during their meal service. The Dietary Manager revealed it was the responsibility of the nursing staff and CNAs to ensure all residents had drinks with every meal. The Dietary Manager revealed she liked beverages given out before trays were delivered but staff could pass drinks out anytime during meal service. The Dietary Manager revealed the risk of not having drinks during meal service or throughout the day could have resulted in residents having hydration concern. The Dietary Manager revealed the facility's ice machine was not working for two days and during those two days they were obtaining ice from other buildings. An interview with CNA L on 03/05/2026 at 10:34 a.m. revealed during meal service sometimes kitchen staff provided resident drinks, but when the kitchen was short the CNAs or nurses provided the drinks to the residents. CNA L revealed all residents should have had a drink with their meals. CNA L revealed residents should not have gotten their drinks after their meal, they should have had it before or during their meal. CNA L revealed CNAs and nurses should have been monitoring residents to ensure they had drinks. CNA L was unable to answer what the risks were for residents that had not received drinks during meal service because she insisted all residents get drinks during meal service. An interview with the DON on 03/05/2026 at 1:12 p.m. revealed all residents should have had drinks during their meals. The DON revealed dietary staff were responsible for determining the type of drink. The DON revealed the nursing department should have been observing whether residents received drinks throughout the day and during meal service. The DON revealed best practice was drinks were served before the meals were served. The DON revealed the risk to the residents of not having received drinks during the meal would have been a decrease in satisfaction for the residents and increased frustration. The DON revealed it was the responsibility of the CNAs to provide water and ice to residents several times during their shift. The DON revealed all the staff received in service training on resident rights and hydration. The DON revealed lack of drinking water throughout the day could have led to resident dehydration. An interview with the Administrator on 03/05/2026 at 1:20 p.m. revealed all residents should have been given drinks with their meals. The Administrator revealed the expectation was residents stay hydrated throughout the day. The Administrator revealed the risk to the residents of not having gotten drinks at mealtime or throughout the day was dehydration. Record review of the facility's policy entitled, Nutrition/Hydration Management, dated 1/2026, reflected .Nutrition and hydration management is an interdisciplinary process designed to improve residents' quality of life. The program emphasizes regular assessment and monitoring of nutritional and hydration status through clinical indicators such as body weight, biochemical measures, and hydration levels, with prompt responses to unplanned weight changes or hydration concerns. Individualized care plans are developed for each resident based on comprehensive assessments, ensuring tailored interventions to meet specific needs. The management program is consistently implemented and evaluated for effectiveness, with adjustments made as necessary. Nursing staff receive ongoing training in current nutrition and hydration practices to maintain high-quality care standards.

Based on observation, interview, and record review, the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health for 1 of 5 residents (Resident #66) reviewed for foot care. The facility failed to provide adequate foot care for Resident #66. This failure could place residents at risk for infection, impaired mobility, and poor foot health as well as a decline in their quality of life.Record review of Resident #66's face sheet, dated 3/5/26, reflected a [AGE] year-old male, admitted [DATE]. Resident #66 had the following active diagnoses: need for assistance with personal care, chronic pain, unsteadiness on feet, mood disorder, Generalized Anxiety Disorder ( a chronic mental health condition defined by excessive, uncontrollable, and persistent worry about daily events) and Major Depressive Disorder (a mental health condition characterized by persistent intense feelings of sadness, hopelessness and loss of interest in activities).Record review of Resident #66's Order Summary Report, dated 3/5/26, reflected an active order dated 3/4/26 Resident request for Podiatrist consult for toenails.Record review of Visit Summary from Podiatrist on 12/5/25 reflected Resident #66 was not seen.Record review of Resident #66's MDS Comprehensive assessment, dated 12/4/25, revealed resident's cognition was intact with a BIMS score of 15.Resident #66 needed partial assistance with putting footwear on and taking it off.Record review of Resident #66's Care Plan Progress Note, dated 1/15/26, reflected, .A quarterly care plan meeting was conducted with the resident, who is their own responsible party, and the interdisciplinary team.The resident was referred to ancillary services for podiatry, dental, and optometry.Record review of Visit Summary from Podiatrist on 2/12/26 reflected Resident #66 was not seen.During an observation and interview of Resident #66 in his room on 03/03/2026 at 10:21 a.m. revealed resident's toenails were long, thin, jagged with yellow discoloration. Resident #66 revealed his toenails hurt and the podiatrist needed to cut them. Resident #66 revealed when the podiatrist came last month, he was told he was not on the list for services. Resident #66 revealed he told his nurses several times he needed to see the Podiatrist because he wanted his toenails cut. He revealed the last time his toenails were cut was at another facility and had not gotten them cut at this facility since his re-admission. During an interview with LVN I on 03/04/2026 at 2:05 p.m., LVN I revealed she cut Resident #66's fingernails on Sunday (3/1/26) but had not cut his toenails. LVN I revealed she asked him if he wanted his toenails cut and he did not respond. LVN I revealed she was unsure if Resident #66 had gotten his toenails cut since his admission to the facility. LVN I revealed she had not noticed Resident #66's toenails were long, but she would ensure he was referred to Podiatry. LVN I denied Resident #66 had ever asked her to see the Podiatrist and noted Resident #66 typically asked for everything. LVN I revealed the risk to the resident of not having had his nails cut timely would have been infection, ingrown nails or pain.An interview with the Social Worker Interim on 03/05/2026 10:20 a.m. revealed Resident #66 was on the podiatry list since July of 2025 and she was unsure why he was not seen. The Social Worker Interim revealed the resident was on the list for Podiatry and was scheduled for 3/27/26. The Social Worker Interim revealed Podiatry came to the facility monthly and was not sure of the reason he was not seen. The Social Worker Interim revealed the possible reason he was not seen was the Podiatrist saw residents every 60 days and they probably attempted to see him while he was out of the facility between July of 2025 and November of 2025 and assumed he continued not at the facility when they came, and his name was on the list in error. The Social Worker Interim revealed she was unable to say the risk to the resident for not being seen by Podiatry because it was a nursing thing.An interview with the DON on 03/05/2026 at 12:58 p.m. revealed the nurses' assessed residents every Sunday and identified whether a resident needed Podiatry services. The DON revealed once the resident was identified they provided the resident's information to the social worker and the social worker would add them to the Podiatry list. The DON revealed he was unaware whether Resident #66 needed podiatry services and revealed Resident #66 had never asked him for Podiatry services. The DON revealed Resident #66 was provided nail care on Sunday and had not requested podiatry. The DON was unable to provide documentation that showed Resident #66 was provided with toenail care or that the resident had declined toenail care. The DON revealed he could not say what the risk was to the resident for not having had nail care because it was dependent on the condition of the resident's nails during his assessment. The DON revealed if the nails were thick, long and discolored then the resident would have been at risk of infection or pain.Record review of the facility's policy entitled, Referrals to Outside Services, dated 8/2020 reflected .The Director of Social Services coordinates the referral of residents to outside agencies/programs to fulfill resident needs for services not offered by the Facility. To facilitate this process, the Facility maintains service provider contracts with a variety of providers. Services may coordinate include, but are not limited to dental, audiology, vision, psychiatric, and podiatry services.

Based on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one of two (Residents #92) residents reviewed for feeding tubes. The facility failed to ensure LVN G administered medications through Resident #92's G-Tube by gravity, and instead she pushed the water flushes and medication with the plunger and syringe on 03/03/26. This failure could place residents at risk of abdominal discomfort, nausea and tube rupture.Findings included: Record review of Resident #92's Quarterly MDS assessment, dated 12/25/25, reflected a [AGE] year-old female admitted to the facility on [DATE]. Staff assessed Resident #92 to be severely cognitively impaired. She received 51% or more of total calories through tube feeding. Diagnoses included traumatic brain injury (a disruption in brain function caused by a violent blow) and dysphasia (difficulty swallowing). Record review of Resident #92's Care Plan, dated 09/17/25, reflected, [Resident #92] requires tube feeding.related to dysphagia .Interventions Every shift 30 ml pre/post medication and 5-10 ml water between each medication . Record review of Resident #92's Physicians Order Summary Report, dated 03/04/26, reflected, .every shift flush enteral tube with 30 ml water pre/post medication administration and 5-10 ml water between each medication . with a start date of 03/15/24. During an observation on 03/03/26 at 11:09 a.m. revealed LVN G at the medication cart pouring two tablets of Tylenol 325 mg from the bottle and placing the tablets into a plastic sleeve and crushing them. LVN G poured the crushed pills into a plastic medication cup and added 10 cc of water to the cup. LVN G then filled a plastic cup with water, put on gloves and gown and entered Resident #92's room. LVN G placed the G-tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) pump on hold, assessed the resident's lung and bowel sounds and elevated the head of bed to approximately 80 degrees. LVN G then retrieved a Luer lock syringe (medical device with screw on tip), attached the syringe to the G-tube and checked for residual (remaining left over portion). LVN G then removed the syringe, drew up 30 cc of water and connected it to the G-Tube and pushed the water into the tube with the plunger rather than allowing it to flow by gravity. She then disconnected the Luer lock syringe, drew up the dissolved Tylenol and re-attached the syringe to the g-tube and again pushed the medication in with the plunger, instead of allowing it to flow by gravity. LVN G then removed the syringe, drew up 30 cc of water, reattached the syringe to the G-tube and plunged it through the G-Tube. In an interview with LVN G on 03/03/26 at 11:20 a.m., she stated Resident #92 had a small G-tube which required them to use the Luer lock syringe. She stated she did not think she could give the medication or water by gravity because of the type of syringe they had to use. She stated she had not tried to give the medication by gravity. She stated she was not sure of the risk of pushing medications versus giving them by gravity. During an interview on 03/03/25 at 12:55 p.m., the DON stated the facility policy was to flush G-tubes with 30cc of water before and after medications, and medications were to be given by gravity. He stated pushing the medications could cause discomfort to Resident #92. He stated they would in-service the staff to ensure all were aware of the facility's protocol. Record review of the facility's policy, Medication-Administration, revised January 2025, reflected, To ensure medications administered via enteral tubes (G-tube.) are delivered safely, effectively, and in accordance with prescriber orders, manufacturer guidelines, .and current nursing standards of practice.Pour the dissolved or diluted medication into the syringe and allow the medication to flow by gravity. Do not force flush.

Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured and stored in accordance with current accepted professional principles for 1 of 3 medication carts (Nurse cart for Hall 200) observed for medication storage. The facility failed to ensure LVN G kept Resident #92's medications secured during medication administration on 03/03/26. This failure could place residents at risk of gaining access to unlocked medications that were not prescribed to them. Findings included: During an observation on 03/03/26 at 11:09 a.m. revealed LVN G was at the medication cart in front of Resident #92's room. LVN G poured two tablets of Tylenol 325 mg from the bottle and placed the tablets into a plastic sleeve and crushed them. LVN G poured the crushed pills into a plastic medication cup and added 10 cc of water to the cup. LVN G then filled a plastic cup with water. LVN G then put on gloves and a gown and entered Resident #92's room, leaving the medication on top of the medication cart out of the sight of LVN G. There were two residents observed in the hallway close proximity of the medication cart. LVN G placed the G-tube pump on hold, assessed the resident's lung and bowel sounds and elevated the head of bed to approximately 80 degrees. LVN G's back was to the medication cart and out of her clear site. After assessing Resident #92, LVN G returned to the medication cart and retrieved the medication and cup of water and re-entered the resident's room and administered the medication During an interview with LVN G on 03/03/26 at 11:20 a.m., she stated she though it was kay to leave the medication on top of the medication cart as long as it was within her sight. She then acknowledged her back was to the medication cart while she was assessing the resident and positioning her for the medication administration. She stated the risk of leaving the medication on top of the cart in the hallway was another resident could pick it up and take it. In an interview on 03/03/25 at 12:55 p.m. the DON stated all the staff were trained on medication storage and the expectation of keeping medication carts locked and secured and were never to leave medication on top of the cart unsecured. He stated leaving it on the cart, out of the sight of the staff, could result in another resident picking up the medication and taking something not prescribed for them. He stated they would in-service the staff on proper medication storage and handling. Record review of the facility's policy titled, Medication Storage, revised January 2026, reflected, To establish standard that safeguard residents by preventing unauthorized access to medications.Store medications in clean, dry, well-lit, temperature-controlled areas.Security and access.Access is restricted to authorized, licensed staff.Direct observation Standard: A cart may remain unlocked only when it is continuously withing the authorized staff members direct, unobstructed line of sight, without requiring significant head turning or repositioning.

Based on observation, interview and record review, the facility failed to provide the therapeutic diets as prescribed by the attending physician for 1 (Resident #13) of 3 residents observed for therapeutic diets.The facility failed to provide Resident #13 with his regular diet minced and moist (MM5) texture as designated on his physician order on 3/4/2026.This failures could place residents at risk for poor intake, weight loss, unmet nutritional needs, and choking.Findings included:Record review of Resident #13's annual MDS Assessment, dated 01/03/2026, reflected Resident #13 was a [AGE] year-old male readmitted to the facility on [DATE]. His diagnoses included stroke (disruption in blood flow to the brain), hypertension (high blood pressure), malnutrition, and dysphagia (difficulty swallowing, indicating a disruption in moving food or liquid from the mouth to the stomach). He had BIMS of 0 indicating Resident #13 had severe cognitive impairment.Record review of Resident #13's Care plan, revised on 1/20/2026, reflected, Focus: [Resident #13] has a diet order other than Regular and is at risk for unplanned weight loss or gain. Regular diet, Minced & Moist (MM5) texture, thin consistency. Goal: [Resident #13] will maintain ideal weight and receive proper nutrition daily for x 90 days. Intervention.[Speech therapy] evaluation and Treatment per Physicians orders as condition warrants. (IDDSI [The International Dysphagia Diet Standarizations Initiative] Minced & Moist (MM5) diet is soft, cohesive, bite-sized, or minced food (4mm for adults) requiring minimal chewing and no biting.)Record review of Resident #13's physician order, dated 12/29/2025, reflected, Regular Diet Minced and Moist (MM5) texture, thin consistency. Record review of Resident #13's lunch meal ticket, dated 3/4/2026, reflected, Diet: Regular, texture: Minced and Moist MM5). Resident's choice meal: Pureed black beans, Minced potato salad (no onion/ no celery/ relish), pureed fruit cobbler, **alternate choices** minced marinated chicken with thick gravy (MM5). During an observation on 03/04/2026 at 12:26 p.m., revealed Resident #13 was served whole baked beans, two half slices of bread, one piece of chicken breast covered with gravy, pureed potato salad and frozen nutrition treat for lunch. Resident #13 pulled chicken apart with fork and used left hand only to put a small piece of chicken in his mouth. Resident #13 did not appear to struggle with swallowing or coughing. ADON C was present in the dining room for lunch service. During an interview on 03/04/26 at 12:27 p.m., Resident #13 was attempted to be interviewed regarding his diet, however Resident #13 did not answer any questions. During an observation and interview on 03/04/26 at 12:28 p.m., ADON C stated Resident #13's meal did not match his meal ticket and stated it was the wrong texture. ADON C was observed calling the Dietary Manager to check Resident #13's lunch meal. Resident #13 did not take any more bites of his meal. During an observation and interview on 3/04/26 at 12:30 p.m., the Dietary Manager stated Resident#13 was on minced and moist diet and should have been served pureed beans, pureed breads and minced chicken. She took Resident #13's meal to the kitchen and provided him with a new lunch meal that included minced chicken, pureed beans, pureed bread and pureed potato salad. Resident #13 continued to eat his minced and moist texture diet without any difficulty. During an interview on 03/04/2026 at 1:59 p.m., ADON C stated nurses were responsible for checking diet trays before they were passed on to residents. She stated nurses were required to verify the meal texture, portion sizes, and any additional items or adaptive devices. She stated the diet provided to Resident #13 was not of the appropriate texture and the resident was at risk of choking and poor food intake. During an interview on 03/04/2026 2:12 p.m., LVN D stated it was not his turn to check the meal trays but was filling in for a different nurse. He stated nurses were responsible for checking meal trays to ensure the food texture matched the dining ticket and the tray. He stated that if the texture was incorrect, the tray should be taken back to the kitchen and shown to staff so it could be corrected. He stated there was a risk the resident could choke. During an interview on 03/04/2026 2:28 p.m., Speech Therapist E stated she had seen Resident #13 in January 2026 and determined Resident #13's safest diet texture was minced and moist for all foods. She stated any resident who was on minced and moist texture needed to be served minced meats, pureed beans and pureed bread. She stated failure to provide acceptable diet texture could possibly lead to choking and poor swallowing. During an interview on 03/04/2026 at 3:46 p.m., the DON stated nurses assigned to dining room service were responsible for ensuring residents received the correct diet. He stated he conducted a lung assessment for the Resident #13 and notified the physician regarding the incorrect diet texture. He stated that staff were in-serviced on different diet textures per IDDSI standards in January 2026. He stated that the risk of not providing the therapeutic diet as ordered by the physician could lead to choking, poor food intake, and unmet nutritional needs. During an interview on 03/05/2026 at 9:26 a.m., the Dietary Manager stated the diet aide calls-out the diet order, and the cook prepared the plate in the kitchen. She stated once the tray was prepared, it should be placed on the cart to be put into service and checked by nursing for accuracy. She stated that a nurse was always present during each meal service. She stated that all cooks and dietary aides were trained on diet textures and procedures. She stated the risk, in addition to resident dissatisfaction, was risk of choking, included the possibility of not following the physician's orders for therapeutic diet. Record review of facility policy entitled, Therapeutic Diets , dated 1/1/2025, reflected, Purpose: To ensure that the Facility provides therapeutic diets to residents that meet nutritional guidelines and physician orders. Policy. Therapeutic diets are diets that deviate from the regular diet and require a physician's order. Per the physician's order, therapeutic diets are planned, prepared, and served.

Based on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided with such care, consistent with professional standards of practice and the comprehensive person-centered care plan, for one of two (Resident #71) reviewed for quality of care. The facility failed to ensure the supplemental oxygen was provided at the physician ordered rate for Resident #71. This failure could place residents who received oxygen therapy at risk of oxygen toxicity. Findings included: Record review of Resident #71's quarterly MDS assessment, dated 01/05/26, reflected a [AGE] year-old female, admitted to the facility on [DATE] and readmitted [DATE]. She had a BIMS score of 4 which indicated she was severely cognitively impaired. Diagnoses included respiratory failure, pneumonia (serious lung infection), dementia, and dysphagia (difficulty swallowing). She was dependent on ADLs and required maximum assistance with transfers. The MDS assessment did not indicate she received oxygen therapy in the previous 14 days. Record review of Resident #71's care plan, dated 12/15/25, reflected, [Resident #71] has impaired gas exchange related to pneumonia, acute hypoxemic respiratory failure (condition where the lungs cannot adequately transfer oxygen to the blood) .Interventions.Administer oxygen as prescribed or per standing order. Record of Resident #71's Physician order summary report, dated 03/05/26, reflected, oxygen at 2 Liters per minute via nasal cannula every shift., with a start date of 02/02/26. Record review of Resident #71's MAR, dated March 2026, reflected, .O2 @ 2 liters per minute via nasal cannula every shift with a start date of 02/02/26. The MAR was signed off by staff on the day shift, evening shift and night shift from 03/01/26 through the day shift on 03/04/26 which indicated O2 was administered at 2 liters per minute. During an observation on 03/03/26 at 10:45 a.m., revealed Resident #71 had a nasal cannula in place, and the oxygen flow rate was set to deliver 3.5 liters per minute via an oxygen concentrator. During an interview with Resident #71 on 03/03/26 at 10:46 a.m. was attempted, but resident was non-responsive. An observation 03/04/26 at 1:12 p.m. of Resident #71 revealed her lying in her bed with nasal cannula in place. The oxygen concentrator was set to deliver 3.5 liters per minute of oxygen. In an observation and interview with LVN H on 03/04/26 at 1:55 p.m. he revealed he was the 6:00 a.m. - 2:00 p.m. Charge nurse for today. LVN H entered Resident #71's room observed the concentrator and stated it was set on 3.5 liters per minute. LVN H stated he was not sure what the orders were for the oxygen setting and went to his computer to check the orders and verified the orders were for 2 liters per minute. LVN H retrieved the pulse oximeter (device used to test concentration of oxygen in the blood) and checked the resident oxygen blood levels which had a reading of 93. He stated he was not sure why the concentrator was set on 3.5 liters or who placed it on 3.5 liters per minute. He stated the nurses were responsible for assessing any resident who was on continuous oxygen. He stated he had not assessed her respiratory status today (03/04/26), stating, he had just not gotten around to it today. He stated the nurses had to have orders for the amount of oxygen to be delivered and they were not allowed to give more than was ordered. He stated he would call the MD to determine what rate of oxygen the resident needed. He stated the risk of too much oxygen was toxicity. LVN H re-entered Resident #71's room and turned the oxygen concentrator to 2 liters per minute. An interview with the DON on 03/05/26 at 12:55 p.m. revealed any resident with oxygen had to have an order with the number of liters per minute to be delivered. He stated providing inaccurate amounts of oxygen could make the residents' breathing worse and could result in toxicity. He stated the nurses were supposed to check the oxygen levels each shift and as needed. He stated the doctor usually provided them with a range to be able to adjust the oxygen levels if the resident's oxygen saturation levels dropped below a certain level. He stated he would in-service the staff on the expectation of monitoring while a resident was receiving oxygen. Record review of the facility's policy titled, Oxygen Administration, dated June 2020, reflected, Purpose- To prevent or reverse hypoxemia (low oxygen level) and provide oxygen to the tissue.A physician's order is required to initiate oxygen therapy, except in an emergency situation. The order shall include Oxygen flow rate.Method of administration.usage of therapy (continuous or prn) .Titration (increasing or decreasing) instructions (if indicated) .Indication for use.Oxygen saturation s will be measured and documented at a minimum of daily for resident receiving oxygen therapy.

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #1) of 6 residents reviewed for ADLs. The facility failed to ensure Staff provided consistent showers/baths for Resident #1. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings included: Record review of Resident #1's quarterly MDS assessment, dated 05/19/25, reflected a [AGE] year-old-male admitted to the facility on [DATE]. Resident #1's diagnoses included dementia, muscle weakness, and need for assistance with personal care. His BIMs score of 06/15 indicating sever cognition impairment. His functional status reflected extensive assistance with bathing. Record review of Resident #1's comprehensive plan of care dated 05/27/25 reflected, Focus: Resident#1 has potential for an ADL self-care performance deficit related to Amputation, and Dementia. Goals: resident#1 will demonstrate the appropriate use of adaptive device to increase ability in ( ., toilet use and personal hygiene) through the review date. Intervention . BATHING: The resident requires substantial/max assist with bathing. Record review of residents showers schedule revealed Resident #1 was on the evening shower schedule Tuesdays-Thursdays-Saturdays. Record review of Resident#1's undated shower sheet revealed since April 15, 2025, Resident #1 received showers on day of 4/15/25, and 4/22/2025 , bed bath on day of 4/29/25 for the two weeks of April. Resident#1 received shower on 05/01/2025 and refused shower on 05/06/2025 for the May, 2025, and on the day of 06/03/2025 he refused. An observation and interview on 06/04/25 at 04:35 PM, revealed Resident #1 was lying in bed wearing only a T-shirt and the incontinent brief, partially covered with a small blanket. Resident#1 had an odor about him, with unshaved facial hair. Resident#1 stated he had not received showers in a week and wanted to be showered. When asked about his unshaved facial hair, he replied it was okay with him if he was unshaved or having long beard. An interview with the DON on 06/04/25 at 3:41 PM revealed the CNAs were supposed to inform the charge nurse anytime a resident refused a shower. He stated showers were to be done on the shower days, and if the resident refused, they were to notify the charge nurse and they were to document it in the shower sheets. The DON stated charge nurses signed the shower sheets and were expected to ensure residents were showered. The DON said that Resident#1 had dementia and was forgetful, and he was getting his showers all time. He stated lack of personnel hygiene could lead to skin problems and overall dignity. Interview on 06/04/25 at 4:48 PM, LVN C stated residents were showered on their assigned shower days unless they refused. LVN C stated residents were asked three times after refusals and were offered bed baths instead. LVN C stated Resident#1 should get his shower in the evening shift every other day or three times a week. She stated herself as a charge nurse was responsible to make sure the CNAs gave residents their showers according to their schedule. She stated the risks to the residents were skin break down, rash, infection development, dignity, and will not feel good about themselves. At the surveyor exit time 7:00 PM on 06/04/2025 the DON was unable to furnish the document to prove Resident#1 was getting his shower as scheduled. A record review of the facility's policy Resident Rights - Quality of Life , revised August 2020, reflected . Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, and individuality. XII. Demeaning practices and standards of care that compromise dignity are prohibited. Facility staff will promote dignity and assist residents as needed .

Based on observation, interview and record review the facility failed to ensure that a resident with urinary incontinence, based on the resident's comprehensive assessment, received the appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #1) of 6 residents reviewed for incontinent care. The facility failed to ensure Resident #1 was assisted with incontinence care and toileting in a timely manner on 06/04/2025. This failure could place residents at risk of skin breakdown, infection and a diminished quality of life by not receiving care and services to meet their toileting needs. Findings included: Record review of Resident #1's quarterly MDS assessment, dated 05/19/25, reflected a [AGE] year-old-male admitted to the facility on [DATE]. Resident #1's diagnoses included dementia, muscle weakness, and need for assistance with personal care. His BIMs score of 06/15 indicating sever cognition impairment. His functional status reflected extensive assistance for personal hygiene. He was frequently incontinent of bowel and bladder. Record review of Resident #1's comprehensive plan of care dated 05/27/25 reflected, Focus: Resident#1 has potential for an ADL self-care performance deficit related to Amputation, and Dementia. Goals: Resident#1 will demonstrate the appropriate use of adaptive device to increase ability in ( ., toilet use and personal hygiene) through the review date. Intervention: Toilet use: the resident requires setup with clean up assistance to use toilet. He is incontinent of bowel and bladder. PERSONAL HYGIENE/ORAL CARE: the resident requires substantial/max assistance with personal hygiene and oral care. Observation and interview on 06/04/25 at 10:10 AM, Resident #1 was lying in bed wearing only a T-shirt and the incontinent brief, partially covered with a small blanket. There was a strong smell of urine in Resident #1's room, the exposed incontinent brief was swollen large with liquid. Resident #1 was unable to answer questions during the interview. CNA A came into Resident #1's room to answer his call light. When asked if Resident #1 had been checked and changed. CNA A stated she had not changed the resident since the start of her shift at 6:15 AM this morning. CNA A shift started at 6:00 AM. CNA A did not provide any explanation for the delay in providing incontinent care to Resident #1. During the process of providing incontinent care to Resident #1 by CNA A this surveyor observed the resident's skin, and there was redness noted on his Scrotum. The charge nurse LVN B was notified by CNA A and got order to apply Antiseptic skin protection external ointment 50% to the reddened area. Interview on 06/04/25 at 11:50 AM, LVN B stated the charge nurses and CNAs supposed to do rounding at least every 2 hours to check residents and change them if they were wet. LVN B stated the risk of incontinent care not being provided on time would be skin break down, and infection. Interview on 06/04/25 at 3:41 PM the DON stated the charge nurses and CNAs supposed to do rounds room to room at least every 2 hours to check residents and change them if they were wet. The DON stated the risk of incontinent care not being provided on time would be skin break down, infection, and resident dignity. A record review of the facility's policy Resident Rights - Quality of Life, revised August 2020, reflected . Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, and individuality. XII. Demeaning practices and standards of care that compromise dignity are prohibited. Facility staff will promote dignity and assist residents as needed by . B. Promptly responding to the resident's request for toileting assistance .

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one (Resident #1) of six resident observed for infection control. Facility failed to ensure CNA A performed hand hygiene and changed gloves while providing incontinence care to Resident # 1. Facility failed to ensure CNA A and LVN B performed hand hygiene before touching clean gloves. This failure could place the residents at risk for infection. Findings included: Record review of Resident #1's quarterly MDS assessment, dated 05/19/25, reflected a [AGE] year-old-male admitted to the facility on [DATE]. Resident #1's diagnoses included dementia, muscle weakness, and need for assistance with personal care. His BIMs score of 06/15 indicating severe cognition impairment. His functional status reflected extensive assistance for personal hygiene. He was frequently incontinent of bowel and bladder. Record review of Resident #1's comprehensive plan of care dated 05/27/25 reflected, Focus: Resident#1 has potential for an ADL self-care performance deficit related to Amputation, and Dementia. Goals: resident#1 will demonstrate the appropriate use of adaptive device to increase ability in ( ., toilet use and personal hygiene) through the review date. Intervention: Toilet use: the resident requires setup with clean up assistance to use toilet. He is incontinent of bowel and bladder. PERSONAL HYGIENE/ORAL CARE: the resident requires substantial/max assistance with personal hygiene and oral care. Observation on 06/04/25 at 10:13 AM revealed CNA A entered Resident #1's room with clean brief, and handful of gloves. She put the supplies on the bedside table. She donned the clean gloves. CNA A unfastened Resident #1's brief. The brief looked soaked with dark yellow liquid inside with strong odor. CNA A folded it and pushed it between Resident #1's legs. CNA A cleaned Resident #1's front area, and his scrotum looked red. CNA A helped Resident #1 turned to his right side. CNA A folded the dirty brief and disposed of it in the trash bag. CNA A, without changing gloves, got a clean brief and applied it on Resident #1. When asked to further check Resident #1's scrotum, she acknowledged the redness. CNA A called LVN B to Resident #1's room. CNA A changed gloves using the pile of gloves she had on the table with hand hygiene and cleaned Resident #1 front area one more time. CNA A removed gloves, pulled the blanket over the resident while waiting for LVN B. LVN B came in holding gloves in her hands, washed hands, and donned the gloves. LVN B checked Resident #1's scrotum, and stated it had some redness, and no skin breakdown, she asked Resident #1 if he had pain, and he denied having pain. LVN B instructed CNA A to put a barrier cream on Resident #1's scrotum. CNA A went outside the room and got cream Peri Guard with more gloves on her hands, and she put them on the table. CNA A washed hands and donned the glove she put over the table. LVN B removed gloves, washed hands, and before exiting the room, LVN B changed her mind and asked CNA A to not put the Peri-Guard cream on the Resident #1 redness until she called the MD and notified him and get order for treatment. CNA A finished putting the brief on Resident #1. CNA A put socks, pants, and shoes on Resident #1. CNA A removed gloves. LVN B came in holding glove in her hands, she put the glove on table washed hands and donned the gloves. CNA A washed hands donned gloves. CNA A unfastened Resident #1 brief and LVN B put the Peri guard cream on Resident #1's scrotum. Both staff helped Resident #1 transfer from bed to wheelchair. Both staff removed gloves, washed hands, and left the room. In an interview on 06/04/25 at 10:42 AM, CNA A stated she was to wash hands before and after care. CNA A also stated she was supposed to change gloves and complete hand hygiene after removing the dirty brief. CNA A stated she was not supposed to get and carry the gloves on her hand before performing hand hygiene. CNA A further stated she used to get the gloves needed for residents' care in a clean plastic bag. CNA A stated she was supposed to change gloves before going from dirty to clean task, and complete hand hygiene before getting the clean gloves to prevent the spread of infection. In an interview on 06/04/25 at 10:47 AM, LVN B when asked for getting, and holding the clean gloves in her hands before performing any form of hands hygiene, she replied, she should not get the gloves before hand hygiene. LVN B stated not following the proper donning of PPE; like contaminating the glove before putting them on; could cause cross contamination, and development of infection for the residents. In an interview on 06/04/25 at 03:41 PM, the DON stated during incontinent care the staff were to complete hand hygiene before and after care. The DON also stated in between care CNA A was to complete hand hygiene and change gloves because her hands, and the gloves were considered dirty after cleaning the resident and removing the dirty brief. The DON further stated the staff were not supposed to carry gloves in their hands going to residents' room before performing hand hygiene. The DON stated the staff were to complete proper donning and doffing of PPE during residents' care to prevent the spread of infection. Record review of the facility policy titled Hand Hygiene, revised June 2020, reflected Policy: The facility considers hand hygiene the primary means to prevent the spread of infections. Procedures: . Facility staff and volunteers must perform hand hygiene procedures in the following circumstances including but not limited to . viii. After removing personal protective equipment . VII. The use of gloves does not replace hand hygiene procedure .

Based on observations, interviews, 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 seven of eight ( RN A, CNA D, CNA G, CNA H, CNA I, CNA J, and MA K) staff members and forty-four of 106 residents (Residents #79, #46, #2, #84, #8, #34, #4, #1, #31, #55, #6, #13, #65, #5, #87, #107, #4, #28, #7, #76, #10, #21, #106, #93, #16, #103, #104, #74, #27, #64, #29, #33, #72, #40, #54, #47, #81, #43, #63, #24, #58, #97, and #99) reviewed for infection control procedures. MA K failed to sanitize the blood pressure cuff before and after usage on Resident #63. RN A failed to disinfect her treatment scissors prior to starting a treatment on Resident #99's foot. CNA G failed to sanitize their hands after direct contact with residents #79, #46, #2, #84, #8, #34, #1, #31, #55, #6, #13, #65, and #5, while serving meals on Hall 100. CNA D failed to sanitize their hands after direct contact with residents #87, #107, #4, #28, #7, #76, #10, and #21 while serving meals on Hall 200. CNA H failed to sanitize their hands after direct contact with residents, #106, #93, #16, #103, 104, 74, #27, #64, #29, and #33 while serving meals on Hall 300. CNA J failed to sanitize their hands after direct contact with residents, #72, #105, #40, #54, #47, #81, and #66 while serving meals on Hall 400. CNA I failed to sanitize their hands after direct contact with residents, #43, #63, #24, #58, and #97 while serving meals on Hall 600. This failure could place residents at risk for healthcare associated cross contamination and infections. Findings included: Record review of Resident #99's admission MDS assessment, dated 11/12/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #99 had diagnoses which included: Diabetes (high sugar), hypertension (high blood pressure), and peripheral vascular disease (blood does not flow to the legs well). Resident #99 was cognitively alert and able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #46's annual MDS Assessment, dated 09/12/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #46 had diagnoses which included: Diabetes (high blood sugar), schizo-affective schizophrenia (mental illness), and hypertension (high blood pressure). Resident #46 was severely cognitively impaired, unable to make decisions, and required one staff for assistance with activities of daily living. Record review of Resident #2's quarterly MDS Assessment, dated 11/27/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included: Hypertension (high blood pressure), heart failure (heart not pumping well), and diabetes (high blood sugar). Resident #2 was alert, able to make decisions, and required one staff for assistance with activities of daily living. Record review of Resident #84's quarterly MDS Assessment, dated 10/03/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #84 had diagnoses which included: hypertension (increased blood pressure), schizophrenia (mental illness), and trans-ischemic attacks (small strokes). Resident #84 was cognitively alert, able to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #8's quarterly MDS Assessment, dated 11/27/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #8 had diagnoses which included: Diabetes (increased blood sugar), and depression (mental illness). Resident #8 was cognitively alert, able to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #34's quarterly MDS Assessment, dated 11/08/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #34 had diagnoses which included: Hypertension (increased blood pressure), depression (mental illness), and convulsions (seizures). Resident #34 was severely cognitively impaired, unable to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #79's quarterly MDS Assessment, dated 10/09/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #79 had diagnoses which included: Hypertension (increased blood pressure), schizophrenia (mental illness), and depression (mental illness). Resident #79 was cognitively alert, able to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #1's annual MDS assessment, dated 11/20/2024, revealed an [AGE] year-old male who admitted to the facility on [DATE] and readmission on 08/02/2024. Resident #84 had diagnoses which included: Hypertension (increased blood pressure), schizophrenia (mental illness), and dementia (confusion and forgetfulness). Resident #84 was severely cognitively impaired, unable to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #31's quarterly [in process] MDS assessment, dated 12/12/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #31 had diagnoses which included: Diabetes (increased blood sugar), and cardio-vascular accident (stroke). Resident #31 was severely cognitively impaired, unable to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #55's quarterly MDS assessment, dated 11/15/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #55 had diagnoses which included: Hypertension (increased blood pressure), bi-polar disorder (mental illness), and depression (mental illness). Resident #55 was moderately cognitively impaired, able to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #6's quarterly MDS assessment, dated 12/06/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #6 had diagnoses which included: Hypertension (increased blood pressure), schizophrenia (mental illness), and dementia (confusion and forgetfulness). Resident #6 was severely cognitively impaired, unable to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #13's annual MDS assessment, dated 12/09/2024, revealed a [AGE] year-old male who admitted to the facility on ,d+[DATE]. Resident #13 had diagnoses which included: Hypertension (increased blood pressure), diabetes (increased blood sugar), and heart failure (heart weak and unable to pump correctly). Resident #13 was alert cognitively, able to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #65's quarterly MDS assessment, dated 10/11/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE] and readmission on 08/14/2024. Resident #65 had diagnoses which included: Diabetes (increased blood sugar), depression (mental illness), and paraplegia (loss of usage legs). Resident #65 was alert cognitively, able to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #5's quarterly MDS assessment, dated 12/07/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #5 had diagnoses which included: Depression (mental illness), and diabetes (increased blood sugar). Resident #5 was severely cognitively impaired, unable to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #87's quarterly MDS assessment, dated 09/27/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #87 had diagnoses which included: Hypertension (increased blood pressure), diabetes (increased blood sugar), and end-stage renal disease (kidneys do not work without assistance through a machine). Resident #87 was severely cognitively impaired, unable to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #107's 5-day Medicare MDS assessment, dated 12/08/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #107 had diagnoses which included: Hypertension (increased blood pressure), depression (mental illness), and diabetes (increased blood sugar). Resident #107 was cognitively alert, able to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #4's quarterly MDS assessment, dated 11/25/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE] and readmit on 03/15/2023. Resident #4 had diagnoses which included: Alzheimer's disease (degeneration of brain), depression (mental illness), and psychotic disorder (mental illness). Resident #4 was severely cognitively impaired, unable to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #28's quarterly MDS assessment, dated 11/28/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #28 had diagnoses which included: Hypertension (increased blood pressure), depression (mental illness), and dementia (confusion and forgetfulness). Resident #28 was severely cognitively impaired, unable to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #7's annual MDS assessment, dated 11/07/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE] and readmission on 10/18/2021. Resident #7 had diagnoses which included: Hypertension (increased blood pressure), psychotic disorder (mental illness), and diabetes (increased blood sugar). Resident #7 was cognitively alert, able to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #76's quarterly MDS assessment, dated 11/20/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #76 had diagnoses which included: Hypertension (increased blood pressure), cardio-vascular accident (stroke), and diabetes (increased blood sugar). Resident #76 was cognitively alert, able to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #10's annual MDS assessment, dated 11/01/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #10 had diagnoses which included: Chronic obstructive pulmonary disease (lungs do not work correctly), psychotic disorder (mental illness), and insomnia (does not sleep well at night). Resident #10 was cognitively alert, able to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #21's quarterly MDS assessment, dated 09/30/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #21 had diagnoses which included: Hypertension (increased blood pressure), schizophrenia (mental illness), and cerebral infract (stroke). Resident #21 was cognitively alert, able to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #106's admission MDS assessment, dated 11/24/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #106 had diagnoses which included: Renal insufficiency (kidneys do not work well), hypoglycemia (low blood sugar), and respiratory failure (could not breath without assistance). Resident #106 was cognitively alert, able to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #93's annual MDS assessment, dated 11/28/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE] with a readmission on 11/22/2024. Resident #93 had diagnoses which included: Anemia (not enough iron), depression (mental illness), and heart failure (weak heart). Resident #93 was cognitively alert, able to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #16's quarterly MDS assessment, dated 10/17/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #16 had diagnoses which included: Hypertension (increased blood pressure), schizophrenia (mental illness), and bipolar disorder (mental illness). Resident #16 was moderately cognitively impaired, able to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #103's admission MDS assessment, dated 11/12/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #103 had diagnoses which included: Hypertension (increased blood pressure), cardio-vascular accident (stroke), and diabetes (increased blood sugar). Resident #103 was moderately cognitively impaired, able to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #104's admission MDS assessment, dated 11/19/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #104 had diagnoses which included: Hypertension (increased blood pressure), cardio-vascular accident (stroke), and diabetes (increased blood sugar). Resident #10 was cognitively alert, able to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #74's quarterly [in progress] MDS assessment, dated 12/12/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #74 had diagnoses which included: Hypertension (increased blood pressure), cardio-vascular accident (stroke), and diabetes (increased blood sugar). Resident #74 was cognitively alert, able to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #27's quarterly MDS assessment, dated 10/03/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #27 had diagnoses which included: Hypertension (increased blood pressure), cardio-vascular accident (stroke), and hyperlipidemia (increased cholesterol). Resident #27 was severely cognitively impaired, unable to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #64's quarterly MDS assessment, dated 10/15/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #64 had diagnoses which included: Hypertension (increased blood pressure), cardio-vascular accident (stroke), and diabetes (increased blood sugar). Resident #64 was cognitively alert, able to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #29's quarterly MDS assessment, dated 09/14/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #29 had diagnoses which included: Hypertension (increased blood pressure), depression (mental illness), and diabetes (increased blood sugar). Resident #29 was cognitively alert, able to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #33's quarterly MDS assessment, dated 11/22/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #33 had diagnoses which included: coronary artery disease (clogged up arteries), peripheral vascular disease (poor circulation to the legs), and dementia (confusion and forgetfulness). Resident #33 was cognitively alert, able to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #72's quarterly MDS assessment, dated 11/15/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #72 had diagnoses which included: Hypertension (increased blood pressure), heart failure (heart is weak, fluid on heart), and diabetes (increased blood sugar). Resident #72 was cognitively alert, able to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #40's quarterly MDS assessment, dated 10/11/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #40 had diagnoses which included: Hypertension (increased blood pressure), cardio-vascular accident (stroke), and dementia (confusion and forgetfulness). Resident #40 was severely cognitively impaired, unable to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #54's quarterly MDS assessment, dated 10/12/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE] with readmission on 04/04/2024. Resident #54 had diagnoses which included: Dementia (forgetfulness and confusion), anxiety (anxious), and depression (mental illness). Resident #54 was severely cognitively impaired, unable to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #47's annual MDS assessment, dated 10/19/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #47 had diagnoses which included: Chronic pain (pain), cardio-vascular accident (stroke), and quadriplegia (no full use of arms and legs). Resident #47 was cognitively alert, able to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #81's quarterly MDS assessment, dated 11/27/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #81 had diagnoses which included: Hypertension (increased blood pressure), cardio-vascular accident (stroke), and history of mental and behavioral disorders (mental illness). Resident #81 was cognitively alert, able to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #43's quarterly MDS assessment, dated 11/08/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE] with readmit on 04/13/2024. Resident #43 had diagnoses which included: Dementia (forgetfulness and confusion), bi-polar disorder (mental illness), and malignant carcinoid tumor of rectum (rectal cancer). Resident #43 was severely cognitively impaired, unable to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #63's quarterly MDS assessment, dated 10/03/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #63 had diagnoses which included: Hypertension (increased blood pressure), cardio-vascular accident (stroke), and diabetes (increased blood sugar). Resident #63 was moderately cognitively impaired, unable to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #24's quarterly MDS assessment, dated 10/31/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE] with readmission 10/18/2023. Resident #24 had diagnoses which included: Hypertension (increased blood pressure), osteomyelitis (infection of the bone), and depression (mental illness). Resident #24 was cognitively alert, able to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #58's quarterly MDS assessment, dated 09/22/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #58 had diagnoses which included: Hypertension (increased blood pressure), heart failure (heart weak, fluid around the heart), and dementia (forgetfulness and confusion). Resident #58 was severely cognitively impaired, unable to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #97's admission MDS assessment, dated 10/13/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #97 had diagnoses which included: Hypertension (increased blood pressure), anemia (not enough iron), and dementia (forgetfulness and confusion). Resident #97 was cognitively alert, able to make decisions, and required assistance of one staff for activities of daily living. Record review of Resident #66's quarterly MDS assessment, dated 11/02/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #66 had diagnoses which included: Diabetes (increased sugar), and hypertension (increased blood pressure). Resident #99 was cognitively alert, able to make decisions, and required assistance of one staff for activities of daily living. Observation and interview on 12/10/2024 at 10:22 a.m. with MA K revealed the MA checking the blood pressure on Resident #63. The MA did not clean the blood pressure cuff prior to using the cuff on the resident. The MA did not attempt to clean the blood pressure cuff after using, until the DON stepped up to the cart and whispered to MA K and showed the MA a container of purple top sanitizing wipes. MA K stated he had not cleaned the blood pressure cuff in between usage on the other residents because he had forgotten. MA K stated if the blood pressure cuff was not cleaned between usage it could spread infections. Observation on 12/10/24 beginning at 12:10 p.m., CNA G was observed to enter Hall 100. CNA G entered Resident's #46, #2, #84, #8, #34, #79, #1, #31, #55, #6, #13, #65, and #5 rooms. While serving the meals to the residents, CNA G moved and adjusted bedside tables, positioned, and assisted residents to sit up, opened, and unwrapped utensils, and removed tops off drinks for the residents. CNA G did not cleanse his hands with hand sanitizer or wash his hands, between each meal tray served. CNA G did not have on gloves. He did not complete hand hygiene before going to the next resident. Observation on 12/10/24 beginning at 12:21 p.m., CNA D was observed to be serving meals on Hall 200. CNA D entered Resident's #87, #107, #4, #28, #7, #76, #10, and #21 rooms. While serving the meals to the residents, CNA D moved and adjusted bedside tables, positioned, and assisted residents to sit up, opened, and unwrapped utensils, and removed tops off drinks for the residents. CNA D did not cleanse his hands with hand sanitizer or wash his hands, between each meal tray served. CNA D did not have on gloves. He did not complete hand hygiene before going to the next resident. Observation on 12/10/24 beginning at 12:30 p.m., CNA H was observed to be serving trays on Hall 300. CNA H entered Resident's #106, #93, #16, #103, #104, #74, #27, #64, #29, and #33 rooms. While serving the meals to the residents, CNA H moved and adjusted bedside tables, positioned, and assisted residents to sit up, opened, and unwrapped utensils, and removed tops off drinks for the residents. CNA H did not cleanse her hands with hand sanitizer or wash her hands, between each meal tray served. CNA H did not have on gloves. She did not complete hand hygiene before going to the next resident. Observation on 12/10/24 beginning at 12:39 p.m., CNA J was observed to be serving meal trays Hall 400. CNA J entered Resident's #72, #40, #54, #47, #81, and #66 rooms. While serving the meals to the residents, CNA J moved and adjusted bedside tables, positioned, and assisted residents to sit up, opened, and unwrapped utensils, and removed tops off drinks for the residents. CNA J did not cleanse her hands with hand sanitizer or wash her hands, between each meal tray served. CNA J did not have on gloves. She did not complete hand hygiene before going to the next resident. Observation on 12/10/24 beginning at 12:46 p.m., CNA I was observed to be serving meal trays Hall 600. CNA I entered Resident's #43, #63, #24, #58, and #97 rooms. While serving the meals to the residents, CNA I moved and adjusted bedside tables, positioned, and assisted residents to sit up, opened, and unwrapped utensils, and removed tops off drinks for the residents. CNA I did not cleanse her hands with hand sanitizer or wash her hands, between each meal tray served. CNA I did not have on gloves. She did not complete hand hygiene before going to the next resident. Observation and interview on 12/11/24 at 10:00 a.m., revealed RN A did not cleanse her treatment scissors prior to using the scissors to treat Resident #99's right leg and foot ulcer. RN A stated she cleaned them after use, but when the state surveyor walked up to her treatment cart and said she wanted to go see her treat this wound, she was not prepared. RN A stated she just forgot, she did state if the scissors were not cleaned prior to use and after this could cause germs to spread. An interview on 12/10/2024 at 12:32 p.m. with CNA H revealed she was in a hurry to serve the trays, she did not want the food to get cold and she saw me watching her, so she just forgot. The CNA stated she had been trained on hand hygiene and how to use hand sanitizer between each tray, and it could spread infection if she did not clean her hands. An interview on 12/10/24 at 1:00 p.m., CNA G stated he did not complete hand hygiene after having direct contact with residents. CNA G stated he was supposed to use the hand sanitizer in between serving each tray or wash his hands. CNA G said he had been educated on completing hand hygiene. CNA G stated he did not sanitize his hands, after the first meal tray that was served because he was nervous, and he forgot. CNA G stated he knew it could spread germs if he did not sanitize his hands properly. An interview on 12/10/2024 at 1:15 p.m. with CNA D revealed he was helping to serve in the dining room and when he came out of the dining area, the trays were already on the hallway, so he was in a hurry to get the trays served so the food did not get cold. The CNA stated he had been in-serviced on hand hygiene and when to use hand sanitizer between each meal served. An interview on 12/10/2024 at 1:37 p.m. with CNA J revealed she had been called in because someone had called in today and she had been trying to catch up all morning. CNA J stated she just forgot to use hand sanitizer between each meal. The CNA stated if you do not use sanitizer or wash your hands then you could spread germs. An interview on 12/10/2024 at 1: 45 p.m. with CNA I revealed the trays on the hallway were already on the hall and she was serving them late, so she was in a hurry. She stated she had residents she had to assist to eat on the hallway, so she was in a hurry and forgot to use the hand sanitizer. The CNA stated she did know to use hand sanitizer and it was there on the hall available to use but she just forgot. An interview with the DON on 12/12/24 at 9:45 a.m., revealed that all staff has been trained on infection control. The DON offered the in-services that had been completed for hand hygiene dated 11/2024, the CNAs that served today were listed on the in-service. The DON stated, I have trained the staff, if the staff do not listen then I do not know what else to do with them. The DON did not respond concerning follow-up to the training to assure the staff understood and was following the hand hygiene. I should get credit for at least training the staff. The DON stated if the CNAs do not use appropriate hygiene, they can spread germs to the residents and themselves. The DON stated he had trained the nursing staff and the medication aides on cleaning equipment after each use, including the glucometers, thermometers, and blood pressure cuffs. The DON stated he could not understand why the MA did not clean the blood pressure cuff. This DON stated this could also spread infection, it the equipment was not cleaned properly. The DON was the infection control preventionist. Record review of an in-service dated November 2024 and December 2024 log revealed CNA B, CNA D, CNA G, CNA H, CNA I, and CNA J received handwashing and hand sanitizing training, to prevent the spread of infection. Further review of in-service logs revealed an in-service conducted in November 2024 reflected: when passing trays in the hallways, sanitize after going in every room. Remember to wash your hands before starting meal service and use hand sanitizer between each tray served. Record review of an in-service dated November 2024 reflected MA K had received an in-service on cleaning equipment with the provided sanitation wipes between each use to prevent the spread of infection. Further review reflected the DON had followed-up with a 1:1 in-service with MA K on 12/12/2024 after the state surveyor had brought this failure to the DON's attention. Record review of the Facility's Policy titled Hand Hygiene revised June 2020 reflected: This facility considers hand hygiene the primary means to prevent the spread of infections . 1. Facility staff are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections .III. Facility staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, residents, and visitors . IV. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based rub etc.) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policy Facility staff: a.must perform hand hygiene procedures in the following circumstances including but not limited to . B. Alcohol based hand hygiene products can and should be used to decontaminate hands: i. immediately upon entering a resident occupied area .ii. Immediate upon exciting a resident occupied area .iii. Before moving from one resident to another in multiple-bed room . Review of facility's Policies and Procedure titled: Cleaning and disinfection of Resident-Care items and Equipment revised June 2020. c. non-critical items are those that come in contact with intact skin but not mucus membranes. (1) Non-critical resident-care items include bedpans, blood pressure cuffs, crutches, and computers. (2) Most non-critical reusable items can be decontaminated where they are used

Based on observations, interviews, and record review, the facility failed to ensure all assistive devices were maintained and free of hazards for six (Residents #22, #34, #48, #60, #67, and #89) of 6 residents reviewed for essential equipment. The facility failed to properly maintain wheelchairs for Residents #22, #34, #48, #67, and #89. The facility failed to properly maintain the overbed table for Resident #60. These failures could place residents at risk for equipment that is in unsafe operating condition, that could cause injury. Findings included: Review of Resident #22's quarterly MDS assessment, dated 10/08/2024, reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unsteadiness on feet (unsafe standing), muscle wasting and atrophy (weakness), abnormalities of gait and mobility (unable to walk safely), and diabetes (high blood sugar). Further review of the MDS reflected the resident was cognitively severely impaired and unable to make decisions for themselves. Review of Resident #22's plan of care dated 10/24/2024 with updates reflected goals and approaches to include wheelchair mobility for locomotion. Observation on 12/10/2024 at 12:30 p.m., revealed Resident #22 was sitting in her wheelchair, in the dining room, and had no skin problems. The wheelchair's right armrest was cracked with foam exposed. The left armrest was missing. Review of Resident #34's quarterly MDS assessment, dated 11/08/2024, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses of hypertension (high blood pressure), muscle weakness (muscle deterioration), difficulty in walking, and unsteadiness on feet (no balance). Further review of the MDS reflected the resident was cognitively moderately impaired and able to make decisions for themselves. Review of Resident 34's plan of care dated 10/08/2024 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 12/10/24 at 12:45 p.m., revealed Resident #34 was sitting in her wheelchair in the dining room and the wheelchair's right armrest was cracked with exposed foam. There were no skin tears on her arms. Resident #34 stated she would like to have a smooth arm rest, this one was rough. The resident stated she had not told anyone, but staff could have noticed it and got her a new armrest. Review of Resident #48's admission MDS assessment, dated 10/08/2024, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses of nontraumatic intracerebral hemorrhage in brain stem (bleeding in the back of your brain) cerebral infraction (stroke), lack of coordination (cannot walk), and unsteadiness on feet (cannot stand alone safely). Further review of the MDS reflected the resident was cognitively severely impaired and unable to make decisions for themselves. Review of Resident #48's updated plan of care dated 10/24/2024 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 12/02/2024 at 12:47 p.m., revealed Resident #48 was sitting in his wheelchair in the dining room and the wheelchair's left and right armrests were cracked with exposed foam. There were no skin tears on his arms. Review of Resident #60's annual MDS assessment, dated 09/17/2024, reflected he was a [AGE] year-old male admitted to the facility on [DATE], and readmission on 09/14/2024, with diagnoses of osteomyelitis of the left foot and ankle (infection of the bone of the left foot), absence of right leg below the knee (leg is missing below knee), lack of coordination (cannot walk), and unsteadiness on feet (cannot stand alone safely). Further review of the MDS reflected the resident was not cognitively impaired and able to make decisions for themselves. Review of Resident #60's updated plan of care dated 10/08/2024 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 12/02/2024 at 1:50 p.m., revealed Resident #60 was sitting on the side of his bed in his room. There were no skin tears on his arms. The resident was getting a drink out of his water pitcher sitting on the overbed table. The overbed table was missing all the veneer on the outer end of the table and exposing rough wood substance underneath. The resident stated he had not paid too much attention to the overbed table, but now he sees it and he wanted a new one. Review of Resident #67's quarterly MDS assessment, dated 09/16/2024, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses of hypertension (high blood pressure), muscle weakness (muscle deterioration), difficulty in walking, and unsteadiness on feet (no balance). Further review of the MDS reflected the resident was cognitively moderately impaired and able to make decisions for themselves. Review of Resident #67's updated plan of care dated 11/18/2024 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 12/10/24 at 12:49 p.m., revealed Resident #67 was sitting in his wheelchair in the dining room and the wheelchair's right armrest was cracked with exposed foam. The entire back of the wheelchair was cracked open and peeling off. There were no skin tears on his arms. Review of Resident #89's quarterly MDS assessment, dated 10/16/2024, reflected she was a [AGE] year-old female admitted to the facility on [DATE], and readmission on 09/28/2024, with diagnoses of cerebral infarction (stroke), muscle weakness (muscle deterioration), and unsteadiness on feet (no balance). Further review of the MDS reflected the resident was cognitively alert and able to make decisions for themselves. Review of Resident #89's updated plan of care dated 11/15/2024 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 12/10/24 at 12:52 p.m., revealed Resident #69 was sitting in her wheelchair in the dining room and the wheelchair's right armrest was cracked with exposed foam. There were no skin tears on her arms. In an interview on 12/11/2024 at 10:30 a.m., MA C stated when a resident's wheelchair needed repair the staff were to report it to the Maintenance Director. MA C stated we report to the Maintenance Director by writing in the electronic system or just telling him. MA C was unaware of any wheelchair that required repair. The MA stated the equipment had to be safe or the residents could get hurt. In an interview on 12/11/2024 at 11:00 a.m., with the Plant Operations revealed the staff informed the Maintenance Supervisor of equipment repair by logging into the electronic system. The Plant Operations verified the Maintenance Supervisor was the person who repaired the wheelchairs, but checking the Plant Operations did not see anything in the electronic system for any wheelchairs that required new armrest or backs. The Plant Operations stated the equipment needed to be in good repair so the residents did not get hurt. In an in interview on 12/12/2024 at 10:20 a.m., with the DON revealed he was not aware of any wheelchairs that required repair in the facility. The DON stated between therapy and the maintenance department the staff would tell them if a wheelchair required repair. Attempts were made to interview the therapy department, but they were all unavailable. In an in interview on 12/12/2024 at 2:20 p.m., with the Administrator revealed he was not aware of any wheelchairs that required repair in the facility. The Administrator stated there were plenty of parts and other wheelchairs available, he would see that the wheelchairs were repaired. The Administrator stated the staff was responsible to let the maintenance department know. Review of the Facility's Policy titled Maintenance services dated revised August 2020 reflected Maintenance service shall be provided to areas of the building, grounds, and equipment . G. establishing proprieties to providing repair services . j. maintaining all mechanical, electrical, and patient care equipment in safe operating condition .3. The maintenance director is responsible for developing and maintaining a schedule of maintenance services to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for two (Hall 100 and Hall 600) of six halls observed for physical environment. The facility failed to ensure rooms and bathrooms toilets, and sinks were clean, safe, and in good repair in several rooms on Hall 100 and Hall 600. These failures could place residents at risk for diminished quality of life. Findings included: An observation on 12/12/2024 at 8:30 a.m. revealed in resident room [ROOM NUMBER]'s bathroom, the sink was hanging loosely on the wall. The base of the toilet was black with grim, and the caulking was missing surrounding the entire base of the toilet. The wall on the A side of the room had the paint missing, with black marks across the entire lower part of the wall. An observation on 12/12/2024 at 8:45 a.m., revealed in resident room [ROOM NUMBER]'s bathroom the door protector was loose on the top left corner of the door. Further observation revealed inside the bathroom, the sink was hanging loosely on the wall and there was a liquid stain down the wall next to the toilet. An observation on 12/12/2024 at 9:00 a.m. revealed, in resident room [ROOM NUMBER]'s bathroom, the toilet seat had the white paint chipped off exposing the veneer underneath. Further observation revealed the sink hanging loosely on the wall. An observation on 12/12/2024 at 09:07 a.m. in resident room [ROOM NUMBER]'s bathroom, revealed the base of the toilet was black with grim, and the caulking was missing surrounding the entire base of the toilet. The toilet seat was missing, the white paint was chipped off and the veneer underneath was exposed. Further observation revealed the paint missing from the entire lower part of the wall on the A side of the room. An observation on 12/12/2024 at 09:15 a.m., in resident room [ROOM NUMBER]'s bathroom, the base of the toilet was black, and the caulking was missing around the entire base of the toilet. An observation on 12/12/2024 at 09:20 a.m., in resident room [ROOM NUMBER]'s bathroom, revealed the entire front of the toilet seat had the white paint chipped off and the veneer was exposed. In an interview on 12/12/2024 at 9:45 a.m. with the Plant Operations revealed that he would make sure that the repairs were made by the maintenance supervisor for this facility. He stated the staff was supposed to use the electronic system for reporting, but they did not. The Plant Operations stated they have been in-serviced on the system, but they still just tell the supervisor. The Plant Operations stated he could review all the facilities and if there was something in the system that had been reported that was not corrected, he would contact the maintenance supervisor for the campus and follow-up to see why the repairs had not been completed. The Plant Operations checked the electronic system and there were no entries concerning sinks and toilets in the system. In an interview on 12/12/2024 at 11:17 a.m. with Resident #60 revealed he wanted his room and bathroom to be cleaned and he knew that the man who could fix it, needed to come and do it. The resident said it had been that way for a long time; the stains on the wall by the toilet. In an interview on 12/12/2024 at 11:30 a.m. with Resident #79 revealed that he wanted his bathroom to be clean and he wanted a new toilet seat, he stated he had not told anyone that he wanted a new toilet seat. In an interview on 12/12/2024 at 11:27 p.m., Housekeeper E revealed she was responsible for cleaning the rooms and bathrooms on hall 100 and sometimes hall 600. The Housekeeper stated she would report to her supervisor if she found something in one of the resident's rooms that required repair. Housekeeper A stated she had noticed that some of the bathroom's sinks were loose, but she did not report it because she thought the sinks were not that loose. The housekeeper stated if the repairs were not completed it could cause harm to the residents. In an interview on 12/12/2024 at 12:18 p.m., LVN B revealed that if there were maintenance issues for the hallway, there was an electronic system the staff would use to report needed repairs. The LVN stated she had not reported any maintenance problems recently. LVN B stated she would report because something broken could cause harm to the resident. In an interview on 12/12/24 at 2:30 p.m. with the Administrator revealed the bathrooms had been renovated last year and the resident's treated everything so poorly, it was hard to keep everything in good repair. The Administrator stated this was the residents' home and by not keeping it clean and in good repair it can develop germs. Review of the Policy and Procedure Resident Room and Environment dated revised August 2020 reflected to provide residents with a safe, clean, comfortable, and homelike environment I. Facility Staff aim to create a personalized, homelike atmosphere, paying close attention to the following: A Cleanliness and order;

Based on observations, interviews, and record reviews the facility failed to accommodate the needs and preferences of four of 10 residents (Resident #3, Resident #20, Resident #96, and Resident #19) reviewed for accommodation of needs. The facility failed to place Resident #3's call light within reach on 12/11/2024. The facility failed to place Resident #20's call light within reach on 12/11/2024. The facility failed to place Resident #96's call light within reach from 12/10/2024 until 12/11/2024. The facility failed to place Resident #19's call light within reach on 12/11/2024. This failure could place residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency. Findings included: Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed Resident #3 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of stroke, seizure disorder, unsteadiness on feet, and aphasia (language disorder that affects the ability to speak). The MDS also revealed a BIMS score of 09 (suggested moderate cognitive impairment). Record review of Resident #3's care plan, updated on 10/23/2024, revealed Resident #3 was at risk for falls, and an intervention for this focus area was to ensure the resident's call light was within reach. Record review of Resident #20's quarterly MDS assessment dated [DATE] revealed Resident #20 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of stroke, aphasia (language disorder that affects the ability to speak), unsteadiness on feet, need for assistance with personal care, and lack of coordination. The MDS also revealed a BIMS score of 04 (suggested severe cognitive impairment). Record review of Resident #20's care plan, updated on 10/18/2024, revealed Resident #20 was at risk for falls, and an intervention for this focus area was to ensure the resident's call light was within reach. Record review of Resident #96's admission MDS assessment dated [DATE] revealed Resident #96 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of necrotizing fasciitis (serious bacterial infection that destroys tissue under the skin), cellulitis (bacterial skin infection) of the right upper limb, and hypertension (high blood pressure). The MDS also revealed a BIMS score of 15 (suggested no cognitive impairment). Record review of Resident #96's care plan, updated on 12/10/2024, revealed Resident #96 had a potential for an ADL self-care deficit, and an intervention for this focus area was to encourage the resident to use bell to call for assistance. Record review of Resident #19's quarterly MDS assessment dated [DATE] revealed Resident #19 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of stroke, urgency of urination, need for assistance with personal care, and unsteadiness on feet. The MDS also revealed a BIMS score of 06 (suggested severe cognitive impairment). Record review of Resident #19's care plan, updated on 11/15/2024, revealed Resident #19 had a potential for an ADL self-care deficit, and an intervention for this focus area was to encourage the resident to use bell to call for assistance. In an observation on 12/10/2024 at 10:15 a.m., Resident #96 was resting in bed with his eyes closed. Resident #96's call light was observed curled up under the resident's bed. In an observation and interview on 12/11/2024 at 9:37 a.m., Resident #96's call light was observed curled up under the resident's bed. Resident #96 stated he did not know where his call light was, but it was usually clipped to his bed. Resident #96 stated he would have to leave his room and look for help if he needed assistance. Resident #96 stated he was not concerned with not having his call light because he did not use it often. In an observation and interview on 12/11/2024 at 9:43 a.m., Resident #19's call light was observed on the floor next to her bed. Resident #19 stated she could not reach the call light and did not know where it normally was. Resident #19 was unable to provide further information due to cognitive impairment. In an observation and interview on 12/11/2024 at 1:58 p.m., Resident #3 was sitting in a wheelchair on the left side of her bed. Resident #3's call light was clipped on a curtain on the right side of the bed. Resident #3 was able to point at the call light, but shook her head no, when asked if she could reach it. Resident #3 was unable to provide additional information due to aphasia (language disorder that affects the ability to speak). In an observation and interview on 12/11/2024 at 2:02 p.m., Resident #20 was sitting in a wheelchair near the foot of his bed. Resident #20's call light was laying on a pillow at the head of the bed. Resident #20 stated he would like to lay down but was not able to reach the call light. Resident #20 would not state anything else except he wanted to lay down. In an observation and interview on 12/11/2024 at 2:04 p.m., ADON L entered Resident #20's room and stated Resident #20 could not use his call light because it was not within reach. ADON L stated this placed Resident #20 at risk for not being able to call for help, and that he would ensure Resident #20's call light remained within reach after assisting him to bed. In an interview on 12/11/2024 at 3:36 p.m., the DON stated the nursing team was responsible for monitoring that call lights were appropriately placed. The DON stated department heads also monitored call light placement when they rounded first thing in the morning and rounded one time in the afternoon. The DON stated each department head was assigned two halls. The DON reported the risk to the residents was that they would not be able to tell staff what they needed or felt. The DON did not state the expectation but stated call lights were important. In an interview on 12/12/2024 at 10:07 a.m., the ADM stated call lights were expected to be placed where residents could reach them. The ADM stated the risk to the residents was that they may not get their needs met or it could lead to an injury. The ADM stated everybody was responsible for monitoring call light placement and should check call light placement every time they entered a room. Review of facility policy titled Communication - Call System, with a revision date of 6/2020, revealed Call cords will be placed within the resident's reach in the resident's room.

Based on observations, interviews, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, including acute charting guidelines and high blood pressure necessary to care for resident's needs as identified through resident assessments and nursing documentation, for 1 (Resident #63) of 2 residents reviewed for quality of care. 1. MA K failed to communicate, and use the acute charting guidelines in the MAR, for charting of the increased blood pressure, and report to the charge nurse. By not reporting or domenting LVN B was unaware Resident #63 required a follow-up assessment, due to an increased blood pressure. These failures placed residents at risk for complications to include unnoticed change in condition and for residents not to receive needed nursing assessments. Findings included: Review of Resident #63's quarterly MDS dated [DATE] revealed the resident was a [AGE] year-old male admitted on [DATE]. Diagnoses to included: Kidney failure (Kidneys weak), hypertension (increased blood pressure), multiple intracranial hemorrhages (bleeding in the brain), diabetes (increased sugar), anxiety (anxious), and cerebral infarction due to thrombosis (stroke due to blood clot in the brain). Resident #69 was severely cognitively impaired, unable to make decision for himself, and required extensive assistant for activities of daily living. Review of Resident #63's care plan dated 10/05/24 revealed problems addressed included the resident's needs for functional status, and high blood pressure. The care plan reflected Resident #69 required assistance of two for ADLs to include bed mobility. Goals included the resident's high blood pressure, the cerebral infraction, he would receive adequate assessment, and treatment with communication for any change of condition. Review of Resident #63's consolidated physician orders dated December 2024 reflected, Lisinopril (blood pressure medication) tablet 10mg give one tablet by mouth one time a day for hypertension. Hold for systolic blood pressure less than 110 and diastolic blood pressure less than 60 and pulse less than 60 notify MD/NP/ PA for related changes. Norvasc (blood pressure medication) oral tablet 5mg 2 tablets by mouth one time a day for hypertension hold for systolic blood pressure less than 110, diastolic blood pressure less than 60 and pulse less than 60 notify MD/NP/PA for related changes, and Ativan (anti-anxiety medication) oral tablet 0.5mg give tablet by mouth two-times a day for anxiety. Review of Resident #63's Medication Administration Record dated 11/2024 reflected the resident had received: 1) Lisinopril tablet 10mg one time a day, 2) Norvasc 5mg two tablets one time a day for the entire month of November. Further review reflected Resident #69 had his blood pressure checked prior to the medication administration. MA K had taken the blood pressure and administered the blood pressure medications seventeen times in the month of November. Review of the progress notes dated 12/01/2024 through 12/12/2024, reflected Resident #63 had no documented changes in his condition. There had been no assessment of Resident #69 or communication with the physician, nurse practitioner, or physician assistant related to the change in the resident's condition. In an observation and interview on 12/10/2024 at 10:22 a.m. with MA K revealed the MA took the blood pressure of Resident #69 on his right arm, the results were 136/124. MA K stated he was going to administer the resident's blood pressure medications and his anti-anxiety medication and then recheck his blood pressure in about twenty minutes. The MA stated he was not going to document the blood pressure of the resident at this time, he would wait and see if it goes down and then document those results of his blood pressure. MA K did not inform his charge nurse and proceeded to move to the next resident to administer medication. In a follow-up interview on 12/10//2024 at 10:45 a.m. revealed MA K had already rechecked the blood pressure and showed the state surveyor in the Medication Administration Record that the results of Resident #63's blood pressure was 147/89. The MA had stated he had not told the charge nurse, since the blood pressure went down to a normal range. In an interview on 12/10/24 at 11:00 p.m. with LVN B revealed that if a resident's blood pressure was abnormal, the MA should report to the nurse. LVN B showed the state surveyor in the clinical record the dashboard where vital signs as well as other information concerning residents' conditions was located. LVN B stated if there was an abnormal blood pressure, when the staff member documented the blood pressure it would show-up. Review of the dashboard with LVN B reflected no abnormal blood pressures documented for Resident #63. The LVN stated she was not aware of any changes in Resident #63's blood pressure, and she had not noted any change in his condition in the past two weeks. The LVN stated if the nurse is not informed then they cannot assess the resident and inform the physician, this could result into a problem for the resident that could have been prevented. In an interview on 12/11/2024 at 10:00 a.m. with MA K revealed he had been in-serviced on blood pressures and reporting. MA K validated when he took the blood pressure the first time, he did not report it to his charge nurse and he waited twenty minutes and rechecked the blood pressure of Resident #63 and that was the blood pressure he documented. In an interview on 12/11/2024 at 10:49 a.m. with MA K revealed he could not recall how often in a week he had completed this process with Resident #63, and he had no other residents that he did this with. MA K stated he had attended an in-service on the procedure for reporting blood pressures to the charge nurse, but in a follow-up interview he stated he did not say that. In an interview on 12/11/2024 at 10:55 a.m. with MA C revealed if a resident had a high or low blood pressure when she took it, she would report to her charge nurse right away. She stated she would administer the medications, but still inform my charge nurse. In an interview with LVN O on 12/10/2024 at 2:30 p.m. revealed that the MA was supposed to report to the nurse in charge when checking blood pressures if the blood pressure was high or low, then we call the physician, and follow orders. LVN O stated he was unaware of any blood pressure problems related to Resident #69 and had not noted any changes in his condition in the past 2 weeks. LVN O stated he had sent the month of November's blood pressures for Resident #63 to the nurse practitioner. LVN O stated that was what the nurse practitioner that wanted us to , so she can review the blood pressures. LVN O stated if the blood pressure was not reported then the resdiet could suffer an unnoticed change of condition, causing a decline. In an interview with the DON on 12/12/24 at 9:45 a.m., revealed that all staff nurses and medication aides had received in-services on reporting abnormal blood pressures. The DON provided the in-services for reporting blood pressure changes dated 10/2024 and 11/2024. MA K had attended the in-service in October 2024. The DON stated, I have trained the staff, if the staff do not listen then I do not know what else to do with them. The DON did not respond concerning follow-up to the training to assure the staff understood. The DON stated, I should get credit for at least training the staff. The DON stated he could not understand why the MA did not report the blood pressure to the charge nurse. The DON provided to the state surveyor a one-on-one in-service dated 12/12/2024 with MA K on reporting abnormal blood pressures to the charge nurse. If the staff does not follow my in-service and training it could cause problems for the residents not receiving quality care. In an interview on 12/12/2024 at 3:00 p.m. with Physician N revealed he was not aware of blood pressure changes with Resident #63. The physician stated the nursing staff was particularly good about communicating with him and his staff concerning changes in resident's conditions. Physician N stated if a resident had changes in his/her blood pressure the charge nurse should contact him, so that medication changes could occur, or monitoring could begin. The physician stated the MA should be communicating with the nurse in charge about any changes related to a resident. The physician stated not communicating appropriately about changes in a resident could result in a negative outcome for the resident, but in this case the resident was stable. Review of the policy and procedure Change of Condition Notification date June 2020 reflected to ensure residents, family, legal representatives, and physician are informed of changes in the resident's condition in a timely manner. II. The Facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal; representative when the resident endures a significant change in their condition cause by, but not limited to: . B. Significant change in the resident's condition . Procedure I. the Licensed Nurse will notify the resident's Attending Physician when there is an: . C. A significant change in the resident's physical, mental, or psychosocial status .deterioration in health .D. A need to alter treatment .III Notifying the Physician: A. The Attending Physician will be notified timely with a resident's change in condition

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's kitchen reviewed for food safety. 1. The facility failed to ensure dented cans were placed in a separate storage area. These failures could place residents at risk for food-borne illness and cross contamination. Findings included: Observation of the dry storage area on 12/10/2024 at 9:20am revealed the following: -1 46oz can of tomato juice was dented on the middle right. -1 66.5oz of light chunk tuna was dented on the top left. -1 6lbs diced tomatoes was dented on the top right. In an interview with the DM on 12/10/2024 at 9:30am she stated dented cans were stored in her office. She stated when dented cans were identified, the dented cans were returned to the vendor. She stated dented cans were provided weekly to the vendor. She stated the risks of dented cans not stored in a separate area was they could cause food poison and food borne illness if used. In an interview with [NAME] F on 12/10/2024 at 11:47am she stated dented cans were stored separately. She stated the risks of dented cans not stored separately was they could cause bacteria if used. Record review of the facility ' s Food Storage Policy, dated revised September 26, 2024 reflected, Policy Statement: food items will be stored, thawed, and prepared in accordance with good sanitary practice. XI. Dented or bulging cans should be placed in separated area and returned for credit. Record review of the U.S. FDA Food Code 2022 reflected: Chapter 3 . section 3-101.11. Safe, Unadulterated, and Honestly Presented: . A primary line of defense in ensuring that food meets the requirements of S 3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting and processing, they do not fall victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. Th: e regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. eCFR- Code of Federal Regulations are indicating within the text by an *- www.ecfr.gov

Based on interviews, observations, and record reviews, the facility failed to obtain timely laboratory services to meet the needs of its residents for one (Resident #59) of five residents reviewed for laboratory services. The facility failed to collect labs for Resident #59 on 12/06/2024 as ordered by the physician. This failure could place residents at risk for a delay in ensuring treatment needs are identified and addressed. Findings included: Record review of Resident #59's annual MDS assessment dated [DATE] revealed Resident #59 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of stroke, diabetes, and heart failure. The MDS also revealed a BIMS score of 15 (suggested no cognitive impairment). Record review of Resident #59's care plan, updated on 12/10/2024, revealed Resident #59 was on antibiotic therapy for bone infection and urosepsis (urinary tract infection that has spread to the rest of the body). An intervention for this focus area was to report pertinent lab results to the physician. Record review of Resident #59's physician order dated 11/22/2024 revealed an order to obtain laboratory tests in the morning every Friday. The order listed the laboratory tests as CBC with diff (provided information about cells in the bloodstream), CMP (measured electrolytes in the bloodstream), CRP (assisted in measuring the inflammation within the body), ESR (assisted in measuring the inflammation within the body), CK (assisted with measuring inflammation or muscle injury within the body), and liver function tests. Record review of Resident #59's laboratory results on 12/12/2024 at 12:39 p.m., revealed laboratory tests were completed for Resident #59 on 11/29/2024 then again on 12/10/2024 at 8:45 p.m. No laboratory tests were performed on Friday, 12/06/2024. In an interview and observation on 12/10/2024 at 2:00 p.m., ADON L reported the laboratory tests for Resident #59 should have been performed last week but had not been completed. ADON L stated this could place the resident at risk for infection or getting sick. ADON L reported that the ADONs and the DON monitored laboratory tests by checking the laboratory book every day. Observed ADON L check the laboratory book and ADON L reported the laboratory tests were not written down for last week. ADON L stated there was no way to know if the laboratory tests should have been repeated unless it had been written down in the laboratory book. In an interview on 12/11/2024 at 3:36 p.m., the DON reported that ADON M was responsible for monitoring laboratory tests and that the DON was the backup. The DON reported that he and ADON M checked the laboratory book daily. The DON reported that he did not know how the laboratory tests for Resident #59 were missed, and the risk to the residents was delayed decision making by the doctor. The DON stated his expectation was if laboratory tests were not collected 100% of the time, then to at least be close. In an interview on 12/11/2024 at 3:42 p.m., ADON M reported she monitored the laboratory tests daily by checking the laboratory book and the laboratory website daily. ADON M reported she was unsure how the laboratory tests for Resident #59 were missed. ADON M did not state how this would affect the residents. In an interview on 12/12/2024 at 10:07 a.m., the ADM stated the expectation was that laboratory tests would be completed as soon as possible. The ADM stated the risks to residents if laboratory tests were not completed was that the residents' condition could deteriorate and require hospitalization . The ADM stated the nurses and the ADONs were responsible for monitoring laboratory tests. In an interview on 12/12/2024 at 10:42 a.m., Physician N reported laboratory tests for Resident #59 were ordered weekly because Resident #59 was receiving antibiotics for osteomyelitis (bone infection) from a wound. Physician N stated that laboratory tests were completed weekly to monitor for adverse reactions. Physician N stated the expectation was for the facility to obtain laboratory tests weekly if ordered and report the results to him. Physician N stated there was no potential for adverse reactions with just one week of laboratory tests missed. Review of facility policy titled Laboratory, Diagnostic and Radiology Services, with a revision date of 6/2020, revealed Laboratory, diagnostic and radiology services will be coordinated pursuant to an order by a physician and the facility is responsible for the quality and timeliness of services provided by the laboratory, diagnostic or radiology provider.

Based on interview and record review, the facility failed ensure residents were free of any significant medication errors for one (Residents #1) of five residents reviewed for medications. 1. The facility failed to ensure LVN A held the Losartan Potassium 100 MG oral tablet when Resident #1's diastolic pressure and pulse was less than 60 on 10/05/24. 2. The facility failed to ensure RN B held the Losartan Potassium 100 MG oral tablet and Hydralazine HCl 50 MG oral tablet when Resident #1' diastolic pressure and pulse was less than 60 on 10/12/24. 3. The facility failed to ensure LVN C held the Hydralazine HCl 50 MG oral tablet when Resident #1's diastolic pressure and pulse was less than 60 on 10/05/24 and 10/06/24. 4. The facility failed to ensure RN D held the Hydralazine HCl 50 MG oral tablet when Resident #1's diastolic pressure and/or pulse was less than 60 on 10/04/24 and 10/08/24. These failures could place residents at risk of not receiving their medications as ordered or possible illness. Findings included: Record review of Resident #1's face sheet, dated 10/18/24, reflected a [AGE] year-old male, who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had a diagnosis of Nontraumatic Intracerebral Hemorrhage in Brain Stem (stroke when a blood clot forms in the brain), Hyperlipidemia (high levels of fat in the blood), Type 2 Diabetes (body does not produce enough insulin or use insulin properly), Hypertensive Heart Disease without Heart Failure (chronic high blood pressure causes complications to the heart), Chronic Kidney Disease, and End Stage Renal Disease (terminal condition where kidneys can no longer filter waste from the blood). Record review of the active physician's order dated 10/03/24, reflected the following: Losartan Potassium Oral Tablet 100 MG Give 1 tablet via G-tube in the morning for Hypertension. Hold for SBP <110, DBP <60 and/or HR/Pulse <60 and notify MD/NP/PA. Hydralazine HCl Oral Tablet 50 MG Give one tablet via G-tube every 8 hours for Hypertension. Hold for SBP <110, DBP <60 and/or HR/pulse <60 and notify MD/NP/PA. Record review of Resident #1's Medication Administration Record dated October 2024 reflected the following: 10/04/24 15:00 (3:00 PM) dose RN D documented a blood pressure reading of 135/58 and a pulse of 58. RN D documented the Hydralazine as given. 10/05/24 LVN A documented a blood pressure reading of 130/58 and a pulse of 55. LVN A documented the Losartan as given. 23:00 (11:00 PM) dose LVN C documented a blood pressure reading of 128/50 and a pulse of 72. LVN C documented the Hydralazine as given. 10/06/24 23:00 (11:00 PM) dose LVN C documented a blood pressure reading of 130/50 and a pulse of 54. LVN C documented the Hydralazine as given. 10/08/24 15:00 (3:00 PM) RN D documented a blood pressure reading of 118/86 and a pulse of 52. RN D documented the Hydralazine as given. 10/12/24 RN B documented a blood pressure reading of 147/56 and a pulse of 57. RN B documented the Losartan as given. Record review of the progress notes on Resident #1's electronic record reflected not documented adverse effects. On 10/18/24 at 10:35 AM, Surveyor called Resident #1's Primary Care Physician; there was no answer, and no voicemail could be left. In an interview on 10/18/24 at 12:20 PM, Resident #1 stated he was just about to take a nap, said he was okay and did not have any concerns. On 10/18/24 at 2:36 PM, Surveyor called Resident #1's Primary Care Physician; there was no answer, and no voicemail could be left. In an interview on 10/18/24 at 3:15 PM, RN B stated he did not remember giving Losartan or Hydralazine to Resident #1 incorrectly. He stated he just started working on his own at the facility could not remember all residents or their medications. RN B stated the risk of not giving those medications as ordered was the blood pressure could drop. In an interview with the DON and the Administrator on 10/18/24 at 3:17 PM, the DON stated the facility trained the nurses to follow the physician's orders. The DON stated all nurses should be following the physician's orders. The DON stated he would complete a re-education with staff, because the physician orders should be followed. The DON stated there had been no adverse effects with Resident #1. The DON stated he tried to reconcile the medication administration records weekly but did not know why or how he missed the issue with the medications not given as ordered. The DON stated the risk of not giving the medications as ordered was a decrease in blood pressure. The Administrator stated he agreed with the DON, not giving the medication as ordered could leave to a decrease in blood pressure. On 10/18/24 at 3:25 PM, Surveyor called RN D and did not receive an answer or returned call. On 10/18/24 at 3:40 PM, Surveyor called LVN C and did not receive an answer or a return call. In an interview on 10/18/24 at 3:46 PM, LVN A stated she did not recall giving the Losartan to Resident #1 incorrectly. She stated she always checked Resident #1's blood pressure manually and knew to follow the doctor's order. LVN A stated the risk of not following the doctor's order was the resident's blood pressure could drop. She stated she would not give medication outside of the parameters. Record review of the facility's undated policy titled, Medication Administration, reflected the following: Purpose To provide practice standards for safe administration of medications for residents in the Facility. VI. Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, may be performed as required by state law, and the results recorded. VII. When administration of the drug is dependent upon vital signs or testing, the vital signs/testing will be completed prior to administration of the medication and recorded in the medical record . Procedure IV. Nursing Staff will keep in mind the seven rights of medication when administering medication: A. The right medication B. The right amount C. The right resident D. The right time E. The right route F. Right indication G. Right outcome . V. Additional considerations include: C. The Rule of 3 - The Licensed Nurse administering medications will perform 3 checks comparing the physician's order, pharmacy label, and Medication Administration Record (MAR). . VII. The resident's MAR will be reviewed for allergies and/or special considerations for administration including: A. Manufacturer's specifications (not recommendations) regarding the preparation and administration of the drug or biological. B. Accepted professional standards and principles. C. Vital sign parameters and lab results as appropriate. VIII. Compare the Licensed Practitioner's prescription/order with the MAR (first check).

Based on interview, and record review, the facility failed to protect a resident's right to be free from neglect for 1 (Resident #1) of two residents reviewed for neglect. The facility failed to protect Resident #1 from neglect when they failed to conduct adequate therapeutic drug monitoring of Resident #1's lab levels who was receiving lithium. This led to Resident #1 being admitted to acute care hospital on 06/30/23 and was diagnosed with acute toxic encephalopathy secondary to lithium toxicity. Lab records revealed Resident #1's lithium level was 5.3 mmol/L (critical level) when he arrived at the hospital. The noncompliance was identified as PNC. The IJ began on 06/01/23 and ended on 10/02/23. The facility had corrected the noncompliance before the survey began on 02/27/24. This failure placed residents at risk for neglect and for serious adverse outcomes including drug toxicity, need for hospitalization , and/or death. Findings included: Record Review of Resident #1's Comprehensive MDS, dated [DATE], reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included anxiety disorder, depression, schizophrenia [a serious mental disorder in which people interpret reality abnormally], elevated blood pressure, and type 2 diabetes mellitus. His BIMS score was 08 which indicated Resident #1's cognition was moderately impaired. Functional status reflected Resident #1 was extensive assist and required assistance of 1 staff for toileting and personal hygiene. Record review of Resident #1's Care Plan reflected the following: Focus: Resident #1 requires psychotropic medications (lithium) for diagnosis of schizoaffective disorder bipolar type. Goal: Resident #1 will be/remain free of drug related complications. Interventions: administer medications as ordered, monitor/document for side effects and effectiveness. Record review of Resident #1's Order Summary for June 2023 revealed the following: Lithium carbonate oral tablet 300 mg. Give 1 tablet by mouth two times a day. The order was prescribed on 06/01/23 by MD. Further review revealed: - No order to monitor lithium level routinely. - Psych Services company may treat and evaluate for psych medication management. The order was prescribed on 06/07/23. - UA/C/S STAT for drowsiness. The order was prescribed on 06/26/23. - Lithium level in AM. The order was prescribed on 06/29/23. Record review of the MAR for Resident #1 revealed the resident received Lithium carbonate oral tablet 300 mg. 55 times out of 55 opportunities between the dates of 06/01/23 through 06/30/23. Record review of Resident #1 Laboratory Report dated 06/30/23 revealed: Lithium, Serum critical! 4.5 mmol/l. Reference range: 0.6-1.2. Record review of Resident #1's nurses note dated 06/30/23 electronically signed at 04:00 PM revealed LVN A called NP and notified her about Resident #1 critical level of lithium. NP gave an order to send Resident #1 to the hospital for further evaluation. Record review of Resident #1's nurses note dated 06/30/23 electronically signed at 08:01 PM by the DON revealed Resident #1 was lethargic; LVN A called 911 and sent Resident #1 to the hospital for further evaluation and treatment. Record review of hospital History of Present Illness Report for Resident #1, dated 06/30/23, revealed, This is a [AGE] year-old male with past medical history of schizoaffective disorder, diabetes mellitus who presented to the hospital via EMS from the nursing home with lithium toxicity . Level lithium done at SNF showed levels of 4.5 on 6/29/23 . In the ED today patient's lithium level was 5.3. Record review of the Hospital History and Physical Reports for Resident #1, dated 06/30/23, revealed the following: Assessment and plan: - Acute on chronic kidney disease (when kidneys suddenly become unable to filter waste products from your blood) in presence of lithium toxicity. Plan on dialyzing patient. - Lithium toxicity. Lithium level 5.3 on admission; recheck levels after dialysis and 6 hours later. - Acute toxic encephalopathy (a reversible brain dysfunction syndrome caused by factors such as systemic toxemia) secondary to lithium toxicity. Record review of the Hospital Chemistry report for Resident #1, dated 06/30/23, revealed the following lab results: BUN (what forms when protein breaks down) 68 mg/dL (6 - 24 mg/dL); Creatinine (this test is done to see how well the kidneys work) 6.20 mg/dL (0.7 - 1.3 mg/dL); and eGFR (a test that measures the level of kidney function) Non-African American 9.6 (60 or above is normal). Lithium level 5.3 mmol/l (0.2 - 1.6). Record review of Pharmacy Recommendations Report dated 06/07/23 revealed: Resident #1. The following anti-psychotic medication requires documentation of psych diagnosis to support long-term therapy. Lithium currently linked to mood. The report did not reveal any recommendation about monitoring lithium level. Interview on 02/28/23 at 1:27 PM, the NP stated the expectation for a resident on lithium was typically to have the initial level with the admission labs and would continue to monitor the lithium level. The NP stated she did not remember Resident #1. The NP stated monitoring lithium level would help to adjust the dose and prevent lithium toxicity. On 02/27/24 at 10:12 AM, attempted to call the RP, unsuccessful. Interview on 02/28/23 at 04:09 PM, Pharmacy Consultant stated she conducted a medication review for Resident #1 on 06/06/23. She stated she did include the lithium, but she did not remember why she did not include the monitoring level. She stated resident on lithium required routine monitoring to avoid toxicity. Interview on 02/28/23 at 12:51 PM, the MD stated her expectation of residents who received lithium was they often checked lithium level if a resident had issues. The MD stated if a resident was on psychotropic medication, she would refer the resident to the psych doctor. The MD stated she did not remember what happened with Resident #1. She stated if Resident #1 was on lithium she would refer him to psych services. The MD also stated if the psych services had made an order to monitor lithium level, she would have agreed to it. Record review of Resident #1 psychiatric services note dated 06/20/23 revealed the following: Referring: MD. Service provided: New referral. The notes did not reveal lithium monitoring. On 02/28/24 at 12:08 PM, Attempted to call Psych Services staff, unsuccessful. Interview on 02/28/23 at 05:29 PM, the DON stated not providing appropriate lithium monitoring would be considered neglect. He stated the expectation for a resident receiving lithium was labs were to be drawn and to monitor lithium level. The DON stated monitoring labs for psych medication were usually ordered by the MD or by the psych doctor. The DON stated he was unsure why monitoring labs were not ordered by the MD for Resident #1. The DON stated the potential risk to the resident in not having labs done to monitor lithium level, the lithium dose could be too high and have adverse effects such as toxicity. Interview on 02/29/23 at 12:20 PM, the RNC stated the normal practice for a resident receiving lithium was the serum level be checked routinely depending on the physician order. He stated the expectation the nurse to notify the physician if a resident on lithium did not have an order for monitoring lithium level. He stated not doing so would be neglect. The Adm was notified on 02/29/24 at 03:05 PM that a PNC IJ situation had been identified due to the above failures. It was determined these failures placed Resident #1 in an IJ situation on 06/01/23. The facility implemented the following interventions: Review of a neglect/abuse in-service dated 09/25/23 was provided by the Adm to all staff Record review of order listing report reflect Resident #2 on lithium. Interviews and record review reflected serum level for lithium was done routinely and reflected no concerns. Record review of the inservice dated 10/02/23 revealed the RNC in-serviced ADONs and nurses on timely report labs, notify physician on time, review admission orders. Notify physician if monitoring order for psych medication was missing. Further review of the inservice dated 10/02/23 revealed charge nurse would review all new admission orders and verify with the physician on all new lithium and required lab orders, ADONs would be responsible for reviewing the admission orders in the interval of 24 hours for lithium have the appropriate monitoring orders. The DON would review the admission orders in 72 hours, and the RNC would do a weekly review. Record review of the inservice dated 10/02/23 revealed the RNC in-serviced the DON, ADON B, ADON C and LVN A on Lab/Radiology/Physician orders: transcribing physician orders and clarification of physician order relater to medication monitoring. An impromptu Quality Assurance and Performance Improvement was completed on 10/09/23with the MD, Administrator, DON, ADONs, and Social Worker. Record review revealed on 02/28/23, the facility reviewed of all residents in the facility and identified no other resident on lithium or any other psychotropic medication requiring therapeutic monitoring. Interview on 02/28/23 were conducted from 2:23 PM to 5:29 PM with the following staff who represented all shifts: ADON B, ADON C, LVN D, LVN E, LVN A, LVN F, LVN G, and MA I. Individual interviews revealed they had received in-service training on abuse and neglect. All staff were able to verbalize understanding of in-service training regarding abuse and neglect. Interviews on 02/29/23 were completed from 11:48 AM to 12:12 PM with the DON, ADON B, and ADON C which revealed they were in-serviced on abuse and neglect. Review of the facility's policy titled Abuse Prevention and Prohibition Program, revised August 2020 reflected, .Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property On 02/29/24 at 3:05 PM the Administrator was informed an Immediate Jeopardy was determined to have existed from 06/01/23 to 10/02/23. The IJ was determined to have been removed on 10/02/23 due to the facility's implemented actions that corrected the non-compliance prior to the beginning of the investigation on 02/27/24.

Based on interview and record review, the facility failed to ensure each resident's drug regimen did not have an excessive dose, for an excessive duration, with inadequate monitoring for 1 of 2 residents (Resident #1) reviewed for unnecessary medications. The facility failed to conduct adequate therapeutic drug monitoring of Resident #1's lab levels who was receiving lithium. This led to Resident #1 being admitted to acute care hospital on 06/30/23 and was diagnosed with acute toxic encephalopathy secondary to lithium toxicity. Lab records revealed Resident #1's lithium level was 5.3 mmol/L (critical level) when he arrived at the hospital. The noncompliance was identified as PNC. The IJ began on 06/01/23 and ended on 10/02/23. The facility had corrected the noncompliance before the survey began on 02/27/24. This failure could place residents taking psychotropic medications at risk for serious adverse outcomes including drug toxicity, need for hospitalization , and/or death. Findings included: Record Review of Resident #1's Comprehensive MDS, dated [DATE], reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included anxiety disorder, depression, schizophrenia [a serious mental disorder in which people interpret reality abnormally], elevated blood pressure, and type 2 diabetes mellitus. His BIMS score was 08 which indicated Resident #1's cognition was moderately impaired. Functional status reflected Resident #1 was extensive assist and required assistance of 1 staff for toileting and personal hygiene. Record review of Resident #1's Care Plan reflected the following: Focus: Resident #1 requires psychotropic medications (lithium) for diagnosis of schizoaffective disorder bipolar type. Goal: Resident #1 will be/remain free of drug related complications. Interventions: administer medications as ordered, monitor/document for side effects and effectiveness. Record review of Resident #1's Order Summary for June 2023 revealed the following: Lithium carbonate oral tablet 300 mg. Give 1 tablet by mouth two times a day. The order was prescribed on 06/01/23 by MD. Further review revealed: - No order to monitor lithium level routinely. - Psych Services company may treat and evaluate for psych medication management. The order was prescribed on 06/07/23. - UA/C/S STAT for drowsiness. The order was prescribed on 06/26/23. - Lithium level in AM. The order was prescribed on 06/29/23. Record review of the MAR for Resident #1 revealed the resident received Lithium carbonate oral tablet 300 mg. 55 times out of 55 opportunities between the dates of 06/01/23 through 06/30/23. Record review of Resident #1 Laboratory Report dated 06/30/23 revealed: Lithium, Serum critical! 4.5 mmol/l. Reference range: 0.6-1.2. Record review of Resident #1's nurses note dated 06/30/23 electronically signed at 04:00 PM revealed LVN A called NP and notified her about Resident #1 critical level of lithium. NP gave an order to send Resident #1 to the hospital for further evaluation. Record review of Resident #1's nurses note dated 06/30/23 electronically signed at 08:01 PM by the DON revealed Resident #1 was lethargic; LVN A called 911 and sent Resident #1 to the hospital for further evaluation and treatment. Record review of hospital History of Present Illness Report for Resident #1, dated 06/30/23, revealed, This is a [AGE] year-old male with past medical history of schizoaffective disorder, diabetes mellitus who presented to the hospital via EMS from the nursing home with lithium toxicity . Level lithium done at SNF showed levels of 4.5 on 6/29/23 . In the ED today patient's lithium level was 5.3. Record review of the Hospital History and Physical Reports for Resident #1, dated 06/30/23, revealed the following: Assessment and plan: - Acute on chronic kidney disease (when kidneys suddenly become unable to filter waste products from your blood) in presence of lithium toxicity. Plan on dialyzing patient. - Lithium toxicity. Lithium level 5.3 on admission; recheck levels after dialysis and 6 hours later. - Acute toxic encephalopathy (a reversible brain dysfunction syndrome caused by factors such as systemic toxemia) secondary to lithium toxicity. Record review of the Hospital Chemistry report for Resident #1, dated 06/30/23, revealed the following lab results: BUN (what forms when protein breaks down) 68 mg/dL (6 - 24 mg/dL); Creatinine (this test is done to see how well the kidneys work) 6.20 mg/dL (0.7 - 1.3 mg/dL); and eGFR (a test that measures the level of kidney function) Non-African American 9.6 (60 or above is normal). Lithium level 5.3 mmol/l (0.2 - 1.6). Record review of Pharmacy Recommendations Report dated 06/07/23 revealed: Resident #1. The following anti-psychotic medication requires documentation of psych diagnosis to support long-term therapy. Lithium currently linked to mood. The report did not reveal any recommendation about monitoring lithium level. Interview on 02/28/23 at 1:27 PM, the NP stated the expectation for a resident on lithium was typically to have the initial level with the admission labs and would continue to monitor the lithium level. NP stated she did not remember Resident #1. NP stated monitoring lithium level would help to adjust the dose and prevent lithium toxicity. On 02/27/24 at 10:12 AM, attempted to call the RP, unsuccessful. Interview on 02/28/23 at 04:09 PM, Pharmacy Consultant stated she conducted a medication review for Resident #1 on 06/06/23. She stated she did include the lithium, but she did not remember why she did not include the monitoring level. She stated resident on lithium required routine monitoring to avoid toxicity. Interview on 02/28/23 at 1:27 PM, the NP stated the expectation for a resident on lithium was typically to have the initial level with the admission labs and would continue to monitor the lithium level. The NP stated she did not remember Resident #1. The NP stated monitoring lithium level would help to adjust the dose and prevent lithium toxicity. Interview on 02/28/23 at 12:51 PM, the MD stated her expectation of residents who received lithium was they often checked lithium level if a resident had issues. The MD stated if a resident was on psychotropic medication, she would refer the resident to the psych doctor. The MD stated she did not remember what happened with Resident #1. She stated if Resident #1 was on lithium she would refer him to psych services. The MD also stated if the psych services had made an order to monitor lithium level, she would have agreed to it. Record review of Resident #1 psychiatric services note dated 06/20/23 revealed the following: Referring: MD. Service provided: New referral. The notes did not reveal lithium monitoring. On 02/28/24 at 12:08 PM, Attempted to call Psych Services staff, unsuccessful. Interview on 02/28/23 at 05:29 PM, the DON stated the expectation for a resident receiving lithium was labs were to be drawn and to monitor lithium level. The DON stated monitoring labs for psych medication were usually ordered by the MD or by the psych doctor. The DON stated he was unsure why monitoring labs were not ordered by the MD for Resident #1. The DON stated the potential risk to the resident in not having labs done to monitor lithium level the lithium dose could be too high and have adverse effects such as toxicity. Interview on 02/29/23 at 12:20 PM, the RNC stated the normal practice for a resident receiving lithium was the serum level be checked routinely depending on the physician order. He stated the expectation the nurse to notify the physician if a resident on lithium did not have an order for monitoring lithium level. The Adm was notified on 02/29/24 at 03:05 PM that a PNC IJ situation had been identified due to the above failures. It was determined these failures placed Resident #1 in an IJ situation on 06/01/23. The facility implemented the following interventions: Record review of the in-service dated 10/02/23 revealed the RNC in-serviced the DON on tracking on Lithium monitoring. Record review of order listing report reflect Resident #2 on lithium. Interviews and record review reflected serum level for lithium was done routinely and reflected no concerns. Record review of the in-service dated 10/02/23 revealed the RNC in-serviced ADON and nurses timely report labs, notify physician on time, review admission orders. Notify physician if monitoring order for psych medication was missing. Further review of the inservice dated 10/02/24 revealed charge nurse would review all new admission orders and verify with the physician on all new lithium and required lab orders, ADONs would be responsible for reviewing the admission orders in the interval of 24 hours for lithium have the appropriate monitoring orders. The DON would review the admission orders in 72 hours, and the RNC would do a weekly review. Record review of the inservice dated 10/02/23 revealed the RNC in-serviced the DON, ADON B, ADON C and LVN A on Lab/Radiology/Physician orders: transcribing physician orders and clarification of physician order relater to medication monitoring. An impromptu Quality Assurance and Performance Improvement was completed on 10/09/23 with the MD, Administrator, DON, ADONs, and Social Worker. On 02/28/23, review of all residents in the facility and identified no other resident on lithium or any other psychotropic medication requiring therapeutic monitoring. Interviews on 02/28/23 were conducted from 2:23 PM to 5:29 PM with the following staff who represented all shifts: ADON B, ADON C, LVN D, LVN E, LVN A, LVN F, LVN G, and MA I. Individual interviews revealed they were in-serviced on lithium toxicity and lab monitoring. The charge nurse would review all new admission orders and verify with the physician on all new lithium and required lab orders. Interviews on 02/29/23 were completed from 11:48 AM to 12:12 PM with the DON, ADON B, and ADON C which revealed they were in-serviced on tracking lithium monitoring and being responsible to check the new admission orders in timely manner. They were also educated on follow up labs to all high-risk medications. Review of the facility's policy titled Guidelines for Psychotherapeutic Medications, not dated reflected, .V. Anticonvulsant / Antimania Therapy. A. When anticonvulsants are utilized for treatment of behavior, monitoring of behaviors and side effects shall be completed. Informed consent shall be obtained and documented for each new order or dose increase. Serum drug levels shall be performed per physician order and the physician shall be notified of results according to facility policy On 02/28/24 at 6:20 PM the Administrator was informed an Immediate Jeopardy was determined to have existed from 06/01/23 to 10/02/23. The IJ was determined to have been removed on 10/02/23 due to the facility's implemented actions that corrected the non-compliance prior to the beginning of the investigation on 02/27/24.

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of four residents (Resident #1) reviewed for supervision. The facility failed to implement procedures, monitoring and interventions to prevent Resident #1 (who was identified with severe cognitive impairment and being at moderate risk for elopement) from eloping from the facility unsupervised on 06/24/23 and his whereabouts remained unknown. An Immediate Jeopardy (IJ) situation was identified on 06/28/23 at 1:02 p.m. While the IJ was removed on 06/29/23, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm that was not immediate, due to the facility's need to evaluate the effectiveness of the corrective systems . This failure could place residents at risk for injury and/or death from elopement-related harm, including vehicular accidents, falls, missing medications, and extreme weather exposure. Findings include: Record review of Resident #1's quarterly MDS assessment, dated 04/26/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident had diagnoses which included Cerebrovascular Accident (stroke-interruption of blood flow to a part of the brain either by a blockage or rupture of a blood vessel), age-related cognitive decline, and ataxic gait (difficulty walking-poor balance). The MDS reflected he had a BIMS of 5, which indicated severe cognitive impairment and the resident was ambulatory with an unsteady gait. The MDS assessment did not reflect any wandering behavior. Record review of Resident #1's care plan, with a review date of 03/31/23, addressed the resident's impaired cognition due to age-related cognitive decline, risk for falls and communication problems. The resident's moderate risk for elopement was not addressed . Record review of Resident #1's Elopement Risk Evaluations, dated 02/11/23 and 05/11/23, revealed the resident was a moderate risk for elopement. The evaluation reflected the resident ambulated or propelled self, might go outdoors on occasion but made no attempt to leave grounds. Record review of the Provider Investigation Report, dated 06/25/23, revealed Resident #1 was independently ambulatory and was noted missing from the facility on 06/24/23 at approximately 7:40 p.m. after his daughter arrived for a visit. The resident was last seen at approximately 7:30 p.m. in the dining room. Facility staff searched the facility, the entire campus to include three other facilities on the campus and the surrounding neighborhood. Resident #1 was not located. The facility reviewed camera footage and noted the resident exiting the facility on 06/24/23 at approximately 7:50 p.m. using a vehicle that was exiting the gate as a shield from security staff posted at the entrance/exit gate. Interview on 06/27/23 at 9:00 a.m., the Administrator stated he was notified of Resident #1's elopement on 06/24/23. He stated the resident had not been located yet and was seen on Sunday (06/25/23) at a local Walmart near the highway (2.12 miles away). The Administrator stated the staff member thought the resident had signed out on a pass . Interviews on 06/27/23 at 10:05 a.m. and 06/29/23 at 10:07 a.m. with charge nurse, LVN A she stated she provided care for Resident #1 during the day shift. She stated the resident required no special supervision, was ambulatory, forgetful and she never saw him exhibit any exit seeking behaviors or verbalizations about leaving the facility. LVN A stated she was surprised to hear the resident eloped. She further stated she was not aware the resident was at risk for elopement. Interview on 06/27/23 at 10:16 a.m., CNA B stated she usually provided care for Resident #1 during the day shift and was on duty and assigned to the resident during the evening shift of 06/24/23 when he left the facility. She stated she was not aware Resident #1 was a risk for elopement and was very surprised he had eloped. CNA B stated the resident was forgetful and she saw him go for the smoke break after dinner on 06/24/23. The last time she saw Resident #1 was at 7:00 p.m. or 7:30 p.m. on 06/24/23 in the dining room where residents occasionally hung out. She further stated she never saw Resident #1 exhibit any exit seeking behaviors. Interview on 06/27/23 at 11:24 a.m. with charge nurse, LVN C, she stated she provided care for Resident #1 during the evening shift on 06/24/23 when the resident eloped from the facility. She stated she was passing medications when she saw a lady standing near the resident's room. The lady stated she was there to see Resident #1 . She and other staff searched for the resident but were unable to locate him. She stated she was not aware the resident was an elopement risk and never saw it coming. She stated she never saw Resident #1 exhibit any exit seeking behavior and was unable to recall the last time she saw the resident on the evening of 06/24/23. Interview on 06/27/23 at 11:41 a.m., HA D stated she supervised the residents when smoking on the evening of 06/24/23. She recalled seeing Resident #1 in the dining room at approximately 4:00 p.m., during the resident's smoke break. She stated the resident did not come out to smoke but remained in the dining room looking out onto the smoking area. She stated the resident usually stayed in his room and she never saw him act as if he wanted to leave the facility. Interview on 06/27/23 at 2:33 p.m., the Administrator and DON stated Resident #1 never signed out of the facility or went anywhere off campus. Interview on 06/27/23 at 3:00 p.m., the Regional Nurse Consultant stated Resident #1 was not a risk for elopement and the elopement evaluations indicated he was a moderate risk for elopement, were not correct. He stated since admission the resident had never exhibited any behaviors that would equal an elopement risk. He further stated sometimes assessments led you to choices that did not represent the resident. Interview on 06/27/23 at 3:22 p.m., CNA E stated he provided care for Resident #1 and the resident was ambulatory without the use of any device. He was on duty during the evening of 06/24/23 when the resident eloped from the facility. He was not aware the resident was not in the facility until a lady told him she was at the facility to visit Resident #1. He and other staff searched on and off the campus but were unable to locate the resident. CNA E stated he was surprised the resident left the facility and he did not know the resident was a risk for elopement and never saw the resident attempting to leave the facility. Interview on 06/28/23 at 11:13 a.m., the DON and Regional Nurse Consultant stated they were not aware their elopement evaluations were not correctly capturing resident's risk for elopement. They stated the issue came to the forefront after the State Surveyor intervention on 06/27/23. The Regional Nurse Consultant stated updates to the electronic health record system were ongoing since November 2022. No explanation was provided about why Resident #1's elopement evaluation had not been updated if they currently felt it was incorrect . Interview on 06/28/23 at 11:35 a.m., CNA F stated she had worked at the facility for less than two weeks. She stated she saw Resident #1 at the local Walmart on Sunday (06/25/23) at approximately 4:30 p.m. or 5:00 p.m. and thought he was on pass. She stated the resident was standing outside of the store and did not appear to be in any distress. She stated she did not know the Resident #1 or that he was missing but recognized his face as a resident from the facility. Interview on 06/28/23 at 2:17 p.m., the Administrator stated he monitored nurse managers to ensure the systems they monitored were being done sufficiently by talking to and interviewing staff and during meeting such as QA meetings. He stated nursing staff determined Resident #1 was at risk for elopement but did not implement any interventions to address the resident's risk for elopement. Interview on 06/28/23 at 3:00 p.m., the DON stated elopement evaluations were completed for residents on admission, quarterly and with changes in condition . Interview on 06/28/23 at 4:08 p.m., the ADON stated the new process for a.m. and p.m. meetings would include not only checking for resident's elopement risk scores but also monitoring to ensure interventions were in place for residents triggered to be at moderate or higher elopement risk. Interview on 06/28/23 at 4:43 p.m., the DON stated the nurse managers (DON, ADON and MDS) would now be responsible for ensuring care plans/interventions were developed for residents who were at risk for elopement but in the past, it had been the responsibility of the MDS nurse . Interview with the facility Medical Director on 06/29/23 at 10:12 a.m., she stated she was also Resident #1's primary physician. She stated she was not aware Resident #1 was a moderate risk for elopement and was shocked when he left the facility as he never attempted to leave before. Her expectation was if a resident was determined to be at risk the information be communicated to nursing staff and the resident be monitored and kept an eye on to note if he left or attempted to leave the facility. She stated she would ensure the issue of the elopement evaluations not matching the residents was brought to the QA meeting. She stated the elopement evaluation was possibly incorrect, but nurses should have been made aware . Interview on 06/29/23 at 10:49 a.m., the MDS nurse stated her understanding was the nurse who completed an elopement evaluation would also initiate care planning with elopement interventions. She would have only been aware a resident was at risk for elopement by reviewing the nurse's documentation or by word of mouth. She verbalized understanding of the training received and that she and other nurse managers were now responsible for ensuring interventions were in place for residents at risk of elopement. Interview on 06/29/23 at 11:45 a.m., the DON stated the plan for ensuring elopement evaluations and interventions were in place was the IDT checked elopement evaluations weekly but Resident #1's was missed. During the daily standup and stand down meetings elopement scores were checked but nothing further was done to address a resident's risk for elopement. The DON stated training regarding the facility's elopement policy/procedure was provided to nursing staff on 04/10/23. Record review of in-service training, dated 04/10/23, prior to Resident #1's elopement, revealed training related to the facility's elopement and wandering policy/procedure was provided to nursing staff. The training addressed identifying residents at risk for elopement, minimizing any possible injury as a result of elopement and documenting preventative interventions in the resident's medical record. Record review of the facility's policy/procedure entitled Wandering and Elopement, revised August 2020, revealed the purpose was to enhance the safety of residents of the facility. The policy included identifying residents at risk for elopement and minimizing any possible injury as a result of elopement. The policy/procedure further reflected in part: The Licensed Nurse, in collaboration with the interdisciplinary team, will assess residents upon admission, readmission, quarterly and upon identification of significant change in condition to determine their risk for wandering/elopement. The resident's risk for elopement and preventative interventions will be documented in the resident's medical record and will be reviewed and re-evaluated by the IDT upon admission, readmission, quarterly and upon change in condition. IDT may consider interventions in Elopement Risk Reduction Approaches for residents identified to at risk for elopement. Record review of the facility's, undated, Elopement Risk Reductions Approaches revealed approaches included: Providing adequate physical and social environments that provided activities appropriate for the resident's cognitive functioning and interests, as well as opportunities for walking, exploring and social interaction. Ensuring that residents were able to move about freely, were monitored and remained safe. Accounting for each resident on a regular basis, including having a resident sign-in/sign out policy. Developing a care plan and an update process that promoted choice, mobility, and safety. Basing the care plan on assessments, family, and caregiver involvement. This was determined to be an Immediate Jeopardy (IJ) on 06/28/23 at 1:02 p.m. The Administrator was notified. The IJ template was provided via email on 06/28/23 at 1:13 p.m . The Plan of Removal was submitted by the facility and was accepted on 06/29/23 at 2:24 p.m. : Summary of Details which lead to outcomes. On 6/28/2023 during a complaint survey at [the facility and address], HHSC surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The facility failed to update the residents care plan and interventions that led to the resident eloping, which current whereabouts unknown. The notification of the alleged immediate jeopardy states as follows: The resident eloped from the facility on the evening of 06/24/23. Facility staff searched on and off the premises, the police were notified but the resident was not located. Identify residents who could be affected. All residents have the potential to be affected. Identify responsible staff/ what action taken. 1. Training for all licensed nursing staff on completion of accurate elopement assessments was initiated on 6/27/2023 by Regional Nurse consultant . 2. Training for all licensed nursing staff was initiated on 6/27/23, on notification of elopement assessments that trigger for moderate or higher will require DON, ADON and/or MDS notification. Training was conducted by the RNC . 3. Training for DON/ADON/MDS was initiated on 6/27/23 on care plan completion and interventions regarding elopement assessment for those that trigger as moderate or higher risk by Regional Nurse Consultant. 4. DON/ADON/MDS/weekend supervisor retraining was initiated on 6/27/23 by the Regional Nurse Consultant of overview of reviewing elopement risk assessment for accuracy, completion, interventions and updating care plans to reflect elopement risk. 5. DON/ADON/MDS completed audit of all resident elopement assessments on 6/27/23 . 6. All residents with moderate risk score were care planned by DON/ADON/MDS on 6/27/23, with no residents at imminent risk identified. 7. All staff retraining has been initiated 6/24/2023 on response to resident elopement. No staff will be allowed to return to work without completion of required training. Training was initiated by the DON. In-Service conducted. 1. Training for all staff on response to resident elopement initiated on 6/24/23. a. The Facility Staff member who finds that a resident is missing will alert the charge Nurse. b. The Charge Nurse will call CODE PINK and organize a search. Facility Staff will search areas of the Facility, including common areas, bathrooms, showers, outside areas, etc . c. If the resident cannot be located, the Charge Nurse will notify Administrator/designee ii. Director of Nursing Services/designee, Attending Physician iv. Responsible Party. 2. Training for all licensed nursing staff on completion of accurate elopement assessments initiated on 6/27/23. 3. Training for all licensed nursing staff was initiated on 6/27/23, on notification of accurate elopement assessments that trigger for moderate or higher to notify DON/ADON/MDS. 4. Training for DON/ADON/MDS/weekend supervisor was initiated on 6/27/23 on care plan completion and interventions regarding elopement assessment for those that trigger as moderate or higher. 5. Retraining was initiated on 6/27/23 with DON/ADON/weekend supervisor for oversight of reviewing elopement risk assessment for accuracy, completion, interventions and updating care plans to reflect elopement risk. Implementation of Changes Training for DON/ADON/MDS/weekend supervisor was initiated on 6/27/23 on care plan completion and interventions regarding elopement assessment for those that trigger as moderate or higher. The changes were started by the Regional Nurse Consultant. The changes were implemented effective on 6/27/2023 and training was completed on 6/28/2023. Staff will not be allowed to work until they have been fully re-educated. All new hires will be educated on elopement protocol/response prior to working the floor. The Director of Nursing will ensure competency through signing of in service, verbalization of understanding and completion of returned questionnaire. All licensed nurses will notify DON/ADON/MDS if elopement risk is moderate or higher. The DON/ADON/MDS will review all elopement assessments daily in morning clinical meeting and care plan if necessary. Weekend supervisor/ designee will review all elopement assessments over the weekend for accuracy and care plan if necessary. Regional Nurse Consultant will complete audit of elopement assessments daily x 30 days then weekly thereafter. Monitoring The Administrator/Director of Nursing/Assistant Director of Nursing/Regional Nurse Consultant will be responsible for monitoring the implementation and effectiveness of in-service on 6/28/2023. o The Administrator/Director of Nursing/Assistant Director of Nursing/Regional Nurse Consultant will monitor/review all elopement assessments daily x4 weeks, then weekly thereafter and report any adverse finding during QAPI . o Director of Nursing/Assistant Director of Nursing will conduct a daily audit of Elopement assessment x4 weeks, then weekly thereafter and report any adverse findings during QAPI. o Residents will be monitored by staff every shift for any exit seeking behaviors. Any changes will be reported to the Administrator Director of Nursing and Assistant Director of Nursing immediately for appropriate action . Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 6/28/2023 and conducted an Ad HOC QAPI regarding the missing resident, elopement protocol, elopement assessments and care plans. The Medical Director, [physician name] was notified about the immediate Jeopardy on 6/28/2023, the Plan of removal was reviewed and accepted by medical director. Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, and social services director to review the plan of removal on 6/28/2023. Who is responsible for implementation of process? The Director of Nursing and Administrator will be responsible for implementation of New Process. The New Process/ system was started on 6/28/2023. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy verbally issued on 6/28/23. Monitoring of the POR included the following: Interviews were conducted with facility staff across multiple shifts on 06/29/23 from 3:19 p.m. to 4:10 p.m. Staff interviewed were LVN A, LVN G, LVN H, RN I, RN J, LVN K, and RN L . Interviews with the staff revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on completing elopement evaluations and notifying nursing management to include the MDS nurse if a resident triggered for moderate or higher risk for elopement. They were all aware of the elopement book being located at the receptionist's desk and at the nurse's station. They stated if a resident triggered for moderate risk of elopement, they were to monitor the resident for attempts to leave the facility and if a resident triggered for higher than moderate risk they would monitor and ensure staff stayed with the resident until management initiated a move to the secured building on campus. Record review of in-service training logs and competency tests, dated 06/27/23, 06/28/23 and 06/29/23, revealed education included the facility's elopement protocol, resident supervision, accurate completion of elopement assessments, notification of the DON, ADON or MDS nurse of any resident triggering for moderate or higher risk of elopement , and care plan completions with interventions to address elopement risks. The Administrator was informed the Immediate Jeopardy was removed 06/29/23 at 5:00 p.m. The facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of corrective systems that were put into place.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one of four residents (Resident #1) reviewed for care plans. The facility failed to implement a care plan which included monitoring and interventions to prevent Resident #1 (who was identified with severe cognitive impairment and being at moderate risk for elopement) from eloping from the facility, unsupervised on 06/24/23 and his whereabouts remained unknown. An Immediate Jeopardy (IJ) situation was identified on 07/19/23. While the IJ was removed on 07/19/23, 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 failure could place residents at risk for injury and/or death from elopement-related harm, which included vehicular accidents, falls, missing medications, and extreme weather exposure. Findings include: Record review of Resident #1's quarterly MDS assessment, dated 04/26/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident had diagnoses which included Cerebrovascular Accident (stroke-interruption of blood flow to a part of the brain either by a blockage or rupture of a blood vessel), age-related cognitive decline, and ataxic gait (difficulty walking-poor balance). He had a BIMS of 5, which indicated severe cognitive impairment and the resident was ambulatory with an unsteady gait. The MDS assessment did not reflect any wandering behavior. Record review of Resident #1's care plan, with a review date of 03/31/23, addressed the resident's impaired cognition due to age-related cognitive decline, risk for falls and communication problems. The resident's moderate risk for elopement was not addressed. Record review of Resident #1's Elopement Risk Evaluations, dated 02/11/23 and 05/11/23, revealed the resident was a moderate risk for elopement. The evaluation reflected the resident ambulated or propelled self, might go outdoors on occasion but made no attempt to leave grounds. Record review of the Provider Investigation Report, dated 06/25/23, revealed Resident #1 was independently ambulatory and was noted missing from the facility on 06/24/23 at approximately 7:40 p.m. after his family member arrived for a visit. The resident was last seen at approximately 7:30 p.m. in the dining room. The facility staff searched the facility, the entire campus to include three other facilities on the campus and the surrounding neighborhood. Resident #1 was not located. The facility reviewed camera footage and noted the resident exiting the facility on 06/24/23 at approximately 7:50 p.m. using a vehicle that was exiting the gate as a shield from the security staff posted at the entrance/exit gate. Interview on 06/27/23 at 9:00 a.m., the Administrator stated he was notified of Resident #1's elopement on 06/24/23. He stated the resident had not been located yet and was seen on Sunday (06/25/23) at a local Walmart near the highway (2.12 miles away). The Administrator stated the staff member thought the resident had signed out on a pass . Interviews on 06/27/23 at 10:05 a.m. and 06/29/23 at 10:07 a.m. with charge nurse, LVN A, she stated she provided care for Resident #1 during the day shift. She stated the resident required no special supervision, was ambulatory, forgetful and she never saw him exhibit any exit seeking behaviors or verbalizations about leaving the facility. LVN A stated she was surprised to hear the resident eloped. She further stated she was not aware the resident was at risk for elopement. Interview on 06/27/23 at 10:16 a.m., CNA B stated she usually provided care for Resident #1 during the day shift and was on duty and assigned to the resident during the evening shift of 06/24/23 when he left the facility. She stated she was not aware Resident #1 was a risk for elopement and was very surprised he had eloped . CNA B stated the resident was forgetful and she saw him go for the smoke break after dinner on 06/24/23. The last time she saw Resident #1 was at 7:00 p.m. or 7:30 p.m. on 06/24/23 in the dining room where residents occasionally hung out. She further stated she never saw Resident #1 exhibit any exit seeking behaviors. Interview on 06/27/23 at 11:24 a.m. with charge nurse, LVN C, she stated she provided care for Resident #1 during the evening shift on 06/24/23 when the resident eloped from the facility. She stated she was passing medications when she saw a lady standing near the resident's room. The lady stated she was there to see Resident #1. She and other staff searched for the resident but were unable to locate him. She stated she was not aware the resident was an elopement risk and never saw it coming. She stated she never saw Resident #1 exhibit any exit seeking behavior and was unable to recall the last time she saw the resident on the evening of 06/24/23. Interview on 06/27/23 at 11:41 a.m., HA D stated she supervised the residents when smoking on the evening of 06/24/23. She recalled seeing Resident #1 in the dining room at approximately 4:00 p.m., during the resident's smoke break. She stated the resident did not come out to smoke but remained in the dining room looking out onto the smoking area. She stated the resident usually stayed in his room and she never saw him act as if he wanted to leave the facility. Interview on 06/27/23 at 2:33 p.m., the Administrator and DON stated Resident #1 never signed out of the facility or went anywhere off campus. Interview on 06/27/23 at 3:00 p.m., the Regional Nurse Consultant stated Resident #1 was not a risk for elopement and the elopement evaluations indicated he was a moderate risk for elopement, were not correct. He stated since admission the resident had never exhibited any behaviors that would equal an elopement risk. He further stated sometimes assessments led you to choices that did not represent the resident . Interview on 06/27/23 at 3:22 p.m., CNA E stated he provided care for Resident #1 and the resident was ambulatory without the use of any device. He was on duty during the evening of 06/24/23 when the resident eloped from the facility. He was not aware the resident was not in the facility until a lady told him she was at the facility to visit Resident #1. He and other staff searched on and off the campus but were unable to locate the resident. CNA E stated he was surprised the resident left the facility and he did not know the resident was a risk for elopement and never saw the resident attempting to leave the facility. Interview on 06/28/23 at 11:13 a.m., the DON and the Regional Nurse Consultant stated they were not aware their elopement evaluations were not correctly capturing resident's risk for elopement. They stated the issue came to the forefront after the State Surveyor intervention on 06/27/23. The Regional Nurse Consultant stated updates to the electronic health record system were ongoing since November 2022. No explanation was provided about why Resident #1's elopement evaluation had not been updated if they currently felt it was incorrect. Interview on 06/28/23 at 11:35 a.m., CNA F stated she had worked at the facility for less than two weeks. She stated she saw Resident #1 at the local Walmart on Sunday (06/25/23) at approximately 4:30 p.m. or 5:00 p.m. and thought he was on pass. She stated the resident was standing outside of the store and did not appear to be in any distress. She stated she did not know the Resident #1 or that he was missing but recognized his face as a resident from the facility. Interview on 06/28/23 at 2:17 p.m., the Administrator stated he monitored nurse managers to ensure the systems they monitored were being done sufficiently by talking to and interviewing staff and during meeting such as QA meetings. He stated nursing staff determined Resident #1 was at risk for elopement but did not implement any interventions to address the resident's risk for elopement. Interview on 06/28/23 at 3:00 p.m., the DON stated elopement evaluations were completed for residents on admission, quarterly and with changes in condition . Interview on 06/28/23 at 4:08 p.m., the ADON stated the new process for a.m. and p.m. meetings would include not only checking for resident's elopement risk scores but also monitoring to ensure interventions were in place for residents triggered to be at moderate or higher elopement risk. Interview on 06/28/23 at 4:43 p.m., the DON stated the nurse managers (DON, ADON and MDS) would now be responsible for ensuring care plans/interventions were developed for residents who were at risk for elopement but in the past, it had been the responsibility of the MDS nurse . Interview with the facility Medical Director on 06/29/23 at 10:12 a.m., she stated she was also Resident #1's primary physician. She stated she was not aware Resident #1 was a moderate risk for elopement and was shocked when he left the facility as he never attempted to leave before. Her expectation was if a resident was determined to be at risk the information be communicated to nursing staff and the resident be monitored and kept an eye on to note if he left or attempted to leave the facility. She stated she would ensure the issue of the elopement evaluations not matching the residents was brought to the QA meeting. She stated the elopement evaluation was possibly incorrect, but nurses should have been made aware. Interview on 06/29/23 at 10:49 a.m., the MDS nurse stated her understanding was the nurse who completed an elopement evaluation would also initiate care planning with elopement interventions. She would have only been aware a resident was at risk for elopement by reviewing the nurse's documentation or by word of mouth. She verbalized understanding of the training received and that she and other nurse managers were now responsible for ensuring interventions were in place for residents at risk of elopement. Interview on 06/29/23 at 11:45 a.m., the DON stated the plan for ensuring elopement evaluations and interventions were in place was the IDT checked elopement evaluations weekly, but Resident #1's was missed. During the daily standup and stand down meetings elopement scores were checked but nothing further was done to address a resident's risk for elopement. The DON stated training regarding the facility's elopement policy/procedure was provided to nursing staff on 04/10/23 . Record review of in-service training, dated 04/10/23, prior to Resident #1's elopement, revealed training related to the facility's elopement and wandering policy/procedure was provided to nursing staff. The training addressed identifying residents at risk for elopement, minimizing any possible injury as a result of elopement and documenting preventative interventions in the resident's medical record. Record review of the facility's policy/procedure entitled Wandering and Elopement, revised August 2020, revealed the purpose was to enhance the safety of residents of the facility. The policy included identifying residents at risk for elopement and minimizing any possible injury as a result of elopement. The policy/procedure further reflected in part: The Licensed Nurse, in collaboration with the interdisciplinary team, will assess residents upon admission, readmission, quarterly and upon identification of significant change in condition to determine their risk for wandering/elopement. The resident's risk for elopement and preventative interventions will be documented in the resident's medical record and will be reviewed and re-evaluated by the IDT upon admission, readmission, quarterly and upon change in condition. IDT may consider interventions in Elopement Risk Reduction Approaches for residents identified to at risk for elopement. Record review of the facility's, undated, Elopement Risk Reductions Approaches revealed .Developing a care plan and an update process that promoted choice, mobility, and safety. Basing the care plan on assessments, family, and caregiver involvement. This was determined to be an Immediate Jeopardy (IJ) on 07/13/23 at 9:40 AM. The Administrator was notified. The Administrator was provided with the IJ template via email on 07/13/23 at 11:26 AM. The Plan of Removal submitted by the facility was accepted on 07/13/23 at 2:35 PM: Summary of Details which lead to outcomes. On 07/13/23, the HHSC surveyor, re-opened the visit (06/29/23) and provided an IJ Template for F656, a previous IJ Template was received on 06/29/23 for F689, notification that the Survey Agency had determined that the conditions at the center constitute immediate jeopardy to resident health. The facility failed to update the residents care plan and interventions that led to the resident eloping, which current whereabouts unknown. The notification of the alleged immediate jeopardy states as follows: The resident eloped from the facility on the evening of 06/24/23. Facility staff searched on and off the premises, the police were notified, but the resident was not located. Identify residents who could be affected. All residents have the potential to be affected. Identify responsible staff/ what action taken. 1. Training for all licensed nursing staff on completion of accurate elopement assessments was initiated on 6/27/2023 by Regional Nurse consultant. 2. Training for all licensed nursing staff was initiated on 6/27/23, on notification of elopement assessments that trigger for moderate or higher will require DON, ADON and/or MDS notification. Training was conducted by the RNC . 3. Training for DON/ADON/MDS was initiated on 6/27/23 on care plan completion and interventions regarding elopement assessment for those that trigger as moderate or higher risk by Regional Nurse Consultant. 4. DON/ADON/MDS/weekend supervisor retraining was initiated on 6/27/23 by the Regional Nurse Consultant of overview of reviewing elopement risk assessment for accuracy, completion, interventions and updating care plans to reflect elopement risk. 5. DON/ADON/MDS completed audit of all resident elopement assessments on 6/27/23. 6. All residents with moderate risk score were care planned by DON/ADON/MDS on 6/27/23, with no residents at imminent risk identified. 7. All staff retraining has been initiated 6/24/2023 on response to resident elopement. No staff will be allowed to return to work without completion of required training. The DON initiated training. In-Service conducted. 1. Training for all staff on response to resident elopement initiated on 6/24/23. a. The Facility Staff member who finds that a resident is missing will alert the charge Nurse. b. The Charge Nurse will call CODE PINK and organize a search. Facility Staff will search areas of the Facility, including communal areas, bathrooms, showers, outside areas, etc. c. If the resident cannot be located, the Charge Nurse will notify Administrator/designee ii. Director of Nursing Services/designee, Attending Physician iv. Responsible Party. 2. Training for all licensed nursing staff on completion of accurate elopement assessments initiated on 6/27/23. 3. Training for all licensed nursing staff was initiated on 6/27/23, on notification of accurate elopement assessments that trigger for moderate or higher to notify DON/ADON/MDS. 4. Training for DON/ADON/MDS/weekend supervisor was initiated on 6/27/23 on care plan completion and interventions regarding elopement assessment for those that trigger as moderate or higher. 5. Retraining was initiated on 6/27/23 with DON/ADON/weekend supervisor for oversight of reviewing elopement risk assessment for accuracy, completion, interventions and updating care plans to reflect elopement risk. Implementation of Changes Training for DON/ADON/MDS/weekend supervisor was initiated on 6/27/23 on care plan completion and interventions regarding elopement assessment for those that trigger as moderate or higher. The Regional Nurse Consultant started the changes. The changes were implemented effective on 6/27/2023 and training was completed on 6/28/2023. Staff will not be allowed to work until they have been fully re-educated. All new hires will be educated on elopement protocol/response prior to working the floor. The Director of Nursing will ensure competency through signing of in service, verbalization of understanding and completion of returned questionnaire. All licensed nurses will notify DON/ADON/MDS if elopement risk is moderate or higher. The DON/ADON/MDS will review all elopement assessments daily in morning clinical meeting and care plan if necessary. Weekend supervisor/ designee will review all elopement assessments over the weekend for accuracy and care plan if necessary. Regional Nurse Consultant will complete audit of elopement assessments daily x 30 days then weekly thereafter. Monitoring The Administrator/Director of Nursing/Assistant Director of Nursing/Regional Nurse Consultant will be responsible for monitoring the implementation and effectiveness of in-service on 6/28/2023. o The Administrator/Director of Nursing/Assistant Director of Nursing/Regional Nurse Consultant will monitor/review all elopement assessments daily x4 weeks, then weekly thereafter and report any adverse finding during QAPI . o Director of Nursing/Assistant Director of Nursing will conduct a daily audit of Elopement assessment x4 weeks, then weekly thereafter and report any adverse findings during QAPI. o Residents will be monitored by staff every shift for any exit seeking behaviors. Any changes will be reported to the Administrator Director of Nursing and Assistant Director of Nursing immediately for appropriate action. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 6/28/2023 and conducted an Ad HOC QAPI regarding the missing resident, elopement protocol, elopement assessments and care plans. The Medical Director, [physician name] was notified about the immediate Jeopardy on 6/28/2023, the Plan of removal was reviewed and accepted by medical director. Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, and social services director to review the plan of removal on 6/28/2023. Who is responsible for implementation of process? The Director of Nursing and Administrator will be responsible for implementation of New Process. The New Process/ system was started on 6/28/2023. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy verbally issued on 6/28/23. Monitoring of the POR included the following: Interviews were conducted with facility staff across multiple shifts on 06/29/23 from 3:19 p.m. to 4:10 p.m. Staff interviewed were LVN A, LVN G, LVN H, RN I, RN J, LVN K, and RN L . The staff revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on completing elopement evaluations and notifying nursing management to include the MDS nurse if a resident triggered for moderate or higher risk for elopement. They were all aware of the elopement book being located at the receptionist's desk and at the nurse's station. They stated if a resident triggered for moderate risk of elopement, they were to monitor the resident for attempts to leave the facility and if a resident triggered for higher than moderate risk they would monitor and ensure staff stayed with the resident until management initiated a move to the secured building on campus. Record review of in-service training logs and competency tests, dated 06/27/23, 06/28/23 and 06/29/23, revealed education included the facility's elopement protocol, resident supervision, accurate completion of elopement assessments, notification of the DON, ADON or MDS nurse of any resident triggering for moderate or higher risk of elopement, and care plan completions with interventions to address elopement risks. Record Review of Elopement Audits dated 06/29/23 included new admissions the elopement assessment score, risk, wander guard if ordered was to be checked for placement and functioning care plan in place if they were a risk and the elopement binder updated. Care plans were updated accordingly . In an interview on 07/13/23 at 12:11 PM, the MDS Nurse said all residents who were identified as an elopement risk were assessed and care planned with appropriate interventions, such as, a wander guard, increased monitoring, more involvement in activities, etc . She said the residents' assessed as an elopement risk were in the elopement binder, at the nurses' station. She said the elopement assessments were updated and care planned with each MDS assessmen t. She said if a resident had a change of condition and began exhibiting signs/symptoms for increased risk of elopement, the nurses were to assess, notify the Administrator, DON, and MDS Nurse, so they could update the assessment and develop and individualized care plan to address interventions to prevent elopement. Record Review of the Elopement Risk Binder indicated it was up to date with the residents' pictures and face sheets. In an interview on 07/13/23 at 12:30 PM, Medical Records said she updated the elopement binder. She said the DON notified her if she needed to put a resident's picture and face sheet in the binder. She said she was tasked with keeping the binder up to date. In an interview on 07/13/23 at 1:06 PM, the DON said the Elopement Assessment Scoring of all residents was reviewed every morning in the IDT meeting, to ensure care planning was done with the appropriate interventions. He provided the Elopement Assessment Scoring Report dated 07/13/23 for admissions and re-admissions from 07/01/23 - 07/13/23. In an interview on 07/13/23 at 1:15 PM with LVN N, who worked the 6:00 AM - 2:00 PM shift, said she was educated on the new policy to care plan all residents who were at moderate or imminent risk of elopement. She said all residents at moderate or above elopement risk had their picture and face sheets in the elopement binder. She said if a resident began to exhibit signs/symptoms of exit seeking/elopement behavior, she notified the MD, DON, Administrator and MDS Nurse. She said the nurses conducted the elopement assessment and the care plan elopement risk interventions. In an interview on 07/13/23 at 2:40 PM, on the 2:00 PM - 10:00 PM shift with RN M, who worked all shifts, was aware of the elopement policies and procedures, which included care planning. In an interview on 07/13/23 at 2:45 PM, on the 2:00 PM - 10:00 PM shift, LVN H was aware of the elopement policies and procedures, which included care planning. The Administrator was informed the Immediate Jeopardy was removed on 07/13/23 at 3:00 PM. The facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of corrective systems that were put into place.

Based on interview and record review, it was determined the facility failed to ensure residents receive services that meet professional standards of clinical practice for one (Resident #1) of six residents reviewed for Cardiopulmonary Resuscitation and the use of an Automated External Defibrillator. Based on interview and record review, it was determined the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents choices for one (Resident #1) of six residents reviewed in the area of Cardiopulmonary Resuscitation and the use of an Automated External Defibrillator. 1. On [DATE], RN A and LVN B failed to suction Resident #1's trachea (an incision in the windpipe to open the restricted airway and enable breathing) to determine if the airway was occluded. RN A, LVN B and CNA D failed to connect the resuscitation bag to [MEDICAL CONDITION]. RN A, LVN B and CNA D incorrectly placed the resuscitation bag over the mouth and nose when Resident #1 was found non-responsive and unconscious. 2.On [DATE], RN A and LVN B failed to instruct CNA D with proper placement of the resuscitation bag over Resident #1's [MEDICAL CONDITION] rescue breathing during CPR. 3. On [DATE], RN A and LVN B failed to initiate the Automated External Defibrillator when RN A determined Resident #1 did not have a pulse. Resident #1 expired on [DATE] at 9:11 AM. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of patterned because the facility was still monitoring the Plan of Removal. These failures could affect the one resident with a [MEDICAL CONDITION] and 19 residents with full code status by placing them at risk for not receiving accurate procedure for CPR and further life-saving procedures, which could result in death. Findings included: Review of Resident #1's face sheet dated [DATE] reflected a [AGE] year old female admitted to the facility on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. Review of Resident#1's admission assessment dated [DATE] reflected Resident #1 was alert to her name and was not able to speak. She was bedfast with right sided [MEDICAL CONDITION] upper and lower extremity and was not weight bearing. She required extensive assistance with two people for ADL's and bed mobility. She was incontinent of bowel and bladder. The admission assessment revealed Resident # 1 had a [MEDICAL CONDITION]. Review of Resident #1's Consolidated Physician order [REDACTED].#1 had an order for [REDACTED]. Change inner cannula PRN (as needed). Change suction canister as needed; .[MEDICAL CONDITION] PRN . Change [MEDICAL CONDITION] .[MEDICAL CONDITION] at bedside for emergency placement? (sic) send with resident if transferred to hospital for replacement every shift. Review of Resident #1's Care Plan dated [DATE] reflected a full Code CPR order in Place, request for CPR to be initiated will be followed. Review of Resident #1's Nurse's note dated [DATE] at 10:22 AM by LVN B, reflected . Approximately at 8:50 AM called to the room by the CNA resident appeared to be unresponsive. Upon assessment noted her to be lying on her stomach. Repositioned and assessed, unable to obtain vital signs. Initiated code BLS (basic life support) with cash cart at bedside. Instructed (CNA E) to call 911 while BSL continued. EMSA (emergency medical service authority) arrived and took over code . continued until 9:22 AM pronounced at that time . Review of Resident #1's Record of Death dated [DATE] reflected Resident #1 expired at the facility on [DATE]. Interview on [DATE] at 7:50 AM with CNA D revealed she seen Resident #1 after breakfast around 8:30 AM, then at approximately 8:45 AM on [DATE], she entered Resident #1's room and noticed she was lying flat. She stated she turned her over and her eyes did not move, she was warm to touch and she had some white stuff around her mouth. CNA D said she went to the doorway and yelled get the crash cart. LVN B entered the room and said the resident was unresponsive and not breathing. CNA D stated CNA E helped her (CNA D) put the back board under Resident #1's back. RN A helped CNA D put the breathing mask over the resident's nose and mouth. CNA D revealed then RN A stated the resident had no pulse and start chest compression. CNA D said LVN B started doing the chest compressions and she (CNA) was squeezing the resuscitation bag. When asked if anyone had suctioned Resident #1's [MEDICAL CONDITION], she stated no and they did not use the AED. An interview on [DATE] at 8:56 AM with RN A charge nurse revealed she heard CNA D yell out get the crash cart. When she entered Resident #1's room, she assessed for a pulse and Resident #1 had a faint pulse. She stated CNA D got the resuscitation bag and placed it over Resident #1's nose and mouth. She stated I helped her hold her chin back. The oxygen tubing from the e-tank was connected to the resuscitation bag. She continued to state, I rechecked for a pulse and she did not have a pulse. I announced start chest compressions. LVN B was doing the chest compression and (CNA D) was doing the ventilation. When asked if Resident #1 had a trach, she stated yes. RN A stated she did not suction the resident'[MEDICAL CONDITION] check for an occlusion or obstruction. She stated no, she wasn't breathing, her chest was not rising. RN A revealed she did not initiate the AED. RN A stated she placed the resuscitation bag over the resident's mouth and nose. RN A was asked to verify where she placed the resuscitation bag and RN A repeated over the mouth and nose of resident. An interview on [DATE] at 12:10 PM with CNA C revealed at approximately 8:45 AM on [DATE], CNA D yelled call 911 get the crash cart. She stated she entered Resident #1's room and called 911 from her cell phone. She revealed Resident #1 was lying on her right side, she was not breathing, no noise coming from [MEDICAL CONDITION] she was not moving. She stated CNA D and CNA E started putting the back board under Resident #1's back. CNA C revealed LVN B entered the room and said the resident was non-responsive and not breathing. CNA C revealed then CNA D and RN A put the breathing mask over the resident's nose and mouth. She stated CNA D started squeezing the resuscitation bag, and LVN B started doing chest compressions. CNA C revealed Resident #1 was not suctioned, and the AED was not used. An interview on [DATE] at 8:25 AM with LVN B revealed at approximately 8:45 AM on [DATE], CNA D yelled to get the crash cart. She stated she entered the room found Resident #1 unresponsive and not breathing. She instructed CNA E to call 911. CNA D started rescue breathing, while RN A held her chin and held her head backward. LVN B stated the resuscitation bag was over the nose and mouth and she connected the oxygen to the resuscitation bag. LVN B stated the RN was the expert. The code continued until the paramedics arrive and the resident was pronounced dead. An interview on [DATE] at 10:37 AM with the DON revealed LVN B called her on [DATE] and informed her Resident #1 had coded and did not make it. She stated RN A was CPR certified and should have known how to handle a code blue. She stated she would expect RN A to have taken over the situation and assessed Resident#1's airway for blockage and used the AED. The DON revealed the nurses had a special training on the use of the AED (unknown date), and all staff had training on the use of the AED on [DATE]. She believed RN A and LVN B panicked during the code. Interview with the DON revealed RN A, LVN B and CNA D were still on duty after the incident on [DATE]. An interview on [DATE] at 11:58 AM with Resident #1's physician revealed he expected the facility to immediately initiate CPR on a resident with a full code status when a resident was unresponsive with no pulse. He stated he did not think a physician needed to write an order to use the AED. Resident #1's physician revealed he would expect the AED to be used on any resident with a full code status. An interview on [DATE] at 9:30 AM with the Administrator revealed RN A and LVN B were CPR certified and should have known how to handle a code blue. Review of RN A's Basic Life Support card revealed it was issued on ,[DATE] and the renewal date was ,[DATE]. Review of LVN B's Basic Life Support card revealed it was issued on [DATE] and the renewal date was ,[DATE]. Review of CNA D's Basic Life Support card revealed it was issued on [DATE] and the renewal date was ,[DATE]. Review of facility's Cardiopulmonary Resuscitation Policy dated ,[DATE] reflected under general guidelines . Specific procedures for CPR may very; verify procedure with the American heart Association and /or the American Red Cross in your area . The policy and procedure for Cardiopulmonary Resuscitation dated ,[DATE] did not address procedures for rescue breathing on a person with a [MEDICAL CONDITION] and AED placement. The policy was revised on [DATE] to address rescue breathing on a [MEDICAL CONDITION] and AED placement. Review of the facility's Automatic External Defibrillator (AED) policy dated ,[DATE] reflected that the AED would be used on victims of sudden [MEDICAL CONDITION] who were unconscious and unresponsive, not breathing and no pulse. AED must be used by or on the order of a physician and consistent with resident's advance directive. Review of the American National Red Cross- Basic Life Support for Healthcare Providers Handbook, 2016, reflected .emergency care procedures outlined in the program materials reflect the standard of knowledge and accepted emergency practices in the United States at the time this manual was published .AEDs are portable electronic devices that automatically analyze the patient's heart rhythm and can provide defibrillation, an electrical shock that may help the heart re-establish a rhythm. When a patient experiences a [MEDICAL CONDITION], an AED should be applied as soon as one is readily available. AEDs deliver defibrillation(s) to patients in [MEDICAL CONDITION] with two specific [MEDICAL CONDITION]: ventricular fibrillation (VF) and [MEDICAL CONDITION] (VT). By using an AED early, the patient's chances of survival are greatly increased. Review of CPR and Rescue Breathing for Adults with [MEDICAL CONDITION] (Ages 12 and Older) at https://www.cincinnatichildrens.org/health/c/adult-trach-cpr dated ,[DATE] revealed .3) after compressions, give breaths using a resuscitation bag attached to the trach. The Administrator was notified on [DATE] at 11:01 AM that an Immediate Jeopardy was identified and a plan of removal was requested at that time The facility's Plan of Removal was accepted on [DATE] at 1:16 PM and included: Implementation of Changes: 1. The facility hired a full time respiratory therapist on [DATE]. 2. The facility removed Resident#2 with a [MEDICAL CONDITION] from the facility, Resident #3 a [MEDICAL CONDITION] resident will not be readmitted into the facility until all staff has been trained [MEDICAL CONDITION] and emergency care of a trach, AED training and CPR certified. 3. Resident #2 and Resident #3 currently had [MEDICAL CONDITION] available in the room. 4. On [DATE] and [DATE] the facility started CPR training and re-in-serving staff on the use of the AED,[MEDICAL CONDITION] with emergency care. 5. CPR policy was changed to [MEDICAL CONDITION] and AED placement. 6. Nurses will attend a local community college for skills check off before working on the floor. 7. On [DATE] RN A and LVN B received in-service and training on CPR on a resident with [MEDICAL CONDITION] the use of the AED, and documentation. 8. All new staff will have CPR Certification and will be checked -off prior to being assigned a resident with a trach. 9. All staff in-service on Abuse and Neglect by Abuse Coordinator- Administrator started on [DATE] and will be completed on [DATE]. 10. In-service for all licensed staff on Change of Condition Assessment was initiated on [DATE] and will be completed on [DATE]. The Plan of Removal concluded with Monitoring: Licensed staff and department heads will make safety rounds every two hours started on [DATE] for the next twenty-four hours. On [DATE]-[DATE], six licensed nurses and three CNAs (RN A, LVN B, CNA D, CNA E, CNA K, LVN I, LVN J, LVN L, LVN M, and LVN N), representing staff from all three shifts and week-end staff were interviewed regarding the in-services and training they received on the facility's CPR with [MEDICAL CONDITION] and AED. They were each able to explain what actions to take if a resident with a [MEDICAL CONDITION] was found unresponsive, not breathing and no pulse by placing the resuscitation bag over [MEDICAL CONDITION] to use the AED. Also if a resident without [MEDICAL CONDITION] found unresponsive, not breathing and no pulse by placing the resuscitation bag over the nose and mouth and to use the AED. Review of in service records dated [DATE] and [DATE] revealed 21 nursing staff that worked on all 3 shifts was in-service on CPR to include oral airway and trach. The DON provided on [DATE] a list of residents with 1 resident with [MEDICAL CONDITION] and 19 residents with full code status.

Based on interview and record review, it was determined the facility failed to properly provide basic life support, including CPR, to a resident requiring such care prior to the arrival of emergency care medical personnel for one (Resident #1) of six reviewed for Cardiopulmonary Resuscitation and the use of an Automated External Defibrillator. Based on interview and record review, it was determined the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents choices for one (Resident #1) of six residents reviewed in the area of Cardiopulmonary Resuscitation and the use of an Automated External Defibrillator. 1. On [DATE], RN A and LVN B failed to suction Resident #1'[MEDICAL CONDITION] determine if the airway was occluded. RN A, LVN B and CNA D failed to connect the resuscitation bag to [MEDICAL CONDITION]. RN A, LVN B and CNA D incorrectly placed the resuscitation bag over the mouth and nose when Resident #1 was found non-responsive and unconscious. 2.On [DATE], RN A and LVN B failed to instruct CNA D with proper placement of the resuscitation bag over Resident #1's [MEDICAL CONDITION] rescue breathing during CPR. 3. On [DATE], RN A and LVN B failed to initiate the Automated External Defibrillator when RN A determined Resident #1 did not have a pulse. Resident #1 expired on [DATE] at 9:11 AM. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of patterned because the facility was still monitoring the Plan of Removal. These failures could affect the one resident with a [MEDICAL CONDITION] and 19 residents with full code status by placing them at risk for not receiving accurate procedure for CPR and further life-saving procedures, which could result in death. Findings included: Review of Resident #1's face sheet dated [DATE] reflected a [AGE] year old female admitted to the facility on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. Review of Resident#1's admission assessment dated [DATE] reflected Resident #1 was alert to her name and was not able to speak. She was bedfast with right sided [MEDICAL CONDITION] upper and lower extremity and was not weight bearing. She required extensive assistance with two people for ADL's and bed mobility. She was incontinent of bowel and bladder. The admission assessment revealed Resident # 1 had a [MEDICAL CONDITION]. Review of Resident #1's Consolidated Physician order [REDACTED].#1 had an order for [REDACTED]. Change inner cannula PRN (as needed). Change suction canister as needed; .[MEDICAL CONDITION] PRN . Change [MEDICAL CONDITION] .[MEDICAL CONDITION] at bedside for emergency placement? (sic) send with resident if transferred to hospital for replacement every shift. Review of Resident #1's Care Plan dated [DATE] reflected a full Code CPR order in Place, request for CPR to be initiated will be followed. Review of Resident #1's Nurse's note dated [DATE] at 10:22 AM by LVN B, reflected . Approximately at 8:50 AM called to the room by the CNA resident appeared to be unresponsive. Upon assessment noted her to be lying on her stomach. Repositioned and assessed, unable to obtain vital signs. Initiated code BLS (basic life support) with cash cart at bedside. Instructed (CNA E) to call 911 while BSL continued. EMSA (emergency medical service authority) arrived and took over code . continued until 9:22 AM pronounced at that time . Review of Resident #1's Record of Death dated [DATE] reflected Resident #1 expired at the facility on [DATE]. Interview on [DATE] at 7:50 AM with CNA D revealed she seen Resident #1 after breakfast around 8:30 AM, then at approximately 8:45 AM on [DATE], she entered Resident #1's room and noticed she was lying flat. She stated she turned her over and her eyes did not move, she was warm to touch and she had some white stuff around her mouth. CNA D said she went to the doorway and yelled get the crash cart. LVN B entered the room and said the resident was unresponsive and not breathing. CNA D stated CNA E helped her (CNA D) put the back board under Resident #1's back. RN A helped CNA D put the breathing mask over the resident's nose and mouth. CNA D revealed then RN A stated the resident had no pulse and start chest compression. CNA D said LVN B started doing the chest compressions and she (CNA) was squeezing the resuscitation bag. When asked if anyone had suctioned Resident #1's [MEDICAL CONDITION], she stated no and they did not use the AED. An interview on [DATE] at 8:56 AM with RN A charge nurse revealed she heard CNA D yell out get the crash cart. When she entered Resident #1's room, she assessed for a pulse and Resident #1 had a faint pulse. She stated CNA D got the resuscitation bag and placed it over Resident #1's nose and mouth. She stated I helped her hold her chin back. The oxygen tubing from the e-tank was connected to the resuscitation bag. She continued to state, I rechecked for a pulse and she did not have a pulse. I announced start chest compressions. LVN B was doing the chest compression and (CNA D) was doing the ventilation. When asked if Resident #1 had a trach, she stated yes. RN A stated she did not suction the resident'[MEDICAL CONDITION] check for an occlusion or obstruction. She stated no, she wasn't breathing, her chest was not rising. RN A revealed she did not initiate the AED. RN A stated she placed the resuscitation bag over the resident's mouth and nose. RN A was asked to verify where she placed the resuscitation bag and RN A repeated over the mouth and nose of resident. An interview on [DATE] at 12:10 PM with CNA C revealed at approximately 8:45 AM on [DATE], CNA D yelled call 911 get the crash cart. She stated she entered Resident #1's room and called 911 from her cell phone. She revealed Resident #1 was lying on her right side, she was not breathing, no noise coming from [MEDICAL CONDITION] she was not moving. She stated CNA D and CNA E started putting the back board under Resident #1's back. CNA C revealed LVN B entered the room and said the resident was non-responsive and not breathing. CNA C revealed then CNA D and RN A put the breathing mask over the resident's nose and mouth. She stated CNA D started squeezing the resuscitation bag, and LVN B started doing chest compressions. CNA C revealed Resident #1 was not suctioned, and the AED was not used. An interview on [DATE] at 8:25 AM with LVN B revealed at approximately 8:45 AM on [DATE], CNA D yelled to get the crash cart. She stated she entered the room found Resident #1 unresponsive and not breathing. She instructed CNA E to call 911. CNA D started rescue breathing, while RN A held her chin and held her head backward. LVN B stated the resuscitation bag was over the nose and mouth and she connected the oxygen to the resuscitation bag. LVN B stated the RN was the expert. The code continued until the paramedics arrive and the resident was pronounced dead. An interview on [DATE] at 10:37 AM with the DON revealed LVN B called her on [DATE] and informed her Resident #1 had coded and did not make it. She stated RN A was CPR certified and should have known how to handle a code blue. She stated she would expect RN A to have taken over the situation and assessed Resident#1's airway for blockage and used the AED. The DON revealed the nurses had a special training on the use of the AED (unknown date), and all staff had training on the use of the AED on [DATE]. She believed RN A and LVN B panicked during the code. Interview with the DON revealed RN A, LVN B and CNA D were still on duty after the incident on [DATE]. An interview on [DATE] at 11:58 AM with Resident #1's physician revealed he expected the facility to immediately initiate CPR on a resident with a full code status when a resident was unresponsive with no pulse. He stated he did not think a physician needed to write an order to use the AED. Resident #1's physician revealed he would expect the AED to be used on any resident with a full code status. An interview on [DATE] at 9:30 AM with the Administrator revealed RN A and LVN B were CPR certified and should have known how to handle a code blue. Review of RN A's Basic Life Support card revealed it was issued on ,[DATE] and the renewal date was ,[DATE]. Review of LVN B's Basic Life Support card revealed it was issued on [DATE] and the renewal date was ,[DATE]. Review of CNA D's Basic Life Support card revealed it was issued on [DATE] and the renewal date was ,[DATE]. Review of facility's Cardiopulmonary Resuscitation Policy dated ,[DATE] reflected under general guidelines . Specific procedures for CPR may very; verify procedure with the American heart Association and /or the American Red Cross in your area . The policy and procedure for Cardiopulmonary Resuscitation dated ,[DATE] did not address procedures for rescue breathing on a person with a [MEDICAL CONDITION] and AED placement. The policy was revised on [DATE] to address rescue breathing on a [MEDICAL CONDITION] and AED placement. Review of the facility's Automatic External Defibrillator (AED) policy dated ,[DATE] reflected that the AED would be used on victims of sudden [MEDICAL CONDITION] who were unconscious and unresponsive, not breathing and no pulse. AED must be used by or on the order of a physician and consistent with resident's advance directive. Review of the American National Red Cross- Basic Life Support for Healthcare Providers Handbook, 2016, reflected .emergency care procedures outlined in the program materials reflect the standard of knowledge and accepted emergency practices in the United States at the time this manual was published .AEDs are portable electronic devices that automatically analyze the patient's heart rhythm and can provide defibrillation, an electrical shock that may help the heart re-establish a rhythm. When a patient experiences a [MEDICAL CONDITION], an AED should be applied as soon as one is readily available. AEDs deliver defibrillation(s) to patients in [MEDICAL CONDITION] with two specific [MEDICAL CONDITION]: ventricular fibrillation (VF) and [MEDICAL CONDITION] (VT). By using an AED early, the patient's chances of survival are greatly increased. Review of CPR and Rescue Breathing for Adults with [MEDICAL CONDITION] (Ages 12 and Older) at https://www.cincinnatichildrens.org/health/c/adult-trach-cpr dated ,[DATE] revealed .3) after compressions, give breaths using a resuscitation bag attached to the trach. The Administrator was notified on [DATE] at 11:01 AM that an Immediate Jeopardy was identified and a plan of removal was requested at that time The facility's Plan of Removal was accepted on [DATE] at 1:16 PM and included: Implementation of Changes: 1. The facility hired a full time respiratory therapist on [DATE]. 2. The facility removed Resident#2 with a [MEDICAL CONDITION] from the facility, Resident #3 a [MEDICAL CONDITION] resident will not be readmitted into the facility until all staff has been trained [MEDICAL CONDITION] and emergency care of a trach, AED training and CPR certified. 3. Resident #2 and Resident #3 currently had [MEDICAL CONDITION] available in the room. 4. On [DATE] and [DATE] the facility started CPR training and re-in-serving staff on the use of the AED,[MEDICAL CONDITION] with emergency care. 5. CPR policy was changed to [MEDICAL CONDITION] and AED replacement 6. Nurses will attend a local community college for skills check off before working on the floor. 7. On [DATE] RN A and LVN B received in-service and training on CPR on a resident with [MEDICAL CONDITION] the use of the AED, and documentation. 8. All new staff will have CPR Certification and will be checked -off prior to being assigned a resident with a trach. 9. All staff in-service on Abuse and Neglect by Abuse Coordinator- Administrator started on [DATE] and will be completed on [DATE]. 10. In-service for all licensed staff on Change of Condition Assessment was initiated on [DATE] and will be completed on [DATE]. The Plan of Removal concluded with Monitoring: Licensed staff and department heads will make safety rounds every two hours started on [DATE] for the next twenty-four hours. On [DATE]-[DATE], six licensed nurses and three CNAs (RN A, LVN B, CNA D, CNA E, CNA K, LVN I, LVN J, LVN L, LVN M, and LVN N), representing staff from all three shifts and week-end staff were interviewed regarding the in-services and training they received on the facility's CPR with [MEDICAL CONDITION] and AED. They were each able to explain what actions to take if a resident with a [MEDICAL CONDITION] was found unresponsive, not breathing and no pulse by placing the resuscitation bag over [MEDICAL CONDITION] to use the AED. Also if a resident without [MEDICAL CONDITION] found unresponsive, not breathing and no pulse by placing the resuscitation bag over the nose and mouth and to use the AED. Review of in service records dated [DATE] and [DATE] revealed 21 nursing staff that worked on all 3 shifts was in-service on CPR to include oral airway and trach. The DON provided on [DATE] a list of residents with 1 resident with [MEDICAL CONDITION] and 19 residents with full code status.

Based on interview and record review, it was determined the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents choices for one (Resident #1) of six residents reviewed in the area of Cardiopulmonary Resuscitation and the use of an Automated External Defibrillator. 1. On [DATE], RN A and LVN B failed to suction Resident #1's trachea (an incision in the windpipe to open the restricted airway and enable breathing) to determine if the airway was occluded. RN A, LVN B and CNA D failed to connect the resuscitation bag to [MEDICAL CONDITION]. RN A, LVN B and CNA D incorrectly placed the resuscitation bag over the mouth and nose when Resident #1 was found non-responsive and unconscious. 2.On [DATE], RN A and LVN B failed to instruct CNA D with proper placement of the resuscitation bag over Resident #1's [MEDICAL CONDITION] rescue breathing during CPR. 3. On [DATE], RN A and LVN B failed to initiate the Automated External Defibrillator when RN A determined Resident #1 did not have a pulse. Resident #1 expired on [DATE] at 9:11 AM. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of patterened because the facility was still monitoring the Plan of Removal. These failures could affect the one resident with a [MEDICAL CONDITION] and 19 residents with full code status by placing them at risk for not receiving accurate procedure for CPR and further life-saving procedures, which could result in death. Findings included: Review of Resident #1's face sheet dated [DATE] reflected a [AGE] year old female admitted to the facility on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. Review of Resident#1's admission assessment dated [DATE] reflected Resident #1 was alert to her name and was not able to speak. She was bedfast with right sided [MEDICAL CONDITION] upper and lower extremity and was not weight bearing. She required extensive assistance with two people for ADL's and bed mobility. She was incontinent of bowel and bladder. The admission assessment revealed Resident # 1 had a [MEDICAL CONDITION]. Review of Resident #1's Consolidated Physician order [REDACTED].#1 had an order for [REDACTED]. Change inner cannula PRN (as needed). Change suction canister as needed; .[MEDICAL CONDITION] PRN . Change [MEDICAL CONDITION] .[MEDICAL CONDITION] at bedside for emergency placement? (sic) send with resident if transferred to hospital for replacement every shift. Review of Resident #1's Care Plan dated [DATE] reflected a full Code CPR order in Place, request for CPR to be initiated will be followed. Review of Resident #1's Nurse's note dated [DATE] at 10:22 AM by LVN B, reflected . Approximately at 8:50 AM called to the room by the CNA resident appeared to be unresponsive. Upon assessment noted her to be lying on her stomach. Repositioned and assessed, unable to obtain vital signs. Initiated code BLS (basic life support) with cash cart at bedside. Instructed (CNA E) to call 911 while BSL continued. EMSA (emergency medical service authority) arrived and took over code . continued until 9:22 AM pronounced at that time . Review of Resident #1's Record of Death dated [DATE] reflected Resident #1 expired at the facility on [DATE]. Interview on [DATE] at 7:50 AM with CNA D revealed she seen Resident #1 after breakfast around 8:30 AM, then at approximately 8:45 AM on [DATE], she entered Resident #1's room and noticed she was lying flat. She stated she turned her over and her eyes did not move, she was warm to touch and she had some white stuff around her mouth. CNA D said she went to the doorway and yelled get the crash cart. LVN B entered the room and said the resident was unresponsive and not breathing. CNA D stated CNA E helped her (CNA D) put the back board under Resident #1's back. RN A helped CNA D put the breathing mask over the resident's nose and mouth. CNA D revealed then RN A stated the resident had no pulse and start chest compression. CNA D said LVN B started doing the chest compressions and she (CNA) was squeezing the resuscitation bag. When asked if anyone had suctioned Resident #1's [MEDICAL CONDITION], she stated no and they did not use the AED. An interview on [DATE] at 8:56 AM with RN A charge nurse revealed she heard CNA D yell out get the crash cart. When she entered Resident #1's room, she assessed for a pulse and Resident #1 had a faint pulse. She stated CNA D got the resuscitation bag and placed it over Resident #1's nose and mouth. She stated I helped her hold her chin back. The oxygen tubing from the e-tank was connected to the resuscitation bag. She continued to state, I rechecked for a pulse and she did not have a pulse. I announced start chest compressions. LVN B was doing the chest compression and (CNA D) was doing the ventilation. When asked if Resident #1 had a trach, she stated yes. RN A stated she did not suction the resident'[MEDICAL CONDITION] check for an occlusion or obstruction. She stated no, she wasn't breathing, her chest was not rising. RN A revealed she did not initiate the AED. RN A stated she placed the resuscitation bag over the resident's mouth and nose. RN A was asked to verify where she placed the resuscitation bag and RN A repeated over the mouth and nose of resident. An interview on [DATE] at 12:10 PM with CNA C revealed at approximately 8:45 AM on [DATE], CNA D yelled call 911 get the crash cart. She stated she entered Resident #1's room and called 911 from her cell phone. She revealed Resident #1 was lying on her right side, she was not breathing, no noise coming from [MEDICAL CONDITION] she was not moving. She stated CNA D and CNA E started putting the back board under Resident #1's back. CNA C revealed LVN B entered the room and said the resident was non-responsive and not breathing. CNA C revealed then CNA D and RN A put the breathing mask over the resident's nose and mouth. She stated CNA D started squeezing the resuscitation bag, and LVN B started doing chest compressions. CNA C revealed Resident #1 was not suctioned, and the AED was not used. An interview on [DATE] at 8:25 AM with LVN B revealed at approximately 8:45 AM on [DATE], CNA D yelled to get the crash cart. She stated she entered the room found Resident #1 unresponsive and not breathing. She instructed CNA E to call 911. CNA D started rescue breathing, while RN A held her chin and held her head backward. LVN B stated the resuscitation bag was over the nose and mouth and she connected the oxygen to the resuscitation bag. LVN B stated the RN was the expert. The code continued until the paramedics arrive and the resident was pronounced dead. An interview on [DATE] at 10:37 AM with the DON revealed LVN B called her on [DATE] and informed her Resident #1 had coded and did not make it. She stated RN A was CPR certified and should have known how to handle a code blue. She stated she would expect RN A to have taken over the situation and assessed Resident#1's airway for blockage and used the AED. The DON revealed the nurses had a special training on the use of the AED (unknown date), and all staff had training on the use of the AED on [DATE]. She believed RN A and LVN B panicked during the code. Interview with the DON revealed RN A, LVN B and CNA D were still on duty after the incident on [DATE]. An interview on [DATE] at 11:58 AM with Resident #1's physician revealed he expected the facility to immediately initiate CPR on a resident with a full code status when a resident was unresponsive with no pulse. He stated he did not think a physician needed to write an order to use the AED. Resident #1's physician revealed he would expect the AED to be used on any resident with a full code status. An interview on [DATE] at 9:30 AM with the Administrator revealed RN A and LVN B were CPR certified and should have known how to handle a code blue. Review of RN A's Basic Life Support card revealed it was issued on ,[DATE] and the renewal date was ,[DATE]. Review of LVN B's Basic Life Support card revealed it was issued on [DATE] and the renewal date was ,[DATE]. Review of CNA D's Basic Life Support card revealed it was issued on [DATE] and the renewal date was ,[DATE]. Review of facility's Cardiopulmonary Resuscitation Policy dated ,[DATE] reflected under general guidelines . Specific procedures for CPR may very; verify procedure with the American heart Association and /or the American Red Cross in your area . The policy and procedure for Cardiopulmonary Resuscitation dated ,[DATE] did not address procedures for rescue breathing on a person with a [MEDICAL CONDITION] and AED placement. The policy was revised on [DATE] to address rescue breathing on a [MEDICAL CONDITION] and AED placement. Review of the facility's Automatic External Defibrillator (AED) policy dated ,[DATE] reflected that the AED would be used on victims of sudden [MEDICAL CONDITION] who were unconscious and unresponsive, not breathing and no pulse. AED must be used by or on the order of a physician and consistent with resident's advance directive. Review of the American National Red Cross- Basic Life Support for Healthcare Providers Handbook, 2016, reflected .emergency care procedures outlined in the program materials reflect the standard of knowledge and accepted emergency practices in the United States at the time this manual was published .AEDs are portable electronic devices that automatically analyze the patient's heart rhythm and can provide defibrillation, an electrical shock that may help the heart re-establish a rhythm. When a patient experiences a [MEDICAL CONDITION], an AED should be applied as soon as one is readily available. AEDs deliver defibrillation(s) to patients in [MEDICAL CONDITION] with two specific [MEDICAL CONDITION]: ventricular fibrillation (VF) and [MEDICAL CONDITION] (VT). By using an AED early, the patient's chances of survival are greatly increased. Review of CPR and Rescue Breathing for Adults with [MEDICAL CONDITION] (Ages 12 and Older) at https://www.cincinnatichildrens.org/health/c/adult-trach-cpr dated ,[DATE] revealed .3) after compressions, give breaths using a resuscitation bag attached to the trach. The Administrator was notified on [DATE] at 11:01 AM that an Immediate Jeopardy was identified and a plan of removal was requested at that time The facility's Plan of Removal was accepted on [DATE] at 1:16 PM and included: Implementation of Changes: 1. The facility hired a full time respiratory therapist on [DATE]. 2. The facility removed Resident #2 with a [MEDICAL CONDITION] from the facility, Resident #3 a [MEDICAL CONDITION] resident will not be readmitted into the facility until all staff has been trained [MEDICAL CONDITION] and emergency care of a trach, AED training and CPR certified. 3. Resident #2 and Resident #3 currently had [MEDICAL CONDITION] available in the room. 4. On [DATE] and [DATE] the facility started CPR training and re-in-serving staff on the use of the AED,[MEDICAL CONDITION] with emergency care. 5. CPR policy was changed to [MEDICAL CONDITION] and AED placement. 6. Nurses will attend a local community college for skills check off before working on the floor. 7. On [DATE] RN A and LVN B received in-service and training on CPR on a resident with [MEDICAL CONDITION] the use of the AED, and documentation. 8. All new staff will have CPR Certification and will be checked -off prior to being assigned a resident with a trach. 9. All staff in-service on Abuse and Neglect by Abuse Coordinator- Administrator started on [DATE] and will be completed on [DATE]. 10. In-service for all licensed staff on Change of Condition Assessment was initiated on [DATE] and will be completed on [DATE]. The Plan of Removal concluded with Monitoring: Licensed staff and department heads will make safety rounds every two hours started on [DATE] for the next twenty-four hours. On [DATE]-[DATE], six licensed nurses and three CNAs (RN A, LVN B, CNA D, CNA E, CNA K, LVN I, LVN J, LVN L, LVN M, and LVN N), representing staff from all three shifts and week-end staff were interviewed regarding the in-services and training they received on the facility's CPR with [MEDICAL CONDITION] and AED. They were each able to explain what actions to take if a resident with a [MEDICAL CONDITION] was found unresponsive, not breathing and no pulse by placing the resuscitation bag over [MEDICAL CONDITION] to use the AED. Also if a resident without [MEDICAL CONDITION] found unresponsive, not breathing and no pulse by placing the resuscitation bag over the nose and mouth and to use the AED. Review of in service records dated [DATE] and [DATE] revealed 21 nursing staff that worked on all 3 shifts was in-service on CPR to include oral airway and trach. The DON provided on [DATE] a list of residents with 1 resident with [MEDICAL CONDITION] and 19 residents with full code status.

Based on interview and record review, it was determined the facility failed to implement their written policies and procedures that prohibited neglect for one (Resident #1) of six residents reviewed for neglect. Based on interview and record review, it was determined the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents choices for one (Resident #1) of six residents reviewed in the area of Cardiopulmonary Resuscitation and the use of an Automated External Defibrillator. 1. On [DATE], RN A and LVN B failed to suction Resident #1's trachea (an incision in the windpipe to open the restricted airway and enable breathing) to determine if the airway was occluded. RN A, LVN B and CNA D failed to connect the resuscitation bag to [MEDICAL CONDITION]. RN A, LVN B and CNA D incorrectly placed the resuscitation bag over the mouth and nose when Resident #1 was found non-responsive and unconscious. 2.On [DATE], RN A and LVN B failed to instruct CNA D with proper placement of the resuscitation bag over Resident #1's [MEDICAL CONDITION] rescue breathing during CPR. 3. On [DATE], RN A and LVN B failed to initiate the Automated External Defibrillator when RN A determined Resident #1 did not have a pulse. Resident #1 expired on [DATE] at 9:11 AM. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of patterned because the facility was still monitoring the Plan of Removal. These failures could affect the one resident with a [MEDICAL CONDITION] and 19 residents with full code status by placing them at risk for not receiving accurate procedure for CPR and further life-saving procedures, which could result in death. Findings included: Review of Resident #1's face sheet dated [DATE] reflected a [AGE] year old female admitted to the facility on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. Review of Resident#1's admission assessment dated [DATE] reflected Resident #1 was alert to her name and was not able to speak. She was bedfast with right sided [MEDICAL CONDITION] upper and lower extremity and was not weight bearing. She required extensive assistance with two people for ADL's and bed mobility. She was incontinent of bowel and bladder. The admission assessment revealed Resident # 1 had a [MEDICAL CONDITION]. Review of Resident #1's Consolidated Physician order [REDACTED].#1 had an order for [REDACTED]. Change inner cannula PRN (as needed). Change suction canister as needed; .[MEDICAL CONDITION] PRN . Change [MEDICAL CONDITION] .[MEDICAL CONDITION] at bedside for emergency placement? (sic) send with resident if transferred to hospital for replacement every shift. Review of Resident #1's Care Plan dated [DATE] reflected a full Code CPR order in Place, request for CPR to be initiated will be followed. Review of Resident #1's Nurse's note dated [DATE] at 10:22 AM by LVN B, reflected . Approximately at 8:50 AM called to the room by the CNA resident appeared to be unresponsive. Upon assessment noted her to be lying on her stomach. Repositioned and assessed, unable to obtain vital signs. Initiated code BLS (basic life support) with cash cart at bedside. Instructed (CNA E) to call 911 while BSL continued. EMSA (emergency medical service authority) arrived and took over code . continued until 9:22 AM pronounced at that time . Review of Resident #1's Record of Death dated [DATE] reflected Resident #1 expired at the facility on [DATE]. Interview on [DATE] at 7:50 AM with CNA D revealed she seen Resident #1 after breakfast around 8:30 AM, then at approximately 8:45 AM on [DATE], she entered Resident #1's room and noticed she was lying flat. She stated she turned her over and her eyes did not move, she was warm to touch and she had some white stuff around her mouth. CNA D said she went to the doorway and yelled get the crash cart. LVN B entered the room and said the resident was unresponsive and not breathing. CNA D stated CNA E helped her (CNA D) put the back board under Resident #1's back. RN A helped CNA D put the breathing mask over the resident's nose and mouth. CNA D revealed then RN A stated the resident had no pulse and start chest compression. CNA D said LVN B started doing the chest compressions and she (CNA) was squeezing the resuscitation bag. When asked if anyone had suctioned Resident #1's [MEDICAL CONDITION], she stated no and they did not use the AED. An interview on [DATE] at 8:56 AM with RN A charge nurse revealed she heard CNA D yell out get the crash cart. When she entered Resident #1's room, she assessed for a pulse and Resident #1 had a faint pulse. She stated CNA D got the resuscitation bag and placed it over Resident #1's nose and mouth. She stated I helped her hold her chin back. The oxygen tubing from the e-tank was connected to the resuscitation bag. She continued to state, I rechecked for a pulse and she did not have a pulse. I announced start chest compressions. LVN B was doing the chest compression and (CNA D) was doing the ventilation. When asked if Resident #1 had a trach, she stated yes. RN A stated she did not suction the resident'[MEDICAL CONDITION] check for an occlusion or obstruction. She stated no, she wasn't breathing, her chest was not rising. RN A revealed she did not initiate the AED. RN A stated she placed the resuscitation bag over the resident's mouth and nose. RN A was asked to verify where she placed the resuscitation bag and RN A repeated over the mouth and nose of resident. An interview on [DATE] at 12:10 PM with CNA C revealed at approximately 8:45 AM on [DATE], CNA D yelled call 911 get the crash cart. She stated she entered Resident #1's room and called 911 from her cell phone. She revealed Resident #1 was lying on her right side, she was not breathing, no noise coming from [MEDICAL CONDITION] she was not moving. She stated CNA D and CNA E started putting the back board under Resident #1's back. CNA C revealed LVN B entered the room and said the resident was non-responsive and not breathing. CNA C revealed then CNA D and RN A put the breathing mask over the resident's nose and mouth. She stated CNA D started squeezing the resuscitation bag, and LVN B started doing chest compressions. CNA C revealed Resident #1 was not suctioned, and the AED was not used. An interview on [DATE] at 8:25 AM with LVN B revealed at approximately 8:45 AM on [DATE], CNA D yelled to get the crash cart. She stated she entered the room found Resident #1 unresponsive and not breathing. She instructed CNA E to call 911. CNA D started rescue breathing, while RN A held her chin and held her head backward. LVN B stated the resuscitation bag was over the nose and mouth and she connected the oxygen to the resuscitation bag. LVN B stated the RN was the expert. The code continued until the paramedics arrive and the resident was pronounced dead. An interview on [DATE] at 10:37 AM with the DON revealed LVN B called her on [DATE] and informed her Resident #1 had coded and did not make it. She stated RN A was CPR certified and should have known how to handle a code blue. She stated she would expect RN A to have taken over the situation and assessed Resident#1's airway for blockage and used the AED. The DON revealed the nurses had a special training on the use of the AED (unknown date), and all staff had training on the use of the AED on [DATE]. She believed RN A and LVN B panicked during the code. Interview with the DON revealed RN A, LVN B and CNA D were still on duty after the incident on [DATE]. An interview on [DATE] at 11:58 AM with Resident #1's physician revealed he expected the facility to immediately initiate CPR on a resident with a full code status when a resident was unresponsive with no pulse. He stated he did not think a physician needed to write an order to use the AED. Resident #1's physician revealed he would expect the AED to be used on any resident with a full code status. An interview on [DATE] at 9:30 AM with the Administrator revealed RN A and LVN B were CPR certified and should have known how to handle a code blue. Review of RN A's Basic Life Support card revealed it was issued on ,[DATE] and the renewal date was ,[DATE]. Review of LVN B's Basic Life Support card revealed it was issued on [DATE] and the renewal date was ,[DATE]. Review of CNA D's Basic Life Support card revealed it was issued on [DATE] and the renewal date was ,[DATE]. Review of facility's Cardiopulmonary Resuscitation Policy dated ,[DATE] reflected under general guidelines . Specific procedures for CPR may very; verify procedure with the American heart Association and /or the American Red Cross in your area . The policy and procedure for Cardiopulmonary Resuscitation dated ,[DATE] did not address procedures for rescue breathing on a person with a [MEDICAL CONDITION] and AED placement. The policy was revised on [DATE] to address rescue breathing on a [MEDICAL CONDITION] and AED placement. Review of the facility's Automatic External Defibrillator (AED) policy dated ,[DATE] reflected that the AED would be used on victims of sudden [MEDICAL CONDITION] who were unconscious and unresponsive, not breathing and no pulse. AED must be used by or on the order of a physician and consistent with resident's advance directive. Review of the American National Red Cross- Basic Life Support for Healthcare Providers Handbook, 2016, reflected .emergency care procedures outlined in the program materials reflect the standard of knowledge and accepted emergency practices in the United States at the time this manual was published .AEDs are portable electronic devices that automatically analyze the patient's heart rhythm and can provide defibrillation, an electrical shock that may help the heart re-establish a rhythm. When a patient experiences a [MEDICAL CONDITION], an AED should be applied as soon as one is readily available. AEDs deliver defibrillation(s) to patients in [MEDICAL CONDITION] with two specific [MEDICAL CONDITION]: ventricular fibrillation (VF) and [MEDICAL CONDITION] (VT). By using an AED early, the patient's chances of survival are greatly increased. Review of CPR and Rescue Breathing for Adults with [MEDICAL CONDITION] (Ages 12 and Older) at https://www.cincinnatichildrens.org/health/c/adult-trach-cpr dated ,[DATE] revealed .3) after compressions, give breaths using a resuscitation bag attached to the trach. The Administrator was notified on [DATE] at 11:01 AM that an Immediate Jeopardy was identified and a plan of removal was requested at that time The facility's Plan of Removal was accepted on [DATE] at 1:16 PM and included: Implementation of Changes: 1. The facility hired a full time respiratory therapist on [DATE]. 2. The facility removed Resident#2 with a [MEDICAL CONDITION] from the facility, Resident #3 a [MEDICAL CONDITION] resident will not be readmitted into the facility until all staff has been trained [MEDICAL CONDITION] and emergency care of a trach, AED training and CPR certified. 3. Resident #2 and Resident #3 currently had [MEDICAL CONDITION] available in the room. 4. On [DATE] and [DATE] the facility started CPR training and re-in-serving staff on the use of the AED,[MEDICAL CONDITION] with emergency care. 5. CPR policy was changed to [MEDICAL CONDITION] and AED placement. 6. Nurses will attend a local community college for skills check off before working on the floor. 7. On [DATE] RN A and LVN B received in-service and training on CPR on a resident with [MEDICAL CONDITION] the use of the AED, and documentation. 8. All new staff will have CPR Certification and will be checked -off prior to being assigned a resident with a trach. 9. All staff in-service on Abuse and Neglect by Abuse Coordinator- Administrator started on [DATE] and will be completed on [DATE]. 10. In-service for all licensed staff on Change of Condition Assessment was initiated on [DATE] and will be completed on [DATE]. The Plan of Removal concluded with Monitoring: Licensed staff and department heads will make safety rounds every two hours started on [DATE] for the next twenty-four hours. On [DATE]-[DATE], six licensed nurses and three CNAs (RN A, LVN B, CNA D, CNA E, CNA K, LVN I, LVN J, LVN L, LVN M, and LVN N), representing staff from all three shifts and week-end staff were interviewed regarding the in-services and training they received on the facility's CPR with [MEDICAL CONDITION] and AED. They were each able to explain what actions to take if a resident with a [MEDICAL CONDITION] was found unresponsive, not breathing and no pulse by placing the resuscitation bag over [MEDICAL CONDITION] to use the AED. Also if a resident without [MEDICAL CONDITION] found unresponsive, not breathing and no pulse by placing the resuscitation bag over the nose and mouth and to use the AED. Review of in service records dated [DATE] and [DATE] revealed 21 nursing staff that worked on all 3 shifts was in-service on CPR to include oral airway and trach. The DON provided on [DATE] a list of residents with 1 resident with [MEDICAL CONDITION] and 19 residents with full code status.

Based on interview and record review, the facility failed to implement policies and procedures that prohibit neglect for one (Resident #1) of six residents reviewed for neglect. Based on interview and record review, it was determined the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents choices for one (Resident #1) of six residents reviewed in the area of Cardiopulmonary Resuscitation and the use of an Automated External Defibrillator. 1. On [DATE], RN A and LVN B failed to suction Resident #1's trachea (an incision in the windpipe to open the restricted airway and enable breathing) to determine if the airway was occluded. RN A, LVN B and CNA D failed to connect the resuscitation bag to [MEDICAL CONDITION]. RN A, LVN B and CNA D incorrectly placed the resuscitation bag over the mouth and nose when Resident #1 was found non-responsive and unconscious. 2.On [DATE], RN A and LVN B failed to instruct CNA D with proper placement of the resuscitation bag over Resident #1's [MEDICAL CONDITION] rescue breathing during CPR. 3. On [DATE], RN A and LVN B failed to initiate the Automated External Defibrillator when RN A determined Resident #1 did not have a pulse. Resident #1 expired on [DATE] at 9:11 AM. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of patterned because the facility was still monitoring the Plan of Removal. These failures could affect the one resident with a [MEDICAL CONDITION] and 19 residents with full code status by placing them at risk for not receiving accurate procedure for CPR and further life-saving procedures, which could result in death. Findings included: Review of Resident #1's face sheet dated [DATE] reflected a [AGE] year old female admitted to the facility on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. Review of Resident#1's admission assessment dated [DATE] reflected Resident #1 was alert to her name and was not able to speak. She was bedfast with right sided [MEDICAL CONDITION] upper and lower extremity and was not weight bearing. She required extensive assistance with two people for ADL's and bed mobility. She was incontinent of bowel and bladder. The admission assessment revealed Resident # 1 had a [MEDICAL CONDITION]. Review of Resident #1's Consolidated Physician order [REDACTED].#1 had an order for [REDACTED]. Change inner cannula PRN (as needed). Change suction canister as needed; .[MEDICAL CONDITION] PRN . Change [MEDICAL CONDITION] .[MEDICAL CONDITION] at bedside for emergency placement? (sic) send with resident if transferred to hospital for replacement every shift. Review of Resident #1's Care Plan dated [DATE] reflected a full Code CPR order in Place, request for CPR to be initiated will be followed. Review of Resident #1's Nurse's note dated [DATE] at 10:22 AM by LVN B, reflected . Approximately at 8:50 AM called to the room by the CNA resident appeared to be unresponsive. Upon assessment noted her to be lying on her stomach. Repositioned and assessed, unable to obtain vital signs. Initiated code BLS (basic life support) with cash cart at bedside. Instructed (CNA E) to call 911 while BSL continued. EMSA (emergency medical service authority) arrived and took over code . continued until 9:22 AM pronounced at that time . Review of Resident #1's Record of Death dated [DATE] reflected Resident #1 expired at the facility on [DATE]. Interview on [DATE] at 7:50 AM with CNA D revealed she seen Resident #1 after breakfast around 8:30 AM, then at approximately 8:45 AM on [DATE], she entered Resident #1's room and noticed she was lying flat. She stated she turned her over and her eyes did not move, she was warm to touch and she had some white stuff around her mouth. CNA D said she went to the doorway and yelled get the crash cart. LVN B entered the room and said the resident was unresponsive and not breathing. CNA D stated CNA E helped her (CNA D) put the back board under Resident #1's back. RN A helped CNA D put the breathing mask over the resident's nose and mouth. CNA D revealed then RN A stated the resident had no pulse and start chest compression. CNA D said LVN B started doing the chest compressions and she (CNA) was squeezing the resuscitation bag. When asked if anyone had suctioned Resident #1's [MEDICAL CONDITION], she stated no and they did not use the AED. An interview on [DATE] at 8:56 AM with RN A charge nurse revealed she heard CNA D yell out get the crash cart. When she entered Resident #1's room, she assessed for a pulse and Resident #1 had a faint pulse. She stated CNA D got the resuscitation bag and placed it over Resident #1's nose and mouth. She stated I helped her hold her chin back. The oxygen tubing from the e-tank was connected to the resuscitation bag. She continued to state, I rechecked for a pulse and she did not have a pulse. I announced start chest compressions. LVN B was doing the chest compression and (CNA D) was doing the ventilation. When asked if Resident #1 had a trach, she stated yes. RN A stated she did not suction the resident'[MEDICAL CONDITION] check for an occlusion or obstruction. She stated no, she wasn't breathing, her chest was not rising. RN A revealed she did not initiate the AED. RN A stated she placed the resuscitation bag over the resident's mouth and nose. RN A was asked to verify where she placed the resuscitation bag and RN A repeated over the mouth and nose of resident. An interview on [DATE] at 12:10 PM with CNA C revealed at approximately 8:45 AM on [DATE], CNA D yelled call 911 get the crash cart. She stated she entered Resident #1's room and called 911 from her cell phone. She revealed Resident #1 was lying on her right side, she was not breathing, no noise coming from [MEDICAL CONDITION] she was not moving. She stated CNA D and CNA E started putting the back board under Resident #1's back. CNA C revealed LVN B entered the room and said the resident was non-responsive and not breathing. CNA C revealed then CNA D and RN A put the breathing mask over the resident's nose and mouth. She stated CNA D started squeezing the resuscitation bag, and LVN B started doing chest compressions. CNA C revealed Resident #1 was not suctioned, and the AED was not used. An interview on [DATE] at 8:25 AM with LVN B revealed at approximately 8:45 AM on [DATE], CNA D yelled to get the crash cart. She stated she entered the room found Resident #1 unresponsive and not breathing. She instructed CNA E to call 911. CNA D started rescue breathing, while RN A held her chin and held her head backward. LVN B stated the resuscitation bag was over the nose and mouth and she connected the oxygen to the resuscitation bag. LVN B stated the RN was the expert. The code continued until the paramedics arrive and the resident was pronounced dead. An interview on [DATE] at 10:37 AM with the DON revealed LVN B called her on [DATE] and informed her Resident #1 had coded and did not make it. She stated RN A was CPR certified and should have known how to handle a code blue. She stated she would expect RN A to have taken over the situation and assessed Resident#1's airway for blockage and used the AED. The DON revealed the nurses had a special training on the use of the AED (unknown date), and all staff had training on the use of the AED on [DATE]. She believed RN A and LVN B panicked during the code. Interview with the DON revealed RN A, LVN B and CNA D were still on duty after the incident on [DATE]. An interview on [DATE] at 11:58 AM with Resident #1's physician revealed he expected the facility to immediately initiate CPR on a resident with a full code status when a resident was unresponsive with no pulse. He stated he did not think a physician needed to write an order to use the AED. Resident #1's physician revealed he would expect the AED to be used on any resident with a full code status. An interview on [DATE] at 9:30 AM with the Administrator revealed RN A and LVN B were CPR certified and should have known how to handle a code blue. Review of RN A's Basic Life Support card revealed it was issued on ,[DATE] and the renewal date was ,[DATE]. Review of LVN B's Basic Life Support card revealed it was issued on [DATE] and the renewal date was ,[DATE]. Review of CNA D's Basic Life Support card revealed it was issued on [DATE] and the renewal date was ,[DATE]. Review of facility's Cardiopulmonary Resuscitation Policy dated ,[DATE] reflected under general guidelines . Specific procedures for CPR may very; verify procedure with the American heart Association and /or the American Red Cross in your area . The policy and procedure for Cardiopulmonary Resuscitation dated ,[DATE] did not address procedures for rescue breathing on a person with a [MEDICAL CONDITION] and AED placement. The policy was revised on [DATE] to address rescue breathing on a [MEDICAL CONDITION] and AED placement. Review of the facility's Automatic External Defibrillator (AED) policy dated ,[DATE] reflected that the AED would be used on victims of sudden [MEDICAL CONDITION] who were unconscious and unresponsive, not breathing and no pulse. AED must be used by or on the order of a physician and consistent with resident's advance directive. Review of the American National Red Cross- Basic Life Support for Healthcare Providers Handbook, 2016, reflected .emergency care procedures outlined in the program materials reflect the standard of knowledge and accepted emergency practices in the United States at the time this manual was published .AEDs are portable electronic devices that automatically analyze the patient's heart rhythm and can provide defibrillation, an electrical shock that may help the heart re-establish a rhythm. When a patient experiences a [MEDICAL CONDITION], an AED should be applied as soon as one is readily available. AEDs deliver defibrillation(s) to patients in [MEDICAL CONDITION] with two specific [MEDICAL CONDITION]: ventricular fibrillation (VF) and [MEDICAL CONDITION] (VT). By using an AED early, the patient's chances of survival are greatly increased. Review of CPR and Rescue Breathing for Adults with [MEDICAL CONDITION] (Ages 12 and Older) at https://www.cincinnatichildrens.org/health/c/adult-trach-cpr dated ,[DATE] revealed .3) after compressions, give breaths using a resuscitation bag attached to the trach. The Administrator was notified on [DATE] at 11:01 AM that an Immediate Jeopardy was identified and a plan of was requested at that time The facility's Plan of Removal was accepted on [DATE] at 1:16 PM and included: Implementation of Changes: 1. The facility hired a full time respiratory therapist on [DATE]. 2. The facility removed Resident#2 with a [MEDICAL CONDITION] from the facility, Resident #3 a [MEDICAL CONDITION] resident will not be readmitted into the facility until all staff has been trained [MEDICAL CONDITION] and emergency care of a trach, AED training and CPR certified. 3. Resident #2 and Resident #3 currently had [MEDICAL CONDITION] available in the room. 4. On [DATE] and [DATE] the facility started CPR training and re-in-serving staff on the use of the AED,[MEDICAL CONDITION] with emergency care. 5. CPR policy was changed to [MEDICAL CONDITION] and AED placement. 6. Nurses will attend a local community college for skills check off before working on the floor. 7. On [DATE] RN A and LVN B received in-service and training on CPR on a resident with [MEDICAL CONDITION] the use of the AED, and documentation. 8. All new staff will have CPR Certification and will be checked -off prior to being assigned a resident with a trach. 9. All staff in-service on Abuse and Neglect by Abuse Coordinator- Administrator started on [DATE] and will be completed on [DATE]. 10. In-service for all licensed staff on Change of Condition Assessment was initiated on [DATE] and will be completed on [DATE]. The Plan of Removal concluded with Monitoring: Licensed staff and department heads will make safety rounds every two hours started on [DATE] for the next twenty-four hours. On [DATE]-[DATE], six licensed nurses and three CNAs (RN A, LVN B, CNA D, CNA E, CNA K, LVN I, LVN J, LVN L, LVN M, and LVN N), representing staff from all three shifts and week-end staff were interviewed regarding the in-services and training they received on the facility's CPR with [MEDICAL CONDITION] and AED. They were each able to explain what actions to take if a resident with a [MEDICAL CONDITION] was found unresponsive, not breathing and no pulse by placing the resuscitation bag over [MEDICAL CONDITION] to use the AED. Also if a resident without [MEDICAL CONDITION] found unresponsive, not breathing and no pulse by placing the resuscitation bag over the nose and mouth and to use the AED. Review of in service records dated [DATE] and [DATE] revealed 21 nursing staff that worked on all 3 shifts was in-service on CPR to include oral airway and trach. The DON provided on [DATE] a list of residents with 1 resident with [MEDICAL CONDITION] and 19 residents with full code status.

Based upon observation, interview, and record review, it was determined the facility failed to ensure personal safety devices were used to prevent accidents for three (Residents #1, #2, and #3) of six residents resulting in one (Resident #1) resident falling and sustaining a left hip fracture. Resident #1 fell on [DATE] and was hospitalized due to a left hip fracture. The resident was care planned to have a bed and chair alarm to assist in preventing the resident from falling after she sustained a right hip fracture on 04/27/11. When she fell on [DATE], the resident's bed alarm was not applied and did not sound to alert staff that the resident was attempting to transfer out of her low bed. Another resident notified the nursing staff of the resident's fall. On 05/27/11, two (Residents #2 and #3) of eight current residents identified in the facility who required the use of a personal safety device were observed without their personal safety devices applied properly. Both of these residents resided on one (Hall 200) of the facility's six nursing hallways. This was the same hallway on which Resident #1 resided. In addition, staff did not respond in a prompt manner on 05/27/11 when Resident #2 activated his bed alarm while in his low bed. This failure to ensure Resident #1's personal safety alarm was applied correctly prevented the facility staff from being alerted to the resident attempting to transfer from her bed unassisted. Resident #1 fell and sustained a left hip fracture as the result of a fall on 05/21/11. These failures had the potential to affect the eight of the facility's 108 current residents in the facility who were identified as requiring the use of personal safety alarms to aid in preventing falls. Findings included: 1) Resident #1's Face Sheet dated 11/26/10 reflected she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #1's significant change MDS assessment with an assessment reference date of 05/06/11 and completion date of 05/10/11 reflected Resident #1 scored a 6 out of 15 on the BIMS which reflected she was assessed to have severe cognitive impairment. The MDS assessment further reflected Resident #1 required the extensive assistance of two people for bed mobility, transfer, and bathing. The assessment reflected Resident #1 required the extensive assistance of one person to walk, for locomotion on/off the unit, and toilet use. In addition, the assessment reflected Resident #1 was not steady and only able to stabilize with human assistance when moving from a seated to a standing position, walking, moving on and off the toilet, and during surface-to-surface transfers. She was assessed to be unable to turn around and face the opposite direction while walking. Mobility devices used normally by the resident were a walker and wheelchair as reflected by the MDS assessment. Resident #1's Care Plan dated 04/29/11 reflected: "Problem Onset: 04/29/2011 Multiple falls associated with history of falling at NH. Potential for further falls. Does not ask for assistance when transferring. Decline in cognition. *Will receive no serious injury that requires hospitalization from falling for the next 90 days; * Call light in reach when she is in room. * Give resident verbal reminders not to transfer without assistance. * Obtain pertinent information at time of fall to identify precipitating factors. * Assist with transfers for stability per staff. * Assess medications as needed that may increase resident fall risk. * Therapy to screen as needed. * Physical assessment for injuries as needed. * Notify physician/family of falls as needed. * Low bed manual/electric in low position while resident in bed/full mat. * Bed/chair alarm." 2) On 05/27/11 at 9:14 AM, Resident #1's family member was interviewed via telephone. He/She explained he/she expressed to concerns regarding Resident #1 falling after she returned to the facility from the hospital on [DATE]. He/She stated the resident had been pushed by another resident on 04/27/11, and she sustained a right hip fracture at the time. When she returned to the facility, the resident began falling. The family member stated Resident #1 fell four times on the weekends. The family member stated he/she spoke with a weekend nurse, and he/she urged them to watch Resident #1 more closely. He/She stated the weekend nurse, whom he/she could not identify by name, told the family they would have to wait until Monday to see what the doctor ordered. The family member explained Resident #1 was confused, and she was constantly trying to get up on her own. He/She explained Resident #1 was independent and capable of walking unassisted prior to the hip fracture. The family member stated he/she went to the facility during the week to speak with nursing staff, and he/she stated it was decided Resident #1 would be moved to a room closer to the nurses' station for closer monitoring. In addition, the resident was placed on a low bed with mats, and she had personal safety alarms in place. However, on 05/21/11 at approximately 5:00 AM, Resident #1 fell from her bed. The family member stated he/she visited the resident later that day at the facility. While at the facility, he/she spoke with Resident #4, who resided in the room next door to Resident #1. Resident #4 informed the family member he heard Resident #1 fall that morning, and he called the nurse on his cell phone to get her help. The family member stated Resident #1 was hospitalized that day, and it was determined she had a left hip fracture requiring a rod placement. This was in addition to the right hip fracture she sustained at the facility on 04/27/11. 3) A Resident Incident Report completed by LVN A and dated 05/21/11 reflected: "Narrative of incident and description of injuries...: Resident (Resident #1) noted sitting on buttock on floor in front of bed, denies pain & discomfort, no (symbol used) s/s of swelling to extremities, no (symbol used) tramu (sic) to head noted." The time of the incident was recorded as 5:40 AM. LVN A's attached handwritten Witness Statement dated 05/21/11 reflected: "Resident noted sitting on buttock on floor in front of bed, denies pain & discomfort, no (symbol used) s/s of swelling to extermities (sic), no (symbol used) tramu (sic) to head noted. Resident moves all exermities (sic) well. Alert & oriented to name. Resident assisted x 2 staff members to bed." CNA B's attached handwritten Witness Statement dated 05/25/11 reflected: "On 5-20-11 Nurse ________ ____ (LVN) (LVN A) called me to Rm (Resident #1) for B-bed pt. (______ (Resident #1)). Pt was on the mat on the floor. I had just completed my rounds for 200 hall. I assisted Ms. ______ (Resident #1) back onto her bed. The nurse assessed her for injuries. Pt stated she was in pain a little bit. No other comments on incident." RN E documented the following Progress Note also attached to the facility's Resident Incident Report regarding Resident #1's incident on 05/21/11: "5/21/11 8AM (8:00 AM) - Pt in room on her bed calling for nurse to help her. Upon arriving to Pt room she c/o being sore to right (symbol used) hip area. Pain meds Norco 5/325 mg given as ordered. Pt cont to call for help. VSS 97.4 (temperature)- 82 (pulse) - 18 (respirations) - 128/72 (blood pressure). New bruising, edema, tenderness with (symbol used) palpitation to left (symbol used) hip area per pt. STAT xray called again by wknd supp to find out when they will be arriving to facility for xray. It was reported to supp they did not get any call early AM. Will be in as soon as possible. Will cont to monitor. 8:20 AM - Pt denies pain ate dinner, but Pt c/o tenderness with (symbol used) movement and will not extend left (symbol used) leg cont to monitor. 9 AM (9:00 AM) - Pt (family member) (RP) ____ ______ by bedside. Pt talking and laughing with (symbol used) family. (Other family member) present too. 11 AM (11:00 AM) - Pt in bed denies pain or distress. 11:30 AM - DON notified by wknd supp that xray not done yet awaiting for STAT xray. 1 PM (1:00 PM) - STAT xray arrived. Hip & pelvic xray done but when about to reposition pt to cont xray pt started c/o severe pain Norco routine 5/325 given. 1:15 PM - PA ______ notified via phone, message left to call back. N/O to send pt to ______ ______ (hospital) for possible fx of the hip/pain. Per pt pain is now a 2 on pain scale. It was an 8 initially. RP - ____ ______ notified. 1:30 PM - ___ (Ambulance) transportation notified. Cont to monitor. Pt c/o tenderness - denies severe pain - pain a one on scale at this time. ___ (Ambulance) arrived. Pt transported to ______ ______ (hospital) ER. Called in reported to ____ __ (Hospital Nurse) in ER Dept. Pt (family member) notified plus phone no. to ______ Hosp ER (Dallas) given to (family member)...." 4) Resident #4 was interviewed on 05/27/11 at 11:35 AM at the facility regarding Resident #1's incident. He stated on the morning of 05/21/11 the CNAs had just finished making their rounds on Hall 200 where he and Resident #1 both resided. He stated he heard some loud noises that sounded like someone had gotten up and fallen. He stated he was awake at the time watching television. He stated upon hearing the loud noises he put his call light, and he waited about 5 - 10 minutes. He stated he did not hear the call light making the sound he usually heard which sounded like a ding, and he thought the call lights might have not been working. He then used his personal cell phone to call the nurses' station. He stated he talked to the nurse, and he told her what he heard. He stated she immediately responded. He stated he found out Resident #1 had fallen, and she was probably to trying to get up and go to the bathroom on her own. Resident #4 was asked if he heard an alarm sounding when he heard the loud noises. He stated he did not hear an alarm. For clarification purposes, he was aware of the personal safety alarms used by some of the residents in the facility that sounded when they got up. He confirmed he was aware of such devices, and he denied hearing one the morning Resident #1 fell . 5) CNA B was interviewed via telephone on 05/27/11 at 12:59 PM. She confirmed she was a 10:00 PM - 6:00 AM CNA at the facility. She stated she was working on Hall 200 on 05/21/11. She stated she had just completed her rounds on Hall 200, and she had gone to drop something off at the soiled linen room. She was called to Resident #1's room by LVN A. When she got to Resident #1's room, she observed Resident #1 lying with her body partially on the mat and the floor next to the bed. CNA B was asked if she heard the bed alarm sounding when she entered Resident #1's room. She stated she thought she heard the alarm, and the resident might have been sitting on it on the mat. CNA B stated she did not normally work on the hall, and she had previously been working at the facility as a sitter for another resident. When asked how she knew which residents were supposed to have personal safety alarms, she stated she oriented with CNA F. She stated CNA F told her about all of the residents on the hall. She stated that was how she found out about the residents who needed an alarm. When asked if she had provided any care to Resident #1 on her last rounds on Hall 200, she stated she had assisted the resident early during the shift with toileting. 6) LVN A was interviewed via telephone on 05/27/11 at 3:13 PM. She confirmed she worked at the facility as a 10:00 PM - 6:00 AM Charge Nurse. She stated at around 5:40 AM on 05/21/11 she received a phone call from Resident #4. She stated Resident #4 informed her someone had fallen. She explained the call lights in the building were malfunctioning that morning. She went down Hall 200 where Resident #4 resided, and she discovered Resident #1 sitting on her buttocks on the floor mat by her bed. She stated she felt Resident #1's hips to see if they were even, and she did not feel anything. She stated she then called the x-ray company to order a STAT x-ray. LVN A was asked if Resident #1's personal safety alarm or bed alarm was sounding upon her entry to the room. She stated it was not sounding, and it was not attached to the resident. She stated she observed the bed alarm on the resident's bed. 7) RN E was interviewed via telephone on 05/27/11 at 3:05 PM. She stated she normally worked at the facility as a 2:00 PM - 10:00 PM Charge Nurse, but she filled in for someone on the 6:00 AM - 2:00 PM shift on 05/21/11. When she arrived at the facility that day, she stated she received report from LVN A that Resident #1 had fallen around 5:00 AM. She stated the resident was not complaining of pain at that time, and there were no apparent injuries. Later that morning, she stated Resident #1's family members visited her, and the resident was observed talking and laughing with them. She stated once the x-ray technicians arrived at the facility they were able to do one x-ray, but when they tried to move Resident #1 she began to scream out in pain. She stated she contacted the resident's PA, and she received an order to send the resident to the hospital. 8) LVN G was interviewed at the facility on 05/27/11 at 2:16 PM. She stated she met with Resident #1's family for a care plan conference after the resident began falling following her return from the hospital on [DATE]. She stated the family was concerned about the falls. To address the falls, they decided to move Resident #1 to a room closer to the nurses' station because the room she was residing in was at the end of a hallway. They also decided to place the resident in a low bed with a mat next to the bed on the floor, and bed and chair alarms were used as well. 9) The DON was interviewed at the facility on 05/27/11 at 2:25 PM. He stated he received a call from the nursing staff on 05/21/11 regarding the x-ray service not showing up at the facility to x-ray Resident #1. He stated he immediately contacted the owner of the x-ray, and he was told the x-ray technicians got held up at another facility. When he spoke with RN E, she told him Resident #1 was fine when her family visited her. He stated when he spoke with the nursing staff regarding Resident #1 there did not seem to be any problems. He was asked if there was a place on the Incident Report to reflect what interventions or approaches were identified to prevent and address falls after a resident had a fall. He stated there usually was something. The DON was asked about the lack of documentation on the Incident Report regarding how the resident was found with regards to her having her personal safety alarm in place when she fell on [DATE]. He acknowledged this information was not included in LVN A's report. 10) The Administrator was interviewed at 3:30 PM on 05/27/11. He stated he was out-of-town on 05/21/11, but he received a text message from the DON regarding the fall. He did not hear anything more about Resident #1's fall until the morning meeting on Monday, 05/23/11. He did not have any knowledge about the resident's alarm not sounding or possibly not being applied correctly when she fell on [DATE]. 11) On 05/27/11, the facility provided the surveyor with a list of all residents who required the use of personal safety devices. This list reflected eight of the facility's current 108 residents required the use of a personal safety device including Resident #1. During observation rounds on 05/27/11, six of the eight listed residents were observed, and of the six residents, two (Residents #2 and #3) did not have their personal safety devices applied correctly. Both of these residents resided on Hall 200 where Resident #1 resided. At 1:30 PM on 05/27/11, the surveyor began observation rounds in the facility to determine if the personal safety devices of the residents on the list were being applied and used appropriately. Resident #2 was the first resident observed at 1:30 PM. During the observation, he was seated in his wheelchair in his room. A blue alarm box and cord were observed in the front pocket of his plaid shirt. The alarm was not attached to anything, which meant it would not activate and sound if the resident attempted to rise out of the wheelchair. At 1:32 PM on 05/27/11, the surveyor went to Resident #3's room. The resident was in bed at the time with her covers pulled up over her head. The resident was lying on her left side. The blue personal alarm box could be seen underneath the top of the pillow she had her head on at that time. CNA D entered the room during this observation. She was asked where the resident's alarm was attached. She proceeded to remove the blue alarm box from under the pillow. She was asked where the cord was attached. She pulled the cord, and the clip was not attached to anything, which meant it would not activate or sound if the resident attempted to transfer/roll out of bed. At 1:34 PM on 05/27/11, the surveyor returned to Resident #2's room. He was still seated in the wheelchair in his room, but the personal safety alarm was attached appropriately to the wheelchair. The cord was clipped to the back of his shirt. At 2:00 PM on 05/27/11, LVN C was interviewed regarding Residents #2 and #3. He was informed of the observations of the residents' safety devices not being applied correctly. He stated both Residents #2 and #3 were able to remove the personal safety devices because they knew what they were. When asked how the CNAs who worked on his hall knew which residents required personal safety devices, he stated he had a meeting each morning with the CNAs. He stated he discussed his expectations of the aides to include ensuring that the personal safety devices were still working and had functional batteries. At 3:18 PM on 05/27/11, the surveyor, who was working in the room next door to Resident #2's room, heard a loud alarm sounding. The surveyor went into the hallway, and staff were observed at the nurses' station and in an office across the hall. None of the staff were observed responding to the sounding alarm. The surveyor walked down the hall and discovered that the alarm was sounding in Resident #2's room. Resident #2 was observed lying awake on his low bed pulling at the personal safety alarm attached to his bedding. At 3:22 PM on 05/27/11, the DON responded to Resident #2's sounding alarm. This was approximately four minutes after the surveyor first heard the alarm sounding. 12) Resident #2's Face Sheet dated 03/22/11 reflected he was admitted to the facility on [DATE] with a re-admission on 02/18/11. Resident #2's April 2011 Physician order [REDACTED]. Resident #2's Care Plan dated 02/18/11 reflected: "Problem Onset: 02/18/2011 Has has (sic) history of a (sic) falls, potential to fall associated with cva and low vision. * Receive no injury due to falling for next 90 days. * Use wheelchair to transport resident, or assist with ambulation as needed. * Call light in reach when he is in room. * Check for needs q 2 hours and prn. * Keep room free of clutter. * Needs supervision with transfer and and (sic) ambulation. * Obtain pertinent information at time of fall to identify precipitating factors. * Assess medications as needed that may increase resident fall risk. * Therapy to screen as needed. * If resident gets up to walk, supervise him due to unsteady gait. * Bed/chair alarm. * Low bed. * Give resident verbal reminders not to transfer without assistance. * Assist with transfers for stability per staff." Resident #2's significant change MDS assessment with an assessment reference date of 04/02/11 and completion date of 04/03/11 reflected Resident #2 rarely or never understood others or was understood by others. The assessment reflected he had severe cognitive impairment with both short-term and long-term memory problems. The MDS assessment also reflected Resident #2 required the extensive assistance of one person for transfers and bed mobility. 13) Resident #3's Face Sheet dated 05/03/11 reflected she was admitted to the facility on [DATE]. Resident #3's April 2011 Physician order [REDACTED]. The orders also reflected Resident #3 was supposed to have a chair alarm on while up in a chair, and a bed alarm when she was in bed. Resident #3's Care Plan updated on 04/09/11 reflected: "Problem Onset: 10/22/2010 Resident has at home history of falls with recent fall in NH....Continues to have falls does not ask for assistance with transferring, falls on 3-7-11, 3-14-11, 3-20-11. *Will receive no serious injuries that requires hospitalization s from falling for the next 90 days. * Give resident verbal reminders not to transfer without assistance. * Bed/Chair alarm. * Obtain pertinent information at time of fall to identify precipitating factors. * Assess medications as needed that may increase resident fall risk. * Assist with transfers for stability per staff. * Therapy to screen as needed. * Monitor positioning when up in wheelchair and reposition for safety as needed. * Physical assessment for injuries as needed. * Notify physician/family of falls as needed." Resident #3's quarterly MDS assessment with an assessment reference date of 04/09/11 and a completion date of 04/18/11 reflected Resident #3 scored a 5 out of 15 on the BIMS, which indicated the resident had severe cognitive impairment. The MDS assessment further reflected Resident #3 required the extensive assistance of one person for bed mobility and transfers. The resident was assessed to not be steady and only able to stabilize with human assistance when moving from seated to standing positions, walking, moving on and off the toilet, and during surface-to-surface transfers. 14) The eight residents potentially affected by this failure were identified on a list entitled 'Personal Safety Devices', which was provided by the facility and was undated.