Every finding on record at Briarcliff Health Center

Based on interviews and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 12 medication carts reviewed for pharmacy services (Nurse Cart A/B, Nurse Cart B/C, MA Cart B/C). The facility failed to ensure the nursing staff responsible for the safekeeping of narcotics performed and rightfully documented 81 change of shift narcotic counts from July 1 through July 21, 2026 for Nurse Cart A/B, Nurse Cart B/C, and MA Cart B/C medication carts. The facility failed to ensure MA-F did not sign as having completed a change of shift narcotic count before the change of shift narcotic count occurred on July 22, 2026. These failures could place residents at risk for missing medications administration and possible drug diversion. Findings included: Observation and record review on 07/21/2026 at 09:12 AM of the medication carts and the July 2026 Controlled Substance Count Records indicated there were multiple missing signatures indicating change of shift narcotic counts were not completed as required from 07/01/2026 to 07/22/2026. The count sheets indicated the carts were to be counted at the beginning and end of each shift. Missing signatures for 07/01/2026 through 07//22/2026 were as follows: The Controlled Substance Count Record for Nurse Cart A/B was noted to have 32 missing signatures indicating 29 change of shift counts were not performed on the following dates and times:6am: 5 missing signatures noted for July 1, 3,11, 16, and 17, 2026,2pm: 13 missing signatures noted for July 3, 7, 8, 9, 10, 13, 14, 15, 16, 17, 20, and 21, 2026,10pm: 14missing signatures noted for July 2, 3, 7, 8, 9, 10, 13, 14, 15, 16, 20, and 21, 2026. The Controlled Substance Count Record for Nurse Cart B/C was noted to have 10 missing signatures indicating 10 change of shift counts were not performed on the following dates and times:6am: 4 missing signatures noted for July 11,12, 13, and 21, 2026,2pm: 2 missing signatures noted for July 17 and 21, 2026, 10pm: 4 missing signatures noted for July 10, 11, 12, and 21, 2026. The Controlled Substance Count Record for MA Cart B/C was noted to have 56 missing signatures indicating 42 change of shift counts were not performed on the following dates and times:6am: 21 missing signatures noted for July 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17,18, 19, 20, and 21, 2026,2pm: 14 missing signatures noted for July 1, 3, 4, 5, 11, 12, 18, and 19, 2026. 10pm: 21 missing signatures noted for July 1, 3, 4, 5, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, and 21, 2026. During an interview on 07/22/2026 at 09:15 AM, LVN-B said the licensed nurses and medication aides were supposed to perform a narcotic count at each shift change. LVN-B said the nurse or medication aide going off duty was supposed to count the narcotics with the nurse or medication aide coming on duty. She said the nursing staff who performed a change of shift narcotic count signed the Controlled Substance Count Record to indicate the change of shift narcotic count had been done. She said if the count record wasn't signed, then the change of shift narcotic count was considered not done. LVN-B said change of shift narcotic counts were important for preventing a drug diversion or loss of medications. During an interview on 07/22/2026 at 10:10 AM, MA-F said she counted the narcotics when she came on duty with the night nurse and counted with the medication aide who relieved her at the end of her shift. MA-F could not explain what the signatures on the Controlled Substance Count Records were for. While reviewing the Controlled Substance Count Record with MA-F, it was noted that MA-F had already signed the form as having performed the 02:00 PM change of shift narcotic count. MA-F could not explain why she had signed as having performed a narcotic count inventory before the 2pm shift had started. During an interview on 07/22/2026 at 10:35 AM, MA-H said change of shift narcotic counts were important for ensuring there were no missing or unaccounted for narcotics. She said missing signatures indicated the change of shift narcotics counts were not done. During an interview 07/22/2026 at 10:45 AM, LVN-G said there was no acceptable excuse for not performing change of shift narcotic counts or signing the count sheets after performing the change of shift narcotic counts. She said change of shift narcotic counts were supposed to be done by 2 staff persons, the nurse or medication aide coming on duty and the medication aide or nurse going off duty. LVN-G said the task of performing change of shift narcotic counts was important for ensuring all narcotics are accounted for. She said the signatures on the narcotic count sheets were proof the change of shift count was done. During an interview on 06/28/2026 at 02:05 PM, the ADON said the purpose of narcotic counts between the oncoming and off-going medication aides and nurses was to ensure all narcotics were accounted for and to reduce the risk of misappropriation or unaccounted for narcotics. She said the nurses and medication aides had received training on performing change of shift narcotic counts and signing the Controlled Substance Count records as evidence of performing those counts. She said the unit managers, herself, and the DON were ultimately responsible for ensuring the nursing staff performed their duties. A review of the facility's policy dated December 2018 and titled Medication - Controlled Administration indicated the following: Standard: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, and record keeping in the facility, in accordance with federal and state laws and regulations. Procedure: . 7. At each shift change, a physical inventory (counting) of controlled medications, as defined by state laws, is conducted by two licensed clinicians and is documented on an audit record.

Based on interviews and record review, the facility failed to ensure residents have the right to request, refuse, and or discontinue treatment and to formulate an advance directive for 1 (Resident #96) of 6 residents reviewed for resident rights. The facility failed to have Resident #96's Out-of-Hospital Do Not Resuscitate (OOH DNR) followed through in a timely manner. This failure could place residents at risk of not having their end-of-life wishes honored. Record review of Resident #96's admission record dated 06/19/2026 revealed he was an [AGE] year-old male admitted on [DATE]. His relevant diagnoses included Type 2 Diabetes Mellitus, essential hypertension, Parkinson, kidney failure (a condition in which the kidneys lose the ability to remove waste and balance fluids), chronic obstructive pulmonary (a group of lung diseases that block airflow and make it difficult to breathe), and lack of coordination ( a neurological condition that causes difficulty controlling muscle movements and balance). A record review of a quarterly MDS assessment dated [DATE] noted Resident #96 had a BIMS score of 14 which indicated cognitively intact brain function. Record review of Resident #96's care plan dated 06/26/2026 reflected a focus of full code status, his interventions, in part, included to ensure his advanced directives, care wishes, and code status would be respected and honored as indicted (date initiated 6/29/2026). Record review of Resident #96's order summary dated 06/19/2026 reflected a Full Code Status. A record review of Resident #96's EHR noted his profile was flagged with a Full Code status. A record review of an OOH DNR form with witness signatures dated 07/14/2026 indicated the form was signed by Resident #96's agent represented by his medical Power of Attorney. Further review of the form indicated the physician signed and dated 7/14/2026. During an interview on 07/21/2026 at 10:30 a.m., the ADON said it was the responsibility of the facility's SW to ensure an OOH-DNR form was obtained and correctly completed for each DNR resident. She said as long as there was an active DNR order, the code status of DNR would be entered on the resident's medical electronic record (profile and care plan). She said if a resident coded, nursing staff would immediately check the resident's electronic medical record for their code status under their profile and ensure there was an active DNR order. She said as long as their profile and order matched, the resident would be considered a DNR. The ADON said she had instructed the nursing staff that if they had any doubt about a resident's code status, to immediately call the resident's representative. The ADON said, whatever is active as an order is what would be most current. The ADON said the topic of advanced directives was part of the nurse's skill check offs, which were done yearly or as needed. During an interview on 07/21/2026 at 03:58 PM, the SW said she was responsible for ensuring OOH DNR forms were properly executed with dated signatures of both the person requesting DNR status and the physician. She said she had been on vacation, and at that time, it was the responsibility of the Unit manager, who did not follow through with orders or placed them correctly in the charts. The SW said incomplete and inaccurately executed OOH DNR forms could place residents at risk for receiving resuscitation actions against their desired wishes and/or instructions. A review of the facility's undated policy titled Advance Directives and Associated Documentation indicated the following: It is the policy of this facility to implement the resident decisions and directives that are in compliance with State and/or Federal Law and the policies of this facility.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 5 residents (Resident #7) reviewed for care plans. 1.The facility failed to ensure Resident #7's comprehensive care plan included interventions to address antibiotic therapy for the treatment of a urinary tract infection. 2.The facility failed to ensure Resident #7's comprehensive care plan addressed Resident #7's history of reoccurring urinary tract infections. These failures could place residents at risk for not receiving care and services to meet medical, mental, psychosocial, and nursing needs. Findings included: Record review of Resident #7's face sheet dated 07/22/2026 indicated Resident #7 was a [AGE] year-old female who admitted to the facility 08/28/2023. She had diagnoses which included urinary tract infection (condition resulting from by bacteria entering the urinary system) and dementia (a condition that affects memory, thinking, and the ability to perform daily activities). Record review of Resident #7's significant change MDS assessment dated [DATE] noted Resident #7 had a BIMS score of 9 indicating her cognition was moderately impaired. She was incontinent of bowel and bladder, non-ambulatory, and dependent on staff for most activities of daily living. The same MDS indicated Resident #7 had a urinary tract infection. Record review of Resident #7's physician's orders indicated Resident #7 had an order dated 07/10/2026 for an antibiotic, Bactrim DS, to be administered twice a day for 10 days for treatment of a urinary tract infection. Record review of Resident #7's undated care plan indicated Resident #7 had a urinary tract infection and was at risk for increased temperature, dehydration, pain/discomfort, and adverse reactions to antibiotic therapy. The care plan also identified Resident #7 as having urinary tract infections on 12/11/2025, 03/28/2026, 05/31/2026, and 07/11/2026. The care plan included the physician's order for antibiotic therapy for the treatment of urinary tract infection. There were no interventions to address the identified risks of antibiotic therapy, increased temperature, dehydration, and pain/discomfort. There were no interventions to address Resident #7's reoccurring history of urinary tract infections. During an interview on 07/22/2026 at 08:50 AM, Resident #7 said she did not know if she had a urinary tract infection or not. She said she depended on her family and the nurses to take care of her medical needs. Resident #7 denied having any pain. During an interview on 07/22/2026 at 10: 45 AM, the ADON said Resident #7's care plan did not include any interventions to address Resident #7's reoccurring urinary tract infections nor the identified risks of antibiotic therapy for the treatment of Resident #7's current urinary tract infection. She said the care plan team was responsible for ensuring the residents' care plans were specific to each resident's needs. She said the DON, unit managers, MDS nurse, and herself reviewed medical records during the daily morning meeting to identify needed changes, additions, or updates to the care plans. The ADON said Resident #7's care plan should have been updated to include interventions to address Resident #7's risks associated with antibiotic therapy and Resident #7's history of reoccurring urinary tract infections. She said not identifying a residents' needs in the care plan could result in delayed healing or worsening of condition. Record review of the facility's policy date July 2028 and titled Interdisciplinary Plan of Care indicated the following: The facility's interdisciplinary team will plan appropriate care and treatment based on the resident/patient's characteristics, strengths, needs, severity of condition, impairment, disability, or disease. The planning process is directed toward achieving and maintaining each resident/patient's highest practicable physical, psychosocial, and functional status. The plan of care will be person-centered.

Based on observation, interview, and record review, the facility failed to provide liquids consistent with the resident's needs, for 1 of 3 (Resident #20) residents reviewed for food and nutrition services.The facility failed to ensure CNA A did not serve iced water at breakfast on 07/21/2026 to Resident #20 who required nectar-thickened liquids. This failure could place residents who have dysphagia at risk for aspiration (breathing in foreign objects).Findings included:Record review of Resident #20's face sheet dated 2/11/25, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included abnormal weight loss, high blood pressure, congestive heart failure, legal blindness, pain and anxiety.Record review of Resident #20's quarterly MDS assessment dated [DATE], indicated Resident #20 had clear speech, was usually understood and usually understood others. The MDS assessment indicated Resident #20 had a BIMS of 05 which indicated her cognition was severely impaired. The MDS assessment indicated Resident #20 was dependent with all ADLs and required assistance with eating. The MDS assessment indicated Resident #20 had a mechanically altered diet.Record review of Resident #20's undated comprehensive care plan indicated Resident #20 had a nutritional problem or potential for a nutritional problem.and a need for a mechanically altered diet related to weight loss and difficulty swallowing. The care plan interventions included monitoring for coughing or choking during meals or swallowing medications, holding food in mouth/cheeks (pocketing), or drooling.Record Review of Resident #20's clinical record a dietary note dated 02/11/2026 at 1:38 PM by the RD indicated .Diet: Regular diet, Pureed texture, Nectar consistency; FMP (fortified meal plan). Record review of Resident #20's physician's order summary report dated 07/21/2026, indicated Resident #20 had the following order: Regular diet, pureed texture, nectar thick consistency liquids, and fortified food plan with each meal with an order start date of 10/27/2025.During an observation and interview on 07/21/2026 at 8:40 AM Resident #20 was being fed by CNA A. The dietary department had placed a glass of iced water on the tray instead of nectar thickened water along with a nectar thickened glass of orange juice. There were no thickened liquids at the bedside. When asked about the iced water CNA A said the resident was not to have iced water and she said she found a partial glass of leftover thickened water on her chest of drawers and was giving her that to drink.During an observation, interview and record review on 07/21/2026 at 8:56 AM the DM got a case of nectar thickened water with lemon from storage in her office. She took one carton and gave it to the MAs to put in the medication room refrigerator. She said dietary supplied thickened liquids to nursing to keep in the refrigerator in the medication room. She said CNAs would have to go to the medication room if they needed thickened liquids for the residents when they did not have a meal tray. She said to her knowledge nursing would need to provide a container at bedside for thickened liquids to be placed in to be kept cool because the instructions on the carton indicate to keep refrigerated after opening. The DM said Resident #20 received thickened liquids and could not say why dietary staff had placed a glass of iced water on the breakfast tray. The dietary slip placed on Resident #20's tray had Nectar Thick highlighted to draw attention to it for dietary and nursing staff. She said she did not know why dietary staff would give the resident one thickened item and not the other thickened item. The thickened liquid carton indicated After opening may be kept up to 7 days under refrigeration.During an interview on 07/21/2026 at 9:00 AM LVN B (responsible for hall A and the left half of B hall) said thickened liquids were kept in small ice chests at the bedside unless the residents have a refrigerator. During an interview on 07/21/2026 at 9:10 AM CNA A said sometimes they would just give them a big box of thickened liquid to put at the bedside. She said there was nothing used to keep it cool and it would usually sit on the bedside table. She said she had never gone to the medication room to get thickened liquids for residents.During an interview on 07/21/2026 at 9:15 AM LVN C (responsible for hall C and the right half of B hall) said the kitchen usually gave them a big carton of thickened liquids from the kitchen pantry. She said it would be placed at the bedside and labeled and dated when opened. She said it was supposed to be kept cool but they did not have any containers to keep them on ice. She said the MAs had a small black plastic container they used on the medication cart to keep thickened liquids and/or their nutritional supplement cool while they passed their medications.During an interview on 07/21/2026 at 9:25 AM LVN D said thickened liquid containers were placed in the medication room refrigerators so staff can get access to the thickened liquids throughout the day. She said the MAs did not leave them on their carts but use it for their medication pass and return it to the refrigerator. She said the thickened liquids were not left at bedside because they need to be kept cool and there was nothing at bedside to keep them in.During an interview on 07/21/2026 at 9:30 AM the ADON said they used to have small ice coolers that were kept at the bedside for individual serving cups of sealed thickened liquids. She said Resident #20 did not like cool beverages so if she had the individual sized cups of thickened beverages it could be kept at room temperature until it was opened. She said at lunch on 07/20/2026 when she was checking the lunch trays before they were served to the residents on hall C, Resident #20's tray received iced water and iced tea on her tray. She said she took the tray back to the kitchen so the proper liquids could be placed on the tray. She said she was going to talk to the DM about getting the individual cups of thickened liquids after she talked with the administrator about getting some small bedside ice chests. She said a negative effect of Resident #20 drinking thin liquids when she was on a nectar thickened liquid diet was she could get aspirate pneumonia. During an interview on 07/21/2026 at 9:40 AM the Administrator said she did not know why the facility had stopped using the small ice chests at the residents' bedsides to hold the thickened liquid cups. She said the thickened liquids came as part of the dietary budget but does not know why they stopped using the individual sized cups. She said she had staff on the way to purchase some small ice chests for bedside use.During an interview on 07/21/2026 at 10:00 AM the DM said she had some individual cups of thickened liquids as part of her emergency supplies. She said the individual cups were only 4 oz. So they were not used for tray service because it was not enough liquid to provide at meals. She said they used the 46 oz. sized containers for meal service and to give to the nursing staff for their medication pass. She said a 46 oz. carton could be kept chilled at the bedside in a container of ice as well as the individual sized cups.During an interview on 07/21/2026 at 11:55 AM the ADON said they had no policy on thickened liquids being at the bedside. She said she had called her corporate office and corporate instruction was liquids came on the meal trays at the meal service, medication pass and residents could always ask for liquids. The ADON said she understood that not all residents had the ability to ask for a drink of liquid.During an interview on 07/23/2026 at 9:00 AM CNA E said thickened liquids came from the kitchen on the residents' trays. She said she never went to the medication room to get thickened liquids for the residents to drink. Record review of the facility's policy, Hydration Status Management/Improvement dated August 2018, indicated: .Interdisciplinary Team members in managing/improving the resident/patient's hydration status by monitoring, evaluating, and/or treating risk factors effecting the resident/patient's hydration status . The policy did not indicate providing fluids in a consistency the resident can safely drink.

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect , exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involve serious bodily injury, to the administrator of the facility and to other officials, which included the State Survey Agency, in accordance with State Law through established procedures to report to state agency for 1 of 7 Residents (Resident #66 ) reviewed for abuse and neglect. The facility failed to report the results of an unwitnessed incident to the State Survey Agency. Resident #66 was found in another resident's room lying in the bed, staff member reported blood on the resident left hand, side of bed and under bedframe. Staff nurse conducted assessment, lacerations noted between the 3rd and 4th finger on left hand, pressure dressing applied to stop bleeding, and EMS called. Resident#66 was sent to the hospital where she received 7 sutures. This failure could place residents at risk for abuse, neglect, and serious bodily injury by not reporting incidents as required. Findings included: Record review of Resident #66 face sheet, dated 5/21/2025, revealed an [AGE] year-old female who was admitted to the facility 06/17/2024, with diagnoses which included dementia, bipolar disorder, psychotic disturbance, anxiety, depressive disorder, pulmonary edema, acute respiratory disease, gastro esophageal reflux disease, hypertension, lack of coordination, and osteoporosis. Record review of Resident # 66 quarterly MDS dated [DATE] revealed Brief Interview for Mental Status (BIMS), a score of 3 indicated severely impaired (never/rarely made decisions). Wandering presence, behavior of this type occurred 1 to 3 days. Resident #66 was located on a secured unit. Resident # 66 was dependent; a helper completed all the activities for the resident. Record review of Resident #66 care plans dated 05/13/2025 indicated Resident #66 had 7 stitches between her 2nd & 3rd finger on her left hand. Approach to treat area as ordered by MD. Measure and record description of area. Goal, the resident's laceration will heal without complication. Record review of Resident #66 accident /incident report dated 5/11/2025 at 3:15 PM, indicated while making rounds staff CNA found Resident #66 lying in another resident's room bed. She had noted blood to the resident left hand and on side of bed frame, immediately reported to staff nurse. Staff nurse conducted assessment, lacerations noted between the 3rd and 4th finger on left hand, pressure dressing applied to stop bleeding, and EMS called. Resident#66 was sent to the hospital where she received 7 sutures. This incident was unwitnessed. Weekend Staff nurse reported the incident to the Physician, ADON, and the resident's family member. Record review of Resident #66 nurses progress notes dated 05/11/2025 at 3:49 PM revealed staff found Resident #66 in another resident's room bed. Blood was noted on resident's left hand, resident assessed to find where blood was coming from. Staff nurse found deep laceration on left hand between 3rd and 4th fingers. The resident said, she did not know what happen. Staff nurse cleansed laceration, pressure applied to stop bleeding, no other injury noted. EMS called, transported the resident to ER for treatment of laceration. Documented all parties notified. Record review of Emergency Department (ED) hospital records dated 5/11/2025 revealed Resident presented to ED via EMS evaluation of left-hand laceration. The resident was unclear how she sustained laceration. ED comments: left hand in web space between middle and ring finger, the resident had a 2 cm laceration at the base of the middle finger. ED course of action dated 05/11/2025 at 4:10 Consent obtained for emergent situation, simple repair, number of sutures placed was seven. Record review of Resident #66 nurses progress notes dated 05/11/2025 at 7:17 PM revealed, staff nurse called Resident #66 PR, and indicated Resident #66 had returned to the facility after a laceration repair and had seven stitches between her 2nd & 3rd finger on her left hand. During an observation and interview on 05/19/2025 at 10:30 AM, Resident #66 was in secured unit common area in a wheelchair, noted left hand with 7 sutures, no dressing on left hand, the resident said her hand was sore, but it was better now. Resident #66 could not state how she had cut her hand and sustained the laceration. During an interview on 05/21/2025 at 10:30 AM, ADON said, she was notified by LVN D of the incident on 5/11/2025, indicated that Resident #66 was sent to the hospital to be further treated for laceration. ADON said, she reported the incident to DON immediately, and reviewed the Garden Unit camera's video located in the hallways on the secure units on her cell phone from home. She said, she reviewed the video to track the time of entry and that no one entered the room before or after the resident. She said, the only other entry into the room was when a staff aide found resident in room [ROOM NUMBER], alone. Indicated on 5/12/2025 after further investigation, it was concluded the resident had fallen and gotten herself back up by pulling on the bed frame of the bed which caused the laceration to the hand. She said, the Maintenance department was notified and bed frame was padded. The ADON said she had not witnessed any abuse or neglect and if so, would report it to the DON, and the ADM who was the Abuse Coordinator. During an interview on 05/21/2025 at 10:45 AM, DON said, he was notified by the ADON of the incident that occurred on 05/11/2025. He said, he reviewed the Garden Unit camera's video located in the hallways on the secure units, and notified the ADM who was the Abuse Coordinator. DON said, after further investigation and reviewing the video, on the audio he heard a thump and concluded the resident fell and acquired the lacerations by pulling herself up by the bed frame, which explained the blood on the bed, under bed frames. The DON said he felt this incident was not abuse or neglect, and did not need to be reported to the State Agency. But concluded he had reported the incident to the ADM., and left the decision to the ADM to report the incident to the State Agency. During an interview on 05/21/2025 at 10:55 AM, ADM said, the 05/11/2025 incident was reported to her by the DON, and said, she had reviewed the Garden Unit camera's video located in the hallways. ADM said, after further investigation and reviewing the video, on the audio she said, she heard a thump and concluded the resident fell and acquired the lacerations by pulling herself up by the bed frame, which explained the blood on the under-bed frames. The ADM said, she felt this incident was not abuse or neglect, and did not meet the State Agency guidelines in reporting this incident. Record review of the facility's Abuse, Neglect, Exploitation and Reporting Requirements policy revised on 09/08/22 indicated, .If a covered individual reasonably suspects that a crime has occurred against a resident or person receiving care in the health Center, the individual must report the suspicion to the Abuse and/or Neglect Coordinating and follow the Federal/State regulations. If the suspected crime involves serious bodily injury, the incident must be reported within 2 hours .or defined by state regulations . Record review of the facility's Prevention and Reporting: Suspected resident/Patient Abuse, neglect, and or Misappropriation of Property dated 12/2018 indicated, means an injury involving extreme physical pain; . requiring medical intervention such as surgery, hospitalization , Section A 1.1.4: the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident. 41695

Based on interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 4 of 6 (Resident #1, Resident #2, Resident #3, and Resident #4) residents reviewed for ADLs. The facility did not provide scheduled showers for Resident #1, Resident #2, Resident #3, and Resident #4 These failures could place residents at risk of not receiving services/care and decreased quality of life. Findings included: 1. Record review of the face sheet dated 8/13/24 indicated Resident #1 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia, anxiety, and depressive disorder. Record review of the MDS dated [DATE] indicated Resident #1 was understood by others and usually understood others. The MDS indicated Resident #1 had a BIMS of 03 indicating she was severely cognitively impaired. The MDS indicated Resident #1 did not reject care. The MDS indicated Resident #1 required supervision or touching assistance with showers/bathing. Record review of the care plan last revised 6/11/24 indicated Resident #1 required full time nursing care and will be admitted for long term placement. Record review of an undated shower schedule indicated Resident #1 was scheduled for showers on Mondays, Wednesdays, and Fridays on the 6:00 a.m. to 2:00 p.m. shift. Record review of the July 2024 calendar indicated Mondays, Wednesdays, and Fridays for this month were on the following dates: 7/1/24, 7/3/24, 7/5/24, 7/8/24, 7/10/24, 7/12/24, 7/15/24, 7/17/24, 7/19/24, 7/22/24, 7/24/24, 7/26/24, 7/29/24, and 7/31/24. Record review of the facility's shower sheets for July 2024 indicated there were not any shower sheets for Resident #1. Record review of the August 2024 calendar through August 13, 2024, indicated the Mondays, Wednesdays, and Fridays for this month were on the following dates: 8/2/24, 8/5/24, 8/7/24, 8/9/24, and 8/12/24. Record review of the facility's shower sheets for August 2024 indicated Resident #1 received a shower on 8/12/24. Record review of the ADL Category Report dated 7/7/24 through 8/12/24 indicated Resident #1 had not received any showers/bathing. 2. Record review of face sheet dated 8/13/24 indicated Resident #2 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, psychotic disorder with delusions (a disorder having false or fixed belief involving a real-life situation that could be true but is not), and muscle wasting and atrophy (the gradual loss of muscle tissue, size, and strength). Record review of the MDS dated [DATE] indicated Resident #2 was rarely/never understood by others and rarely/never understood others. The MDS indicated Resident #2 did not have a BIMS score. The MDS indicated Resident #2 rejected care 4-6 days out of 7 but not daily. The MDS indicated Resident #2 required substantial/maximum assist with showers/bathing. Record review of the comprehensive care plan last revised 8/6/24 indicated Resident #2 had an ADL self-care deficit and required assistance with A) Oral care B) Dressing C) Transfers D) Bathing E) Grooming F) Eating related to weakness, decreased mobility, and altered mentation with interventions including assist with bathing, dressing, and grooming daily and as needed. Record review of an undated shower scheduled indicated Resident #2 was scheduled for showers on Mondays, Wednesdays, and Fridays on the 2:00 p.m. to 10:00 p.m. shift. Record review of the July 2024 calendar indicated the Mondays, Wednesdays, and Fridays for this month were on the following dates: 7/1/24, 7/3/24, 7/5/24, 7/8/24, 7/10/24, 7/12/24, 7/15/24, 7/17/24, 7/19/24, 7/22/24, 7/24/24, 7/26/24, 7/29/24, and 7/31/24. Record review of the facility's shower sheets for July 2024 indicated Resident #2 received a shower on 7/23/24. Record review of the August 2024 calendar through August 13, 2024, indicated the Mondays, Wednesdays, and Fridays for this month were on the following dates: 8/2/24, 8/5/24, 8/7/24, 8/9/24, and 8/12/24. Record review of the facility's shower sheets for August 2024 indicated Resident #2 received showers on 8/7/24 and 8/12/24. Record review of the ADL Category Report dated 7/7/24 through 8/12/24 indicated Resident #2 received a shower/bath on 7/26/24 7/29/24, 7/31/24, 8/1/24, and 8/12/24. 3. Record review of the face sheet dated 8/13/24 indicated Resident #3 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, depression, and restless leg syndrome (a condition characterized by a nearly irresistible urge to move the legs, typically in the evenings). Record review of the MDS dated [DATE] indicated Resident #3 usually understood others. The MDS indicated Resident #3 had a BIMS of 06 indicating she was severely cognitively impaired. The MDS indicated Resident #3 rejected care 1-3 days out of 7. The MDS did not indicate Resident #3's functional status with showers/bathing. Record review of the comprehensive care plan last revised 5/30/24 indicated Resident #3 had an ADL self-care deficit. Resident required assist with transfers, oral care, dressing, eating, grooming, and bathing related to decreased mobility, weakness, and altered mentation with interventions including assist resident with bathing as needed. Record review of an undated shower schedule indicated Resident #3 was scheduled for showers on Tuesdays, Thursdays, and Saturdays on the 2:00 p.m. to 10:00 p.m. shift. Record review of the July 2024 calendar indicated Tuesdays, Thursdays, and Saturdays were on the following dates: 7/2/24, 7/4/24, 7/6/24, 7/9/24, 7/11/24, 7/13/24, 7/16/24, 7/18/24, 7/20/24, 7/23/24, 7/25/24, 7/27/24, and 7/30/24. Record review of the facility's shower sheets for July 2024 indicated Resident #3 received a shower/bath on 7/4/24 and 7/8/24. Record review of the August 2024 calendar through August 13, 2024, indicated Tuesdays, Thursdays, and Saturdays were on the following dates: 8/1/24, 8/3/24, 8/6/24, 8/8/24, 8/10/24, and 8/13/24. Record review of the facility's shower sheets for August 2024 indicated Resident #3 received showers on 8/10/24 and 8/12/24. Record review of the ADL Category Report dated 7/7/24 through 8/12/24 indicated Resident #3 did not receive a shower/bath. 4. Record review of the face sheet dated 8/13/24 indicated Resident #4 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, depression, and anxiety. Record review of the MDS dated [DATE] indicated Resident #4 was usually understood by others and usually understood others. The MDS indicated Resident #4 had a BIMS of 01 indicating he was severely cognitively impaired. The MDS indicated Resident #4 rejected care 1-3 days out of 7. The MDS indicated Resident #4 required substantial/maximum assist with showers/bathing. Record review of the comprehensive care plan last revised 8/9/24 indicated Resident #4 had an ADL self-care deficit. Resident requires assist with transfers, oral care, dressing, eating, grooming, and bathing related to decreased mobility, weakness, and altered mentation with interventions including assist resident with bathing as needed. Record review of an undated shower scheduled indicated Resident #4 was scheduled for showers on Tuesdays, Thursdays, and Saturdays on the 2:00 p.m. to 10:00 p.m. shift. Record review of the July 2024 calendar indicated Tuesdays, Thursdays, and Saturdays were on the following dates: 7/2/24, 7/4/24, 7/6/24, 7/9/24, 7/11/24, 7/13/24, 7/16/24, 7/18/24, 7/20/24, 7/23/24, 7/25/24, 7/27/24, and 7/30/24. Record review of the facility's shower sheets for July 2024 indicated there was not any shower sheets for Resident #4. Record review of the August 2024 calendar through August 13, 2024, indicated Tuesdays, Thursdays, and Saturdays were on the following dates: 8/1/24, 8/3/24, 8/6/24, 8/8/24, 8/10/24, and 8/13/24. Record review of the facility's shower sheets for August 2024 indicated Resident #4 received showers on 8/3/24 and 8/11/24. Record review of the ADL Category Report dated 7/7/24 through 8/12/24 indicated Resident #4 received a shower on 8/12/24. During an interview on 8/13/24 at 1:17 p.m. CNA B said residents received their showers on a schedule and was either scheduled on the 6:00 a.m.-2:00 p.m. shift or the 2:00 p.m.-10:00 p.m. shift and Monday, Wednesday, and Friday or Tuesday, Thursday, and Saturday. CNA B said if a resident refused their shower they should be reapproached again later, and the charge nurse should be notified. CNA B said showers were not documented in the computer system, they were documented on shower sheets. CNA B said all shower sheets were turned into the nurses. CNA B said the importance of residents receiving their scheduled showers was to prevent skin breakdown and hygiene. During an interview on 8/13/24 at 1:20 p.m. CNA C said she usually worked the 6:00 a.m.-2:00 p.m. shift in the women's secured unit. CNA C said residents received their showers 3 times a week as scheduled and as needed. CNA C said Resident #3 sometimes refused showers if she was worked up. CNA C said Resident #1 did not refuse showers often and was easily re-directed. If Resident #1 was too worked up, she would refuse a shower and would get a bed bath instead. CNA C said if a resident refused a shower the charge nurse should be notified, and the resident should be reapproached later. CNA C said the importance of the residents receiving their scheduled showers was hygiene. During an interview on 8/13/24 at 1:25 p.m. LVN A said she was a charge nurse in the memory care unit. LVN A said residents received their showers 3 times a week on schedule. LVN A said Resident #1 rarely refused showers and was easily re-directed if she refused. LVN A said Resident #3 rarely refused showers. LVN A said if a resident refused their shower staff should try again at a later time. LVN A said the importance of residents receiving their scheduled showers was their hygiene and health. LVN A said showers were documented on shower sheets and in the computer. LVN A said if showers were not documented it could not be proved they were completed. During an interview on 8/13/24 at 2:00 p.m. the DON said he expected showers to be given as scheduled and as needed. The DON said the facility did have some difficult residents who sometimes required family intervention to get them to shower. The DON said if a resident was being combative towards staff, he did not for both the resident and staff's safety expect staff to pursue a shower at that time. The DON said if a resident was combative or refused a shower, he expected staff to reapproach the resident later or get another staff member to reapproach the resident. The DON said showers were documented on shower sheets and turned in to the unit managers. The DON said he retrieved the shower sheets daily prior to morning meeting. The DON said if a shower was not documented that it had been completed it could not be proven the resident received their shower. The DON said the importance of resident receiving their scheduled showers was infection control, skin integrity, and quality of life. During an interview on 8/13/24 at 2:29 p.m. the Regional Nurse Consultant said the facility did not have a policy regarding ADLs specifically. Record review of the facility's Bathing-Shower Procedure dated March 2019 indicated, [The] purpose [was] to provide personal hygiene [and] to stimulate circulation .Record bath as applicable. Record review of the facility's Bathing-Tub Procedure dated March 2019 indicated, [The] purpose [was] to provide personal hygiene, to stimulate circulation, [and] to reduce tension for the resident/patient .document bath on the bath record. Record review of the facility's Bed Bath-Complete Procedure dated March 2019 indicated, [The] purpose [was] to provide personal hygiene, to stimulate circulation, [and] to promote muscular relaxation and relieve fatigue .Report to Nurse any pertinent observations of resident/patient during bathing including condition of skin. Record review of the facility's Bed Bath-Partial Procedure dated March 2019 indicated, [The] purpose [was] to provide personal hygiene, to stimulate circulation, [and] to promote muscular relaxation and relieve fatigue .Report to Nurse any pertinent observations of resident/patient during bathing including condition of skin.

Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 3 of 4 residents (Residents #1, Resident #2, and Resident #3) reviewed for hospice services. The facility did not ensure Resident #1, #2 and #3's hospice skilled nurse progress notes were a part of the resident records in the facility. This failure could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. Findings included: 1. Record review of the face sheet dated 5/30/24 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, pain, dementia, and anxiety disorder. Record review of the care plan last revised on 3/31/24 indicated Resident #1 was receiving hospice services. Record review of the Hospice Interdisciplinary Group (IDG) Comprehensive Assessment Plan of Care Report dated 5/7/24 indicated Resident #1's most recent IDG meeting was on 4/26/24, The Hospice IDG Comprehensive Assessment Plan of Care Report indicated Resident #1 would have a skilled nurse visit once a week for 8 weeks. Record review of Resident #1's hospice binder on 5/30/24 indicated there was only one skilled nurse note for Resident #1 dated 4/29/24. Record review of the facility's contract with Resident #1's hospice provider dated 11/11/21 indicated, .Hospice staff visit will be scheduled based on the need of the hospice patient according to the agreed upon plan of care .Information/Documentation provided to facility on admission of hospice patient for non-inpatient hospice services and ongoing .f. copies of clinical notes after each visit . 2. Record review of the face sheet dated 5/30/24 indicated Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including COPD, chronic respiratory failure, dementia, abnormal weight loss, and stroke. Record review of the MDS dated [DATE] indicated Resident #2 was usually understood by others and usually understood others. The MDS indicated Resident #2 was severely cognitively impaired with a BIMS of 04. The MDS indicated Resident #2 had a condition or chronic disease that may have resulted in a life expectancy of less than 6 months. Record review of the care plan last revised 5/29/24 indicated Resident #2 was receiving palliative/hospice services related to end stage disease process starting 4/7/24. Record review of the Hospice Certification and Plan of Care dated 3/8/24 indicated Resident #2 had a certification period of 3/8/24 to 6/5/24. The Hospice Certification and Plan of Care indicated Resident #2 would have skilled nurse visits twice a week for 2 weeks, once a week for 12 weeks, and 3 as needed feeling. Record review of Resident #2's hospice binder on 5/30/24 indicated there was only one skilled nurse note for Resident #2 dated 3/8/24. Record review of the facility's contract with Resident #2's hospice provider dated 3/9/23 indicated, .Hospice staff visits will be scheduled based on patient/family need and according to the agreed upon plan of care .Information/Documentation provided to the facility on admission and on-going .6. Copies of clinical notes after each visit . 3. Record review of the face sheet dated 5/30/24 indicated Resident #3 was an [AGE] year-old female re- admitted to the facility on [DATE] and discharged from the facility on 4/18/24 with diagnoses including dementia, senile degeneration of the brain (mental decline associated with aging), abnormal weight loss, and diabetes. Record review of the physician orders dated 4/30/24 through 5/30/24 indicated Resident #3 had an order to admit to hospice services. Record review of the MDS dated [DATE] indicated Resident #3 was sometimes understood by others and sometimes understood others, The MDS indicated Resident #3 was severely cognitively impaired with a BIMS of 02. The MDS indicated Resident #3 had a condition or chronic disease that mas have resulted in a life expectancy of less than 6 months. Record review of the care plan last revised 4/7/24 indicated Resident #3 was receiving palliative care/hospice services related to end stage disease process starting 4/7/24. Record review of Resident #3's Hospice Team Care Plan dated 4/17/24 indicated Resident #3 was admitted to hospice services on 3/13/24. The Hospice Team Care Plan indicated Resident #3 would have skilled nurse visits once a week for 12 weeks starting on 3/13/24 and ending on 4/8/24. The Hospice Team Care Plan indicated Resident #3 would have skilled nurse visits once a week for 12 weeks starting 4/7/24. Record review of Resident #3's hospice binder on 5/30/24 indicated there were only 2 skilled nurse notes dated 4/8/24 and 4/15/24. Record review of the facility's contract with Resident #3's hospice provider dated 1/20/14 indicated, .Hospice, together with the facility staff, shall document all communications with provider representatives or staff in writing in the patient's record. Hospice staff shall promptly document all information related to visits, orders, revisions to orders, patient status, changes in status or condition, responses to medications or therapies, patients and family needs or requests in the patient's clinical chart . During an interview on 5/30/24 at 12:09 p.m. LVN A said a resident receiving hospice services should have a hospice binder from the hospice provider that included the resident's diagnoses, medication orders, and code status. LVN A said to find out when the last hospice nurse visit was or information regarding the last hospice nurse visit staff were required to call the hospice provider. LVN A said there was not a way for facility staff to view a hospice nurse's notes. During an interview on 5/30/24 at 12:28 p.m. the DON said he did not look at the hospice binders regularly. The DON said the only time he looked at the hospice binders was to find out when the last time the hospice provider was at the facility to see a particular resident. The DON said he could determine the last time a hospice provider was at the facility to see a resident by looking in the hospice binder for the sign in sheet or nursing note. The DON said when a hospice nurse made a visit to a resident on the nurse's next visit to the facility, they would insert the previous visit's nursing note into the resident's hospice binder. The DON said it was the SW's responsibility to ensure the hospice binders contained the residents' code status and orders. The DON said the hospice provider was responsible for ensuring they had all the appropriate or required paperwork in the hospice binders. The DON said he did not check to ensure the hospice nurse's notes were in the residents' hospice binders. The DON said he knew the hospice nurses were making visits to the residents as he had seen them in the facility and had seen the facility's nurses speaking with the hospice nurses regarding the residents they had seen. During an interview on 5/30/24 at 12:38 p.m. the Administrator said she was not normally involved in clinical stuff. The Administrator said she expected the hospice binders to include information from hospice visits to a resident, the services the hospice provider was providing to each resident, and the residents' orders. The Administrator said the importance of ensuring all the appropriate and required hospice information was in each resident's binder was for continuity of care. Record review of the facility's Hospice Care policy dated 12/2008 indicated, The facility participates in hospice care as an approach to caring for terminally ill residents/patients that require palliative care such as relief of pain and uncomfortable symptoms, as opposed to providing curative care. All covered hospice services will be available as necessary to meet the needs of the resident/patient prior to the resident/patient's admission .

Based on observation, interview and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 2 beverage service areas. (ABC halls common dining area). The facility failed to ensure the large ice machine outside of the main kitchen, the ice dispenser, and the coffee and iced tea dispensers in the ABC halls common dining area were clean. These failures could place residents who consumed ice, coffee and tea from these machines, at risk of being served in unsanitary conditions and for food borne illness. Findings included: During an observation of the ABC halls common dining area, on 04/08/2024 at 12:37 PM, revealed the ice machine in the common dining area was dirty with black, slimy scum, and rust build up on the entire grate of the drain of the ice dispenser machine. During an observation of the ABC halls common dining area, on 04/09/2024 at 5:30 PM, revealed the ice machine in the common dining was dirty with black, slimy scum, and rust build up on the entire grate of the drain of the ice dispenser machine. During an observation of the ABC halls common dining area, on 04/10/2024 at 9:00 AM, the ice machine in the common dining was dirty with black, slimy scum, and rust build up on the entire grate of the drain of the ice dispenser machine, the coffee and tea dispensers were dirty with slimy build up and the filter basket had rusted, and the rusted water ran into the tea. During an interview with the DM on 04/10/2024 at 09:00 AM, she said dietary was responsible for keeping the ice, coffee, and tea dispenser machines clean. She said she was responsible for cleaning the ice machine outside of the kitchen. She said, I guess we didn't clean the coffee and tea dispensers. During an interview with the Morning Cook A on 04/10/2024 at 09:15 AM., he said dietary was responsible for keeping the ice, coffee, and tea dispenser machines clean. He said he usually would come out after each meal and clean the three dispensers, but he had been off and could not account for what someone else does. Record Review of the Dietary Cleaning Log, there was not a cleaning schedule for the tea dispenser. During an interview with the DM on 04/10/2024 at 11:10 AM, she, the new company has changed the cleaning schedule form and the beverage bar was left off, but she said she would make sure it gets added on. Record review of an undated policy, Sanitation . #12 Ice Machine and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions. The dietary department will clean ice machines weekly or/and as needed. #14 Coffee area cleaned daily. Review of the FDA Food Code 2022: 4-6 Cleaning of Equipment, (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Pf (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. (E) Except when dry cleaning methods are used as specified under S 4-603.11, surfaces of UTENSILS and EQUIPMENT contacting FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cleaned: (4) In EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUIPMENT such as ice makers, cooking oil storage tanks and distribution lines, BEVERAGE and syrup dispensing lines or tubes, coffee bean grinders, and water vending EQUIPMENT: (a) At a frequency specified by the manufacturer, or(b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold.

47204 Based on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening for 2 of 12 residents reviewed for PASRR (Residents #17 and #92). The facility failed to ensure Residents #17 and Resident #92 had accurate PASRR Level 1 Screenings indicating diagnoses of mental illness and refer the residents to the state designated authority. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs. Findings included: Resident #17 Record review of a face sheet dated 04/10/2024 indicated Resident #17 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included dementia, mood disorder with depressive features (persistent feeling of sadness and loss of interest also called clinical depression), depression (a mental disorder involving a depressed mood or loss of pleasure or interest in activities for long periods of time), and major depressive disorder ( a persistently low or depressed mood). Record review of Section I of the Comprehensive (admission) MDS assessment, dated 09/27/2021, indicated Resident #17 had a diagnosis of depression. Section N of the same MDS assessment indicated Resident #17 had received antidepressant medication to treat depression for 7 of 7 days of the assessment period. Record review of a physician's order dated 09/21/2021 indicated Resident #17 was to receive Remeron, an antidepressant medication for the treatment of major depressive disorder upon admission to the facility. Record review of Resident #17's PASRR Level 1 Screening completed on 09/20/2021 indicated in section C0100 there was no evidence of this individual having mental illness. Resident #92 Record review of a face sheet dated 04/10/2024 indicated Resident #92 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included psychotic disorder with delusions (a disorder in which the affected person has a distorted sense of reality and cannot distinguish the real from the unreal) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of Section I of the Comprehensive (admission) MDS assessment, dated 06/22/2023, indicated Resident #92 had a diagnosis of bipolar disorder. Section N of the same MDS assessment indicated Resident #92 had received antipsychotic medication for 7 of 7 days of the assessment period. Record review of a physician's order dated 06/15/2023 indicated Resident #92 was receiving the medication, Remeron, for treatment of bipolar disorder. Record review of Resident #92's PASRR Level 1 Screening completed on 06/14/2023 indicated in section C0100 there was no evidence of this individual having mental illness. During an interview on 04/10/2024 with MDS Nurse B, she said the MDS department was responsible for PASRR functions. She said the Skilled MDS Nurse was assigned the task of reviewing the Level 1 PASRRs to ensure accuracy and appropriate follow-up actions. She said the person who would have reviewed Resident #17's PASRR Level 1 was no longer working at the facility. MDS Nurse B said the LA should have been notified of Resident #17's and Resident #92's inaccurate PASRR Level 1 screenings. She said a Form 1012 should have been completed for Resident #17 since Resident #17 had a primary diagnosis of dementia. MDS Nurse B said it was important for the PASRR Level 1 Screening to be accurate because the facility needed to make sure the residents were getting the correct resources.

Based on interview and record review, the facility failed to ensure a resident had the right to be free of abuse for 1 of 8 residents reviewed for abuse. ( Resident #1) Resident #1 was intimidated, suffered pain and mental anguish, and forced to allow care against her will by CNA A on 3/11/24. CNA A refused to take no for an answer when Resident #1 told her she did not want to be transferred. CNA A pushed back at Resident #1's flailing hands and reached under her arms and transferred her against her will from her wheelchair to her bed. Resident #1 complained of back pain when she was transferred by CNA A. CNA A was hollering at Resident #1 and told her she was afraid for nothing. CNA A was close to Resident #1's face talking loudly in an intimidating manner. CNA A reached between Resident #1's legs to check if she was wet and the resident was begging her not to, but CNA A continued. The noncompliance was identified as past non-compliance (PNC). The IJ began on 3/11/24 and ended on 3/21/24. The facility had corrected the noncompliance before the survey began. The negative findings placed residents at risk of abuse, mental anguish, and pain. Findings included: Record review of Resident #1's face sheet with no date indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnose were heart failure, anxiety disorder, high blood pressure, and left lower quadrant pain. Record review of Resident #1's MDS assessment dated [DATE] indicated she had severe cognitive impairment. She required substantial/maximal assistance with bed to chair transfer and toilet transfer. During an interview on 4/5/24 at 11:45 a.m. the MDS nurse said Resident #1's MDS indicated the resident required two people for transfer. Record review of Resident #1's Care Plan dated 2/22/24 indicated a Problem of the resident required assistance with transfers due to decreased mobility, weakness and altered mentation. She used a wheelchair for ambulation. Some of the approaches were do not force the resident to perform a care activity, call the resident's family for assistance with ADL issues. Transfer resident per instructions on resident assistant guide. Record review of Resident #1's nursing note dated 3/11/24 at 8:15 p.m. indicated a grievance was brought to the nurse by a family member. Resident #1 was immediately assessed to ensure she was safe, skin showed no signs of bruising, the resident was calm and in no distress at this time. Resident #1 did ask for a pain pill but later declined it. The incident was immediately reported to administrative staff. Record review of Resident #1's nursing note indicated a note recorded as late entry on 3/12/24 at 11:32 a.m. indicated on 3/11/24 at 7:47 p.m. this nurse receive report from the charge nurse concerning an incident with CNA and reviewed the video with the family member. The Family member said CNA A was rude and handled Resident #1 roughly. Resident #1 said she was not fearful and had no new complaints of pain. Signed by ADON. Record review of a Provider Investigation Report indicated on 3/11/24 at 8:15 p.m. the family member reported CNA A approached Resident #1 and would not take no for an answer when attempting to put her to bed. Resident #1 said she was afraid the aide would drop her. The family member stated CNA A manhandled Resident #1. The family member said Resident #1 told her CNA A was rough with her and would not take no for an answer. The investigation findings were confirmed. The agency aide was blocked from returning to the facility. Record review of an email dated 3/12/24 from the administrator to HHSC Complaint and Incident Intake mailbox indicated . The Agency aide (CNA A) was terminated from our building meaning she was placed on a do not return list. In the conversation with the family and watching the video, it was determined that the aide was unnecessarily loud, and rude to the resident . Review of video provided by the family of Resident #1 dated 3/11/24 with a start time of 6:39 p.m. CNA A was seen in the room with Resident #1 sitting in the wheelchair adjacent to the bed. The aide told the Resident #1, Hold your arms up cause I'm not going to drop you. Resident #1 said, I do not want you to lift me, no, no, no. The aide was seen getting down in the resident's face saying, Hey, hey in a loud voice. CNA A was just about screaming at Resident #1 saying What's the problems? Resident #1 said, I don't want you to lift me. The aide said, Why? with hand gestures and her head was lowered down to the resident's face. Resident #1 said, I am afraid you will drop me. CNA A again loudly told Resident #1 I have never dropped you, I have put you in the bed before with no help. The aide told the Resident #1, Now don't start that today. You are fighting me. Resident #1 said repeatedly I am fighting you, I am fighting you, I am fighting you. The aide said, For what? Resident #1 and CNA A fumble back and forth a little, with CNA A moving her hands one way, and Resident #1 trying to block her hands another. Resident #1 begs her, Please don't do this to me. The resident is seen trying to flail her hands and CNA A pushed Resident #1's hands out of the way. CNA A reached under the resident's arms and lifted her to the bed. When the aide sits the resident on the bed she said, What was all of that for? You are in the bed honey. The resident said, You hurt my back. The aide turns Resident #1 around and put her legs in the bed, and told her that was uncalled for. The resident's knees are bent. CNA pulled Resident's house shoes off her feet. The back of the Resident #1's head was pressed into the headboard and the resident was on her bottom with her shoulders and in the air. The aide said, I don't have time for that, that was unnecessary, all of it, and walks out of the room. The aide came back in the room with a brief and gloves. The aide tells the resident ,You have cameras all in this room. I am not going to do anything to hurt you or me. Resident #1 asked her, What? the aide points to the camera and says loudly, You have cameras all over this room, I am not going to do anything to hurt you or me. So cut that out. CNA A was putting on her gloves. The video showed CNA A used gestures with lot of neck rolling back and forth, hand shaking, and shoulder jerking gestures as she gave her speech. The aide pulled Resident #1's legs apart and continued to do what she was doing as Resident #1 was saying, Please don't do that. CNA A told Resident #1, I am checking to see if you are wet. In a loud voice. CNA A put the brief on the table. Resident #1 asked, What is your name. The aide told her name. Resident # 1 asked, Why did you come in here and act that way? CNA A said, I did not come in here and act no way. I came in here to put you in the bed, and you started. She raised Resident #1's head up and told her to stretch her legs out, and the resident did so. The aide told her, You was doing all that hollering and screaming for no reason. Then she put a pillow behind the resident's head and then two. The resident said that was too many. The aide took one pillow out, rolled her bedside table over the bed. Walked out and turned off the light. Total time of the video 3 minutes and 4 seconds. During an interview on 4/3/24 at 1:15 p.m. in Resident #1's room the family member of Resident#1 said she was very upset by the things she saw on the video regarding CNA A and the treatment of Resident #1. She said she had brought that video to the attention of the facility staff and the aide was let go. During that interview Resident #1 said she remembered the incident and did not want to talk about it at all. During an interview on 4/5/24 at 11:07 a.m. the ADON said she saw the video regarding Resident #1. She said when CNA A walked in the room she was agitated, a little upset, and was working that hall by herself. The ADON said Resident #1 asked her if she was going to go and get help to transfer her. She said CNA A told her no. The ADON said Resident #1 wanted two people to transfer her but did not require two. She said Resident #1 told CNA A she needed go and get someone else because she did not want to fall. The ADON said CNA A told Resident #1 she had transferred her alone before. She said the aide proceeded to put Resident #1 on the bed without help and without incident. The ADON said when CNA A laid Resident #1 down there was no pillow, and she looked uncomfortable. She said CNA A left the room and came back. She said then CNA A put the pillow under Resident #1's head. The DON said it was not so much what the aide said to the resident, it was her tone of voice and her agitation. She said CNA A was in a disagreement with the resident and did not use a pleasant voice. The ADON said she had never seen any behaviors like that from CNA A before. She said during the incident CNA A told Resident #1 there was a camera in the room, so she was aware it was there. The ADON said when the family member talked to her initially there was no mention of abuse. The ADON said the family member said CNA A was rough and condescending. She said on the next day when the family member came back, the family member told the former DON it was abuse. During an interview on 4/5/24 at 11:40 a.m. Administrator said she watched the video and did substantiate abuse regarding Resident #1. She said in her opinion the CNA was disparaging or offensive. She did not have a statement from CNA A. The Administrator said she took everything to the QA committee and spoke to the Medical Director regarding the abuse. She said she also completed in services on abuse and the resident's right to refuse. During an interview on 4/5/24 at 12:08 p.m. the RNC said she had watched the video regarding Resident #1 and it was abuse. She said they had in serviced staff to make sure if a resident said no then the staff were to honor their request and leave them alone. Record review of the facility Abuse policy dated April 2021 indicated Abuse of any kind against residents was strictly prohibited. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Physical abuse includes, but is not limited to hitting, slapping, biting, punching, or kicking. Corporal ( physical) punishment used to control behavior is recognized as a form of abuse. Record review of the facility Quality Assurance Performance Improvement Committee Meeting dated 3/21/24 indicated during the meeting they spoke of abuse involving an agency staff, and on in service of staff when a resident says no they mean no. They spoke of resident rights and monitoring. All staff agreed to Inservice staff on Resident Rights and Reporting abuse. The form was signed by department heads and the Medical Director. Record review of the facility Provider investigation report dated 3/18/24 had the attached in services that indicated staff were in serviced on resident rights to refuse care, right to refuse medications, baths, eating, changing brief, and incontinent care. The in service indicated if a resident said no then walk away and get the nurse. Encouraging and coaxing the resident was acceptable to the point the resident said no. Do not argue with the resident. Also, an in service on abuse that indicated timely reporting of abuse, when to report, and who to report to. Interviews were conducted with facility staff regarding in services on abuse neglect and resident rights of when a resident says no it means on 4/5/24 between 12:56 p.m. through 1:45 p.m. with 8 CNAs and 4 LVNs. The staff interviewed were: At 12:56 p.m. CNA F At 12:59 p.m. CNA L At 1:10 p.m. LVN J At 1:04 p.m. CNA H At 1:07 p.m. CNA N At 1:17 p.m. LVN C At 1:23 p.m. CNA E At 1:27 p.m. LVN K At 1:34 p.m. CNA G At 1:32 p.m. LVN M At 1:38 p.m. CNA I At 1:45 p.m. CNA O Interviews indicated theses facility staff were knowledgeable about the facility abuse policy. They said they were in serviced on resident rights and when a resident said no that means do not force the resident to do something they did not want to do. They were also familiar with abuse, reporting in a timely manner, and who to report abuse to. The noncompliance was identified as PNC. The IJ began on 3/11/24 and ended on 3/21/24. The facility had corrected the noncompliance before the survey began.

Based on interview and record review the facility failed to ensure a resident was treated with dignity and respect for 1 of 8 residents reviewed for dignity. (Resident #3) Resident #3 was the victim of humiliation due to Resident #2 being allowed to urinate on him for two nights. The staff were aware of the first incident on 3/30/24 and allowed Resident #2 to continue to reside in the room with Resident #3 and a second incident occurred on 3/31/24. This failure caused a resident to be humiliated and dehumanized. Findings included: Record review of Resident # 3's face sheet with no date indicated he was a [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were high blood pressure, anxiety, depression, stroke and paralysis, unsteadiness on feet, and lack of coordination. Record Review of Resident #3's quarterly MDS assessment dated [DATE] indicated the resident was cognitively intact. The resident had functional limitations in range of motion of the upper and lower extremities and used a walker to assist with mobility. The resident required partial to moderate assistance with most ADLs. He required supervision with transfers and mobility. Record review of Resident #3's Care Plan dated 2/8/24 indicated a Problem of potential communication deficit related to cognition and late effects related to stroke. The resident had unclear speech but was usually understood and understood others. Some of the approaches were to allow for quality time to communicate, be sensitive to non verbal communication, and do not rush. A Problem of the resident required assistance with ADLs due to decreased mobility and altered mentation due to stroke and right sided hemiplegia. Some of the approaches were assist with ADLs as needed. Record review of Resident #3's nursing note dated 3/30/24 at 3:55 a.m. indicated roommate (Resident #2) got up and walked over to Resident #3's side of the room. Once by Resident #3's bed Resident #3 said Resident # 2 took off his brief with feces and began urinating all over his side of the room and on his belongings. The nurse cleaned the area and separated the residents. Resident #2 Record review of Resident # 2's face sheet indicated he was an [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were dementia, unsteadiness on feet, repeated falls, adult failure to thrive, depression with anxiety, and Parkinson's disease( disorder of the central nervous system that affects movements, often including tremors). The sheet indicated he was discharged on [DATE]. Record review of Resident #2's Brief Interview for Mental Status indicated he had severe cognitive impairment. Record review of Resident #2's Care Plan dated 3/28/24 reflected he had Problems of Pressure Ulcer and DNR status only. Record review of Resident #2's nursing notes indicated: On 3/30/24 at 3:55 a.m. Resident was found walking in the hall with brief off and wearing only a shirt outside his room. The nurse assisted the patient to his wheelchair for safety. Upon entering the room, a brief with feces was on the floor in front of the roommate's (Resident #3) bed. There were also two piles of feces around the roommate's bed and large amounts of urine all over the roommates belonging. The roommate reported Resident #2 walked over to his side of the room and took off his brief and used the restroom all over his side of the room. The nurse cleaned up the area and Resident #2 was brought to the nurse's station for monitoring due to confusion and inability to redirect. On 3/30/24 at 10:25 p.m. Resident #2 refused to stay in bed. Staff brought him to the nurse's station due to fall risks and attempt to get out of chair. On 3/31/24 at 4:17 p.m. Resident #2 had increased anxiety and restlessness. The nurse was monitoring at the nurse's station most of the shift. Resident had a fall; he was being monitored by all staff. The resident went over to roommates' side while he was in bed and urinated all over the bed, sheets, and blankets. The aide got it all cleaned up and the resident cleaned and brought to the nurse's station. During an interview on 4/2/24 at 3:50 p.m. CNA B said she worked with Resident #2 trying to get out of bed and had frequent falls. She said on 3/30/24 Resident #2 urinated and defecated all on his roommates' side of the room. During an interview on 4/2/24 at 4:00 p.m. Resident #3 had a speech impairment and was hard to understand. He would start to say something and stop as if gathering his thoughts, and then apologize. Resident #3 said his roommate (Resident #2) got up at night and had BM all over the floor on his side of the room on 3/30/24 at 4:00 a.m. in the morning. Resident #3 said Resident #2 urinated all over him and on his side of the room. Resident #3 said he asked Resident #2 to stop, and he did not until he was finished. He said he asked the staff to move Resident #2 and they said they could not. He said they told him he had to wait until Monday, 4/1/24 to ask to have Resident #2 moved to another room. He said they gave him the call light and told him to pull the light if anything happened again. Resident #3 said nothing happened for a while, so he had let his guard down. He said it happened again on Sunday, 3/31/24 morning. Resident #3 said Resident #2 urinated all over him and his bed. He said he pulled the call light, and the staff came but Resident #2 had done his business by the time they got there. During an interview on 4/3/24 at 7:46 a.m. the ADON said Resident #2 was admitted from home on 3/26/24. She said they were told he had been aggressive with the family members at home. The ADON said during the short time he was at the facility he would not sit down; he had a very unsteady gait and frequent falls. When he was redirected, he would become agitated and was placed on an antianxiety medication as needed. She said she had received a call on the morning of 3/30/24 about 4:00 a.m. saying Resident #2 had walked to his roommate's (Resident #3) side of the room and took off his brief and urinated in Resident #3's shoes and defecated in his chair. She said the room was cleaned by staff. She said they had told her Resident #3 was upset. She said the staff questioned her about moving Resident # 2 but they did not have any empty rooms on that unit. She said they had empty rooms in the building just not on that unit. The ADON said when they move a resident from one unit to the other, they required administrative approval. She said the nurse called the physician and received an order for an antipsychotic medication. The ADON said as far as she knew that type of incident had only occurred once. She was not aware of the second incident on 3/31/24. The ADON said Resident #2 had spent the night in that room with Resident # 3 on 3/30/24 and 3/31/24. During an interview on 4/3/24 at 8:00 a.m. Resident #3 said he did not remember the exact time of the second incident with Resident #2. He just knew that it happened two times. He said he was upset and felt humiliated to be treated like he was a bathroom. He said he had asked the staff to move Resident #2 the first time but was told he had to wait until Monday, 4/1/24 when the Administrator was in the building. During an interview on 4/3/24 at 9:35 a.m. LVN C said during the day she kept Resident #2 at the nurse's station. He did not spend much time in the room because he was a high fall risk. He was constantly trying to get up and would be verbally aggressive. She said Resident #3 did not want Resident #2 in the room with him because he wet all over him and his bed. LVN C said Resident #3 was upset and he was usually very calm and easy going. During an interview on 4/3/24 at 9:56 a.m. the RNC said when she arrived on 4/1/24, Resident #3 was in the hallway waiting to talk to Administrator. During an interview on 4/3/24 at 10:07 a.m. Administrator said Resident #3 was waiting on her when she arrived on 4/1/24. Resident #3 said his roommate Resident #2 had defecated on his chair and urinated all over his side of the room. The Administrator said Resident #3 did not say a whole lot to her but was pretty upset. She said they had gone into morning meeting and decided to move Resident #2 in a room by himself on a different hall. She said she did not know until today there were two incidents with Resident #2. During a telephone interview on 4/5/24 at 11:31 a.m. RN D (weekend nurse) said Resident #2 told her it happened again Resident #2 urinated all over him. She said she had asked Resident #2 what had happened, and he could not tell her. RN D said the first time the incident had happened they discussed moving Resident #2 to another room, but they did not have a single room that they could put him in on that hall. She said Resident #3 was upset and did not like it, but said he understood. The RN said during the day and evening hours they kept Resident #2 at the nurse's station. She said the incidents would be in the middle of the night or about 4 or 5 in the morning. She said Resident #3 said he wanted to know who to report his concerns to and he was told the Administrator would be back on 4/1/24. Record review of the facility's Resident [NAME] of Rights dated January 2004 indicated Each the Resident [NAME] of Rights must provide that each resident in the personal care facility has the right to be treated with respect, consideration, and recognition of his or her dignity and individuality. A resident shall receive personal care and private treatment in a safe and decent living environment.

Based on interview and record review the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for 1 of 3 residents reviewed for transfer/discharge. (Resident #2) The family of Resident #2 were told to come and get him without any prior notification or discharge planning for a safe and smooth discharge. The family of Resident #2 were told the resident would be admitted to the behavioral hospital for behavior issues and then transferred to another facility but instead spent about 24 hours in the ER. These negative findings could cause a resident to have no safe and comfortable place for discharge. Findings included: Record review of Resident # 2's face sheet indicated he was an [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were dementia, unsteadiness on feet, repeated falls, adult failure to thrive, depression with anxiety, and Parkinson's disease (disorder of the central nervous system that affects movements, often including tremors). The sheet indicated the resident was discharged from the facility on 4/1/24. Record review of Resident #2's Brief interview for Mental Status Review indicated he had severe cognitive impairment. Record review of Resident #2's Care Plan dated 3/28/24 reflected he had Problems of Pressure Ulcer and DNR status only. Record review of Resident #2's nursing notes indicated: On 4/1/24 at 1:02 p.m. received a new order to start mechanical soft diet. On 4/1/24 at 3:35 p.m. Resident #2 was being discharged home with all medications and belongings due to the resident not meeting criteria of the facility. The family will arrive and will transport the resident home. Signed by ADON During an interview on 4/2/24 at 11:24 a.m. the family member said the facility admitted Resident #2 on 3/26/24. She said during the admission process she told the Director of Admissions that Resident #2 was a sex offender. She said she gave him the card of the person who he reported to. The family member said the Director said that was fine and she did not think anything of it. The family member said she went to visit Resident #2 on 4/1/24 and they told her of the behaviors he had over the weekend urinating and defecating on the roommate and the roommate's things. She said while she was there, they did not say anything about discharge. Then later they called to say because he was a sex offender he could not be in the facility. The family member said they gave them no warning at all just come and get him. She said the first plan was they were going to send him to the behavior hospital and the family was there waiting on him. Then they called back and said no the family had to come and get him. She said she knew once they went to get him the facility would no longer be responsible for finding him a place to transfer. She said they were told they had all his belonging and medications ready for his discharge. She said the other family member went to get him. The Director of Admissions had told them everything was set up at the behavior hospital for Resident #2's admission. She said however when they got there, the hospital said they knew nothing about Resident #2 coming and would not admit him. He had been in the ER since yesterday with no place to go. During an interview on 4/2/24 at 2:32 p.m. the Director of Admissions said Resident #2 was admitted under false pretenses. He said the family put him and the facility in bad situation. the Director of Admissions said the family did not inform him Resident #2 was a registered sex offender. The older family member said she told him Resident #2 was a sex offender, but she had not. He said if she had done so the resident would never have been admitted . He said according to their admission handbook and policy they could not admit a sex offender. He said it puts their residents and family members at risk, especially if small children accompany the family. The Director of Admissions said Resident #2 had major behaviors, and he was only at the facility for a few days. He said on Resident #2's second night, he urinated on a man while he was in the bed and defecated in his shoe. The Director of Admissions said that happened on 3/31/24 and Resident #2 was discharged the next day. He said the family member was visiting and she let everyone know that Resident #2 was a sex offender. The Director of Admissions said Resident #2 did not want to stay at the facility. He said he helped the family with discharge by contacting the behavior hospital for admission. He said he called the hospital and helped him get set up there. He said the family told him before Resident #2 was admitted that he had an order to be admitted to Behavioral Hospital. The discharge plan was they would take Resident #2 to the hospital and once he was stable, they could find alternative placement. During a telephone interview on 4/2/24 at 2:59 p.m. the Director of Admissions called Resident #2's younger family member. The family member said she was told all they had to do was take Resident #2 to the hospital and he would be admitted . They said he was still in the ER. That family member was very upset with the Director of Admissions. The family member said she was told Resident #2's paperwork would be at the hospital. The family said when they got to the hospital the hospital staff had no idea Resident #2 was coming. She said Resident #2 had been evaluated and he had no medical reason to be admitted to the hospital and he did not qualify for a psychiatric admission. She said even if he had qualified, they did not have a bed. She said she picked Resident #2 up at the nurse's station, with his medications and belongings. She said she was not asked to sign anything, and the only discharge plan that was voiced to her was take the resident to the behavior hospital and all would be taken care of. She said she had tried to call the Director of Admissions several times for assistance but had not received a return call. During an interview on 4/2/24 at 3:07 p.m. the Director of Admissions said he did not say anything during the call because the family member was so upset but he did call and set up the admission for Resident #2. He said he had sent the facility's initial admission paperwork that did not have anything about him being a sex offender to the hospital. During a telephone interview on 4/2/24 at 3:10 p.m. the ER Hospital RN said Resident #2 was still in ER. The RN said she was familiar with the Director of Admissions said and no one told them Resident #2 was coming to the hospital. During a telephone interview on 4/2/24 at 3:15 p.m. the hospital SW said their policy was if the family picked up a Resident from the nursing home and brought them to the hospital then the facility was not responsible for taking the resident back. She said Resident #2 was seen by the psychiatric team, and it was determined he could not be committed to the hospital but be admitted on a voluntary basis. The SW said right now they were looking for placement for the resident and had no luck thus far. During an interview on 4/2/24 at 3:55 p.m. the Administrator said the facility Admission Policy said they could not admit a sex offender. Resident #2 was admitted , and they did not know. On Monday 4/1/24 Resident #2's family member was at the nurse's station broadcasting that he was a sex offender. She said at that point she turned the discharge over to the Director of Admission's because he had admitted him. The Administrator said as far as she knew Resident #2 went home with family. During an interview on 4/3/24 at 8:55 a.m. Resident #2's family member said they took Resident#2 back home yesterday evening on 4/2/24. The family member said they had to take him. She said they did not have a bed and they were still looking for a facility to transfer to. The family member said Resident #2 showed very little emotion because of his mental status but it was difficult for him to have to get adjusted to different environments. She said it was really hard on the family because they thought he had a safe place to live and the facility had basically thrown him out. During an interview on 4/3/24 at 7:46 a.m. the ADON said Resident #2 was admitted from home on 3/26/24. She said they were told he had been aggressive with the family members at home. The ADON said during the short time he was at the facility he would not sit down; he had a very unsteady gait and frequent falls. When he was redirected, he would become agitated and was placed on an antianxiety medication as needed. She said she had received a call on the morning of 3/30/24 about 4:00 a.m. saying Resident #2 had walked to his roommate's side of the room and took off his brief, urinated in his roommate's shoes, and defecated in his chair. She said the room was cleaned by staff. She said she thought the physician was involved in the discharge but after looking at the chart she did not see a discharge order. She said basically they found out Resident #2 was a sex offender and he had to go. He should not have been admitted in the first place. During an interview on 4/3/24 at 9:56 a.m. the RNC said she was at the nurse's station talking to Resident #2's family member when they said out of the blue he was a sex offender. She said she told the Administrator, and she took it from there. She said to her knowledge no one knew. The RNC said the Director of Admissions said no one told him. During an interview on 4/3/24 at 10:07 a.m. the Administrator said during morning meeting they were looking at moving Resident #2 to another room. She said she was informed the family was at the nurse's station saying Resident#2 was a registered sex offender on 4/1/24. She said their policy said they did not admit sex offenders. She said the RNC agreed per their policy they were not able to have him in the facility. She said she had turned the discharge over to the Director of Admissions because he had admitted him. Record review of the facility discharge /Transfer Policy dated December 2018 indicated a facility must establish, maintain and implement identical policies and practices regarding transfer and discharge provision of services for all individuals regardless of payor source. The facility must include documentation in the medical record to support the indication for transfer, who is responsible to make the documentation and the requirements for information that must be conveyed to the receiving provider at the time of transfer or discharge. Facility initiated transfer or discharge was one in which did not originate through a resident's verbal or written request was not in alignment with the residents' stated goals for care preferences. The determination for the facility-initiated transfer/discharge cannot be based on solely on the resident's status at the time of transfer. When the facility-initiated transfer/discharge meets the criteria under limited conditions for transfer, the facility will ensure the conditions was fully evaluated and documented in the medical record.

Based on interview and record review the facility failed to implement an admission policy and did not disclose to a resident notice of special service limitations prior to admission for 1 of 3 residents reviewed for admission (Resident #2) Resident #2 was admitted to the facility and did not meet the facility admission criteria due to being a registered sex offender. This negative finding could have placed residents and family member at risk for possible abuse. Findings Included: Record review of Resident # 2's face sheet with no date indicated he was an [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were dementia, unsteadiness on feet, repeated falls, adult failure to thrive, depression with anxiety, and Parkinson's disease (disorder of the central nervous system that affects movements, often including tremors). The sheet indicated the resident was discharged from the facility on 4/1/24. Record review of Resident #2's Brief Interview for Mental Status Review indicated he had severe cognitive impairment. Record review of Resident #2's Care Plan dated 3/28/24 reflected he had Problems of Pressure Ulcer and DNR status only. Record review of Resident #2's nursing notes indicated: On 4/1/24 at 3:35 p.m. Resident #2 was being discharged home with all medications and belongings due to the resident not meeting criteria of the facility. The family will arrive and will transport the resident home. Signed by ADON. During an interview on 4/2/24 at 11:24 a.m. the family member said the facility admitted Resident #2 on 3/26/24. She said during the admission process she told the Director of Admissions that Resident #2 was a sex offender. She said she gave him the card of the person who he reported to. The family member said the Director said that was fine and she did not think anything of it. The family member said she went to visit Resident #2 on 4/1/24 and while she was there, they did not say anything about discharge. Then later they called to say because he was a sex offender he could not be in the facility. The family member said they gave them no warning at all just come and get him. She said the first plan was they were going to send him to the behavior hospital and the family was there waiting on him. Then they called back and said no they had to come and get him. During an interview on 4/2/24 at 2:32 p.m. the Director of Admissions said Resident #2 was admitted under false pretenses. He said the family put him and the facility in bad situation. The Director of Admissions said the family did not inform him Resident #2 was a sex offender. The older family member said she told him Resident #2 was a sex offender, but she had not. He said if she had done so the resident would never have been admitted . He said they often have families in the facility with their children. He said having a registered sex offender in the building put residents, families, and children at risk. He said according to their admission handbook and policy they could not admit a sex offender. The Director of Admissions said Resident #2 was having major behaviors, and he was only at the facility for a few days. He said the family member was visiting and she let everyone know that Resident #2 was a sex offender. The Director of Admissions said Resident #2 did not want to stay at the facility. During an interview on 4/2/24 at 3:55 p.m. the Administrator said the facility Admission Policy said they could not admit a sex offender. Resident #2 was admitted , and they did not know. On Monday 4/1/24 Resident #2's family member was at the nurse's station broadcasting that he was a sex offender. She said at that point she turned the discharge over to the Director of Admissions because he had admitted him. The Administrator said as far as she knew Resident #2 went home with family. During an interview on 4/3/24 at 7:46 a.m. the ADON said Resident #2 was admitted from home on 3/26/24. She said basically they found out Resident #2 was a sex offender and he had to go. He should not have been admitted in the first place. During an interview on 4/3/24 at 9:35 a.m. LVN C said on 4/1/24 the family member came to the facility and was at the nurses station talking about Resident #2 being a sex offender. She had gone to the Administrator and reported what the family said about Resident #2 being a sex offender. During an interview on 4/3/24 at 9:56 a.m. the RNC said she was at the nurse's station talking to Resident #2's family member when they said out of the blue, he was a registered sex offender. She said she told the Administrator, and she took it from there. She said to her knowledge no one knew. The RNC said the Director of Admissions said no one told him. She said it was in their admission policy they could not admit a sex offender. During an interview on 4/3/24 at 10:07 a.m. the Administrator said she was informed the family was at the nurse's station saying Resident#2 was a sex offender. She said when she questioned the Director of Admissions, he did not know Resident #2 was a sex offender. She said she in serviced the Admissions Director about their policy of not admitting residents with that type of background. She said there was a school less than mile away. She said residents were supposed to be checked prior to admission. She just knew their policy said they did not admit them. She said the RNC agreed per their policy they are not able to have him in the facility. She said she had turned the discharge over to the Director of Admissions because he had admitted him. Record review of an in-service training dated 4/1/24 over the Admissions Process of which to admit, how to admit and the Admission Policy. The in service indicated to check each resident on the website prior to admission. It was signed by the Director of Admissions. Record review of the facility Preadmission/Admission Criteria dated October 2017 indicated the facility will not accept those high-risk diagnostic category residents who have abusive behavior towards themselves and others. Those resident categories may include but are not limed to Registered Sex Offender.

Based on interview and record review, the facility failed to ensure the resident had the right to be free from neglect for 1 of 7 (Resident #1) residents reviewed for neglect. The facility failed to ensure staff performed CPR for resident #1 until emergency services arrived. The facility failed to ensure the AED was utilized when Resident #1 was found unresponsive. These failures resulted in an identification of an Immediate Jeopardy (IJ) On [DATE] at 1:40 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk for neglect by not receiving appropriate life saving measures resulting in a decline in health or death. Findings Included: 1. Record review of the face sheet dated [DATE] indicated Resident #1 was an [AGE] year-old female readmitted to the facility on [DATE] with diagnoses including end stage renal disease (the last stage of long-term kidney disease), diabetes, hypertension (elevated blood pressure), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). The face sheet indicated Resident #1 was a full code (in the event of cardiac arrest, CPR will be initiated). Record review of MDS dated [DATE] indicated Resident #1 was understood by others and usually understood others. The MDS indicated Resident #1 had a BIMS score of 15 and was cognitively intact. The MDS did not indicate Resident had a DNR advanced directive in place. Record review of the care plan last revised [DATE] did not indicate Resident #1's code status. Record review of the physician orders dated [DATE] through [DATE] indicated Resident #1 had an order for code status of full code starting [DATE]. Record review of the nursing progress note dated [DATE] written by LVN WWW indicated that Nurse WWW received report from a CNA of Resident #1 not breathing. The progress note indicated Nurse WWW transported the crash cart to Resident #1's room and assessed resident for code status. The progress note indicated a CNA called 911. The progress note indicated Resident #1 was without respirations and CPR was initiated. The progress note indicated when EMS arrived, they took over. The progress note indicated the nurse practitioner was contacted and gave an order for 2 LVNs to pronounce death. The progress note indicated LVN WWW and LVN AAA pronounced Resident #1 deceased . Record review of the ambulance report dated [DATE] indicated, .Arrived to the facility and was directed to [Resident #1's room] by staff. [Resident #1] was found lying supine in bed upon our arrival with no staff in room. No evidence of CPR or Basic Life support noted. An LVN directed us to the room with [Resident #1] when we accidentally walked by it. [LVN WWW] stated We rounded on her at 3 am and she was sleeping. [LVN WWW] states that they found her unresponsive and not breathing at 0507, so they called us. Patient has medical history as noted, is on medications as noted, and has NKDA as noted. 803 arrived on the scene to the patient laying in the room with no nursing home staff tending to her and no equipment such as crash cart, AED, or BVM as well as no staff noted anywhere near the room. All staff were at desk in the center of the Nursing home when attempted to contact for patient information leading up to time of calling us. [Resident #1] was laying supine in the bed upon our arrival covered with the three blankets with head upon a pillow. Patient was unresponsive and breathing was apneic (cessation of breathing). No pulse was found to carotid or femoral area. [Resident #1] was attached to monitor as CPR was about to be started, but obvious signs of death were noted including pooling of blood on majority of posterior portion of body, and slight rigor-mortis noted to arms when they were attempted to be moved for pad placement and CPR. Obvious signs of death were noted as mentioned above. Monitor had asystole (when the heart stops beating entirely) noted in all three leads as noted in attached picture. Skin was cold and dry to touch. Nursing home staff was found sitting at station and asked if they had performed CPR prior to our arrival. [LVN WWW] states We seen her clearly dead when approached her earlier, so we didn't even attempt. Nurse informed me the patient did not have a DNR and was full code status . During an interview on [DATE] at 2:02 p.m. LVN AAA said she remembered the incident with Resident #1. LVN AAA said she was not Resident #1's charge nurse on the night shift from [DATE]-[DATE]. LVN AAA said a CNA came to the nurse's station and grabbed the other nurse. LVN AAA said they were gone for some time and when the other nurse returned, she said Resident #1 was unresponsive. LVN AAA said she looked up Resident #1's code status, grabbed the crash cart, went to Resident #1's room and initiated CPR. LVN AAA said she did not stop CPR until EMS arrived. LVN AAA said they received an order from the physician for 2 LVNs to pronounce death. When asked if it was in her scope of practice to pronounce death LVN AAA said it was in the facility's policy. During an interview on [DATE] at 8:10 a.m. LVN WWW said she worked the overnight shift on [DATE]. LVN WWW said she was an agency nurse. LVN WWW said she had been Resident #1's nurse that night. LVN WWW said at approximately 5:00 am a CNA came to get her to go to Resident #1's room. LVN WWW said when she entered Resident #1's room, she noticed her facial color was pale. LVN WWW said after she assessed Resident #1, she went to the nurse's station and told LVN AAA she thought Resident #1 was deceased . LVN WWW said she had hospice training in the past. LVN WWW said LVN AAA grabbed the crash cart, and they went to Resident #1's room. LVN WWW CPR was initiated. LVN WWW said she did a couple of chest compressions on Resident #1. LVN WWW said when they pulled the sheet down it was noted Resident #1's body was cool to the touch, she had slight mottling on her legs, her fingers were purple, and her blood was pooling. LVN WWW said at that point CPR was stopped. LVN WWW said when EMS arrived, they questioned why CPR was not being performed. LVN WWW said she had informed EMS the resident was deceased . LVN WWW said she had always been told an LVN cannot pronounce death. LVN WWW said the DON told them to call the physician to get an order to pronounce death. LVN WWW said she reached the physician via text messages and was given the order for 2 LVNs to pronounce death. When asked if this was in her scope of practice LVN WWW said it was what the facility told her to do. During an interview on [DATE] at 10:17 a.m. LVN WWW said the AED was not turned on or used when CPR was initiated on Resident #1. Record review of the facility's Automatic External Defibrillator (AED) policy dated [DATE] indicated, The facility will use the Automatic External Defibrillator (AED) to treat victims who experience sudden cardiac arrest. It is only applied to victims who show all signs of cardiac arrest such as: unconscious, unresponsive, not breathing normally, and have no pulse. Procedure: Active EMS by calling 911 Bring AED to the resident location Press On button Follow the prompts as given by the AED Prepare the resident by removing any clothing from the resident's chest Wipe away any excess moisture from chest Quickly shave excess chest hair if necessary Pull pads from storage slot Remove pads from packaging Pads may only be used once Apply pads Continue to follow the prompts given by the AED Continue CPR as directed by the AED until EMS arrives . Record review of the facility's Identifying Types of Abuse policy dated [DATE] indicated, As part of the abuse prevention strategy, volunteers, employees, and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents. Abuse of any kind against residents is strictly prohibited. Abuse prevention includes recognizing and understanding the definitions and types of abuse that can occur .Having the knowledge and ability to provide care and services, but choosing not to, constitutes abuse . Record review of the facility's Cardiopulmonary Resuscitation (CPR)-Basic Life Support (BLS) policy dated [DATE] indicated, The objective of the CPR policy is to provide basic life support based until emergency medical services arrives, consistent with the resident advanced directives, in the absence of an advance directive or Do Not Resuscitate Order and if the resident does not show clinical signs of death. The facilities strive to assure all clinicians are certified on BLS-Cardiopulmonary Resuscitation through programs approved by the American Heart Association and/or American Red Cross .CPR will be initiated unless: decision not to initiate CPR has previously been made by the resident/patient, CPR will be initiated for any resident/patient, visitor, or staff member who experience cardiopulmonary arrest while in the facility. Residents presents with obvious signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present . Record review of the facility's undated Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy indicated, Residents have the right to be free from abuse, neglect misappropriation of resident property and exploitation . The Administrator was notified on [DATE] at 1:55 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The DON was provided the Immediate Jeopardy template on [DATE] at 2:02 p.m. The facility's Plan of Removal was accepted on [DATE] at 4:25 p.m. and included: In-service to all staff about life saving measures were provided on [DATE] and on [DATE] with a post test. The in-service was specifically about: verification of code status in the resident's medical chart, that advance directive orders cannot be accepted verbally and can only be accepted on the proper OOH form which must be dated and signed by the physician, about who can order a DNR, and that CPR cannot be stopped once started until EMS arrives and takes over the CPR process. Presenter of in-service: ADON Abuse and neglect prevention in-service was given to all staff at the facility on [DATE] and on [DATE] with a post test. The in-service was specifically about: About the type of abuse and neglect, prohibition of abuse and neglect of residents, reporting all potential occurrences of abuse and neglect, about who the abuse and neglect facility coordinator was, and illustrations of potential cases of abuse and neglect were given as well. Presenter of in-service: ADON and RN regional consultant. In-service was completed on [DATE] for all nursing staff regarding CPR regulations, code status orders, and advance directive related care. The in-service was specifically about: verification of code status in the resident's medical chart, advance directive orders cannot be accepted verbally and can only be accepted on the proper OOH form which must be dated and signed by the physician, about who can order a DNR, that CPR cannot be stopped once started until EMS arrives and takes over the CPR process. Presenter of in-service: ADON Pronouncement of death regulations - in-service started on [DATE] and continued [DATE] for all licensed nursing staff. The in-service was specifically about: RN's and licensed physicians are the only ones that can pronounce a resident's death, the role LVN's have in pronouncing a residents death per the board of nursing (that LVN's cannot pronounce), that a nurse cannot verbally accept DNR orders and must have an OOH form signed and dated by the licensed physician, documentation of occurrence that must include, date, time of death, and the name and title of the person pronouncing the death of the resident. Presenter of in-service: Regional Nurse Consultant Hospice nurse and hospice administrator were in-serviced on [DATE] by the facility administrator, including facility nurses, that they will not accept verbal CPR stop orders from a hospice nurse and about the need to provide the correct and appropriate care related to their advance directive. On [DATE] and [DATE], all nursing staff were educated about the requirement to document events accurately and to report any irregularities to the administrator. Presenter of in-service: ADON. On [DATE], the DON was in-serviced in depth on the importance of documentation and including everything that had occurred accurately. Presenter of in-service: the Administrator, the Medical Director, with RN nursing consultant and the facility management present. Use of AED in-service started and was completed on [DATE] for all licensed nursing staff. A posttest on use of AED was given and completed by the licensed staff on [DATE]. Presenter of in-service: Regional Nurse Consultant and ADON. CPR certifications were audited on [DATE], and nurses were in-serviced on not initiating CPR if certification is not current. Audit completed by: ICP Director and Staffing coordinator. The facility policy was revised on [DATE]. Regarding current staff, as of today ([DATE]), every licensed nurse at the facility was CPR certified. For new hires, they will be required to provide the facility with CPR certification within a week of hire. A status code audit was completed on [DATE] and [DATE] to ensure no discrepancies regarding code status exist and that the corresponding forms on the chart matched the orders. The audit was completed by: ICP, LVN, and Staffing coordinator. All residents on hospice with DNR orders were checked to ensure their ordered code on the chart matched the signed paperwork in the chart. The audit was completed by: ICP, LVN and Staffing coordinator. For staff not currently at the facility, including agency staff, PRN staff and new hires, in-services and a post test will be provided prior to them working their shift. Start Date: [DATE] Completion Date: [DATE] Responsible: the Administrator, RN Consultant, the ADON or designee Regarding nurse # 1, the CPR check off was completed on [DATE] and nurse # 2, was CPR certified at the facility by a CPR instructor on [DATE]. Action 2: After an internal investigation, the Medical Director was notified by the administrator about the deficient practice on [DATE]. The Medical Director provided education to the Administrator, the DON, and the ADON about CPR guidelines, the need to follow CPR guidelines and regulations, MD orders, with a posttest to validate that participants fully understood the discussed topic. The Administrator, the DON, and the ADONs have passed the test with 100%. Start Date: [DATE] Completion Date: [DATE] Responsible: The Medical Director and RN Regional Nurse Consultant QA Involvement On [DATE] an Ad Hoc QAPI meeting was held with the Medical Director, the Facility Administrator, the Director of Nursing, to review and update policy and protocols in regard to CPR and advance directive orders and care. On [DATE], the Medical director was notified by the administrator of IJ and for the review of the plan of removal. Action 3: The Administrator, the RN Consultant, the DON, and the ADON will monitor all residents with code status, to ensure the order and the paperwork required does match. Process: The administrator and the ADON or designee will review all new or any new changes in code status - daily (M through F) during morning meeting. The Administrator or designee will check on a weekly basis nursing practices when CPR should have occurred to ensure staff was following CPR protocol during morning meeting. The Administrator or designee will also check weekly for signed paperwork, hospice residents with potential DNR codes, their orders for DNR, and for a signed OOH DNR. Monitoring: On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review on [DATE] of a random selection of 13 LVN and RN's CPR certifications indicated nurses reviewed had a current and appropriate CPR certification. Record review on [DATE] of a random selection of 36 resident charts indicated residents reviewed had code status that matched on the face sheet and orders and had DNR's on file for residents who had chosen to be a DNR. Staff interviewed on [DATE] and [DATE] between 8:00 a.m. and 9:50 p.m. (CNA B, CNA C, CNA D, CNA E, CNA F, CMA G, LVN H, LVN J, the Treatment Nurse, CNA K, LVN L, CNA M, RN X, LVN Y, RN Z, CMA AA, ADON BB, ADON CC, CNA DD, CNA EE, CNA FF, RN GG, LVN HH, CMA KK, LVN LL, CNA MM, CNA NN, CNA QQ, CNA VV, LVN WW, the MDS Nurse, CNA XX, CNA YY, CMA ZZ, LVN AAA, LVN BBB, LVN CCC, MA DDD, LVN EEE, CNA FFF, CNA GGG, MA HHH, CNA JJJ, CNA KKK, LVN LLL, LVN MMM, LVN NNN, CNA PPP, LVN QQQ, RN RRR, CNA SSS, LVN TTT, LVN VVV, and LVN WWW) were able to name where to find the code status for a resident, said code status could not be accepted as a verbal order, and a DNR had to be on the appropriate form with a physician's signature. Staff interviewed said an LVN could not pronounce a resident's death, only a physician or a RN could pronounce death. Staff interviewed said documentation must be accurate without any omissions. Staff interviewed on [DATE] and [DATE] between 8:00 a.m. and 9:50 p.m. (CNA B, CNA C, CNA D, CNA E, CNA F, CMA G, LVN H, LVN J, the Treatment Nurse, CNA K, LVN L, CNA M, RN X, LVN Y, RN Z, MA AA, ADON BB, ADON CC, CNA DD, CNA EE, CNA FF, RN GG, LVN HH, CMA KK, LVN LL, CNA MM, CNA NN, CNA QQ, CNA VV, LVN WW, the MDS Nurse, CNA XX, CNA YY, MA ZZ, LVN AAA, LVN BBB, LVN CCC, CMA DDD, LVN EEE, CNA FFF, CNA GGG, CMA HHH, CNA JJJ, CNA KKK, LVN LLL, LVN MMM, LVN NNN, CNA PPP, LVN QQQ, RN RRR, CNA SSS, LVN TTT, LVN VVV, and LVN WWW, Housekeeper A, [NAME] N, Dishwasher P, Dishwasher Q, Dishwasher R, Assistant Kitchen Manager, Dietary Helper S, Dietary Manager, Housekeeper T, Floor Technician, Housekeeper V, Housekeeper W, Assistant Activity Director, DOR, OT PP, Housekeeper RR, ST SS, Laundry Aide TT, Human Resources Manager, Transportation Driver) were able to name all types of abuse and neglect including physical, mental, sexual, and misappropriation of property. Staff were able to name the Abuse Coordinator as the Administrator. Staff said witnessed or reported abuse should be reported to the Abuse Coordinator immediately. During an interview on [DATE] at 3:28 p.m. the Medical Director said he attended a QAPI meeting regarding the failure. The Medical Director said he educated the Administrator, the DON, and the ADON's not to accept any verbal orders for a DNR. The Medical director said a DNR needed to be well marked in the chart and if not, CPR needed to be performed until the EMS arrived. The Medical Director said he thought the facility had relied on the hospice company to have the DNR in the charts. The Medical Director said the hospice facility had it and there was some breakdown in the hospice system. The Medical Director said either an MD or RN can pronounce a death. The Medical Director said he thought they have drilled it in the staffs' minds now. The Medical Director said he thought after this IJ, staff had a greater understanding and going forth should have the proper education on what they needed to do for the residents. During an interview on [DATE] at 12:10 p.m. the DON said she was in-serviced regarding CPR. The DON said she was in-serviced regarding pronouncing death and only an RN, MD, and JP can pronounce death. The DON said you could not stop CPR until the EMS resumed care. The DON said CPR must be started if a resident did not have a DNR. The DON said if a resident was a full code, then CPR should be started. The DON said CPR could be administered as an AED was being set up. The DON said the AED was located by the exit towards the memory. The DON said a DNR was ordered by the physician. The DON said the facility must have the physical DNR. The DON said staff could look in the EMR and chart to see a resident's code status. The DON said staff should document everything on their shift. The DON said she thought a communication error occurred because of incompetence. The DON said after the in-services, she felt they are compliant to perform their assigned duties correctly, and we will continue to have in-services. The DON said they had a QAPI (Quality Assurance and Performance Improvement) meeting where the topics of documentation and a system for our code status to be in place and available to staff were discussed. During an interview on [DATE] at 12:21 p.m. the Administrator said staff had been in-serviced regarding CPR, AED, Pronouncement of Death, and Abuse/neglect. The Administrator said the CPR in-service addressed the requirement of having an up-to-date CPR certification to perform CPR. The Administrator said staff could look in the chart to see a resident's code status. The Administrator said once a person starts CPR they can only stop when EMS physically takes over. The Administrator said staff cannot take a verbal DNR order over the phone. The Administrator said there had to be a hard copy of the resident's DNR on the chart. The Administrator said the only people who can pronounce death are a physician, justice of the peace, or RN. The Administrator said the AED was located by the time clock and should be used in a code situation. The Administrator said she thought this failure occurred due to incompetence. The Administrator said she felt after the in-services staff have the equipment and knowledge, they need to perform their duties in a code. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure basic life support, including cardiopulmonary resuscitation (CPR), was provided to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 2 of 7 (Resident #1 and Resident #2) residents reviewed for CPR. The facility failed to ensure staff performed CPR for resident #1 until emergency services arrived. CPR was initiated and then stopped prior to emergency services arrival. The facility failed to ensure staff utilized the AED when Resident #1 was found unresponsive. The facility failed to ensure Resident #2 advance directive was accurate. CPR was initiated on Resident #2 and stopped upon verbal confirmation by hospice agency of Resident #2's DNR. The facility failed to ensure staff were current with CPR training. The facility failed to follow their policy and procedure for Pronouncing death. The facility failed to properly document initiation of CPR for Resident #2. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 1:40 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not receiving necessary life-saving measures, decline in health, and death. Findings include: 1. Record review of the face sheet dated [DATE] indicated Resident #1 was an [AGE] year-old female readmitted to the facility on [DATE] with diagnoses including end stage renal disease (the last stage of long term kidney disease), diabetes, hypertension (elevated blood pressure), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). The face sheet indicated Resident #1 was a full code (in the event of cardiac arrest, CPR will be initiated). Record review of MDS dated [DATE] indicated Resident #1 was understood by others and usually understood others. The MDS indicated Resident #1 had a BIMS of 15 and was cognitively intact. The MDS did not indicated Resident had a DNR advanced directive in place. Record review of the care plan last revised [DATE] did not indicated Resident #1's code status. Record review of the physician orders dated [DATE] through [DATE] indicated Resident #1 had an order for code status of full code starting [DATE]. Record review of the nursing progress note dated [DATE] written by LVN WWW indicated that Nurse WWW received report from a CNA of Resident #1 not breathing. The progress note indicated Nurse WWW transported the crash cart to Resident #1's room and assessed resident for code status. The progress note indicated a CNA called 911. The progress note indicated Resident #1 was without respirations and CPR was initiated. The progress note indicated when EMS arrived, they took over. The progress note indicated the nurse practitioner was contacted and gave an order for 2 LVNs to pronounce death. The progress note indicated LVN WWW and LVN AAA pronounced Resident #1 deceased . Record review of the ambulance report dated [DATE] indicated, .Arrived to the facility and was directed to [Resident #1's room] by staff. [Resident #1] was found lying supine in bed upon our arrival with no staff in room. No evidence of CPR or Basic Life support noted. An LVN directed us to the room with [Resident #1] when we accidentally walked by it. [LVN WWW] stated We rounded on her at 3 am and she was sleeping. [LVN WWW] states that they found her unresponsive and not breathing at 0507, so they called us. Patient has medical history as noted, is on medications as noted, and has NKDA as noted. 803 arrived on the scene to the patient laying in the room with no nursing home staff tending to her and no equipment such as crash cart, AED, or BVM as well as no staff noted anywhere near the room. All staff were at desk in the center of the Nursing home when attempted to contact for patient information leading up to time of calling us. [Resident #1] was laying supine in the bed upon our arrival covered with the three blankets with head upon a pillow. Patient was unresponsive and breathing was apneic (cessation of breathing). No pulse was found to carotid or femoral area. [Resident #1] was attached to monitor as CPR was about to be started, but obvious signs of death were noted including pooling of blood on majority of posterior portion of body, and slight rigor-mortis noted to arms when they were attempted to be moved for pad placement and CPR. Obvious signs of death were noted as mentioned above. Monitor had asystole (when the heart stops beating entirely) noted in all three leads as noted in attached picture. Skin was cold and dry to touch. Nursing home staff was found sitting at station and asked if they had performed CPR prior to our arrival. [LVN WWW] states We seen her clearly dead when approached her earlier, so we didn't even attempt. Nurse informed me the patient did not have a DNR and was full code status . During an interview on [DATE] at 2:02 p.m. LVN AAA said she remembered the incident with Resident #1. LVN AAA said she was not Resident #1's charge nurse on the night shift from [DATE]-[DATE]. LVN AAA said a CNA came to the nurse's station and grabbed the other nurse. LVN AAA said they were gone for some time and when the other nurse returned, she said Resident #1 was unresponsive. LVN AAA said she looked up Resident #1's code status, grabbed the crash cart, went to Resident #1's room and initiated CPR. LVN AAA said she did not stop CPR until EMS arrived. LVN AAA said they received an order from the physician for 2 LVNs to pronounce death. When asked if it was in her scope of practice to pronounce death LVN AAA said it was in the facility's policy. During an interview on [DATE] at 8:10 a.m. LVN WWW said she worked the overnight shift on [DATE]. LVN WWW said she was an agency nurse. LVN WWW said she had been Resident #1's nurse that night. LVN WWW said at approximately 5:00 am a CNA came to get her to go to Resident #1's room. LVN WWW said when she entered Resident #1's room, she noticed her facial color was pale. LVN WWW said after she assessed Resident #1, she went to the nurse's station and told LVN AAA she thought Resident #1 was deceased . LVN WWW said she had hospice training in the past. LVN WWW said LVN AAA grabbed the crash cart, and they went to Resident #1's room. LVN WWW CPR was initiated. LVN WWW said she did a couple of chest compressions on Resident #1. LVN WWW said when they pulled the sheet down it was noted Resident #1's body was cool to the touch, she had slight mottling on her legs, her fingers were purple, and her blood was pooling. LVN WWW said at that point CPR was stopped. LVN WWW said when EMS arrived, they questioned why CPR was not being performed. LVN WWW said she had informed EMS the resident was deceased . LVN WWW said she had always been told an LVN cannot pronounce death. LVN WWW said the DON told them to call the physician to get an order to pronounce death. LVN WWW said she reached the physician via text messages and was given the order for 2 LVNs to pronounce death. When asked if this was in her scope of practice LVN WWW said it was what the facility told her to do. During an interview on [DATE] at 10:17 a.m. LVN WWW said the AED was not turned on or used when CPR was initiated on Resident #1. 2. Record review of the face sheet dated [DATE] indicated Resident #2 was a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses including anxiety disorder, hypokalemia (decreased potassium), shortness of breath, Alzheimer's, and hypertension. The face sheet indicated Resident #2 was a full code. Record review of the MDS dated [DATE] indicated Resident #2 was usually understood by others and usually understood others. The MDS indicated Resident #2 had a BIMS of 00 and was severely cognitively impaired. The MDS did not indicate Resident #2 had a DNR advanced directive. Record review of the care plan last revised [DATE] indicated Resident #2 was receiving hospice services with interventions including assure advance directives were in place per resident and responsible party request. Record review of the physician's orders dated [DATE] through [DATE] indicated Resident #2 had an order for code status: full code starting [DATE]. Record review of the progress noted dated [DATE] written by LVN NNN indicated Resident #2 was sitting in her Geri chair (large, padded chair with wheeled base designed to assist seniors with limited mobility) in front of the nurse's station. The progress note indicated Resident #2 turned pale and was having seizure like activity. The progress note indicated LVN NNN sat Resident #2 up and began to assess her vital signs. The progress note indicated LVN NNN notified the hospice nurse of the change in condition. The progress note indicated Resident #2 had a code status of DNR. The progress note indicated Resident #2 took a gasp and then no respirations were noted. The progress note indicated the hospice nurse pronounced Resident #2 deceased . Record review of LVN NNN's Basic Life Support (CPR and AED) card issued [DATE] indicated her CPR certification expired ,d+[DATE]. During an interview on [DATE] at 1:57 p.m. LVN NNN said she was working the morning of [DATE]. LVN NNN said she was called to the nurse's station due to Resident #2 sitting up in her Geri-chair and turning pale. LVN NNN said Resident #2 started shaking like she was having a seizure. LVN NNN said she called EMS and checked the resident's code status. LVN NNN said CPR was initiated. LVN NNN said she called hospice at 8:15 a.m. to obtain Resident #2's code status as she was trying to get into her computer at the time to determine code status. LVN NNN said the hospice nurse called her back at 8:17 a.m. and informed her Resident #2 was a DNR. LVN NNN said she notified the DON and the hospice nurse that CPR was initiated. LVN NNN said she was told by the DON not to document in Resident #2's chart that she had initiated CPR. LVN NNN said there was not a DNR in Resident #2's chart. During an interview on [DATE] at 1:43 p.m. the DON said she remembered Resident #2 expiring. The DON said she was not at the facility but was given report regarding Resident #2's death. The DON said she had been informed CPR was initiated on Resident #2. The DON said she told LVN NNN not to document the initiation of CPR. The DON said she did not know why she told the nurse not to document the initiation of CPR and that it was a mistake on her part. During an interview on [DATE] at 10:26 a.m. The Patient Care Manager (hospice for Resident #2) said she had no documentation prior to the date of death showing the facility had been given Resident #2's DNR. The Patient Care Manager said the documentation indicated the facility was provided the DNR for Resident #2 on [DATE] at approximately 2:30 pm. The Patient Care Manager said the hospice company's procedure was to fax or email the DNR as soon as they had it completed and signed. The Patient Care Manager said she was unsure why the DNR was not at the facility prior to Resident #2's date of death . During an interview on [DATE] at 11:26 a.m. the SW said she had started at the facility in [DATE]. The SW said after she started at the facility, she did a complete audit of all residents' code status to ensure accuracy in the EMR. The SW said she did weekly scheduled assessments with residents and verified their code statuses at that time. The SW clarified she did not perform weekly assessments on every resident in the facility. The SW said when a resident admits the admissions coordinator usually got the advance directive at that time. The SW said when it came to a resident on hospice that hospice communicated with the nurses, and it was the nurse's responsibility to update the code status, and obtain appropriate paperwork if hospice notified them of a code status change. Record review of the facility's Cardiopulmonary Resuscitation (CPR)-Basic Life Support (BLS) policy dated [DATE] indicated, The objective of the CPR policy is to provide basic life support based until emergency medical services arrives, consistent with the resident advanced directives, in the absence of an advance directive or Do Not Resuscitate Order and if the resident does not show clinical signs of death. The facilities strive to assure all clinicians are certified on BLS-Cardiopulmonary Resuscitation through programs approved by the American Heart Association and/or American Red Cross .CPR will be initiated unless: decision not to initiate CPR has previously been made by the resident/patient, CPR will be initiated for any resident/patient, visitor, or staff member who experience cardiopulmonary arrest while in the facility. Residents presents with obvious signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present . Record review of the facility's Do Not Resuscitate DNR Orders guideline dated [DATE] indicated, .DNR order-means that, while the resident/patient will receive medically appropriate care, cardiopulmonary resuscitation will not be initiated . Record review of the facility's Automatic External Defibrillator (AED) policy dated [DATE] indicated, The facility will use the Automatic External Defibrillator (AED) to treat victims who experience sudden cardiac arrest. It is only applied to victims who show all signs of cardiac arrest such as: unconscious, unresponsive, not breathing normally, and have no pulse. Procedure: Active EMS by calling 911 Bring AED to the resident locations Press On button Follow the prompts as given by the AED Prepare the resident by removing any clothing from the resident's chest Wipe away any excess moisture from chest Quickly shave excess chest hair if necessary Pull pads from storage slot Remove pads from packaging Pads may only be used once Apply pads Continue to follow the prompts given by the AED Continue CPR as directed by the AED until EMS arrives . Record review of the facility's Death of a Resident, Documenting policy revised [DATE] indicated, Appropriate documentation shall be made in the clinical record concerning the death of a resident. A resident may be declared dead by a licensed physician or registered nurse with physician in accordance with state law . Record review of the facility's Narrative policy dated [DATE] indicated, Narrative documentation will reflect the status of the resident/patient or the situation. Each entry will include the actual date and time of the entry .Narrative documentation will be completed during the following circumstances including but not limited to: admission, change in condition, death, discharge, exception to established care plan, physician/family notification, resident/patient or family expressed concern or dissatisfaction, response to treatment. Narrative documentation will include on factual and objective information . The Administrator was notified on [DATE] at 1:55 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The DON was provided the Immediate Jeopardy template on [DATE] at 2:02 p.m. The facility's Plan of Removal was accepted on [DATE] at 4:25 p.m. and included: Inservice was completed on [DATE] for all nursing staff regarding CPR regulations, code status orders and advanced directive related care. The in services were specifically about: verification of code status in the resident's medical chart, and that advanced directives orders cannot be accepted verbally and can only be accepted on the proper OOH form, dated, and signed by the physician. Presenter of in-service: Infection Preventionist. Pronouncement of death regulations - in-service started on [DATE] and continued [DATE] for all nursing staff. The in services were specifically about: RN's and licenses physicians are the only ones that can pronounce a resident's death, the role of the LVN's in pronouncing a residents death per the board of nursing status (that LVN's cannot pronounce), that a nurse cannot verbally accept DNR orders and must have a OOH form signed and dated by the licensed physician, documentation of occurrence that must include, date, time of death, name and title of person pronouncing the death of the resident. Presenter of in-service: Regional Nurse Consultant. Hospice nurse and hospice administrator were in-serviced on [DATE] by the facility administrator, including facility nurses, that they will not accept verbal CPR stop orders from a hospice nurse and about the need to provide the correct and appropriate care related to their advanced directive. On [DATE] and [DATE], all nursing staff were educated about the requirement to document events accurately and to report any irregularities to the administrator. Presenter of in-service: ADON. On [DATE], the DON was in-serviced in depth on the importance of documentation and including everything that had occurred accurately. Presenter of in-service: Administrator, Medical Director, with RN nursing consultant and facility management present. Use of AED in-service started and was completed on [DATE] for all licensed nursing staff. A posttest on use of AED was given and completed by the licensed staff on [DATE]. Presenter of in-service: Regional Nurse Consultant and ADON. CPR certifications were audited on [DATE], and nurses were in serviced on not initiating CPR if certification is not current as per reviewed and revised facility policy - dated [DATE]. Regarding current staff, as of today [DATE], every licensed nurse at the facility is CPR certified. For new hires, they will be required to provide the facility with CPR certification within a week of hire. Audit completed by: ICPC and Staffing coordinator. A status code audit was completed on [DATE] and [DATE] to ensure no discrepancies regarding code status exist and that the corresponding forms on the chart are matching orders. The audit was completed by: ICPC, LVN and Staffing coordinator, LVN. All residents on hospice with DNR orders were checked to ensure their ordered code on the chart matched the signed paperwork in the chart. The audit was completed by: ICPC, LVN and Staffing coordinator, LVN. For staff not currently at the facility, PRN staff and new hires, in services and a post test will be provided prior to them working their shift. Start Date: [DATE] Completion Date: [DATE] Responsible: Administrator, RN Consultant, ADON or designee Monitoring: On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review on [DATE] of a random selection of LVN and RN's CPR certifications indicated nurses reviewed had a current and appropriate CPR certification. Record review on [DATE] of a random selection of resident charts indicated residents reviewed had code status that matched on the face sheet and orders and had DNR's on file for residents who had chosen to be a DNR. Staff interviewed on [DATE] and [DATE] between 8:00 a.m. and 9:50 p.m. (CNA B, CNA C, CNA D, CNA E, CNA F, CMA G, LVN H, LVN J, the Treatment Nurse, CNA K, LVN L, CNA M, RN X, LVN Y, RN Z, CMA AA, ADON BB, ADON CC, CNA DD, CNA EE, CNA FF, RN GG, LVN HH, CMA KK, LVN LL, CNA MM, CNA NN, CNA QQ, CNA VV, LVN WW, the MDS Nurse, CNA XX, CNA YY, CMA ZZ, LVN AAA, LVN BBB, LVN CCC, CMA DDD, LVN EEE, CNA FFF, CNA GGG, CMA HHH, CNA JJJ, CNA KKK, LVN LLL, LVN MMM, LVN NNN, CNA PPP, LVN QQQ, RN RRR, CNA SSS, LVN TTT, LVN VVV, and LVN WWW) were able to name where to find the code status for a resident and said code status could not be accepted as a verbal order and an DNR had to be on the appropriate form with a physician's signature. Staff interviewed said an LVN could not pronounce a resident's death, only a physician or RN could pronounce death. Staff interviewed said documentation must be accurate without any omissions. During an interview on [DATE] at 3:28 p.m. the Medical Director said he attended a QAPI meeting regarding the failure. The Medical Director said he educated the Administrator, DON, and ADON's not to accept any verbal orders for a DNR. The Medical director said a DNR needed to be well marked in the chart and if not CPR needed to be performed until the EMS arrives. The Medical Director said he thought the facility had relied on the hospice company to have the DNR in the charts. The Medical Director said the hospice facility had it and there was some breakdown in the hospice system. The Medical Director said either an MD or RN can pronounce a death. The Medical Director said he thought they have drilled it in the staffs' minds now. The Medical Director said he thought after this IJ staff had a greater understanding and going forth should have the proper education on what they needed to do for the residents. During an interview on [DATE] at 12:10 p.m. the DON said she was in-serviced regarding CPR. The DON said she was in-serviced regarding pronouncing death and only an RN, MD, and JP can pronounce death. The DON said you could not stop CPR until the EMS resumes care. The DON said CPR must be started if a resident did not have a DNR. The DON said if a resident was a full code, then CPR should be started. The DON said CPR could be administered as AED was being set up. The DON said the AED was located by the exit towards the memory. The DON said a DNR was ordered by the physician. The DON said the facility must have the physical DNR. The DON said staff could look in the EMR and chart to see a resident's code status. The DON said staff should document everything on their shift. The DON said she thought a communication error occurred because of incompetence. The DON said after the in-services, she felt they are compliant to perform their assigned duties correctly and we will continue to have in-services. The DON said they had a QAPI (Quality Assurance and Performance Improvement) meeting where the topics of documentation and a system for our code statutes to be in place and available to staff were discussed. During an interview on [DATE] at 12:21 p.m. the Administrator said staff had been in-serviced regarding CPR, AED, Pronounce of Death, and Abuse/neglect. The Administrator said the CPR in-service addressed the requirement of having an up-to-date CPR certification to perform CPR. The Administrator said staff could look in the chart to see a resident's code status. The Administrator said once a person starts CPR they can only stop when EMS physically takes over. The Administrator said staff cannot take a verbal DNR order over the phone. The Administrator said there had to be a hard copy of the resident's DNR on the chart. The Administrator said the only people who can pronounce death are a physician, justice of the peace, or RN. The Administrator said the AED was located by the time clock and should be used in a code situation. The Administrator said she thought this failure occurred due to incompetence. The Administrator said she felt after the in-services staff have the equipment and knowledge, they need to perform their duties in a code. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility for 2 of 3 (LVN WWW and LVN AAA) nurses reviewed for pronouncement of death. The facility failed to ensure LVN WWW and LVN AAA worked within the scope of practice by pronouncing the death of Resident #1. This failure could place residents at risk for receiving services from nursing staff that is outside their scope of practice leading to residents not receiving proper services, decreased quality of life, and injury. Findings Included: 1. Record review of the face sheet dated [DATE] indicated Resident #1 was an [AGE] year-old female readmitted to the facility on [DATE] with diagnoses including end stage renal disease (the last stage of long term kidney disease), diabetes, hypertension (elevated blood pressure), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). The face sheet indicated Resident #1 was a full code (in the event of cardiac arrest, CPR will be initiated). Record review of MDS dated [DATE] indicated Resident #1 was understood by others and usually understood others. The MDS indicated Resident #1 had a BIMS of 15 and was cognitively intact. The MDS did not indicated Resident had a DNR advanced directive in place. Record review of the care plan last revised [DATE] did not indicated Resident #1's code status. Record review of the physician orders dated [DATE] through [DATE] indicated Resident #1 had an order for code status of full code starting [DATE]. Record review of the nursing progress note dated [DATE] written by LVN WWW indicated that Nurse WWW received report from a CNA of Resident #1 not breathing. The progress note indicated Nurse WWW transported the crash cart to Resident #1's room and assessed resident for code status. The progress note indicated a CNA called 911. The progress note indicated Resident #1 was without respirations and CPR was initiated. The progress note indicated when EMS arrived, they took over. The progress note indicated the nurse practitioner was contacted and gave an order for 2 LVNs to pronounce death. The progress note indicated LVN WWW and LVN AAA pronounced Resident #1 deceased . During an interview on [DATE] at 2:02 p.m. LVN AAA said she remember the incident with Resident #1. LVN AAA said she was not Resident #1's charge nurse on the night shift from [DATE]-[DATE]. LVN AAA said a CNA came to the nurse's station and grabbed the other nurse. LVN AAA said they were gone for some time and when the other nurse returned, she said Resident #1 was unresponsive. LVN AAA said she looked up Resident #1's code status, grabbed the crash cart, went to Resident #1's room and initiated CPR. LVN AAA said she did not stop CPR until EMS arrived. LVN AAA said they received an order from the physician for 2 LVNs to pronounce death. When asked if it was in her scope of practice to pronounce death LVN AAA said it was in the facility's policy. During an interview on [DATE] at 8:10 a.m. LVN WWW said she worked the overnight shift on [DATE]. LVN WWW said she was an agency nurse. LVN WWW said she had been Resident #1's nurse that night. LVN WWW said at approximately 5:00 am a CNA came to get her to go to Resident #1's room. LVN WWW said when she entered Resident #1's room, she noticed her facial color was pale. LVN WWW said after she assessed Resident #1, she went to the nurse's station and told LVN AAA she thought Resident #1 was deceased . LVN WWW said she had hospice training in the past. LVN WWW said LVN AAA grabbed the crash cart, and they went to Resident #1's room. LVN WWW CPR was initiated. LVN WWW said she did a couple of chest compressions on Resident #1. LVN WWW said when they pulled the sheet down it was noted Resident #1's body was cool to the touch, she had slight mottling on her legs, her fingers were purple, and her blood was pooling. LVN WWW said at that point CPR was stopped. LVN WWW said when EMS arrived, they questioned why CPR was not being performed. LVN WWW said she had informed EMS the resident was deceased . LVN WWW said she had always been told an LVN cannot pronounce death. LVN WWW said the DON told them to call the physician to get an order to pronounce death. LVN WWW said she reached the physician via text messages and was given the order for 2 LVNs to pronounce death. When asked if this was in her scope of practice LVN WWW said it was what the facility told her to do. During an interview on [DATE] at 3:28 p.m. the Medical Director said either an MD or a RN can pronounce a death. The Medical Director said he thought they have drilled it in the staffs' minds now. During an interview on [DATE] at 12:10 p.m. the DON said she was in-serviced regarding CPR. The DON said she was in-serviced regarding pronouncing death and only an RN, MD, and JP can pronounce death. The DON said she thought a communication error occurred because of incompetence. The DON said after the in-services, she felt they are compliant to perform their assigned duties correctly and will continue to have in-services. During an interview on [DATE] at 12:21 p.m. the Administrator said staff had been in-serviced regarding CPR, AED, Pronounce of Death, and Abuse/neglect. The Administrator said the only people who can pronounce death are a physician, justice of the peace, or RN. The Administrator said she thought this failure occurred due to incompetence. The Administrator said she felt after the in-services staff have the equipment and knowledge, they need to perform their duties in a code. Record review of the facility's Death of a Resident, Documenting policy revised [DATE] indicated, Appropriate documentation shall be made in the clinical record concerning the death of a resident. A resident may be declared dead by a licensed physician or registered nurse with physician in accordance with state law . Record review of the State Board of Nursing's website (www.bon.texas.gov) under the Practice tab Scope-Vocational Nurse Practice indicated, Licensed vocational nurses (LVNs) do not have the authority to legally determine death, diagnose death, or otherwise pronounce death in the State of Texas. Regardless of practice setting, the importance of initiating cardiopulmonary resuscitation (CPR) in cases where no clear do-not-resuscitate (DNR) orders exist is imperative .

Based on observation, interview and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 2 ice machines. The facility failed to ensure the large ice machine inside the locked units was clean. These failures could place residents who consumed ice from this machine, at risk of being served in unsanitary conditions and for food borne illness. The findings include: During an observation of the common area to the locked units, on 03/06/2023 at 12:37 p.m., the large ice machine in the common area was dirty with black slimy scum on the inner most portion of the ice machine door, connecting to the inside wall of the ice machine. During an interview with the Dietary Manager on 03/06/2022 at 12:46 p.m., she said the maintenance director is responsible for keeping this ice machine clean. She said she is responsible for cleaning the ice machine in the front and the maintenance director is responsible for cleaning this one in the back. During an interview with the Maintenance Supervisor on 03/06/23 at 12:48 p.m. He said he is responsible for cleaning the ice machine in the common area of the locked units. When asked how often he clean the ice machine, he said every Monday. When asked how he clean the ice machine, the Maintenance Director said he wipes the ice machine down, on the sides and the top of the door. He said he does not keep a record when he cleans the ice machine. During an interview with LVN-C, on 03/06/23 at 2:05 p.m., she said they use the ice from the ice machine in the common area for the locked units for the residents. She said they use the ice to fill cooler, for ice cups, for water pitchers to pass meds, coolers for UA's (urine specimens) and for family members that may have a birthday party. The facility provided a policy dated September 2018, titled Nutrition Services Practice Manual 7.23.1 Sanitation. Procedure Ice Machine, #3 Wash interior and exterior thoroughly using a clean cloth soaked in warm detergent solution.

Based on observation, interview, and record review the facility failed to post the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care and resident census on a daily basis for 3 of 3 days (03/06/23, 03/07/23, and 03/08/23) reviewed for March 2023 nursing staffing. The facility failed to post the total number of hours worked for licensed nurses and certified nurse aides or the resident census on the staffing sheet for March 6th , 7th , and 8th of 2023. This failure could cause residents, families, and visitors to be unaware of the facility daily staffing requirements. Findings included: During an observation on 03/06/23 at 08:47 a.m., the total number of hours worked by licensed and unlicensed direct care staff and resident census was not posted on the staffing sheet. The staffing sheet was posted in the front lobby and dated 03/06/23. During an observation on 03/07/23 at 08:17 a.m., the total number of hours worked by licensed and unlicensed direct care staff and resident census was not posted on the staffing sheet. The staffing sheet was posted in the front lobby and dated 03/07/23. During an observation on 03/08/23 at 09:17 a.m., the total number of hours worked by licensed and unlicensed direct care staff and resident census was not posted on the staffing sheet. The staffing sheet was posted in the front lobby and dated 03/08/23. During an interview on 03/08/23 at 10:48 a.m., LVN D said she was the staffing coordinator and responsible for posting the staffing sheet daily. LVN D said she did not know the staffing sheets needed to include documentation of the actual staff hours worked each shift, and the resident census. LVN D said she had only worked in this positions for 3 weeks and was using the staffing sheet used by the person she replaced. LVN D said she would correct it. During an interview on 03/08/23 at 11:00 a.m., the DON said LVN D was the staffing coordinator, and she was responsible for posting the staffing sheet daily. The DON said he was unfamiliar with the posting requirements and did not know the staffing sheets needed to include documentation of the actual staff hours worked each shift, and the resident census. The DON said the staffing sheet needed to be corrected and updated with the total hours worked and resident census and would talk to LVN D about it. The DON said the staffing sheet will be updated and corrected today. During an observation on 03/08/23 at 12:35 p.m., the total number of hours worked by licensed and unlicensed direct care staff and resident census was posted on the staffing sheet. The staffing sheet was posted in the front lobby and dated 03/08/23. Record review of the facility policy Daily Work Assignments dated 12/2018 indicated, .7. Maintain/post the daily work assignment sheets as required by State law.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 2 of 3 months reviewed. (November 2021 and January 2022) * The facility did not have the required eight consecutive hours of RN coverage during the month of November 2021 (2 days) and January 2022 (1 day) This failure could place residents at risk for not having their nursing care and medical needs met. Findings included: Record review of RN time sheets for November 2021 indicated there was no RN coverage for 11/25 and 11/26. Record review of RN time sheets for January 2022 indicated there was no RN coverage for 01/16. During an interview on 1/26/22 at 3:00 p.m. HR said an RN via telehealth (the distribution of health-related services and information via electronic information and telecommunication technologies) was not in building and on 11/19/2021 there was no documentation of a RN being physically present in the building, so there was no RN coverage. During an interview on 1/26/22 at 3:34 p.m. the Administrator said telehealth was used for RN coverages and/or support. She said she could not recall if there was a RN physically in the facility on the 11/19/21, 11/25/21, 11/26/21 and 01/16/22 since telehealth was used. She said she could not recall how often telehealth was used and was unsure who was contacted when telehealth was needed for coverage. During an interview on 01/26/22 at 3:48 p.m. the Administrator said there was no RN coverage for 11/25/21, 11/26/21, and 01/16/22. She said it was the DON and her responsibility to ensure there was RN coverage 8 consecutive hours 7 days a week.

Based on observation, interview, and record review the facility failed to ensure an accurate MDS was completed for 1 of 6 residents reviewed for MDS assessment accuracy. (Resident #2) * The facility did not include Resident #2's new diagnoses of [CONDITION(S)] disorder (a condition where symptoms of both psychotic and mood disorders are present together during one episode) and [CONDITION(S)] disorder (a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks) on the quarterly MDS. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of a face sheet dated 01/26/22 indicated Resident #2 was an [AGE] year-old male admitted on [DATE]. His diagnoses included [CONDITION(S)] disorder and [CONDITION(S)] disorder with date diagnosed of 10/21/21. Record review of a care plan dated 10/08/21 indicated a care plan for [CONDITION(S)] drug use for Resident #2 received an antidepressant medication, an antipsychotic medication, and an antianxiety medication. It was updated on 10/21/2021 with a new order received and added diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a quarterly MDS dated [DATE] indicated Resident #2 had no diagnoses of [CONDITION(S)] disorder or [CONDITION(S)] disorder. During an observation and interview on 01/24/22 at 12:15 p.m. Resident #2 was in his room. He was clean, neat, and had no lingering odors. He was wearing pants and socks but had his shirt off. He had oxygen on via nasal cannula. He had been served his lunch tray. He said he was doing fine and had no issues. During an interview on 01/26/22 at 10:48 a.m. MDS Nurse said the diagnoses should have been added to Resident #2's quarterly MDS. She said it was her responsibility to add the new diagnoses to the MDS. She said she missed adding Resident #2's new diagnoses to the quarterly MDS done on 12/20/21. An MDS policy was requested from her at this time.

Based on observation, interview and record review, the facility failed to ensure the right to be free from physical restraints imposed for purpose of convenience and not required to treat the resident's medical symptoms was provided for 1 of 7 residents reviewed for restraints. (Resident #1) CNA A wrapped a bed sheet around Resident #1 and tied the bed sheet to Resident #1's wheelchair. Resident #1 stood and attempted to ambulate with the bed sheet still tethered to the wheelchair. Resident #1 fell and was sent to the hospital and admitted to the trauma ICU and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident received a left chest tube. Resident #1 died three days later. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 4:50 p.m. While the IJ was removed on [DATE] at 3:20 p.m. the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolate due to the facility's need to evaluate the effectiveness of their corrective systems. This failure could affect resident's right to be treated with respect and dignity, limit residents right to choose, take away independence, lower self-esteem, develop of pressure ulcers, cause severe injury or death. Findings included: A consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1 was a [AGE] years old male admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 resided in the secure unit due to exit seeking and other behaviors. There was no order for a Restraint. Resident was prescribed lorazepam tablet; 0.5 mg three times a day for anxiety disorder. A MDS dated [DATE] showed staff assessment of Resident #1 mental status was moderately impaired with disorganized thinking. Resident #1 required extensive one- person assistance with most activities of daily living including walking and transfer. Resident #1 had unsteady balance and only able to stabilize with staff assistance. A care plan dated [DATE] showed Resident #1 had the potential for injury from falls due to poor safety awareness, impulsive, unsteady gait, [CONDITION(S)] drug use, impaired vision and history of falls. Resident #1 used a wheelchair to ambulate, was able to self-propel, walk short distances but with unsteady gait. When Resident #1 attempted to stand, staff were to assist with ambulation until resident was ready to sit back down. Resident had the potential to develop pressure ulcers. Staff were to monitor and encourage independent bed mobility. Care plan did not address restraints. Review of MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #1 was administered lorazepam 0.5 mg by MA A for anxiety. An attempt was made to contact MA A by phone on [DATE] at 12:46 PM and again on [DATE] at 10:36 AM. Hospital admission records dated [DATE] at 4:21 p.m., showed Resident #1 was admitted to the trauma ICU and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . A left pigtail chest tube was placed. On [DATE] resident was discharge from ICU to inpatient Hospice. During an interview and record review with the administrator on [DATE] at 12:10 p.m., an undated video was provided by the administrator. The administrator said the date of the video was [DATE] and the video was time stamped 3:36 p.m. The video contained five residents in the common area, shown on the video. In the video an older Caucasian male, identified by the administrator as Resident #1, was observed walking out of a room into a common area. Resident #1 appeared to be holding a white sheet with both hands. The sheet was wrapped around the front of his legs, between his hips and knees. Resident #1 was walking taking short steps. Trailing behind the resident was a wheelchair. The wheelchair is up-side-down, and the wheels were on top and not rolling on the floor. The resident took about 23 short steps, lost balance, fell forward, and hit his right forehead on the tile floor. The resident was lying on his right side. A staff member in blue or purple scrubs, identified by the administrator as CNA A, walked to where Resident #1 was laying, leaned down, picked up both of the resident's legs and removed the sheet from around the resident's legs. CNA A turned the wheelchair upright. The sheet was still attached to the wheelchair. The CNA stood between Resident #1 and the wheelchair, which blocked the view of the wheelchair from the camera. The CNA then appeared to [NAME] for assistance by holding his left arm in the air. CNA A then attempted to move the resident from his right side to his back by grabbing his left leg and pulling. Another staff dressed in blue scrubs enters the screen and slowly walked toward the resident and the CNA. The staff was identified by the administrator as LVN A. LVN A walked up to Resident #1, bent over, then stood erect, turned and walked back from the same direction as he entered the screen. CNA A turned and pushed the wheelchair into a room. Both staff left Resident #1 on the floor unattended. CNA A could be observed inside the room removing the sheet from the wheelchair. The administrator said what she just witnessed on the video was abuse and should had been reported to the state and law enforcement. During an interview on [DATE] at 2:41 p.m., Resident #1's daughter said she had visited with Resident #1 on [DATE] somewhere around 1:30 p.m. She said Resident #1 was sick at the time and vomiting. She said there were three staff attending Resident #1 at the time including LVN A. She did not get close to him, but she noticed a white sheet wrapped around Resident #1. She said she asked LVN A about the sheet but did not get a clear answer as to the purpose of the sheet. She said on [DATE], Resident #1 was admitted to the hospital with a laceration to his forehead, two broken ribs and a collapsed lung. She said Resident #1 was released to in-patient Hospice on [DATE] and died on [DATE]. She said she did not know the specific cause of death, but the collapsed lung was a major contributing factor. During an interview on [DATE] at 3:02 p.m., LVN B said he sent a text message to the DON on [DATE] at 7:30 a.m., informing the DON Resident #1 had been tied to his wheelchair and he was starting an in-service training on restraints. LVN B said the DON replied, OK. LVN B said on [DATE] he conducted in-service training on restraints for staff working at that time. LVN B said he was not aware of the cause of Resident #1's fall until he reviewed the video on [DATE] when he sent the text message to the DON. During an interview on [DATE] at 9:00 a.m., the DON said he received a text message from LVN B on [DATE] at 7:30 a.m. reporting Resident #1 had been tied to a wheelchair at the time he fell on [DATE] and LVN B was starting in-service training on restraints. DON said he did not report the incident to the administrator because he did not realize at the time Resident #1 had been restrained but thought Resident #1 was just tangled in a bed sheet and fell . Review of a text message dated [DATE] at 7:30 a.m. to DON from LVN B showed .you need to watch the lodge camera on Saturday at 3:36 p.m. DON replied at 7:39 a.m. I don't have access to it here. What's up? at 7:40 a.m., LVN B answered, Resident #1 had a fall yesterday and he had a sheet around him tied. I'm going to do a non-restraint Inservice and you and administrator can follow up tomorrow. At 7:48 a.m., DON replied OK. During an interview on [DATE] at 4:09 p.m., the administrator said the DON did not report Resident #1 being tied to a wheelchair causing him to fall. The administrator said the first time she knew of Resident #1 being tied to the wheelchair was on [DATE] when she spoke with Resident #1's daughter. The administrator said she started an investigation and watched the video recording. Administrator said CNA A confessed to tying Resident #1 to his wheelchair with a bed linen. Administrator said CNA A was terminated on [DATE] for violation of resident rights and failure to follow facility policy. During an interview on [DATE] at 1:07 p.m., CNA A said he had wrapped a bed sheet around Resident #1 and tied the ends to the chair around 10:00 a.m. in order to keep Resident #1 standing up and falling. CNA A said LVN A knew Resident #1 was tied to his wheelchair. CNA A said LVN A spoke with him after the fall and told him to not do it anymore because we would get in trouble. CNA A said there is no way other staff would not have known, because Resident #1 had been tied to the chair since 10:00 a.m. that morning until he fell after 3:00 p.m. CNA A said she spoke to the administrator on [DATE] and confessed to tying Resident #1 to the wheelchair. CNA A said he was terminated on [DATE]. During an interview on [DATE] at 1:45 p.m., LVN A said he did not know Resident #1 had been tied to a wheelchair at the time of the fall. LVN A said CNA A told him later that day about Resident #1 being tied to the wheelchair and it was reported to LVN B. During an interview on [DATE] at 9:00 a.m., the administrator said LVN A did not report Resident #1 or any other resident had been restrained when interviewed on [DATE]. Administrator said LVN B had not reported any other resident being restrained other than Resident #1. During an interview on [DATE] at 03:02 p.m., LVN B said when he asked staff about the fall, staff denied knowledge of Resident #1 being tied to his wheelchair. LVN B said the DON nor the administrator had talked to him about the incident. LVN B said staff were not suspended and no investigation was done on the fall until [DATE] when the family complained to the administrator about Resident #1 being restrained. LVN B said staff working on [DATE] would have known Resident #1 was tied to his wheelchair. A Performance Improvement Plan (PIP) dated [DATE] indicated the facility was in the process of an action plan to address [NAME] reporting. CNA A was terminated [DATE] and LVN A was suspended on [DATE] and terminated on [DATE]. During an interview on [DATE] at 04:09 p.m., the Administrator said a (PIP) was implemented on [DATE] and included In-service training on retrains and reporting of [NAME]. Administrator said the Quality Assurance Performance Improvement (QAPI) meets every fourth Thursday of each month and the issue of reporting and resident restraints will be monitored. A Restraint Alternatives Policy dated [DATE] indicated The purpose of the Restraint Alternative Program is to implement individualized interventions for any resident/patient using physical restraint. The goal of the Restraint Alternative Program is to: Utilize restraint alternative instead of a restraint. Minimize risk of injury related to falls, Optimize dignity and independence. 4. Schedule an Interdisciplinary Plan of Care (IPOC) meeting. Document restraint alternatives on the IPOC. 6. Communicate interventions to staff. Care Plan, Nursing Assistant Assignment Worksheets, Daily Clinical Operations Meeting, 24-hour report, Shift Report. 7. Provide training to staff as needed. 8. Evaluate effectiveness of restraint alternative at each IPOC meeting and PRN (as needed). Review and revise IPOC to reflect restraint alternative interventions. Educate resident/family and/or resident representative on restraint alternatives. Restraint Application A resident must be thoroughly evaluated for use of physical restraints by the interdisciplinary team. Emergency restraint use may be decided by the licensed nurse or IPOC team. To apply a physical restraint. Select the least restrictive restraint as indicated by the resident's condition 3. Select the least restrictive restraint based on assessment date. The administrator was notified on [DATE] at 4:50 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The IJ template was provided to the administrator. The facility's Plan of Removal was accepted on [DATE] at 10:28 a.m. and included: Problem Identified: Resident had a sheet tied around him while he was in a wheelchair. resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Root Cause: CNA placed sheet around resident in wheelchair due to resident history of frequent falls. Charge Nurse on duty did not notice/remove sheet which constituted a restraint. Facility is restraint-free, staff did not follow facility training or procedures. Corrective Action/Plan: 1. Conduct immediate in-services for all nursing staff concerning restraints which will include what constitutes a restraint, that restraints can only be applied after a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Post-test will be completed. RN staff development coordinator to complete in-service. PRN staff that have not already been in-service must complete in-service prior to next shift before being allowed to work. 2. During in-service nursing staff will be questioned concerning if they have witnessed any device in our facility being utilized as a restraint to ensure that we are aware of all occurrences. Staff development nurse interviewed staff during in-service presentation as well as included the question Have you ever witnessed any restraints in use at the facility on the post test. No staff reported witnessing any restraints in the facility. 3. Immediately suspend responsible CNA and Charge Nurse pending completion of investigation which will include reviewing video footage of the incident. Responsible staff's employment will be terminated. 4. Charge Nurse(s) to conduct rounds every 2 hours of every resident to monitor that no device is being utilized as a restraint for a resident. Any occurrence will result in immediate removal of any device and prompt reporting to the Unit Manager/DON. These rounds are documented by charge nurses on each shift and submitted to unit managers daily. 5. Housekeeping, Dietary and Administrative staff will be in-serviced concerning restraint utilization since they are frequently in resident rooms and public areas. They will be asked to immediately report to their supervisor if they see a device such as a sheet being used to restrain a resident. 6. Monitoring will be accomplished by monitoring rounds to ensure that no devices are being utilized as a restraint. Facility is restraint free. Monitoring rounds will be conducted 2x daily Monday thru Friday by Unit Managers. The Weekend Supervisor will also conduct rounds 2x daily on Saturday and Sunday. These monitoring rounds will be completed 2x daily x one month. If any issues are identified the rounds will be extended for another month. Unit managers/Weekend supervisor will complete documentation of daily rounds and submit to Administrator weekly. 7. Facility staff development coordinator will conduct abuse, neglect and reporting guideline in-servicing to all nursing and administrative staff to include facility policy and procedure on abuse and neglect as well as state reporting requirements. 8. Disciplinary action taken on Director of Nursing regarding failure to report incident to Administrator after notified via text on [DATE]. Regional nurse has conducted DON in-service on abuse, neglect, reporting guidelines and his role in reporting incidents. 9. Weekend supervisor will immediately (less than 1 hour) report any incident report verbally by phone to Administrator. On [DATE] at 3:20 PM, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Interview on [DATE] at 12:27 p.m., RN A said she was conducting Inservice training on restraints and [NAME], which included reporting, for all staff including nursing, housekeeping, maintenance, dietary and administration. RN A said PRN staff who had not received the training are required to complete the training before allowed to work. Interview on [DATE] at 2:34 p.m., LVN C said MA A was terminated on [DATE] for failure to assist a resident who had fallen and failure to report a resident being restrained on [DATE]. LVN C said charge nurses are to monitor resident at least every two hours and document any concerns including restraints. LVN C said any violation of Restraint Policy or [NAME] Policy should be documented and reported to the administrator immediately, but no more than one hour. Interviews on [DATE] at (12:58 p.m., CNA B); (1:02 p.m., CNA C); (1:08 p.m. HK A), (1:08 HK B and HK C); ([DATE] 11:08 a.m. MA B), ([DATE] at 3:02 p.m. LVN B) and ([DATE] at 2:34 p.m. LVN C) showed they had received training on restraints and reporting [NAME] to the abuse coordinator, who is the administrator. They were able to provide examples of what is considered a restraint and how to identify [NAME]. Inservice records dated [DATE] through [DATE] showed staff had received training on restraints and [NAME]. Staff included nursing, administration, housekeeping, maintenance and dietary personnel. Employee records showed CNA A was terminated on [DATE] for restraining a resident. LVN A was terminated on [DATE] for failure to report an incident according to facility policy. MA A was terminated on [DATE] for failure to report an incident according to facility policy. On [DATE], DON received a written final notice for failure to report an allegation of [NAME] to the abuse coordinator on [DATE]. DON received Inservice training on [DATE] on reporting allegations of [NAME]. During an interview on [DATE] at 3:05 p.m., the DON said the corporate nurse trained him on reporting [NAME] on [DATE]. DON said he received a written warning for failing to report an incident involving allegations of [NAME] reported to him in a text message on [DATE] at 7:30 a.m. On [DATE] at 3:20 p.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to continue to monitor the effectiveness of their plan of correction.

Based on observation, interview and record review, the facility failed to ensure the right to be free from physical restraints imposed for purpose of convenience and not required to treat the resident's medical symptoms was provided for 1 of 7 residents reviewed for restraints. (Resident #1) CNA A wrapped a bed sheet around Resident #1 and tied the bed sheet to Resident #1's wheelchair. Resident #1 stood and attempted to ambulate with the bed sheet still tethered to the wheelchair. Resident #1 fell and was sent to the hospital and admitted to the trauma ICU and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident received a left chest tube. Resident #1 died three days later. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 4:50 p.m. While the IJ was removed on [DATE] at 3:20 p.m. the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolate due to the facility's need to evaluate the effectiveness of their corrective systems. This failure could affect resident's right to be treated with respect and dignity, limit residents right to choose, take away independence, lower self-esteem, develop of pressure ulcers, cause severe injury or death. Findings included: A consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1 was a [AGE] years old male admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 resided in the secure unit due to exit seeking and other behaviors. There was no order for a Restraint. Resident was prescribed lorazepam tablet; 0.5 mg three times a day for anxiety disorder. A MDS dated [DATE] showed staff assessment of Resident #1 mental status was moderately impaired with disorganized thinking. Resident #1 required extensive one- person assistance with most activities of daily living including walking and transfer. Resident #1 had unsteady balance and only able to stabilize with staff assistance. A care plan dated [DATE] showed Resident #1 had the potential for injury from falls due to poor safety awareness, impulsive, unsteady gait, [CONDITION(S)] drug use, impaired vision and history of falls. Resident #1 used a wheelchair to ambulate, was able to self-propel, walk short distances but with unsteady gait. When Resident #1 attempted to stand, staff were to assist with ambulation until resident was ready to sit back down. Resident had the potential to develop pressure ulcers. Staff were to monitor and encourage independent bed mobility. Care plan did not address restraints. Review of MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #1 was administered lorazepam 0.5 mg by MA A for anxiety. An attempt was made to contact MA A by phone on [DATE] at 12:46 PM and again on [DATE] at 10:36 AM. Hospital admission records dated [DATE] at 4:21 p.m., showed Resident #1 was admitted to the trauma ICU and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . A left pigtail chest tube was placed. On [DATE] resident was discharge from ICU to inpatient Hospice. During an interview and record review with the administrator on [DATE] at 12:10 p.m., an undated video was provided by the administrator. The administrator said the date of the video was [DATE] and the video was time stamped 3:36 p.m. The video contained five residents in the common area, shown on the video. In the video an older Caucasian male, identified by the administrator as Resident #1, was observed walking out of a room into a common area. Resident #1 appeared to be holding a white sheet with both hands. The sheet was wrapped around the front of his legs, between his hips and knees. Resident #1 was walking taking short steps. Trailing behind the resident was a wheelchair. The wheelchair is up-side-down, and the wheels were on top and not rolling on the floor. The resident took about 23 short steps, lost balance, fell forward, and hit his right forehead on the tile floor. The resident was lying on his right side. A staff member in blue or purple scrubs, identified by the administrator as CNA A, walked to where Resident #1 was laying, leaned down, picked up both of the resident's legs and removed the sheet from around the resident's legs. CNA A turned the wheelchair upright. The sheet was still attached to the wheelchair. The CNA stood between Resident #1 and the wheelchair, which blocked the view of the wheelchair from the camera. The CNA then appeared to [NAME] for assistance by holding his left arm in the air. CNA A then attempted to move the resident from his right side to his back by grabbing his left leg and pulling. Another staff dressed in blue scrubs enters the screen and slowly walked toward the resident and the CNA. The staff was identified by the administrator as LVN A. LVN A walked up to Resident #1, bent over, then stood erect, turned and walked back from the same direction as he entered the screen. CNA A turned and pushed the wheelchair into a room. Both staff left Resident #1 on the floor unattended. CNA A could be observed inside the room removing the sheet from the wheelchair. The administrator said what she just witnessed on the video was abuse and should had been reported to the state and law enforcement. During an interview on [DATE] at 2:41 p.m., Resident #1's daughter said she had visited with Resident #1 on [DATE] somewhere around 1:30 p.m. She said Resident #1 was sick at the time and vomiting. She said there were three staff attending Resident #1 at the time including LVN A. She did not get close to him, but she noticed a white sheet wrapped around Resident #1. She said she asked LVN A about the sheet but did not get a clear answer as to the purpose of the sheet. She said on [DATE], Resident #1 was admitted to the hospital with a laceration to his forehead, two broken ribs and a collapsed lung. She said Resident #1 was released to in-patient Hospice on [DATE] and died on [DATE]. She said she did not know the specific cause of death, but the collapsed lung was a major contributing factor. During an interview on [DATE] at 3:02 p.m., LVN B said he sent a text message to the DON on [DATE] at 7:30 a.m., informing the DON Resident #1 had been tied to his wheelchair and he was starting an in-service training on restraints. LVN B said the DON replied, OK. LVN B said on [DATE] he conducted in-service training on restraints for staff working at that time. LVN B said he was not aware of the cause of Resident #1's fall until he reviewed the video on [DATE] when he sent the text message to the DON. During an interview on [DATE] at 9:00 a.m., the DON said he received a text message from LVN B on [DATE] at 7:30 a.m. reporting Resident #1 had been tied to a wheelchair at the time he fell on [DATE] and LVN B was starting in-service training on restraints. DON said he did not report the incident to the administrator because he did not realize at the time Resident #1 had been restrained but thought Resident #1 was just tangled in a bed sheet and fell . Review of a text message dated [DATE] at 7:30 a.m. to DON from LVN B showed .you need to watch the lodge camera on Saturday at 3:36 p.m. DON replied at 7:39 a.m. I don't have access to it here. What's up? at 7:40 a.m., LVN B answered, Resident #1 had a fall yesterday and he had a sheet around him tied. I'm going to do a non-restraint Inservice and you and administrator can follow up tomorrow. At 7:48 a.m., DON replied OK. During an interview on [DATE] at 4:09 p.m., the administrator said the DON did not report Resident #1 being tied to a wheelchair causing him to fall. The administrator said the first time she knew of Resident #1 being tied to the wheelchair was on [DATE] when she spoke with Resident #1's daughter. The administrator said she started an investigation and watched the video recording. Administrator said CNA A confessed to tying Resident #1 to his wheelchair with a bed linen. Administrator said CNA A was terminated on [DATE] for violation of resident rights and failure to follow facility policy. During an interview on [DATE] at 1:07 p.m., CNA A said he had wrapped a bed sheet around Resident #1 and tied the ends to the chair around 10:00 a.m. in order to keep Resident #1 standing up and falling. CNA A said LVN A knew Resident #1 was tied to his wheelchair. CNA A said LVN A spoke with him after the fall and told him to not do it anymore because we would get in trouble. CNA A said there is no way other staff would not have known, because Resident #1 had been tied to the chair since 10:00 a.m. that morning until he fell after 3:00 p.m. CNA A said she spoke to the administrator on [DATE] and confessed to tying Resident #1 to the wheelchair. CNA A said he was terminated on [DATE]. During an interview on [DATE] at 1:45 p.m., LVN A said he did not know Resident #1 had been tied to a wheelchair at the time of the fall. LVN A said CNA A told him later that day about Resident #1 being tied to the wheelchair and it was reported to LVN B. During an interview on [DATE] at 9:00 a.m., the administrator said LVN A did not report Resident #1 or any other resident had been restrained when interviewed on [DATE]. Administrator said LVN B had not reported any other resident being restrained other than Resident #1. During an interview on [DATE] at 03:02 p.m., LVN B said when he asked staff about the fall, staff denied knowledge of Resident #1 being tied to his wheelchair. LVN B said the DON nor the administrator had talked to him about the incident. LVN B said staff were not suspended and no investigation was done on the fall until [DATE] when the family complained to the administrator about Resident #1 being restrained. LVN B said staff working on [DATE] would have known Resident #1 was tied to his wheelchair. A Performance Improvement Plan (PIP) dated [DATE] indicated the facility was in the process of an action plan to address [NAME] reporting. CNA A was terminated [DATE] and LVN A was suspended on [DATE] and terminated on [DATE]. During an interview on [DATE] at 04:09 p.m., the Administrator said a (PIP) was implemented on [DATE] and included In-service training on retrains and reporting of [NAME]. Administrator said the Quality Assurance Performance Improvement (QAPI) meets every fourth Thursday of each month and the issue of reporting and resident restraints will be monitored. A Restraint Alternatives Policy dated [DATE] indicated The purpose of the Restraint Alternative Program is to implement individualized interventions for any resident/patient using physical restraint. The goal of the Restraint Alternative Program is to: Utilize restraint alternative instead of a restraint. Minimize risk of injury related to falls, Optimize dignity and independence. 4. Schedule an Interdisciplinary Plan of Care (IPOC) meeting. Document restraint alternatives on the IPOC. 6. Communicate interventions to staff. Care Plan, Nursing Assistant Assignment Worksheets, Daily Clinical Operations Meeting, 24-hour report, Shift Report. 7. Provide training to staff as needed. 8. Evaluate effectiveness of restraint alternative at each IPOC meeting and PRN (as needed). Review and revise IPOC to reflect restraint alternative interventions. Educate resident/family and/or resident representative on restraint alternatives. Restraint Application A resident must be thoroughly evaluated for use of physical restraints by the interdisciplinary team. Emergency restraint use may be decided by the licensed nurse or IPOC team. To apply a physical restraint. Select the least restrictive restraint as indicated by the resident's condition 3. Select the least restrictive restraint based on assessment date. The administrator was notified on [DATE] at 4:50 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The IJ template was provided to the administrator. The facility's Plan of Removal was accepted on [DATE] at 10:28 a.m. and included: Problem Identified: Resident had a sheet tied around him while he was in a wheelchair. resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Root Cause: CNA placed sheet around resident in wheelchair due to resident history of frequent falls. Charge Nurse on duty did not notice/remove sheet which constituted a restraint. Facility is restraint-free, staff did not follow facility training or procedures. Corrective Action/Plan: 1. Conduct immediate in-services for all nursing staff concerning restraints which will include what constitutes a restraint, that restraints can only be applied after a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Post-test will be completed. RN staff development coordinator to complete in-service. PRN staff that have not already been in-service must complete in-service prior to next shift before being allowed to work. 2. During in-service nursing staff will be questioned concerning if they have witnessed any device in our facility being utilized as a restraint to ensure that we are aware of all occurrences. Staff development nurse interviewed staff during in-service presentation as well as included the question Have you ever witnessed any restraints in use at the facility on the post test. No staff reported witnessing any restraints in the facility. 3. Immediately suspend responsible CNA and Charge Nurse pending completion of investigation which will include reviewing video footage of the incident. Responsible staff's employment will be terminated. 4. Charge Nurse(s) to conduct rounds every 2 hours of every resident to monitor that no device is being utilized as a restraint for a resident. Any occurrence will result in immediate removal of any device and prompt reporting to the Unit Manager/DON. These rounds are documented by charge nurses on each shift and submitted to unit managers daily. 5. Housekeeping, Dietary and Administrative staff will be in-serviced concerning restraint utilization since they are frequently in resident rooms and public areas. They will be asked to immediately report to their supervisor if they see a device such as a sheet being used to restrain a resident. 6. Monitoring will be accomplished by monitoring rounds to ensure that no devices are being utilized as a restraint. Facility is restraint free. Monitoring rounds will be conducted 2x daily Monday thru Friday by Unit Managers. The Weekend Supervisor will also conduct rounds 2x daily on Saturday and Sunday. These monitoring rounds will be completed 2x daily x one month. If any issues are identified the rounds will be extended for another month. Unit managers/Weekend supervisor will complete documentation of daily rounds and submit to Administrator weekly. 7. Facility staff development coordinator will conduct abuse, neglect and reporting guideline in-servicing to all nursing and administrative staff to include facility policy and procedure on abuse and neglect as well as state reporting requirements. 8. Disciplinary action taken on Director of Nursing regarding failure to report incident to Administrator after notified via text on [DATE]. Regional nurse has conducted DON in-service on abuse, neglect, reporting guidelines and his role in reporting incidents. 9. Weekend supervisor will immediately (less than 1 hour) report any incident report verbally by phone to Administrator. On [DATE] at 3:20 PM, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Interview on [DATE] at 12:27 p.m., RN A said she was conducting Inservice training on restraints and [NAME], which included reporting, for all staff including nursing, housekeeping, maintenance, dietary and administration. RN A said PRN staff who had not received the training are required to complete the training before allowed to work. Interview on [DATE] at 2:34 p.m., LVN C said MA A was terminated on [DATE] for failure to assist a resident who had fallen and failure to report a resident being restrained on [DATE]. LVN C said charge nurses are to monitor resident at least every two hours and document any concerns including restraints. LVN C said any violation of Restraint Policy or [NAME] Policy should be documented and reported to the administrator immediately, but no more than one hour. Interviews on [DATE] at (12:58 p.m., CNA B); (1:02 p.m., CNA C); (1:08 p.m. HK A), (1:08 HK B and HK C); ([DATE] 11:08 a.m. MA B), ([DATE] at 3:02 p.m. LVN B) and ([DATE] at 2:34 p.m. LVN C) showed they had received training on restraints and reporting [NAME] to the abuse coordinator, who is the administrator. They were able to provide examples of what is considered a restraint and how to identify [NAME]. Inservice records dated [DATE] through [DATE] showed staff had received training on restraints and [NAME]. Staff included nursing, administration, housekeeping, maintenance and dietary personnel. Employee records showed CNA A was terminated on [DATE] for restraining a resident. LVN A was terminated on [DATE] for failure to report an incident according to facility policy. MA A was terminated on [DATE] for failure to report an incident according to facility policy. On [DATE], DON received a written final notice for failure to report an allegation of [NAME] to the abuse coordinator on [DATE]. DON received Inservice training on [DATE] on reporting allegations of [NAME]. During an interview on [DATE] at 3:05 p.m., the DON said the corporate nurse trained him on reporting [NAME] on [DATE]. DON said he received a written warning for failing to report an incident involving allegations of [NAME] reported to him in a text message on [DATE] at 7:30 a.m. On [DATE] at 3:20 p.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to continue to monitor the effectiveness of their plan of correction.

Based on observation, interview and record review, the facility failed to ensure adequate supervision was provided to prevent an elopement for 1 of 5 residents reviewed for supervision. (Resident #1) The facility did not prevent Resident #1 who was at risk for elopement from leaving the facility without staff knowledge. The resident was found in a parking lot of a neighboring facility that was approximately 380 feet from a major highway during the night. This failure could place residents who reside on the secure unit at risk for injury, neglect or death. An Immediate Jeopardy (IJ) was identified on 08/28/19. While the IJ was removed on 08/29/19, 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 complete in-service training and evaluate the effectiveness of corrective systems. Finding included: A face sheet dated 08/15/19 indicated Resident #1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. A quarterly elopement risk evaluation dated 05/20/19 indicated Resident #1 required dementia care and was able to ambulate independently. The resident had a history of [REDACTED]. Interventions included secured unit. The evaluation indicated the resident was an elopement risk and continue the current plan of care. A care plan dated 05/21/19 indicated Resident #1 had an alteration in thought process, memory impairment, and confusion related to dementia. The care plan indicated the resident may have features of wanting to go home and wandering. Interventions included to reside in a secure unit, allow to wander, redirect away from exit doors, and not allow resident to leave facility without an escort. The care plan indicated the resident was at risk for elopement due to cognitive deficits, wandering behavior and exit seeking. Interventions included secure unit placement, allow to wander freely on secured unit, redirect away from secured exit doors to an activity and do not allow to leave secured unit without an escort. An MDS dated [DATE] indicated Resident #1 was severely impaired cognitively with inattention and disorganized thinking that fluctuated. The resident was independent with ambulation without any assisted device. A nursing note dated 07/30/19 at 2:02 p.m. completed by LVN C indicated Resident #1 was able to exit from the door at the end of [NAME] Hall. The note indicated either the construction staff left the code on the keypad or left the door open and she wandered out. Resident #1 was found by the lead physical therapist in another part of the facility outside of the secured unit. An elopement episode dated 08/03/19 at 12:17 a.m. completed by LVN B indicated Resident #1 left the building and went to the facility next door (approximately 400 ft.). LVN B documented she received a call from a staff member indicating the resident was at their facility. A nursing note dated 08/03/19 at 12:10 a.m. completed by LVN B indicated she received a phone call from a staff member from the facility next door asking if Resident #1 was a resident. The staff member indicated she was found in their front parking lot (approximately 380 ft. from a major highway) and convinced her to come inside. LVN B and an unknown CNA returned resident to the facility via private vehicle. LVN B indicated she asked Resident #1 how she got to the other facility and the resident stated, through the front door. LVN B asked which front door and the resident stated, through the front door of my house. An elopement risk observation note dated 08/03/19 completed by LVN B indicated Resident #1 was in bed on the secured unit resting with her eyes closed at the following times: 1:00 a.m., 2:00 a.m., 3:00 a.m., and 4:01 a.m. An elopement risk observation note dated 08/03/19 at 4:17 a.m. completed by LVN B indicated at approximately 4:10 a.m. the alarm sounded at the north end of the unit, Resident #1 was attempting to go out the door. The note indicated Resident #1 said she was angry with what was going on. Redirection was attempted and unsuccessful, no physical aggression or behavioral episodes noted. Resident #1 was moved to the women's secured unit common area. A behaviors flow sheet dated 07/01/19 through 07/31/19 indicated Resident #1 exhibited exit seeking behaviors as follows: *07/03/19 during the night shift -2 episodes, and *07/31/19 during the day shift - 2 episodes. A behaviors flow sheet dated 08/01/19 through 08/15/19 indicated Resident #1 exhibited 1 episode of exit seeking behaviors during the day shift on 08/06/19. The 8/3/19 elopement was not documented on the flow sheet. A nursing note dated 07/31/19 at 1:37 p.m. completed by LVN C indicated Resident #1 exhibited exit seeking behaviors. During an interview on 08/15/19 at 10:52 a.m., CNA A said she worked the secure unit on 08/03/19 and provided care for Resident #1. CNA A said Resident #1 was sitting in the common area with her around 12:00 a.m., she said Resident #1 told her she was going to bed. CNA A said Resident #1 got up from the couch and walked down the hallway toward her room, she said she did not look to see if Resident #1 went into her room. CNA A said about 15 minutes later LVN B notified her Resident #1 was found in the parking lot of the assisted living facility next door. CNA A said Resident #1 was brought back to the facility by private car, she said she was not sure how Resident #1 was able to get out of the facility. CNA A said she was told a contractor working on the secure unit left a note with the keypad code next to the back-exit door and that was how Resident #1 eloped. CNA A said she did not see a note by the key pad with the code on it during her shift. CNA A said she did not hear an alarm go off when Resident #1 eloped and did not know if the back-exit door had an alarm. During an observation and interview on 08/15/19 at 5:47 a.m., Resident #1 was in her room on the secure unit. Resident #1 said she did not remember getting out of the facility or being found in the parking lot of the assisted living facility next door. During an interview on 08/15/19 at 6:08 a.m., LVN B said she worked the night of 08/03/19 when Resident #1 eloped from the facility. LVN B said she received a phone call from the assisted living facility next door, she said they indicated Resident #1 was found in their front parking lot and was at their facility. LVN B said she drove her car over to the assisted living facility and drove Resident #1 back to the facility. LVN B said Resident #1 told her she got out the front door. LVN B said she was told a contractor working on the secure unit left the keypad code next to the back-exit door key pad; she said she did not see a note by the key pad during her shift. LVN B said she did not know if the back-exit door had an alarm, she said she did not hear an alarm sound when Resident #1 eloped. LVN B indicated she was not sure how Resident #1 eloped from the facility. During an interview on 08/15/19 at 6:08 a.m., LVN C said he worked the morning shift on the secure unit on 08/02/19 and provided care for Resident #1. LVN C said he was told the contractor working on the secure unit left a note with the keypad code next to the back-exit door key pad and that was how Resident #1 eloped. LVN C said on 08/05/19 the same contractor was back on the secure unit and he asked the contractor if he left the code by the back-exit door, he said the contractor denied leaving the code. LVN C indicated during his shift on 8/2/19 he did not see a note with the code on it by the back-exit door. LVN C said he did not know how Resident #1 eloped from the secured unit. During an interview on 08/15/19 at 9:49 a.m., the administrator said she was the abuse coordinator. She said during the night shift on 08/03/19, Resident #1 eloped from the secure unit and was found in the parking lot of the assisted living next door and brought back to the facility. The administrator said she did not do a thorough investigation into the elopement and was not sure how Resident #1 eloped from the facility. During an interview on 08/15/19 at 10:03 a.m., LVN D said she worked the secure unit on 8/2/19 during the evening shift, she said she did not see a note by the door with the code. During an interview on 08/15/19 at 10:03 a.m., CNA [NAME] said she worked the morning shift on 08/02/19. CNA [NAME] said Resident #1 eloped from the secure unit during the night shift on 08/03/19 and could have been injured. During an observation and interview on 08/15/19 at 11:35 a.m., there was a key pad to the right of the back-exit door. At the top right of the door there was a magnetized locking device and at the top left there was a door closure. The door was locked and was unable to be opened. The maintenance assistant opened the door with the keypad code and pushed the door open. As the door closed it did not close completely and the magnetized locking device did not reengage leaving the door unsecure. The alarm sounded 5 seconds after the magnetized locking device was disengaged. The maintenance assistant had to manually shut the door and reenter the keypad code to turn the alarm off and reengage the magnetized locking device to secure the door. The maintenance assistant said the door should shut automatically to reengage the magnetized lock when it closes. The maintenance assistant said if Resident #1 eloped out of the back-exit door she would have to use the code to open the door, get through the door and push the door closed behind her within 5 seconds to prevent the door alarm from going off. The maintenance assistant said he checked the back-exit door a couple days after Resident #1 eloped to ensure it was working. During an interview on 08/15/19 at 11:45 a.m., the maintenance director said the back-exit door has magnetized locking device to secure the door and has an alarm to alert staff the back door was open. The maintenance director said you must enter the code on the key pad to disengage the magnetized locking device to exit out the door. The maintenance director said the back-exit door should shut automatically after it is opened to reengage the magnetized lock. The maintenance director said after Resident #1 eloped from the secure unit he had the maintenance assistant check the back-exit door to make sure it was working properly. The maintenance director said he was not told the back-exit door did not properly close. The maintenance director said the back-exit door needed to be fixed. During an interview on 08/28/19 at 12:14 p.m., LVN C said he worked on 07/30/19, when Resident #1 eloped from the secure unit. LVN C said Resident #1 was found in the hallway by the rehabilitation room and brought back to the secure unit by a physical therapist. LVN C said there was no staff member with Resident #1 when she eloped, he said he documented the incident and thought the physical therapist notified the unit manager. LVN C said the facility did not do an in-service or add any interventions after Resident #1 eloped on 07/30/19. During an interview on 08/28/19 at 12:36 p.m., CNA G said she worked the morning shift on the secure unit. CNA G said Resident #1 was on the secure unit and was an elopement risk. CNA G said she did not know Resident #1 eloped from the secure unit on 07/30/19 and 08/03/19 and started working on the secure unit after that. CNA G said she was unaware of any special interventions in place for Resident #1 and only monitored her the same way as the other residents on the secure unit. During an observation on 08/28/19 at 12:53 p.m., Resident #1 was standing by the nursing station on the secure unit about 10 feet away from an exit door. The door was a double door with a key pad located on the left side of the door with a magnetized locking device on each door. During an interview on 08/28/19 at 12:56 p.m., Resident #1 said she had never tried to leave the facility but had 2 or 3 ways she could get out of the facility if she wanted to. Resident #1 said she would typically look to get out of the facility through a window, she said she would have to break a window or find a screw driver to get out because the windows were screwed down. Resident #1 said another way she would try to get out was to first observe how long it took for the door to close when somebody left through the door. Resident #1 said after she had the timing of the door down she would wait by the door until somebody exited and try to open it before it locked. Resident #1 said she would only attempt this when there are no staff watching her. During an interview on 08/28/19 at 1:06 p.m., the unit manager said she was responsible for overseeing the care and implementing interventions for residents on the secure unit. She said she was working on 7/30/19 when Resident #1 eloped the first time, she said Resident #1 was found wandering inside the facility unaccompanied and brought back to the secure unit by a physical therapist who notified her. The unit manager said there was no incident or elopement event documentation for Resident #1 on 07/30/19. She said she did not investigate the incident or do an in-service regarding Resident #1's elopement on 07/30/19. The unit manager said the facility did not in-service staff or add any new interventions, she said the maintenance staff did shorten the time it took for the doors to lock when entering and exiting the secured unit. She said 08/03/19 Resident #1 eloped from the secured unit and was found at the assisted living facility next door, she said she was on vacation at the time and did not know if the facility in-serviced staff or added any new interventions. The unit manager said there had been no change in how Resident #1 is monitored on the secure unit after both elopements and she encouraged the staff to be more aware of her whereabouts in the secured unit. During an observation and interview on 08/28/19 at 1:43 p.m., there was a door located at the back wall of the dining room in the secure unit. The doorknob on the secure unit side did not turn and was unable to be opened. There was a sign on the door to notify facility staff this was not an exit and the door was to remain closed at all times. The unit manager said the door was locked on the secure unit side and could be opened from the other side. The unit manager said the facility staff were not to access the secure unit from that door but there was no way to know if staff ever used the door. The unit manager said she had not seen any staff use the door. The unit manager opened the door from the other side releasing the doorknob without pulling the door wide open away from her, she walked through the door into the secured unit dining room and the door shut behind her. The unit manager pushed on the door and the door opened from the secure unit side. The unit manager had to pull the doorknob to secure the door. The unit manager attempted it again with the same outcome. The unit manager said the door did not lock and a resident could elope out the door. The unit manager said she did not know if maintenance checked the door after Resident #1 eloped on 07/30/19 and 08/03/19. During an interview on 08/28/19 at 1:57 p.m., LVN C said the door at the back wall of the dining room was locked on the secured unit side and could be opened from the other side. LVN C said the facility staff were not to access the secured unit from that door but there was no way to know if staff ever used the door. LVN C said he did not know the door did not lock when it shut or if maintenance checked the door after Resident #1 eloped on 07/30/19 and 08/03/19. LVN C said a resident could elope out the door. During an observation and interview on 08/28/19 at 2:31 p.m., the maintenance assistant said the door in the dining room was locked on the secured unit side and could be opened from the other side. The maintenance assistant said when the door is opened it should close and lock when it shut. The maintenance assistant opened the door from the other side using the doorknob to open the door, as he opened the door he swung the door open as far as it could open away from him then walked through the door into the secured unit dining room and the door shut behind him. The maintenance assistant pushed on the door and the door would not open. The maintenance assistant was asked to open the door again without swinging the door open as far as it could open. The maintenance assistant was asked to just open the door, release the door knob without swinging the door as far as it could open. The maintenance assistant opened the door from the other side with the doorknob, he released the doorknob without opening the door as far as it could open, walked through the door with a normal gait, into the secured unit dining room and the door shut behind him. The unit manager pushed on the door and the door opened from the secured unit side. The unit manager had to pull the doorknob to secure the door. The maintenance assistance attempted it again with the same outcome. The maintenance assistant said he did not know the door did not close and lock. The maintenance assistant said he did not know Resident #1 eloped on 07/30/19. The maintenance assistant said he did not do any maintenance on that door on or after 07/30/19 or if any other maintenance staff had. An elopement- facility practices policy dated 07/18 indicated, The facility team will assess the environment to identify the potential risks associated with elopement Assess the security of potential internal environmental risk factors including, but not limited to, the following: exit doors The administrator and the business office manager were informed on 08/28/19 at 4:59 p.m. that an IJ situation had been identified due to the above failures. The IJ template was given to the facility on [DATE] at 5:11 p.m. The facility's Plan of Removal was accepted on 8/28/19 at 8:52 p.m. and included: * All nursing staff will be in-serviced concerning wandering behaviors and how to minimize risk of elopements. These inservices will be completed by the nurse managers to include all shifts. This inservice will include the following interventions: ensuring secured doors are locked and closed, frequent visual checks, redirection, structured group activities, and encouraging residents to remain in the lobby areas for increased visualization. These inservices would commence immediately. 6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m. shifts Monday through Friday have been completed. In-services will continue every shift. Night shift will be completed 08/28/19. Inservices will be completed by 08/29/19 at 4:00 p.m. Any staff not able to attend inservice on 8/29/19 will be inserviced before the beginning of their next shift. *Door control services (outside contractor) will inspect all doors on Gardens Memory Care on 8/28/19 to ensure that all doors are in good working condition and close promptly. *Facility will immediately implement every shift door check log. At the beginning of each shift, the CN on all memory care units (secured units), will conduct checks of all exit doors to ensure that the locks work and the doors close securely. They will initial the log when checks are completed. Any issues identified with door closures will be immediately reported to the administrator/maintenance supervisor. *Charge nurses on memory care units (secured units) will be inserviced concerning every shift log to document that all doors in the memory care units are locked/closed securely. These inservices will commence immediately and continue every shift until all charge nurses on the memory care have been inserviced about the door checks and use of the logs. These inservices will commence immediately. Inservices will continue every shift, 6-2 and 2-10 Monday thru Friday until all shifts have been completed. Night shift will be completed 8/28/19. Inservices will all be completed by 8/29/19 at 4:00 p.m. Any staff not able to attend inservice on 8/29/19 will be inserviced before the beginning of their next shift. On 8/29/19 at 4:05 p.m., the surveyor confirmed the Plan of Removal had been implemented sufficiently to lift the IJ by: - 5 nurses (2 from day shift, 3 from evening shift), 1 medication aide (from day shift), and 3 CNAs (2 from day shift and 1 from night shift) were interviewed and said they had been in-serviced on residents with wandering behaviors, visual checks on residents with wandering behaviors and redirection, resident elopements, ensuring secured unit doors are lock/secured, stand by a door that is not secured to prevent a resident elopement and have another staff member notify the administrator or maintenance director about the door not properly working. Licensed nursing staff said they were in-serviced to conduct secured unit door checks at the beginning of their shifts, documenting each door on the door check log the door was checked and working or not working properly. Licensed nursing staff said if a door was not working properly a staff member would stand by the door to prevent a resident elopement until the administrator or maintenance supervisor was notified and the door was fixed. On 08/29/19 at 4:09 p.m., the DON was informed the IJ was lifted; however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete inservice training and evaluate the effectiveness of the corrective system.

Based on interview and record review, the facility failed to consult with the physician about a significant change of condition for 1 of 7 residents reviewed for a change of condition. (Resident #3) Resident #3 experienced changes in her level of consciousness and was unable to take medications; however, the facility did not consult the physician until 29 hours after the changes occured. Resident #3 was sent to the local emergency room and admitted with altered mental status, profound dehydration, urinary tract infection, metabolic acidosis, and [MEDICAL CONDITION] (elevated potassium). Resident #3 was discharged on hospice care to another nursing facility 04/26/15. An Immediate Jeopardy situation was identified on 4/27/15. The Immediate Jeopardy was removed on 4/28/15. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure contributed to a delay in Resident #3 receiving needed medical treatment and could place the census of 196 residents at risk for delay in medical evaluation and treatment or death. Findings included: Physician orders [REDACTED].#3, admitted on [DATE], was [AGE] years old with the [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #3 sometimes was understood by others and she sometimes understood others. Resident #3 required extensive assistance with transfers, dressing, bathing, and personal hygiene. She required setup help only and ate meals independently. Resident #3 was frequently incontinent of bowel and bladder. The facility Medication Administration Record [REDACTED]. During an interview on 4/24/15 at 7:25 p.m., CNA E said she cared for Resident # 3 on the 2 p.m. - 10 p.m. shift on Monday 4/20/15. She said Resident #3 was "out of it". She said she was sleepy and was "not her usual self". She said she managed to get her to eat a few bites of dinner and assisted Resident #3 back to bed. She said she reported Resident #3's changes to LVN D. During an interview on 4/24/15 at 7:40 p.m., LVN D said she cared for Resident #3 on the 2 p.m. - 10 p.m. shift on Monday 4/20/15. She said Resident #3 was her usual self and did not recall a change in her level of consciousness. She said no staff had reported any changes to her. During an interview on 4/27/15 at 6:25 a.m., CNA C said she cared for Resident #3 on the 6 a.m. - 2 p.m. shift on Monday 4/20/15 and Tuesday 4/21/15, on both days Resident #3 was not her usual self. She said Resident #3 would not eat and would not respond when her name was called or when she was touched. She said Resident #3 was leaning to one side Monday when she attempted to get her out of bed and into the geri-chair. She said Resident # 3 was usually able to stand and bear weight. She said Resident #3 would not take fluids. CNA C said she reported Resident #3's change in condition to LVN A. She said Resident #3 was the in the same condition on Tuesday 4/21/15 and that was why she left her in bed. She said she reported Resident #3's changes to LVN D on Tuesday as well. During an interview on 4/27/15 at 6:35 a.m., MA B said on Monday 4/20/15 she could not get Resident #3 to take her medications because she was not responding. She said Resident #3 would not respond to her name being called or by touching her. MA B said she notified LVN A of Resident #3's decline. During an interview on 4/27/15 at 6:40 a.m., LVN A said she cared for Resident #3 on the 6 a.m. - 2 p.m. shift on Monday 4/20/15 and Tuesday 4/21/15, on both days Resident #3 was not her usual self. She said on Monday 4/20/15 Resident #3 seemed sedated and was not eating. She said Resident #3 would not wake up to eat or take medications. LVN A said she did not notify the doctor about Resident #3's condition or document this in the nursing notes on Monday. LVN A said on Tuesday 4/21/15 morning Resident #3 continued to be unresponsive and did not take her morning medications, which was reported to her by MA B. LVN A said she was approached in the hall by Resident #3's husband around noon about his concern about Resident #3's condition. LVN A said she assessed Resident #3 and noted that Resident # 3's "lips were dry and peeling as if she were dehydrated". She said ADON G notified the physician assistant at this time. LVN A said she would usually notify the physician assistant with any changes in condition and would usually complete a SBAR (form used to notify the physician). LVN A said she had not completed this form on Resident #3. She said she did not document any of her findings in the nursing notes which she usually does. The 24 hour report sheet dated Monday 4/20/15 did not indicate that Resident #3 had any problems. There was no indication a physician was notified or any medications were held. A nursing note dated 4/21/15 at 12:00 p.m. indicated Resident #3 had a change in mental status. The note indicated the physician assistant was notified with orders received to send Resident #3 to the emergency room for evaluation and treatment. No further assessment of Resident #3 was documented. There were no nursing notes that could be reviewed for 4/20/15. During an interview on 4/25/15 at 11:05 a.m., Resident #3's husband said he arrived at the facility on 4/20/15 a little after 12:00 p.m. to visit with Resident #3 but she was asleep. He said he could not wake Resident #3 by calling her name or touching her and he sat with her for over an hour but Resident #3 did not wake up and her lunch tray was untouched. He said he returned to the facility on [DATE] a little before 12:00 p.m. and Resident #3 was still wearing her gown and was not responding. He said he approached LVN A in the hall and voiced concern about Resident #3's condition and requested that the physician be notified. During an interview on 4/27/15 at 12:50 p.m., ADON G said Resident #3's husband was in the hall voicing concern that Resident #3 was not awake and requested the physician be called. ADON G said she assisted LVN A with calling the physician assistant and transferring Resident #3 to the emergency room . ADON G said Resident #3 was unresponsive. He said he did not document any of his findings and did not assist LVN A with documentation since LVN A was a new nurse. He said he was not aware of Resident #3's condition on Monday 4/20/15 and no changes had been reported to him. He said he expected the staff to notify him and the physician with any changes in condition. ADON G said he expected staff to document their assessment and interventions in the nursing notes. He said the licensed nurse was responsible for making all notifications of changes to the physicians, the resident, and the resident's representative. ADON G said examples of changes included but not limited to: abnormal findings, changes in appetite and mobility, and neurological changes. The DON was not available for interview. The hospital admission lab results dated 4/21/15 at 1:00 p.m. indicated Resident #3 had the following abnormal results: *lactic acid 601 (normal range 0.4-2.0) *sodium 149 (normal range 133-145), *potassium 5.5 (normal range 3.5-5.1), *chloride 107 (normal range 96-108), *BUN 111 (normal range 8-23) and, *creatinine 3.21 (normal range 0.60-1.30), *The urine WBC 10-20 (normal range 0-5) *A CT scan of the head was negative for acute intercranial abnormality. A hospital history and physical dated 4/21/15 at 4:05 p.m. indicated when Resident #3 arrived in the emergency room her mental status was very altered, she was lethargic and stuporous. She opened her eyes to loud voices and painful stimuli. The laboratory reports indicated Resident #3 had increased potassium and increased BUN and creatinine. Resident #3's general assessment was blood pressure 80/55, heart rate 103, and temperature 95.2. The resident was pale. The assessment indicated Resident #3 had acute [MEDICAL CONDITION]ly secondary to volume depletion [MEDICAL CONDITION], with a urinary tract infection with severe dehydration resulting in acute kidney injury. Resident #3 also presented with [MEDICAL CONDITION] (increased potassium) and metabolic acidosis (Life threatening condition that occurs when the kidneys cannot eliminate acid buildup). Resident #3 was referred for palliative care. The policy and procedure dated April 2012 indicated "The facility will document changes in a resident's condition or significant care issues each shift until the resident's condition is stabilized or the situation is otherwise resolved ... .2. Document facts regarding the change in condition or incident as applicable, including but not limited to: vital signs, physical assessment, resident response, symptoms. 3. Notify physician and document the following: date and time physician notified and orders obtained." The administrator was notified on 4/27/15 at 11:43 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 4/27/15 at 4:56 p.m. and included: "Begin immediate inservicing of Licensed Nurses currently on shift concerning identification/symptoms of changes in resident condition, clinical assessment, documentation of assessment in nursing notes and 24 hour report, and notification of physician. Staff not currently on shift will be inserviced prior to beginning of their next scheduled shift. Begin immediate inservicing for Nursing Assistants currently on shift to include symptoms to report to their Charge Nurse. This will include changes in appetite, changes in level of alertness, changes in behavior (more lethargic or more restless or confused), changes in the color or odor of urine, changes in their ability to ambulate or transfer, changes in their speech, changes in their sleep pattern (more drowsy or not sleeping), any verbal complaints of pain or discomfort, changes in color or temperature of skin. Staff not currently on shift will be inserviced prior to beginning of their next scheduled shift. This inservice will include notification of their nurse manager in the event that a reported change of condition is not followed through by their charge nurse. Nurse Aides will be instructed to report any concerns about resident condition or the response of their charge nurse to the resident's change in condition immediately to their nurse manager either in person or by phone. Nurse Managers will complete walking rounds (starting immediately) with the assigned Charge Nurse of every resident in Briarcliff to assess/monitor for any changes in condition. This will include direct observation of each resident and chart review as needed to ensure that all condition changes have been assessed, documented, interventions put in place, and physician notification has been completed. Nurse Managers will complete daily rounds and chart reviews of any resident noted on the 24 hour report with a change in condition. This will be initiated today and ongoing as a daily routine. This will include review of the clinical documentation in the nursing notes and documentation that the physician was notified of the changes noted. Walking rounds will also be completed by the oncoming and exiting charge nurses at the beginning and end of each shift. In addition to this, Nurse managers which includes the weekend supervisor will complete their own rounds between 0700-0900. Beginning immediately, Staff Development Nurse will ensure that all new nurses as part of their floor orientation receive training concerning documentation in the nurses notes, identification of changes in resident condition, documentation of changes on the 24 hour report and in the nurses notes, and physician notification. Beginning immediately, upon discharge from facility to hospital nurse manager or designees will view the resident chart and 24 hour report to ensure that nurse documentation and physician notification are complete. Licensed Nurse Inservice will include change in policy that any significant change in condition requires a nurse consult with the resident physician or nurse practitioner by phone or in person. If the physician or nurse practitioner is not available at the time of the nurse notification the nurse will document on the 24 hour report that we are awaiting physician return call. This will be reported to the oncoming nurse during report that physician return call is pending. Licensed nurse will continue to contact physician until a consult can be acquired. DON/Administrator will be notified of any issues with physician response time. Anyone on the 24 hour report that has been identified with a change in condition or anyone identified on that shift will be monitored by Licensed Nursing and Licensed Nursing assistants at a minimum of every 2 hours. The frequency will be increased for any resident who is not responding to prescribed treatments or is clinically unstable." On 4/28/15, the survey team confirmed the POR had been implemented sufficiently to remove the IJ as evidenced by: *13 LVNs were interviewed and were able recognize a change of condition and how to respond to that change appropriately. All LVNs voiced procedures to take when notifying the physician and family. All were aware of the required documentation and what information was to be passed along in report as well as walking rounds. *15 CNAs were interviewed and were able to recognize a change of condition and to whom to report the change. All were able to voice to whom they would report the change to if the nurse failed to take appropriate action. On 4/28/15 at 1:30 p.m., the administrator was informed the IJ was removed: however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated 4/24/15 indicated a census of 196.

Based on interview and record review, the facility failed to provide the necessary care and services in accordance with the comprehensive assessment and plan of care for 1 of 7 residents reviewed for a change in condition. (Resident #3) Resident #3 experienced changes in her level of consciousness and was unable to take medications; No accurate assessments were done and the physician was not consulted until 29 hours later when Resident #3 was sent to the local emergency room and admitted with altered mental status, profound dehydration, urinary tract infection, metabolic acidosis, and [MEDICAL CONDITION] (elevated potassium). Resident #3 was discharged on hospice care to another nursing facility 04/26/15. An Immediate Jeopardy situation was identified on 4/27/15. The Immediate Jeopardy was removed on 4/28/15. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure contributed to a delay in Resident #3 receiving needed medical treatment and could place the census of 196 residents at risk for delay in medical evaluation and treatment or death. Findings included: Physician orders [REDACTED].#3, admitted on [DATE], was [AGE] years old with the [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #3 sometimes was understood by others and she sometimes understood others. Resident #3 required extensive assistance with transfers, dressing, bathing, and personal hygiene. She required setup help only and ate meals independently. Resident #3 was frequently incontinent of bowel and bladder. The facility Medication Administration Record [REDACTED]. During an interview on 4/24/15 at 7:25 p.m., CNA E said she cared for Resident # 3 on the 2 p.m. - 10 p.m. shift on Monday 4/20/15. She said Resident #3 was "out of it". She said she was sleepy and was "not her usual self". She said she managed to get her to eat a few bites of dinner and assisted Resident #3 back to bed. She said she reported Resident #3's changes to LVN D. During an interview on 4/24/15 at 7:40 p.m., LVN D said she cared for Resident #3 on the 2 p.m. - 10 p.m. shift on Monday 4/20/15. She said Resident #3 was her usual self and did not recall a change in her level of consciousness. She said no staff had reported any changes to her. During an interview on 4/27/15 at 6:25 a.m., CNA C said she cared for Resident #3 on the 6 a.m. - 2 p.m. shift on Monday 4/20/15 and Tuesday 4/21/15, on both days Resident # 3 was not her usual self. She said Resident #3 would not eat and would not respond when her name was called or when she was touched. She said Resident #3 was leaning to one side Monday when she attempted to get her out of bed and into the geri-chair. She said Resident #3 was usually able to stand and bear weight. She said Resident #3 would not take fluids. CNA C said she reported Resident #3's change in condition to LVN A. She said Resident #3 was the in the same condition on Tuesday 4/21/15 and that was why she left her in bed. She said she reported Resident #3's changes to LVN D on Tuesday as well. During an interview on 4/27/15 at 6:35 a.m., MA B said on Monday 4/20/15 she could not get Resident #3 to take her medications because she was not responding. She said Resident #3 would not respond to her name being called or by touching her. MA B said she notified LVN A of Resident #3's decline. During an interview on 4/27/15 at 6:40 a.m., LVN A said she cared for Resident #3 on the 6 a.m. - 2 p.m. shift on Monday 4/20/15 and Tuesday 4/21/15, on both days Resident # 3 was not her usual self. She said on Monday 4/20/15 Resident #3 seemed sedated and was not eating. She said Resident #3 would not wake up to eat or take medications. LVN A said she did not notify the doctor about Resident #3's condition or document this in the nursing notes on Monday. She said she took Resident # 3's blood pressure, but did not check her blood sugar, temperature, or pulse oximetry. LVN A said on Tuesday 4/21/15 morning Resident #3 continued to be unresponsive and did not take her morning medications, which was reported to her by MA B. LVN A said she was approached in the hall by Resident #3's husband around noon about his concern about Resident #3's condition. LVN A said she assessed Resident #3 and noted that Resident # 3's "lips were dry and peeling as if she were dehydrated". She said ADON G notified the physician assistant at this time. LVN A said she would usually notify the physician assistant with any changes in condition and would usually complete a SBAR (form used to notify the physician). LVN A said she had not completed this form on Resident #3. She said she did not document any of her findings in the nursing notes which she usually does. The 24 hour report sheet dated Monday 4/20/15 did not indicate that Resident #3 had any problems. There was no indication a physician was notified or any medications were held. A nursing note dated 4/21/15 at 12:00 p.m. indicated Resident #3 had a change in mental status. The note indicated the physician assistant was notified with orders received to send Resident #3 to the emergency room for evaluation and treatment. No further assessment of Resident #3 was documented. There were no nursing notes that could be reviewed for 4/20/15. During an interview on 4/25/15 at 11:05 a.m., Resident #3's husband said he arrived at the facility on 4/20/15 a little after 12:00 p.m. to visit with his wife, but she was asleep. He said he could not wake Resident #3 by calling her name or touching her and he sat with her for over an hour, but Resident #3 did not wake up and her lunch tray was untouched. He said he returned to the facility on [DATE] a little before 12:00 p.m. and Resident #3 was still wearing her gown and was not responding. He said he approached LVN A in the hall and voiced concern about Resident #3's condition and requested that the physician be notified. During an interview on 4/27/15 at 12:50 p.m., ADON G said Resident #3's husband was in the hall voicing concern that Resident #3 was not awake and requested the physician be called. ADON G said she assisted LVN A with calling the physician's assistant and transferring Resident #3 to the emergency room . ADON G said Resident #3 was unresponsive. He said he did not document any of his findings and did not assist LVN A with documentation since LVN A was a new nurse. He said he was not aware of Resident #3's condition on Monday 4/20/15 and no changes had been reported to him. He said he expected the staff to notify him and the physician with any changes in condition. ADON G said he expected staff to document their assessment and interventions in the nursing notes. He said the licensed nurse was responsible for making all notifications of changes to the physicians, the resident and the resident's representative. ADON G said examples of changes included but not limited to: abnormal findings, changes in appetite and mobility, and neurological changes. The DON was not available for interview. The hospital admission lab results dated 4/21/15 at 1:00 p.m. indicated Resident #3 had the following abnormal results: *lactic acid 601 (normal range 0.4-2.0) *sodium 149 (normal range 133-145), *potassium 5.5 (normal range 3.5-5.1), *chloride 107 (normal range 96-108), *BUN 111 (normal range 8-23) and, *creatinine 3.21 (normal range 0.60-1.30), *The urine WBC 10-20 (normal range 0-5) *A CT scan of the head was negative for acute intercranial abnormality. A hospital history and physical dated 4/21/15 at 4:05 p.m. indicated when Resident #3 arrived in the emergency room her mental status was very altered, she was lethargic and stuporous. She opened her eyes to loud voices and painful stimuli. The laboratory reports indicated Resident #3 had increased potassium and increased BUN and creatinine. Resident #3's general assessment was blood pressure 80/55, heart rate 103, and temperature 95.2. The resident was pale. The assessment indicated Resident #3 had acute [MEDICAL CONDITION]ly secondary to volume depletion [MEDICAL CONDITION], with a urinary tract infection with severe dehydration resulting in acute kidney injury. Resident #3 also presented with [MEDICAL CONDITION] (increased potassium) and metabolic acidosis (Life threatening condition that occurs when the kidneys cannot eliminate acid buildup). Resident #3 was referred for palliative care. The policy and procedure dated April 2012 indicated "The facility will document changes in a resident's condition or significant care issues each shift until the resident's condition is stabilized or the situation is otherwise resolved ... .2. Document facts regarding the change in condition or incident as applicable, including but not limited to: vital signs, physical assessment, resident response, symptoms. 3. Notify physician and document the following: date and time physician notified and orders obtained." The administrator was notified on 4/27/15 at 11:43 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 4/27/15 at 4:56 p.m. and included: "Begin immediate inservicing of Licensed Nurses currently on shift concerning identification/symptoms of changes in resident condition, clinical assessment, documentation of assessment in nursing notes and 24 hour report, and notification of physician. Staff not currently on shift will be inserviced prior to beginning of their next scheduled shift. Begin immediate inservicing for Nursing Assistants currently on shift to include symptoms to report to their Charge Nurse. This will include changes in appetite, changes in level of alertness, changes in behavior (more lethargic or more restless or confused), changes in the color or odor of urine, changes in their ability to ambulate or transfer, changes in their speech, changes in their sleep pattern (more drowsy or not sleeping), any verbal complaints of pain or discomfort, changes in color or temperature of skin. Staff not currently on shift will be inserviced prior to beginning of their next scheduled shift. This inservice will include notification of their nurse manager in the event that a reported change of condition is not followed through by their charge nurse. Nurse Aides will be instructed to report any concerns about resident condition or the response of their charge nurse to the resident's change in condition immediately to their nurse manager either in person or by phone. Nurse Managers will complete walking rounds (starting immediately) with the assigned Charge Nurse of every resident in Briarcliff to assess/monitor for any changes in condition. This will include direct observation of each resident and chart review as needed to ensure that all condition changes have been assessed, documented, interventions put in place, and physician notification has been completed. Nurse Managers will complete daily rounds and chart reviews of any resident noted on the 24 hour report with a change in condition. This will be initiated today and ongoing as a daily routine. This will include review of the clinical documentation in the nursing notes and documentation that the physician was notified of the changes noted. Walking rounds will also be completed by the oncoming and exiting charge nurses at the beginning and end of each shift. In addition to this, Nurse managers which includes the weekend supervisor will complete their own rounds between 0700-0900. Beginning immediately, Staff Development Nurse will ensure that all new nurses as part of their floor orientation receive training concerning documentation in the nurses notes, identification of changes in resident condition, documentation of changes on the 24 hour report and in the nurses notes, and physician notification. Beginning immediately, upon discharge from facility to hospital nurse manager or designees will view the resident chart and 24 hour report to ensure that nurse documentation and physician notification are complete. Licensed Nurse Inservice will include change in policy that any significant change in condition requires a nurse consult with the resident physician or nurse practitioner by phone or in person. If the physician or nurse practitioner is not available at the time of the nurse notification the nurse will document on the 24 hour report that we are awaiting physician return call. This will be reported to the oncoming nurse during report that physician return call is pending. Licensed nurse will continue to contact physician until a consult can be acquired. DON/Administrator will be notified of any issues with physician response time. Anyone on the 24 hour report that has been identified with a change in condition or anyone identified on that shift will be monitored by Licensed Nursing and Licensed Nursing assistants at a minimum of every 2 hours. The frequency will be increased for any resident who is not responding to prescribed treatments or is clinically unstable." On 4/28/15, the survey team confirmed the POR had been implemented sufficiently to remove the IJ as evidenced by: *13 LVNs were interviewed and were able recognize a change of condition and how to respond to that change appropriately. All LVNs voiced procedures to take when notifying the physician and family. All were aware of the required documentation and what information was to be passed along in report as well as walking rounds. *15 CNAs were interviewed and were able to recognize a change of condition and to whom to report the change. All were able to voice to whom they would report the change to if the nurse failed to take appropriate action. On 4/28/15 at 1:30 p.m., the administrator was informed the IJ was removed: however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated 4/24/15 indicated a census of 196.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent development and worsening of pressure ulcers for 1 of 9 residents reviewed for pressure ulcers. (Resident #11) Resident #11was admitted without pressure ulcers, but was at high risk for the development of pressure ulcers. She developed 4 facility-acquired pressure ulcers (3 Stage II and 1 unstageable) within 4 weeks from returning from the hospital. The facility did not: *assist the resident with turning/repositioning every two hours *complete accurate skin assessments during a 8 day period *provide a pressure relieving mattress for 22 days after the development of 1 pressure sore or 14 days after the development of 3 pressure ulcers; *obtain a dietary recommendation for 17 days after the development 1 pressure sore or 9 days after the development of 3 pressure ulcers; and * provide wound care support nutrition for 6 days after dietary recommendations were made. These failures contributed to the development of new pressure ulcers and the worsening of existing pressure ulcers for Residents #11 and could place the 9 residents with pressure ulcers at risk for developing new pressure ulcers and decline in existing pressure ulcers. Findings included: 1. Physician orders [REDACTED]. A dietary assessment dated [DATE] indicated Resident #11 did not have pressure sores. A Braden scale assessment dated [DATE] indicated Resident #11 was at high risk for pressure sores. The most recent MDS assessment dated [DATE] indicated Resident #11 was totally dependent with bed mobility and personal hygiene, had a catheter, and was incontinent of bowel. The resident had severely impaired mental status and no behavior problems. Resident #11 had no pressure sores. A nurse note dated 07/01/13 at 11:00 a.m. and completed by the former treatment nurse indicated Resident #11was assessed and received a treatment for [REDACTED]. A weekly skin assessment dated [DATE] completed by LVN G indicated Resident #11 had an open area on her sacrum. No measurements or description of the wound was documented on the weekly skin assessment or in the nurse notes. Pressure Skin assessment sheets dated 07/09/13 for Resident #11 indicated the following: Right inner buttock Stage ll 1 x 0.5 cm Stage ll Mid back 2.5 x 2 cm Stage ll Sacrum 2 x 0.5 cm Stage ll Right heel 5 x 2 suspected deep tissue injury A pressure ulcer care plan dated 07/09/13 indicated staff were to provide Resident #11 pressure relieving devices for the bed and Geri-chair. Staff were to assist the resident with turning/repositioning every two hours and as needed, and nutritional needs were to be met according to the RD recommendations. Lab results dated 07/10/13 indicated Resident #11 had a pre-[MEDICATION NAME] of 15 (reference range 18-38) a low [MEDICATION NAME] of 2.7 (reference range 3.5 - 5.0) and a low total protein of 6.1 (reference range 6.4 - 8.4). (Pre-[MEDICATION NAME], and total protein are indicators of nutritional risk.) A dietary assessment dated [DATE] indicated nutritional concerns for 4 pressure sores since 07/01/13. Dietary recommendations were to change tube feeding order to Fibersource HN (higher protein and calories) at 135cc/hr with 25cc/hr water flush for 9 hours at night. That provided 1215 cc formula, 1458 calories, 66 gm protein, and 1209 cc free fluids. Add iron sulfate 325 mg one every day. Dietary recommendations were made 17 days after the development 1 pressure sore and 9 days after the development of 3 pressure ulcers. Physician orders [REDACTED]. During observations on 07/22/13 at 1:20 p.m., 3:15 p.m., 4:45 p.m., and 5:20 p.m., Resident #11 was lying on her left side facing the wall with the head of bed slightly elevated. She had a pillow under her head and a pillow between her legs. During a treatment observation with the treatment nurse on 07/23/13 at 2:30 p.m., Resident #11 had the following pressure ulcers: Right inner buttock 0.9 x 0.4 cm open pressure sore with a pink wound bed and the surrounding area was reddened measuring approximately 1.0 x 1.0 cm. Mid back 1.3 x 0.6 cm pale pink wound bed Sacrum 2.1 x 1.8 cm pale pink open pressure sore and the surrounding area was reddened measuring 1.0 cm Right heel 4.7 x 2.0 brown/black closed suspected deep tissue injury During an interview on 07/23/13 at 2:45 p.m., the treatment nurse said she just started working on 07/12/13. She said Resdient #11 was totally dependent on staff for ADLs and turning and repositioning. She had ordered a specialty low air loss mattress for Resident #11 on Friday 07/19/13 because she had so many pressure sores and was at high risk to develop pressure sores. She said the mattress was to be delivered on 7/22/13. During an interview on 07/24/13 at 2:00p.m., LVN G said she reported the wound on Resident #1's sacrum to the previous treatment nurse on 07/02/13. She said this was the procedure for wounds if the treatment nurse was in the building. The treatment nurse was responsible for measurements, receiving orders, and performing treatments. During an interview on 07/24/13 at 3:30 p.m., the DON said the previous treatment nurse apparently did not do her job, properly document, nor finish her work before she quit. She said she had tried to contact her several times to get information without success. The unit manager was to assure skin assessments and treatments continued prior to hiring another treatment nurse. During an interview on 07/24/13 at 3:45 p.m., LVN H said she assessed Resident #11's skin on 07/09/13 and found the 3 newly developed pressure areas. She said the previous treatment nurse was responsible for doing the skin treatments, pressure assessments, documentation, and notifying the RD. LVN H said the treatment nurse quit and she was left responsible for taking care of her work and the work undone by the previous treatment nurse. LVN H said she attempted to contact the previous treatment nurse several times for information on Resident #11's skin and where the documentation was. The previous treatment nurse never returned her call. LVN H said she was not aware of the new areas until she observed Resident #11. LVN H said the measurements on the weekly pressure log dated 07/01/13 for Resident #11's sacral pressure sore were the measurements she took on 07/09/13. LVN H said she did not have the previous measurements taken by the treatment nurse and could not determine if the area had improved or worsened. LVN H said pressure sore skin assessments were to be done weekly, either by the charge nurse on duty or the treatment nurse. During an interview on 07/24/13 at 2:30 p.m., the RD said she was notified of Resident #11's pressure sores on the 07/18/13 and had written nutritional recommendations. The nutritional orders were not put in effect until 07/24/13 after physician approval. The Clinical Practice guideline #15, treatment of [REDACTED]. The state of the wound is correlated with the severity of nutritional deficits, particularly low protein intakes or a below-normal serum [MEDICATION NAME]". The pressure ulcer staging and recommended products protocol dated July 2012 indicated the following: Stage I - Recommended Guidelines Barrier products per facility protocol Stage II - Recommended Guidelines Rinse with normal saline for wound cleansing prior to applying new dressings. Primary dressings - hydrogels, [MEDICATION NAME], thin films, cover with transparent dressing, change every 4 days and as needed Stage III and IV - Recommended Guidelines Primary dressings - hydrogels, [MEDICATION NAME], calcium alginate Rinse with normal saline for wound cleansing prior to applying new dressings. Cover with transparent dressing, change every 2 - 3days and as needed. There was no protocol for unstageable pressure sores. The International National Pressure Ulcer Advisory Panel website www.npuap.org accessed 07/26/13 noted the following: "A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear." "Category/Stage II: Partial thicknessPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation." "Bruising indicates deep tissue injury." "Suspected Deep Tissue Injury - depth unknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment." The policy and procedure for wound prevention and treatment dated July 2012 indicated the following: "Progression of wound healing will be documented by length, width, and depth measurements, documentation shall also include drainage, odor, color, tunneling, and peri wound condition." The CMS 672 dated 07/22/13 indicated 9 residents had pressure ulcers.