Every finding on record at Brookdale Westlake Hills

Based on observation, interview, and record review, the facility failed to have a person-centered care plan developed and implemented to meet each resident's preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs for three of (52, 67, and 73) eight residents reviewed for care plans. The facility failed to ensure Resident # 67's initial care plan was completed upon admission to reflect Resident #67's need for treatments, such as TPN-Total Parental Nutrition (a method of delivering essential nutrients-carbohydrates, proteins, fats, electrolytes, vitamins, and minerals-directly into the bloodstream via a central vein catheter, bypassing the digestive system. It is used for patients unable to eat or absorb nutrients), PICC- Peripherally inserted central catheter (a long, thin, flexible tube inserted into an upper arm vein and threaded into a large vein near the heart, typically lasting for weeks or months. Used for long-term IV therapy, it reduces needle sticks by enabling safe, repeated delivery of medications, chemotherapy, nutrition, or blood sampling.), EBP-Enhanced Barrier Precautions (an infection control strategy for nursing homes, requiring gowns and gloves during high-contact care to reduce multidrug-resistant organism (MDRO) transmission), JP Drain-Jackson Pratt drain (a bulb-suction device used after surgery to remove internal fluids, reduce swelling, and prevent infection), code status and ABT-Antibiotics ( powerful, prescription-only medications used exclusively to treat bacterial infections. Antibiotics are targeted based on the bacteria type and site of infection). The facility failed to ensure Resident #73's initial care plan was completed upon admission to reflect Resident #73's G-Tube, - Gastrostomy tube (a surgically placed device providing direct, long-term access to the stomach for feeding, fluids, and medication when oral intake is insufficient), EBP, and code status. The facility failed to ensure Resident #52's care plan was completed to reflect Resident #52's code status. These failures could place residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in a decline in physical and psychosocial well-being. Findings included:Record review of Resident #67's face sheet, dated 04/07/2026, reflected an [AGE] year-old male, admitted [DATE], with diagnoses that included Diverticulitis of intestine (the inflammation or infection of small pouches (diverticula) that form in the colon wall, commonly causing severe lower-left abdominal pain, fever, nausea, and changes in bowel habits), other specified sepsis (sepsis is a life-threatening medical emergency caused by the body's extreme, dysfunctional response to an infection, leading to tissue damage, organ failure, and potential death), recurrent major depressive disorder ( a chronic condition characterized by two or more distinct episodes of severe sadness, hopelessness, and loss of interest, separated by at least two months of recovery). Record review of Resident #67's care plan, dated 04/02/2026, reflected Resident #67's risk for falls, potential impairment to skin integrity, pain, and risk for hot liquid injury. Further record review reflected no care plan completed addressing other health concerns, such as the use of antibiotics, TPN infusion, JP drains, code status, and PICC line access. Review of Resident #67's interim care plan initiated 04/02/2026 reflected no to EBP and gastrointestinal issue for Resident #67. Record review of Resident #67's admission skin assessment, dated 04/03/2026, reflected Resident #67 had a PICC line at right arm and 2 JP drains, 1 to the left upper quadrant and the other to the right lower quadrant of the abdomen. Record review of Resident #67's admission MDS assessment dated [DATE] reflected no BIMS score due to MDS not yet being completed. MDS addressed Resident #67's diagnoses as listed above. Record review of Resident #67's physician orders reflected the following:JP Drain #1- empty suction bulb every shift, record output every shift for JP drain #1 dated 04/02/2026.JP Drain #2- empty suction bulb every shift, record output every shift for JP drain dated 04/02/2026.Flush each valved PICC catheter lumen with 10 ml NS prior to medication infusion. Following each medication infusion, flush with 10ml NS. every shift for PICC Line Maintenance dated 04/02/2026.Clinimix/Dextrose (5/15) Intravenous Solution 5 % (Amino Acid Infusion in D15W) Use 60 ml/hr intravenously one time a day for Nutrition dated 04/03/2026.Ciprofloxacin HCl Tablet 500 MG Give 1 tablet by mouth every 12 hours for Infection for 7 DaysADD-DNR dated 04/06/2026. Record review of Resident #73's face sheet, dated 04/08/2026, reflected a [AGE] year-old female, admitted [DATE], with diagnoses including adult failure to strive, gastrostomy status (the presence of a surgically created opening (stoma) in the stomach wall, used for a feeding tube (G-tube) to deliver nutrition, hydration, or medication directly to the stomach. It is used for long-term nutritional support when swallowing is unsafe or oral intake is insufficient.), unspecified severe protein-calorie malnutrition (a critical deficiency of nutrients-specifically energy and protein). Record review of Resident # 73's interim care plan, dated 04/02/2026, reflected feeding tube was not checked, Gastrointestinal not checked, EBP /infection not checked. Record review of Resident #73's comprehensive care plan, dated 04/03/2026. addressed Resident #73's risk for falls, communication problems, ADLs self-care performance deficit, and ADD. There was no other care plan completed for Resident #73 to include other health concerns such as the use of G-tube and EBP management. Record review of Resident # 73's admission MDS assessment, dated 04/06/2026, reflected no BIMS score due to MDS not yet being completed. MDS addressed Resident #67's diagnoses as listed above. Record review of Resident # 73's physician orders reflected the following:Enteral Feed Order four times a day for Nutritional Maintenance Bolus feeding: Jevity 1.5 1 can QID flush 70 mls of water before and after bolus dated 04/03/2026.NPO diet Refer to diet type for texture, NPO consistency, Has Peg tube dated 04/05/2026.Enhanced Barrier Precautions (EBP) for (PEG) dated 04/08/2026.ADD: Full Code dated 04/08/2026 Record review of Resident #52's face sheet, dated 04/08/2026, reflected an [AGE] year-old male, admitted [DATE], diagnoses included hypotension (abnormally low blood pressure), other unspecified disorder of the muscle, history of falling, atrial fibrillation (a common, often chronic arrhythmia characterized by rapid, disorganized electrical activity in the heart's upper chambers (atria), causing a fast, irregular heartbeat), Ischemia cardiomyopathy (a weakened heart muscle (often the left ventricle) caused by reduced blood flow from coronary artery disease or a heart attack, leading to heart failure) Review of Resident # 52's comprehensive care plan, dated 03/27/2026, reflected Resident #52 was at risk for fall, potential/actual impairment to skin integrity, Pressure Ulcer on the sacrum but did not address, ADL Self Care Performance Deficit. Record review reflected the care plan did not address Resident #1's code status and EBP status. Review of Resident # 52's admission MDS assessment, dated 04/01/2026, reflected BIMS score 14 which indicated no cognitive impairment. Review of Resident # 52's physician orders reflected the following:Enhanced Barrier Precautions (EBP) for (wound) dated 04/08/2026.ADD: Full Code dated 04/08/2026 During an interview on 04/09/2026 at 08:20 a.m., the DON stated baseline care plans should be completed with 24-48 hours of admission. The DON stated everything that the resident was being treated for should be carefully planned. The DON stated Resident #67's interim or baseline care plan should have addressed his ABT, TPN, PICC, and any other care area for which the facility was providing care. During an interview on 04/09/2026 at 08:53 a.m., the MDS Nurse stated she was responsible for completing care plans based on the data collection done by the admitting nurse during the admission assessment. She stated that data flowed to the comprehensive care plan and the MDS. The MDS Nurse stated if the data collection was not completed accurately upon admission, the interim care plan was not completed accurately. The MDS Nurse stated that the data collection for the interim care plan should be completed within 2 days. The MDS Nurse stated she builds up on whatever information that was collected by the admitting nurse to complete the comprehensive care plan. The MDS Nurse stated Resident #67's interim care plan should have addressed TPN, ABT, EPB, PICC and it would have flowed to Resident #67's comprehensive care plan. The MDS Nurse stated Resident #73's interim care plan should have addressed G-tube because it was important to know how Resident #73 was being fed but the admitting nurse did not check feeding tube, so the information did not transfer to the comprehensive care plan. The MDS Nurse stated care areas from admission would trigger if the admitting nurse checked the appropriate box that applied. The MDS nurse stated it was important for the admitted nurse to check all that applied for staff to know what care to provide for a particular resident. The MDS nurse stated Advance Directives should be added to the care plan upon admission because when a resident's heart stops, the staff on duty should know what care to provide. The MDS Nurse stated that EBP should be added to the care plan for residents and staff safety, to prevent cross contamination and to alert the staff on what PPE to use when providing care. During an interview on 04/09/2026 at 11:31 a.m., the admission Coordinator stated she was trained on Advanced Directives. She stated the policy for entering advanced directives was three to five days after admission. The admission Coordinator stated if there was not a DNR copy, she would input the resident as a full code. The admission Coordinator stated code status should be put in the residents' records right away. The admission Coordinator stated the staff would not know if the resident was DNR and that was not acceptable. The admission Coordinator stated she monitored to ensure the advance directives were entered into the resident's medical chart by doing an audit. The admission Coordinator stated she did not know why the code status for Residents #67 and Resident #52 were not in the residents' chart or on the care plan. Review of facility's policy titled, Interim Care Plan, revised 03/2026 reflected: An Interim baseline care plan should be developed for each resident within forty-eight (48) hours of admission to the skilled healthcare community.Policy detail1. Within forty-eight (48) hours of admission to the skilled healthcare community, an interim baseline care plan should be developed which includes the minimum healthcare information necessary to care for the residents' immediate health and safety needs.2. The interim care plan should be developed by the admission nurse with the assistance of interdisciplinary team members.3. The Interim care plan should use but not be limited to, the resident's initial goals of care, physician's orders, dietary orders and instructions, therapy orders, resident cognitive, physical, and psycho-social needs, and any PASRR recommendations if applicable.4. The Interim care plan should be person-centered and include services and treatments administered by the community.5. The interim care plan should be used until the completion of the comprehensive assessment, and the comprehensive care plan is developed. Review of facility's policy titled Comprehensive care plan dated 11/2017 reflected: A comprehensive, person-centered Care Plan will be developed for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs that have been identified through a comprehensive assessment.Policy detailA person-centered, comprehensive care plan will be developed and implemented in accordance with the following:1. The Comprehensive Care Plan will describe treatments and services to assist the resident to attain or maintain the highest level of physical, mental, and psychosocial wellbeing.2. The comprehensive care plan is based on a comprehensive assessment which includes, but is not limited to, the MDS, Care Area Assessments, clinical assessments and data collection forms, Therapy Evaluations, psychosocial and cognitive evaluations, physician assessments/consults.

Based on observation, interview, record review, the facility failed to ensure storage of medications used in the facility in accordance with currently accepted professional principles and included the appropriate expiration dates to preserve their integrity for the stored medications, and to store medications properly to prevent deterioration for two medications carts out of four and two nursing carts out of 4 reviewed for medications storage. The facility failed to ensure that the MC-D (hall 200) did not have 1 medication bottle that was undated in the drawer. The facility failed to ensure that the MC-D (hall 200) did not have 7 medication bottles that were labeled incorrectly. The facility failed to ensure that the MC-D (hall 200) did not have 1 white round TAB inside of unlabeled medication cup.The facility failed to ensure that the MC-D (hall 200) did not have 1 unknown orange round TAB. The facility failed to ensure that the MC-E (hall 200) did not have 1 unknown orange round TAB. The facility failed to ensure that the MC-E (hall 200) did not remove 1 bottle of liquid medication. The facility failed to ensure that the MC-E (hall 200) did not have 6 medication bottles that were labeled incorrectly. The facility failed to removed Resident #30's Narcotic medication from the medication cart four days after Resident #30 was discharged from the facility on 04/03/2026. The facility failed to labeled Resident #68's insulin pen with opened date after it was opened and being used. The facility failed to removed Resident #8's scopolamine patch from the medication's cart for seventy-seven days after the medication was discontinued on 01/21/2026. The facility failed to ensure that the NC-E (hall 200) did not remove 2 blister packs with white round tabs after the resident's discharge. The facility failed to ensure that the NC-E (hall 200) did not have 6 medications that were labeled incorrectly. The facility failed to ensure that medication tablet is not removed from the floor in Resident 68's room. This failure could place residents at risk for missed medications and/or receiving unidentified medications. Findings included: Record review of Resident #30's face sheet, dated 04/08/2026, reflected a [AGE] year-old male admitted on [DATE] with diagnoses that included Pressure ulcer of right hip, Paraplegia (the partial or complete paralysis of the lower half of the body, including both legs, usually caused by spinal cord damage in the thoracic, lumbar, or sacral regions), Post Traumatic seizures (abnormal electrical brain events occurring after a traumatic brain injury (TBI), often resulting in seizures), Post traumatic Brain injury- TBI (results from an external force causing brain dysfunction, ranging from mild concussions to severe, long-term impairment), Recurrent Major Depressive Disorder, recurrent ( a chronic condition characterized by two or more distinct episodes of severe sadness, hopelessness, and loss of interest, separated by at least two months of recovery). Face sheet also reflected Resident #30 was discharged on 04/03/2026. Record review of Resident #30's care plan dated 03/06/2026, addressed Resident #30's potential/actual impairment.to skin integrity, an ADL Self Care Performance Deficit r/t right hip flap. Care plan did not address the need for pain medication. Record review of Resident #30's admission MDS assessment, dated 04/06/2026, reflected a BIMS score of 09 which indicated moderate cognitive impairment. Section J-Pain Assessment indicated Resident #30 did not have pain. Record review of Resident #30's physician order, dated 03/06/2026, reflected:Hydrocodone-Acetaminophen Tablet 7.5-325 MG Give 1 tablet by mouth every 6 hours as needed for pain. Record review of Resident #30's MAR, dated ??, reflected:Hydrocodone-Acetaminophen Tablet 7.5- 325 MG Give 1 tablet by mouth every 6 hours as needed for pain -Start Date- 03/06/2026 and D/C date of 04/06/2026. Record review of Resident #30's Narcotic Medication log, dated ??, reflected:Hydrocodone-Acetaminophen Tablet 7.5- 325 MG take 1 tablet by mouth every 6 hours as needed for severe pain with 10 pills being delivered on 03/06/2026. It was noted none was given to Resident #30.Hydrocodone-Acetaminophen Tablet 7.5- 325 MG take 1 tablet by mouth every 6 hours as needed for severe pain with 25 pills being delivered on 03/10/2026. It was noted none was given to Resident #30. Record review of Resident # 8's face sheet date 04/08/2026 reflected a [AGE] year-old female, admitted [DATE] and readmitted [DATE], with diagnoses that included Multiple Sclerosis (a chronic autoimmune disease where the immune system attacks the myelin sheath covering nerves in the brain and spinal cord, causing communication issues between the brain and body), Recurrent Major Depressive Disorder, recurrent a chronic condition characterized by two or more distinct episodes of severe sadness, hopelessness, and loss of interest, separated by at least two months of recovery), Spinal Stenosis (the narrowing of the spinal canal, causing pressure on the nerves and spinal cord), Chronic pain. Review of Resident #8's care plan revised 02/17/2026 addressed Resident #8's risk for falls, at risk for integument.Impairment, potential for pain. Care plan did not address the need for Scopolamine patch (prescription, skin-applied patches placed behind the ear to prevent motion sickness and post-operative nausea). Review of Resident #8's quarterly MDS assessment, dated 01/07/2026, reflected a BIMS score of 05 indicating severe cognitive impairment. Record review of Resident #8's current physician order, dated ??, did not reflect an order for Scopolamine patch. Review of Resident #8's MAR for the month of 12/2025 reflected Resident #8 was not administered Scopolamine patch. It was also reflected Resident #8 had an order for Scopolamine Transdermal Patch 72 Hour (Scopolamine) Apply 1 patch transdermally every 72 hours as needed for secretions -Start Date- 10/21/2025 -D/C Date- 01/21/2026. Review of Resident #8's progress notes, dated 01/21/2026, reflected:Medication: Scopolamine Transdermal Patch 72 HourStart date: 10/21/2025.Stop date: 01/21/2026.Stop reason: unknown. Review of Resident #68's face sheet, dated 04/08/2026, reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus with hyperglycemia-high blood sugar (is a chronic condition characterized by high blood glucose (sugar) due to insulin resistance or insufficient insulin production), acute on chronic systolic (congestive) heart failure, unspecified Atrial Fibrillation (a common arrhythmia characterized by a rapid, chaotic, and irregular heartbeat originating in the heart's upper chambers (atria)), Angina Pectoris (chest pain, pressure, or squeezing caused by reduced blood flow and insufficient oxygen to the heart muscle). Review of Resident #68's care plan initiated 04/03/2026 addressed Resident #67's risk for falls, Congestive HeartFailure r/t dyspnea on exertion and lower extremity swelling, ADL Self Care Performance Deficit r/t General Weakness/Acute Chronic CHF. Resident #68's care plan did not address Type 2 Diabetes and the need for insulin administration. Review of Resident #68's TAR for the month of April 2026 reflected:Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 10 unit subcutaneously one time a day for diabetes -Start Date- 04/04/2026. Review of Resident #68's admission MDS assessment, dated 04/07/2026, reflected o BIMS score due to MDS not yet being completed. MDS addressed Resident #67's diagnoses. Included Type 2 Diabetes Mellitus with hyperglycemia-high blood sugar (is a chronic condition characterized by high blood glucose (sugar) due to insulin resistance or insufficient insulin production), acute on chronic systolic (congestive) heart failure, unspecified Atrial Fibrillation (a common arrhythmia characterized by a rapid, chaotic, and irregular heartbeat originating in the heart's upper chambers (atria)), Angina Pectoris (chest pain, pressure, or squeezing caused by reduced blood flow and insufficient oxygen to the heart muscle). During an observation of MC-D (hall 200) on 04/07/2026 at 1:14 p.m., one undated over the counter medication bottle was opened. During an observation of the MC-D (hall 200) on 04/07/2026 at 1:20 p.m., revealed 7 bottles of open medications did not include the appropriate labeling : month/day/year on the medication bottles. During an observation and interview 04/07/2026 12:09 p.m., with LVN F, while reviewing the 3-west nurse's medication carts, it was observed that Resident # 30 had 2 blister packets of Hydrocodone-Acetaminophen Tablet 7.5- 325 MG take 1 tablet by mouth every 6 hours as needed for severe pain with 10 pills being delivered on 03/06/2026 and the other with 25 pills delivered on 03/10/2026. It was also observed Resident # 68 had Lantus Solostar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) on the medication cart that was not labeled with opened date. LVN F stated Resident #30 was discharged on 04/03/2026 and his medication was kept on the cart for the resident to pick up later. LNV F stated she was not aware if the Resident #30 was notified about picking up his medication later. LVN F stated, the process was, when a narcotic medication was discontinued or a Resident was discharged home, 2 nurses would verify the medication count, sign and take it to the second-floor medication room and give to the manager for clinical service to put in the D/C box after verifying the count. LVN F stated she did not know if an insulin pen had to be labeled with the opened date. LVN F stated an insulin pen was supposed to be refrigerated if not being used. LVN F stated Resident #68's insulin pen was being used. During an observation of the MC-D (hall 200) on 04/07/2026 at 1:22 p.m., one white round TAB stored inside of the unlabeled medication cup. During an observation of the MC-D (hall 200) on 04/07/2026 at 1:36 p.m., 1 orange round TAB which was loose and unlabeled. During an observation of the MC-E (hall 200) on 04/07/2026 at 1:37 p.m., 1 orange round TAB revealed it loose and unlabeled. During an observation of the MC-E (hall 200) on 04/07/2026 at 1:20 p.m., revealed an expired bottle of Glucosamine Chondroitin with a handwritten note on the bottle indicating opened 12/17/24. During an observation of the MC-D (hall 200) on 04/07/2026 at 1:25 p.m., six bottles of open medications revealed did not include the appropriate labeling on the medication bottles. During an observation of the NC-E (hall 200) on 04/07/2026 at 2:04 p.m., two blister packs of Narcotic medications revealed (1 blister pack with 5 Norcocodone-Acet 5 MG-325 MG TABs and 1 blister pack with 20 Norcocodone-Acet 5 MG-325 MG TABs) were not removed from the cart after resident's discharge. During an observation and interview on 04/07/2026 at 3:03 p.m. with MA G, while reviewing the 3-E medication aide cart, it was observed Resident #8 had a box of Scopolamine1 mg (1.5mg) /3-day patch with delivery date of 1/14/2026 still on the cart. According to MA G, Resident #8 no longer received the patch. MA G stated if medication was discontinued, it should be removed from the medication cart immediately. MA G stated usually they would hand the discontinued medication to the charge nurse, and he was not sure why Resident #8's scopolamine patch was still on the medication cart. During an observation of medication administration on 04/08/2026 at 7:20 a.m., MA C dropped Resident #68's white rounded tablet on the floor, the MA C identified the medication as Metformin. Resident #68 received another Metformin tablet and MA C left the dropped medication on the floor. The medication on the resident room's floor was picked up by the ADON after this surveyor pointed at the medication. Record review of Resident #68's undated admission face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included acute chronic systolic (congestive) heart failure (a chronic condition where the heart's left ventricle weakens and cannot contract properly), type 2 diabetes mellites with hyperglycemia (insulin resistance or failure to produce sufficient insulin), unspecified dementia (cognitive decline), unspecified atrial fibrillation (chronic arrhythmia where the heart's upper chambers beat chaotically). During an interview on 04/09/2026 at 08:20 a.m. the DON stated insulins should be labeled with open date to know when they expired and when they can no longer be used. The DON also stated based on standard practice, Narcotic medication should be removed from the cart immediately after being discontinued or discharged from the facility and taken to the appropriate place for destruction. The DON stated it was important to take D/C medications, prescription, and narcotic medications from the medication cart to prevent accidental administration to another Resident. During an interview on 04/09/2026 at 8:33 a.m. with Resident 68 she stated that if the pill dropped on the floor, she does not mind picking it up from the floor and eating it at home. She stated that she is not sure if she would take the pill after it has been on the floor here. She recalled that one of her medications fell on her lap and the staff picked up the medication and went to bring another medication for her yesterday morning. During an interview on 04/09/2026 at 11:03 a.m. the Manager for Clinical Services stated all D/C narcotics and prescription medications should be removed immediately from the medication cart, she verified the count with the charge nurse, they both sign and the medication was put in the destruction box. During an interview on 04/08/2026 at 12:38 p.m. with MA C she stated she has been working here for 4 years. She stated that she looked for the medication on the floor but could not find it. She stated that the resident could pick the medication from the floor and eat it. Resident #68 could get double dose of medication or an adverse reaction. MA C could not recall when she had her medication administration training last time. During an interview on 04/08/2026 at 1:02 p.m., the ADON stated she worked in the facility since December of 2025. The ADON stated that new over-the-counter medication bottles were supposed to be dated when they opened. As far as it is not beyond the label date on the bottle, if there are no instructions for how long the medication can stay. They should be dated; Months, the day it is open. I cannot answer this question until I know what my corporate wants me to say. The ADON stated that she does not know the reason for loose medications found in the medication carts, they were supposed to be discarded. They could have been given to the wrong residents and caused adverse reactions. She stated that any expired medication must be removed from the med carts. They are ineffective for residents and may cause an allergic reaction. The ADON stated that the medications of the discharged residents must be removed from the medication carts. The medication carts are to be audited by nurse managers and pharmacists. She stated, We started removing all expired medication from medication carts. The ADON stated it was not acceptable that the medication was left on the floor of the resident's room. She stated that somebody could pick it up and eat it. The DON stated that the CNA who dropped the medication on the floor should pick it up and dispense it properly. The ADON said the resident could have an adverse reaction if she picks it up and eats it. During an interview on 04/09/2026 at 10:20 a.m. interview with MA D he stated he has been working in the facility for 5 years. He stated that when opening new medication bottles the bottle must be labeled with open date: month/day/year. If the medication was pulled out for dispense it must be labeled with the name of the medication, resident's name. If it was not properly labeled there was possibility someone else would get it. The MA D stated the new over-the-counter medication bottles were supposed to be dated when they were opened. He stated that administering expired medications was ineffective for residents. He did not know the reason for loose medications were in the med carts. The MA D stated that any medications of discharged residents must be removed from the med carts, so they were not administered to the wrong resident. During an interview on 04/09/2026 at 10:39 a.m. with DON she stated she has been working in the facility for 9 days, still in training. When opening the new OTC medication bottle it must be labeled with open date: month/day/year. If the medication is pooled out for dispense the medication cup must be labeled with the name of the medication, resident's name, date, and time. If it is not properly labeled there was possibility someone else will get it. Loose medications were not supposed to be laying in the medications' carts; there is possibility the medication administered to the wrong resident. She stated that any medications of discharged residents were removed from the medication carts because they can be administered to the wrong resident and cause adverse reactions or allergies, depending on the medication. During an interview on 04/09/2026 at 11:19 a.m. with ADM he stated he has been working in this facility since November 2025. He stated If medications were not labeled correctly, it introduces residents to the possibility of med errors. It can negatively affect residents to have undated/expired meds in the med cart by the medication could lose their effectiveness. If medication is observed on the floor, it must be removed. The residents need to be kept safe. Review of facility's policy titled storage and expiration dating of medications and Biologicals revised 08/01/2024 reflected: 10. Facility should ensure medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier.11. Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for open medications. Facility staff should record the date opened on the primary medication container (i.e., vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened.Facility staff may record the calculated expiration date based on date opened on the primary medication container.If a multi-dose vial of an injectable medication has been opened or accessed {e.g., needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. 21. Facility should ensure medications and biologicals for expired or discharged or hospitalized residents are stored separately, away from use, until destroyed or returned to the provider.22. Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with pharmacy return/destruction guidelines and other applicable laws and in accordance with Policy 8.2 (Disposal/Destruction of Expired or Discontinued Medication). Record review of a document provided by the facility titled 5.3 Storage and Expiration Dating Medications and Biologicals with Effective date 12/01/07, Last revised: 5/2005, 10/2011/8/2025, 10/2016 reflected: 11. Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for open medications. Facility staff should record the date opened on the primary medication container (i.e., vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened. 21. Facility should ensure medications and biologicals for expired or discharged or hospitalized residents are stored separately, away from use, until destroyed or returned to the provider. 22. Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with pharmacy return/destruction guidelines and other applicable law, and in accordance with Policy 8.2 (Disposal/Destruction of Expired or Discontinued Medication).

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #41 and Resident #48) of 7 residents reviewed for infection control. The facility failed to ensure MA D performed hand hygiene before and after administering medications to Resident #55 and Resident #48. The facility failed to ensure LVN B performed hand hygiene before going to Resident #55 room. These failures could place residents at risk for cross contamination and the spread of infection. Findings included: During an observation of the medications administration on 04/08/2026 approximately at 7:40 a.m. revealed MA D did not perform hand hygiene before preparing Resident 55's medications. MA D went to Resident 55's room to administer medications. MA D did not perform hand hygiene after administering medications, he left the resident's room and logged back on the facility's laptop without performing hand hygiene and started charting. Further observation on 04/08/2026 approximately at 8:10 a.m. revealed MA D did not perform hand hygiene before he pulled out Resident 48's medications and went to Resident 48's room to administer medications. Record review of Resident #55's undated admission face sheet reflected an [AGE] year-old male admitted on [DATE]. His diagnoses included essential primary hypertension (chronic high blood pressure with no single, identifiable medical cause), chronic kidney disease, stage 1 (mild kidney damage with normal or high function), unspecified atrial fibrillation (chronic arrhythmia where the heart's upper chambers beat chaotically), malignant neoplasm of colon, unspecified (a cancerous tumor in the large intestine), malignant neoplasm of prostate (slow-growing cancer that begins in the prostate) Record review of Resident #55 MDS, dated [DATE], reflected BIMS score of 13 indicating the resident was cognitively intact. Record review of Resident #48's undated admission face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Chronic obstructive pulmonary disease, unspecified (incurable lung disease characterized by chronic airway obstruction), atherosclerotic heart disease of native coronary artery without angina (chronic buildup of plaque in the heart's arteries), heart failure (a chronic condition where the heart cannot pump enough blood to meet the body's needs), urinary tract infection, site not specified (UTI is confirmed, but documentation does not identify the specific location, such as the bladder or kidney). Record review of Resident #48 MDS, dated [DATE], reflected a BIMS score of 15 indicating the resident was cognitively intact. During an interview on 04/09/2026 at 8:20 a.m. with Resident #48 she stated she would not like it if staff did not sanitize or wash their hands before coming into her room. She stated that other residents might have asked staff to move their legs that have slid down of the pillow or fix their pillows or something else and then coming to her room without hand sanitizing or washing hands is not acceptable. During an interview on 04/9/2026 at 10:20 a.m. with MA D he stated he trained in infection control, his last infection control in service was last month. It covered hand hygiene like washing hands for 20-30 seconds and hand sanitizing for every resident care. and hand sanitizing; Not performing properly hand hygiene can spread infection. Putting PPE on, gloves and gown when it is required for the resident on EBP. During an interview on 04/08/2026 at 1:48 p.m., CNA E stated that it was her 4th week working in this facility. She stated she was trained in infection control. She stated she did modules for two days when she was hired, including infection control. She stated the modules covered use of hand sanitizers when in and out of the residents' rooms. Hand washing is required if the hands are visible soiled. Hands can carry a lot of germs. She stated we can get bigger problems if we do not follow the hand hygiene protocol. Wear the PPEs She stated that when going to the residents' rooms with the EBP sign on the door, gowning, gloving is required when providing direct care to resident. During an interview on 04/08/2026 at 1:50 p.m., RN A stated she worked as a clinical nurse for about two months.She stated she was trained in infection control while boarding to this job. The infection control training covered hand hygiene, like washing hands or sanitizing them before touching another resident. Proper wear of PPEs; Gowning, gloving. Washing hands before and after touching residents when providing direct care. Hand sanitizing does not work if hands are visibly soiled. Hands must be sanitized before and after administering medications to the residents. It is important to wash and sanitize hands to prevent spread of infectious organisms between residents. Infection can be brought from outside of the facility and spreader here. During an interview on 04/9/2026 at 10:39 a.m., the DON she stated she has been working here for 9 days. She stated she completed the infection control course online. The course covered good hand hygiene practice. Washing hands when they are visible soiled. Sanitizing hands before going to the resident's room and after leaving the room. Mode of infection transmission. Proper use of PPEs. The importance of following hand hygiene protocol because infection can be transmitted quickly if it is not followed. In an interview on 04/09/2026 at 11:19 a.m., the ADM stated he has been working in this facility since November 2025. He stated he was trained in Infection control. The ADM stated he took online courses that were required by HHS every 2 years and an annual CMS course. He stated the training covered best practices of infection control, hand hygiene, and use of PPEs and wash/sanitize hands before and after providing care to residents. The ADM stated staff should sanitize hands before going to residents' rooms and sanitize hands when leaving the residents' rooms and wash visibly soiled hands. He said put PPE on if it is required before going to the residents' rooms, this is mainly required for the direct care staff. During an observation on 04/08/2026 at 9:08 a.m. hall 200 for infection control revealed LVN B did not perform hand hygiene before and after going to Resident 28's room. Resident 28's room has EBP signs on the door and plastic drawers with PPEs placed at the entrance to the room. Further observation revealed LVN B went directly to Resident 66's room without sanitizing his hands. During an interview on 04/09/2026 at 7:17 a.m., LVN B stated he worked at the facility for over 2 years. He stated he was trained in infection control, he stated he had no idea when he had his last infection control training.LVN B stated the infection control training covered hand hygiene. He stated it depends on the situation if hands must be washed or sanitized; hands must be washed before or after treatment, wound care, blood sugar check. Hand sanitizing before and after giving PRN medication. He stated he is an old school nurse; he usually attends to 3 people before sanitizing hands. Not performing hand hygiene can cause passing germs to other people. Record review of a document provided by the facility titled Policy Name: Handwashing/Hand Hygiene - CS-50-6, dated 10/2015 and revised 03/2026 reflected: G. CDC recommends using Alcohol Based Hand Sanitizer with 60-95% alcohol in healthcare settings. Unless hands are visibly soiled, alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water during routine resident care. 3. Before preparing or handling medications. 14. Before and after entering isolation precaution settings.

Based on interview, and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 2 (Resident #52 and Resident #73) of 10 residents reviewed for advance directives. 1. The facility failed to ensure Resident #52's advanced directives were clearly identified, documented in the resident's electronic medical record, and on the residents' care plan.2. The facility failed to ensure Resident #73's advanced directives were clearly identified, documented in the resident's electronic medical record, and on the residents' care plan.This failure could place residents at risk of not having their end-of-life wishes honored and having incomplete records.Findings included: 1. Record review of Resident #52's face sheet, dated 04/08/2026, revealed an [AGE] year-old male admitted [DATE]. Resident #52 had diagnoses which included muscle weakness, need for assistance with personal care, hypertension (high blood pressure), atrial fibrillation (abnormal heart rhythm), history of falling, ischemic cardiomyopathy (condition where the heart muscles are weakened due to reduced blood flow), and heart disease. Record review of Resident #52's admission MDS, dated [DATE], revealed Resident #52 had a BIMS of 14, which indicated intact cognition. Record review of Resident #52's care plan, dated 03/27/2026, revealed Resident #52's advance directives were not on the care plan. Record review of Resident #52's hospital discharge papers, dated 03/27/2026, revealed Resident #52 had an advance directive of full code. 2. Record review of Resident #73's face sheet, dated 04/08/2026, revealed a [AGE] year-old female admitted [DATE]. Resident #73 had diagnoses which included metabolic encephalopathy (brain disease), protein-calorie malnutrition (inadequate intake of both protein and calories), vascular dementia (lack of blood that carries oxygen and nutrients to a part of the brain), and heart disease. Record review of Resident #73's admission MDS, dated [DATE], revealed Resident #73 had a BIMS of 03, which indicated severe cognitive impairment. Record review of Resident #73's care plan, dated 04/03/2026, revealed Resident #73's The resident has an Advanced Directive(s) and has documentation in their medical record (did not have code status). The goal was, The resident's wishes will be honored and maintained through next review date. The interventions were Honor the resident choice for code status. Record review revealed there was not a code status indicated. During an interview with the ADON on 04/09/2026 at 11:20 a.m., she said she was trained on advanced directives. She said she had not looked up the policy for advanced directives, but she said the policy might be to honor the residents wishes. She said staff were to scan the residents DNR, if they had one, into the resident's medical file. She said if the resident was a full code staff would ask if the resident wanted to have a full code status or a DNR. She said the advanced directives should be in the resident's chart on admission. She said the nurse who admitted the resident should input the advanced directives in the resident's medical file. She said if the advance directive was not in the resident's medical file, the facility would not know what the residents' wishes were. She said she was not sure who monitored to ensure the advanced directives were put in the resident's medical file. She also said she did not know why Resident #52 and Resident #73 did not have their advanced directives in their medical files. During an interview with the Admissions Coordinator on 04/09/2026 at 11:31 a.m., she said she was trained on advanced directives. She said the policy for advanced directives was that staff had three to five days to put the residents advanced directive in their medical chart. She said if the resident did not have a DNR, she entered the resident as a full code until the paperwork was provided for the DNR. She said a resident's advanced directive should be put in the resident's medical file right away. She said she was responsible for putting the advanced directive in a resident's medical file. She said if a resident's advanced directive was not in the resident's medical file staff would not know if the resident was DNR. She said it was not acceptable for the resident's advanced directive to not be in the resident's medical file. She said she monitored to ensure the advanced directives were put into the residents medical file by conducting an audit. She said she did not know why Resident #52 and Resident #73's advanced directive was not in the medical files. During an interview with the ADM on 04/09/2026 at 11:51 a.m., he said he was trained on advanced directives. He said he did not know the policy and did not want to misquote it. He said the residents had the right to have advanced directives. He said the residents' also had the right for staff to follow their wishes. He said the nurses and all licensed individuals were responsible for ensuring the resident's advanced directive was in their medical file. He said if the resident's advanced directive was not in their medical file it could affect the resident's wishes and the grieving process for the family. He said the IDT team monitored to ensure the advanced directives were in the residents medical file. He said the IDT did monthly audits to ensure all residents had the advanced directive in their medical file. He said he did not know why Resident #52 and Resident #73's advanced directives were not in their medical files. Record review of the Advanced Directives Policy, dated 03/2026, revealed, Residents have the right to make choices about their care. They are encouraged to document their wishes and provide the appropriate directives to their families/legal representative, and the HCP. Upon admission to the community or soon thereafter, the community admission coordinator or designee should obtain a copy of resident advance directives, when applicable. The community representative should verify and confirm the resident/legal representative's desire for resident code status, obtain appropriate documentation, and identify resident's desire according to the community's procedure.

Based on interview and record review, the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs for one of 10 residents, (Residents #67), reviewed for unnecessary medications. The facility failed to ensure Resident #67 had an indication/diagnosis for an antibiotic ordered. Resident #67 was receiving Ciprofloxacin HCl Tablet 500 MG without appropriate diagnoses. This failure could place residents at risk of not receiving the appropriate interventions, monitoring, and follow-ups. Findings Included Record review[KA1] of Resident #67's face sheet, dated 04/07/2026, reflected an [AGE] year-old male, admitted [DATE], with diagnoses that included Diverticulitis of intestine (the inflammation or infection of small pouches (diverticula) that form in the colon wall, commonly causing severe lower-left abdominal pain, fever, nausea, and changes in bowel habits), other specified sepsis (sepsis is a life-threatening medical emergency caused by the body's extreme, dysfunctional response to an infection, leading to tissue damage, organ failure, and potential death), recurrent major depressive disorder [KA3] ( a chronic condition characterized by two or more distinct episodes of severe sadness, hopelessness, and loss of interest, separated by at least two months of recovery). Record review of Resident #67's care plan, dated 04/02/2026, reflected Resident #67's risk for falls, potential impairment to skin integrity, pain, and risk for hot liquid injury. Further record review reflected no care plan completed addressing other health concerns, such as the use of antibiotics, TPN infusion, JP drains, code status, and PICC line access. Review of Resident #67's interim[KA5] care plan initiated 04/02/2026 reflected no to EBP, no to gastrointestinal issue. Record review of Resident #67's admission skin assessment, dated 04/03/2026, reflected Resident #67 had a PICC line at right arm and 2 JP drains, 1 to the left upper quadrant and the other to the right lower quadrant of the abdomen. Record review of Resident #67's admission MDS assessment dated [DATE] reflected no BIMS score due to MDS not yet being completed. MDS addressed Resident #67's diagnoses as listed above.Review of Resident #67's physician orders, dated ??, reflected the following:Ciprofloxacin HCl Tablet 500 MG Give 1 tablet by mouth every 12 hours for Infection for 7 Days. The was no specific infection identified on Resident #67's order. Record review of Resident #67's MAR for the month of April 2026 reflected:Ciprofloxacin HCl Oral Tablet 500 MG (Ciprofloxacin HCl) Give 1 tablet by mouth every 12 hours for antibiotic until 04/03/2026 23:59 -Start Date- 04/02/2026 with no diagnosis or indication for the ABT.Ciprofloxacin HCl Tablet 500 MG Give 1 tablet by mouth every 12 hours for Infection for 7 Days -Start Date- without specific diagnosis for the ABT. Record review of facility's infection control log reporting period, dated 04/01/2026 to 04/08/2026, reflected Resident #67 was on ABT Ciprofloxacin HCl Tablet but there was no area where the infection indicated. During an interview on 04/09/2026 at 08:20 a.m., the DON stated if a resident was on ABT, the order should indicate the specific type of infection, not just infection in general. The DON stated, ABT should be specific and should have a diagnosis. Diagnosis should be specific so we can know why the resident is getting the ABT, to know how to access, follow up and if the issue was resolved. During an interview on 04/09/2026 at 08:53 a.m., the MDS Nurse stated if a resident was on ABT, the order had to be specific to enable the staff to know the type of infection to appropriately access and monitor the resident for. Review of facility's policy (no policy on unnecessary meds).

Based on interview and record review, the facility failed to ensure its residents were free of any significant medication errors for 1 (Resident #55) of 3 residents observed and reviewed for medications administration. The facility failed to ensure that MA D did not inaccurately chart two refused medications as administered to Resident # 55. These failures placed the residents at risk of harm or not receiving desired outcomes from medications not administered according to physician's orders and manufacturer's specifications. Findings included: During an observation of administration of medication, on 04/08/2026 at 5:10 PM, revealed Resident #55 refused to take his medications 50 Mg of Senna (combination of stimulant laxative and stool softener used to treat constipation) and 17 Grams of GlycoLax Powder (an osmotic laxative used to treat constipation by increasing water in the stool) were removed from Resident 55's room and properly disposed by MA D. Observation revealed these medications were documented as administered in MAR. Record review of Resident #55's undated admission face sheet reflected an [AGE] year-old male admitted [DATE]. His diagnoses included essential primary hypertension (chronic high blood pressure with no single, identifiable medical cause), chronic kidney disease, stage 1 (mild kidney damage with normal or high function), unspecified atrial fibrillation (chronic arrhythmia where the heart's upper chambers beat chaotically), malignant neoplasm of colon, unspecified (a cancerous tumor in the large intestine), malignant neoplasm of prostate (slow-growing cancer that begins in the prostate). Record review of Resident #55 MDS, dated [DATE], reflected BIMS score of 13 indicating the resident was cognitively intact. Record review of Resident # 55's MAR for April 2026 reflected Resident #55 received 50 Mg of Senna and 17 Grams of GlycoLax Powder on 04/08/2026. During the interview on 04/09/2026 at 7:47 a.m., Resident #55 stated he did not take stool softener medications yesterday morning because his stomach was gurgling since the day before and it was an uncomfortable feeling. He stated, I am very cognitive so I know what medication I am taking and what medications I should not take. I can make an independent decision. During an interview on 04/9/2026 at 10:20 a.m., MA D stated he worked at the facility for five years. He stated that any refused medication must be documented as refused and the reason for refusal and the supervisor, or charge nurse, must be notified. MA D stated if medications were not administered to a resident but documented as given, the staff could be written up. During an interview on 04/09/2026 at 11:30 a.m., RN A started working as a clinical nurse for about two months. RN A stated if a resident refused medication the resident must be educated on the medication he or she refused. RN A stated the procedure was to discard the medication if the medication was refused after educating resident, document it, and report it to doctor, the DON, and charge nurse. RN A stated nurses must be honest if medication was not administered and it must be documented as not administered. RN A stated the resident was not receiving the treatment needed. RN A stated the reason for the refusal must be documented so the physician could make changes if needed. During an interview on 04/09/2026 at 11:37 a.m., LVN B started working at the facility for over two years. He stated any refused medications must be documented as not given and the refused medications must be reported to the NP, doctor, or nurse. He stated he could not recall anyone reporting to him a resident refused medication for a long time. LVN B stated that refused medication must be documented as refused, instead of given, because it was an ethical mistake. During an interview on 04/09/2026 at 11:49 p.m., the ADON stated residents had the right to refuse medications. The ADON said the nurse or med aid must document refused medication, discard them, and notify the nurse. The ADON stated refused medications must be documented as not given as residents were not getting treatment. During an interview on 04/09/2026 at 11:19 a.m. the ADM stated if medication was refused by a resident the medication refusal must be documented, the resident must be educated about potential health risks, such as worsening conditions/side effects, refused medication must be wasted, and the resident's physician must be notified about refusal. Record review of a policy provided by the facility titled Medication & Treatment- Medication Administration Record, Effective date 3/2003, revised 5/2005, 10/2011/8/2025, 10/2016 revealed: 4. After the medication is received and consumed by the resident, the associate will document the 'Administered' chart code that reflects that the medication was taken. If the medication is refused or not given/taken, the associate will document the appropriate chart code in the administration details that reflects the refusal or reason the medication was not given/taken.

Based on observation, interview, and record review, the facility failed to ensure that each resident has a right to secure and confidential personal and clinical records for one (Resident #2) out of 16 residents LVN B was providing care for on 12/03/2024. A. Resident #2's personal health information was left on the unlocked computer screen at the nursing station by LVN B. This failure could result in Resident #2's personal information being exposed to unauthorized individuals. This problem had the potential to affect all 16 residents in care of LVN B on 12/3/2025. The findings included:Record review of Resident #2's face sheet, dated 12/03/2025, revealed an 89-years-old female admitted on [DATE]. Resident's #2's diagnoses included hypothyroidism (underactive thyroid, happens when a thyroid gland doesn't make enough thyroid hormones to meet body's needs), essential hypertension (high blood pressure that is not due to another medical condition), gastro-esophageal reflux disease (a condition in which acidic gastric fluid flows backward into the esophagus, resulting in heartburn), malignant neoplasm of unspecified site of unspecified female breast (breast cancer).Observation on 12/03/2025, at 1:12 p.m. revealed the computer at the nursing station that LVN B was using for reviewing the order for Resident #2 he left unattended without minimizing the screen of the computer leaving the screen open. The computer screen was open with Resident #2's clinical information in Point Click Care (electronic health record system) displayed on the screen. This confidential information was opened for anyone such as visitors or other residents to see. During an interview on 12/03/2025, at 4:21 p.m. with LVN B, he stated that he never minimizes the screen of the computer as it turns off on its own. He said he was not sure how quickly the screen turned off, but he just knew it did. He stated that he was not trained to shut down the computer screen when leaving the nursing station. He stated that he received HIPAA training (Health Insurance Portability and Accountability Act which protects sensitive patient health information from disclosure without consent) at time of hire and annually. He said that he is responsible for closing the computer screen when leaving the nursing station. He stated that leaving a computer without minimizing the computer screen can lead to exposing residents' private medical information to not authorized personnel or public. During an interview on 12/03/2025, at 4:21 p.m. with ADON, she said that the facility's policy was to minimize the computer screen at the nursing station when stepping away from the computer. She stated that if the screen was not minimized someone could have unauthorized access to private clinical information of Resident #2. She said ADON, clinical manager, and ADM monitor the nursing station and nursing carts to ensure the screens are closed. She said they monitor through observation rounds. She said she did not know why the screen was left open at the nursing station. She stated that HIPAA policy in-service was provided to all employees at hire and annually educating them on locking the computer screens. She said that the person who works with residents' private clinical information should lock the screen before walking away. The potential negative effect would be sharing private residents' information with unauthorized personnel. During an interview on 12/03/2025, at 4:39 p.m. with ADM revealed all staff were trained on HIPAA at the time of hire by signing acknowledgements, and at least annually after that. He stated that if a computer is left open, it should be turned off to prevent unauthorized access. He stated that it is the responsibility of whoever works on the computer to make sure it is off before leaving the nursing station. He stated that ADON, clinical manager, and himself monitor the nursing station area all the time to prevent unauthorized personnel behind the nursing station. Record review of facility's staff in-service form dated 10/28/25 and titled: Use and disclosure of protected healthcare information revealed the following instructions to staff: Confidentiality/HIPAA Regulation: The Privacy Policy reflects practices that have been adopted by the facility to protect patients' privacy and security in relation to their Protected Health Information as defined under HIPAA regulation. It is the duty and responsibility of each staff person associated with this facility to be fully familiar with Privacy Policy and to comply with the requirements detailed within it. This in-service was signed by 28 nursing staff members and LVN B attended the training and acknowledged the completion of the HIPAA training.

Based on observations, interviews and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 2 (Resident #1, Resident #2) of 7 residents reviewed for infection control. 1. The facility failed to properly use EBP personal protective equipment during wound care for Resident #1 and Resident #2.2. The facility failed to follow hand hygiene procedure during direct care for Resident #1. This failure could place residents at risk for infection transmission, sepsis, and hospitalization. Findings included: Record review of Resident #1's face sheet, dated 12/02/2025, revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included malignant neoplasm of rectum (rectal cancer occurs when cells in the rectum mutate and grow out of control), major depressive disorder (persistently low or depressed mood), colostomy status (surgery to create an opening for the colon (large intestine) through the belly (abdomen) to allows stool and gas to leave your body when they can't pass through anus, essential hypertension (high blood pressure). Observation on 12/03/2025 at 11:06 a.m. revealed LVN A did not put on the personal protective equipment (gown) before starting the wound care, colostomy (surgical opening in the abdomen to allow stool to exit the body when part of the colon is not functioning properly) and urostomy (a surgical diversion that creates an opening (stoma) in the abdomen to redirect urine from the bladder to an external pouch) care for Resident #1. She did not sanitize her hands between change of the gloves and used contaminated gloves when reached for clean wound care supplies after she cleaned the area around the sacral wound (the triangular region at the base of the spine, just above the buttocks). Record review of Resident #1's order dated 11/4/2025, revealed Sacral wound to clean with normal saline. Pat dry. Apply Anapest with collagen powder. Skin prep peri wound. Cover with foam dressing daily and as needed.Record review of Resident's order dated 11/10/2025 revealed this resident was on contact precautions for urine and enhance barrier precautions (used for infection prevention and control intervention designed to reduce transmission of multidrug resistant organisms to other residents in nursing homes).During an interview on 12/03/2025, with LVN A, she stated that she had an in-service on enhanced barrier precautions and contact precautions protocol with infection control policies earlier this year. She said that enhanced barrier precautions include wearing a gown and gloves when conducting all invasive nursing procedures like wound care and stomas (surgical opening in the body). She stated that she was supposed to wear a gown and gloves when completing wound care and colostomy and urostomy care for Resident #1. She stated that it was too hot in the room and that's why she did not wear the gown, but she had it on earlier in the morning with this patient. She stated that she understood that the negative effect of not following proper EBP or contact precautions every time would be spreading infection and cross contamination. She stated that she is aware of the facility policy for sanitizing hands between gloves change. She stated that not sanitizing her hands could lead to spreading the infection.Observation on 12/03/25, at 1:15 p.m., revealed LVN B performed the wound care for Resident #2. He did not put on the personal protective equipment (gown) before the start of wound care procedure.Interview on 12/03/2025, at 1:25 p.m. with LVN B revealed that he was trained on following EBP protocol for all invasive procedures with residents. He had an in-service on EBP today, 12/03/2025. Nurses are responsible for following the policy He stated that he was aware of potential risk if not following the EBP protocol would be cross contamination and passing the infection to other residents which is detrimental for vulnerable populations in long term care facilitates. Record review of Resident #2's face sheet, dated 12/03/2025, revealed an 89-years-old female admitted on [DATE]. Resident's #2's diagnoses included hypothyroidism (underactive thyroid, happens when a thyroid gland doesn't make enough thyroid hormones to meet body's needs), essential hypertension (high blood pressure that is not due to another medical condition), gastro-esophageal reflux disease (a condition in which acidic gastric fluid flows backward into the esophagus, resulting in heartburn), malignant neoplasm of unspecified site of unspecified female breast (breast cancer).Observation on 12/03/25, at 1:15 p.m., revealed LVN B performed the wound care for Resident #2. He did not put on the personal protective equipment (gown) before the start of wound care procedure.Interview on 12/03/2025, at 1:25 p.m. with LVN B revealed that he was trained on following EBP protocol for all invasive procedures with residents. He had an in-service on EBP today, 12/03/2025. Nurses are responsible for following the policy He stated that he was aware of potential risk if not following the EBP protocol would be cross contamination and passing the infection to other residents which is detrimental for vulnerable populations in long term care facilitates. During an interview on 12/03/2025 at 4:21 p.m. with ADON, she said that the facility's policy on EBP required all nursing staff wear personal protective equipment including gowns and gloves to prevent transmission of infections to other vulnerable residents. The ADON stated the last training on infection control and hand hygiene was conducted last month and during annual skills training sessions, weekly audits, and in huddles. The ADON stated a potential negative outcome for the residents would be cross contamination.During an interview on 12/03/2025 at 4:39 p.m. with ADM, he stated that all staff were trained on infection control policy, hands hygiene and following enhanced barriers and contact precautions. He stated that it was his responsibility as administrator to make sure everybody follows those policies. He stated that ADON and clinical manager provide training to nursing staff on infection control. He said that it is very important to follow infection control policies to prevent cross contamination.The record review of Resident #2's order dated 12/3/2025 revealed right knee wound treatments on shower days: remove dressing for shower, cleans are w/soap and re-apply dry dressing every day shift every Monday, Wednesday and Friday for wound care. Review of facility's Infection Prevention and Surveillance Policy, dated 10/24/2022, reflected: The nurse leader designee shall track, trend and monitor infections on an ongoing basis to assist with the prevention, development and transmission of disease and infection. 6. Assist with implementation of infection control and prevention policies and procedures support associate compliance and resident safety. Record review of Handwashing/Hand Hygiene Policy dated 10/2015 indicated that alcohol-based hand sanitizer should be used after contact with a resident's intact skin. after removing gloves.Record review of Enhanced Barrier Precautions policy dated 9/2022 indicated that enhanced barrier precautions should be utilized to reduce transmission of multi-drug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are indicated along with other precautions ordered like contact precautions.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for two of two medication rooms (second floor and third floor medication rooms) reviewed for pharmacy services. The facility failed to ensure the second and third floor medication rooms did not contain expired supplies. These failures could place residents at risk of receiving inadequate treatments or results or ingesting medications for which they were not prescribed. The findings included: 1. During an observation on [DATE] at 2:30 PM of the second-floor medication storage room with LVN A, expired luer locks (fittings used to secure needles to syringes) were discovered in the storage drawers. During an interview with LVN A on [DATE] at 2:31 PM, when asked what could happen if expired supplies were used on residents, LVN A stated a resident could get an infection or have an adverse effect. During an observation on [DATE] at 3:15 PM of the third-floor medication storage room with LVN B, expired PICC (peripherally inserted central catheter) line starters, expired collection swabs, and expired luer locks were observed on the storage shelves in the room. During an interview with LVN B on [DATE] at 3:17 PM, when asked what could happen if expired supplies were used on residents, LVN B stated a resident could get false results. Review of the facility's policy titled Storage and Expiration Dating of Medications and Biologicals, dated [DATE] and revised on [DATE], noted the facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis. Review of the facility's policy titled Storage and Expiration of Medications, Biologicals, Syringes and Needles, dated [DATE] and revised on [DATE], noted the facility should ensure that medications and biologicals for each resident are stored in the containers in which they were originally received.

Based on observations, interview, and record review, the facility failed to maintain an infection prevention control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Resident#40 and Resident #10) reviewed for infection control related to isolation precautions. 1. The facility failed to ensure isolation precaution signage and personal protective equipment (PPE) were in place for Resident #40 who had been identified as requiring enhanced barrier precautions (EBP). 2. The facility failed to ensure CNA A utilized isolation precautions, including PPE and hand hygiene, for Resident #10, who had been identified as requiring contact precautions. These failures could result in the spread of infection to other residents and staff. The findings included: 1. Record review of Resident #40's face sheet dated 1/27/2025 revealed resident [AGE] year-old male with relevant diagnoses of cutaneous abscess of left axilla (an infection of the tissue between the left chest and shoulder, commonly known as the armpit) and benign prostatic hyperplasia (enlargement of the prostate gland that can cause difficulty or inability to urinate). Record review of Resident #40's MDS dated [DATE] revealed BIMS of 12, suggesting moderately altered cognition. MDS also reported that resident had indwelling foley catheter (device inserted externally through urethra into bladder to allow passage of urine) and surgical wound requiring surgical wound care. Record review on 2/12/2025 of Resident #40's active orders in the electronic medical record included orders for ongoing care of indwelling catheter (orders dated 1/28/2025), wound care to wound on left chest (order dated 1/29/2025), and enhanced barrier precautions (EBP) for (foley/wounds) (order dated 1/28/2025). During observation on 2/12/2025 at 10:16AM, it was noted that there was no signage indicating EBP precautions or PPE cart present on exterior of Resident #40's room. During additional observation on 2/12/2025 at 3:20PM, EBP signage and PPE remained absent. Interview with LVN C commenced on 2/12/2025 at 3:24PM. LVN C indicated awareness of Resident #40's order for EBP precautions and was unaware that signage and PPE cart were not in place. LVN C stated that EBP precautions included gown, gloves, and washing hands before taking care of resident to prevent infection. At completion of interview, LVN C placed EBP signage and PPE cart at exterior of resident's room. A policy titled Enhanced Barrier Precautions Policy revised 02/2025 was provided by Administrator on 2/13/2025. Relevant text includes: 9. Signs are posted in the door or wall outside the resident room indicating EBP precautions and PPE are required. 10. PPE is available prior to entering the resident rooms. During interview with DON on 2/14/2025 at 09:08AM, DON reported awareness of absent EBP and PPE cart for Resident #40 on 2/12/2025. DON stated that the required elements for EBP precautions had been in place previously and was unsure why items were not present on that date. DON stated that the need for EBP precautions is typically discovered during interdisciplinary care plan meetings and then implemented immediately. DON stated that all staff have been trained on the required elements of EBP precautions and are expected to always adhere to requirements to prevent infection. 2. Record review of Resident #10's face sheet dated 7/25/2022 revealed resident is [AGE] year old male with diagnosis of need for assistance with personal care. Record review on 2/12/2025 of Resident #40's active orders in the electronic medical record included order dated 2/6/2025 stating place Pt on contact isolation whilst under tx for MRSA UTI (place patient on contact isolation whilst under treatment for methicillin-resistant staphylococcus urinary tract infection). Additional order was present that stated contact isolation for MRSA in urine dated 2/12/2025. During observation on 2/12/2025 at 10:09AM, Resident #40 was noted to have signage present on exterior wall indicating contact precautions and PPE cart near doorway. CNA A was observed entering resident's room without performing hand hygiene and without donning PPE. CNA A took the breakfast tray from resident's bedside table and then exited room with tray without performing hand hygiene. Dual interview with CNA A and CNA B commenced on 2/12/2025 at 10:45AM. CNA A stated that she was aware of contact precautions in place for Resident #40. CNA A stated that contact isolations included wearing a gown, gloves, and mask at all times when in resident's room. CNA B stated that hand sanitizer should be used when you enter the room. CNA A stated that she should not have entered the room without donning PPE but that she felt it was acceptable because she was just grabbing the tray. CNA A stated that not using precautions can cause infection. During interview with DON on 2/14/2025 at 09:08AM, DON stated that all staff have been trained on isolation precautions, including donning PPE on entry if the type of isolation requires it. DON was then notified of observation on 2/12/2025 of CNA A entering Resident #40's room without following contact isolation procedure, and DON indicated that she was already aware of the incident. DON stated that CNA A is not usually on the floor and coming here to help but is now aware of requirements.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 1 of 1 medication rooms ( third floor medication room) and one of four medication carts (third floor Hall E medication aide cart) assessed for drug storage and labeling, as evidenced by: The facility failed to ensure all medications located inside the third floor Hall E medication aide cart were properly labeled. These failures could place residents at risk of receiving inadequate treatments or results or ingesting medications for which they were not prescribed. The findings included: 2. During an observation on 02/12/25 at 3:00 PM of the E Hall medication aide cart on the 3rd floor with MA A, a dosing cup of 1.5 yellow tablets was observed sitting in the med cart drawer in an unlabeled clear dosing cup. During an interview with MA A on 02/12/25 at 3:01 PM, when asked what could happen if unlabeled pills are left in the med cart, MA A stated I don't know. Review of the facility's policy titled Storage and Expiration Dating of Medications and Biologicals, dated 12/01/07 and revised on 08/1/24, noted the facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis. Review of the facility's policy titled Storage and Expiration of Medications, Biologicals, Syringes and Needles, dated 12/01/07 and revised on 01/01/13, noted the facility should ensure that medications and biologicals for each resident are stored in the containers in which they were originally received.

Based on record review and interview, the facility failed to ensure that the resident has the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 2 (Residents #8 and #10) of 6 residents reviewed for unnecessary medications. 1. The facility failed to obtain signed consent prior to administering psychotropic medication Depakote for Resident #8. 2. The facility failed to obtain signed consent prior to administering psychotropic medications Trazodone, Depakote, and Seroquel for Resident #10. These failures could place residents at risk of receiving medications without prior consent and without the option choose alternative treatment or decline based on awareness of risk and benefits of the medications. Findings include: 1. Record review of Resident #8's face sheet dated 6/13/2024 revealed resident is [AGE] year old female with relevant diagnoses of cognitive communication deficit (an impairment in the thought processes that can impact a person's ability to think, speak, read, and interact with others); unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (progressive disorder that impairs thought processes, such as memory, thinking, reasoning, and decision-making causing interference with daily life and activities); anxiety disorder, unspecified (mental health condition characterized by excessive worry, fear, and/or nervousness that can significantly interfere with daily life); and depression (mental health condition that can cause persistent sadness, low-self-esteem, and loss of interest in activities affecting a person's thoughts, feelings, and behaviors). Record review of Resident #8's MDS dated [DATE] revealed BIMS of 13, suggesting intact cognition. Diagnoses of dementia, anxiety disorder, and depression (other than bipolar) were documented. Record review on 2/12/2025 of Resident #8's active orders in the electronic medical record included psychoactive medication of Depakote oral tablet delayed release 125mg (Divalproex Sodium), 1 tablet by mouth two times a day for impulsivity/agitation related to unspecified dementia with an order date of 2/4/2025. Further review of Resident #8's medical records revealed that resident had been receiving Depakote as ordered. Record review of Resident #8's medical record reflected a signed consent for medication Depakote was unable to be located. During an interview with DON on 2/14/2025 at 09:08AM, the DON was notified of signed consent for Depakote prescribed for Resident #8 was not able to be located within the electronic medical record. The DON stated that she would look further into the medical record as well as paper records to locate the document but was unable to recall if consent had been obtained prior to medication initiation. The DON stated that the facility process was to obtain informed consent prior to administration of psychoactive medication and that consents were typically obtained after care plan meetings. The DON also stated that she reviewed orders daily through a generated report and would identify orders requiring consent during this process. The DON stated that failure to obtain consent could cause a delay in care for the resident as medications that required consent would not be administered until consent was obtained. The Administrator provided a signed consent for Depakote on 2/14/2025, dated 2/14/2025, (ten days after resident began receiving medication). 2. Record review of Resident #10's face sheet dated 7/25/2022 revealed resident is [AGE] year old male with relevant diagnoses of bipolar disorder, current episode depressed, moderate (mental health condition characterized by periods of extreme depression and elevated mood); schizoaffective disorder, bipolar type [mental health condition that combines symptoms of schizophrenia (chronic mental health condition that causes difficulty distinguishing reality from their own thoughts and affects a person's thoughts, feelings, and behaviors) and bipolar disorder]; major depressive disorder (depression disorder that significantly interferes with daily life); and anxiety disorder. Record review of Resident #10's MDS dated [DATE] revealed BIMS of 15, suggesting intact cognition. Diagnoses of anxiety disorder, depression (other than bipolar), manic depression (bipolar disease), and schizophrenia (e.g., schizoaffective and schizophreniform disorders) were documented. Record review on 2/12/2025 of Resident's #10's active orders in the electronic medical record included psychoactive medications Trazodone HCl Tablet (medication used to treat depression) 50mg, give 0.5 tablet by mouth at night for insomnia (difficulty sleeping) with an order date of 2/7/2025; Trazodone HCl Oral Tablet 100mg, give 1 tablet by mouth at night for insomnia; Seroquel tablet 300mg (antipsychotic medication used to regulate mood/behaviors/thoughts), give 0.5 tablet by mouth at night for bipolar disorder with an order date of 8/1/2022; and Depakote Tablet Delayed Release 500mg with an order date of 7/26/2022, give 1 tablet by mouth twice daily for bipolar disorder. Further record review revealed that effective 10/21/2021, Resident #10 legal guardianship was appointed to third party representative (representative) by [NAME] County Probate Court #1. Representative was given authority to make decisions regarding medical care. The following signed consents were also located within the electronic medical record: 1. Seroquel, quantity 1, dosage 150, frequency QHS (time of sleep), start date 07/21/2023. Consent was signed 1/23/2024 with two illegible signatures on signature- Resident or Resident's Representative signature area. There is a handwritten note stating verbal permission unable to sign/tremors indicating that resident provided self-consent, verbally. 2. Texas HHS Form 3713 Consent for Antipsychotic or Neuroleptic Medication Treatment for medications listed as: continue as ordered and risks and benefits listed as continue as ordered/ psych eval & treat. Consent was signed 11/22/2022 by health care professional proposing treatment. There is illegible signature on resident or resident's representative signature area and date of 12/28/2022. As this document did not contain specific names of any medications, it could not be attributed to any physician orders during record review. 3. Consents for Trazodone and Depakote were unable to be located within the electronic medical record. Consent for current dosage of Seroquel was also unable to be located within the electronic medical record. During an interview with DON on 2/14/2025 at 09:08AM, the DON was notified that signed consents for current antipsychotic medications prescribed to Resident #10 were unable to be located the electronic medical record. The DON stated that she would look further into the medical record as well as paper records to locate the document. The DON acknowledged that Resident #10 had legal appointed guardian and consent for treatment, including verbal consent, must be obtained from guardian, not resident. The DON stated that the facility process was to obtain informed consent prior to administration of psychoactive medication and that consents were typically obtained after care plan meetings. The DON also stated that she reviewed orders daily through a generated report and would identify orders requiring consent during this process. The DON stated that failure to obtain consent could cause a delay in care for the resident as medications that required consent would not be administered until consent was obtained. The Administrator provided signed consents on 2/14/2025 for Trazodone and Depakote, both documents were dated 2/14/2025 and indicated verbal consent had been obtained from representative. A signed consent for current dosage of Seroquel was not provided at this time.

Based on observation, interview and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 1 of 8 residents (Resident #24) who were observed for call light placement. The facility failed to ensure the call light was within reach for Resident #24. This deficient practice could affect any resident and keep them from calling for help as needed. The findings were: Record review of Resident #24's face sheet, dated 02/13/2025, revealed he was admitted to the facility on [DATE] with diagnoses which included: fracture, cognitive communication deficit, cerebrovascular disease (condition that affects blood flow to the brain), and muscle weakness. Record review of Resident #24's MDS assessment, dated 12/01/2024, revealed the resident's BIMS score was 7, which indicated severe cognitive impairment. The MDS assessment further revealed Resident #24 required substantial/maximal assistance (helper does more than half the effort) for ADL assistance. Record review of Resident #24's care plan, initiated date of 11/27/2024, revealed Resident #24 is at risk for falls d/t general weakness and severe cognition impairment and Be sure call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Observation on 02/12/2025 at 10:31 a.m. revealed Resident #24 lying in bed with his call light lying between the bed frame and bed mattress, out of view and reach of the resident. During an interview on 02/12/2025 at 4:19 pm LVN C observed the call light was not visible to the resident and the resident was unable to reach it. He stated the potential for harm could be a lack of care due to the resident unable to call for help. During an interview on 02/14/2025 at 10:45 am the DON stated that where the call light was located, the resident would not be able to see it or reach it and it should be within the resident's reach. She stated the potential for harm cold be a lack of care since the resident would be unable to use the call light to call for help. She stated that the resident would benefit from a push call light that is placed within reach and visible. Record review of facility's Safety for Residents policy, implemented date 07/2015, read Residents should have a signal device placed within reach. If the resident cannot utilize the community standard call system, an adaptive signal device should be utilized. If the resident cannot utilize an adaptive signal device, provide frequent monitoring to identify resident needs.

Based on observations and record review, the facility failed to store food in accordance with professional standards for food service safety. 1. The facility failed to maintain refrigerated storage area free of contaminants and store food off flooring. 2. The facility failed to discard food items that were beyond labeled use-by date. 3. The facility failed to label food items with use-by date and date items were opened. 4. The facility failed to ensure items in the freezer were covered. These failures could place residents at risk for food contamination and foodborne illness. Findings included: Observation and interview on [DATE] at 10:00AM revealed: During tour of walk-in refrigeration area, food items were found underneath storage racks on the floor, including a cracked egg, a portion of sliced cake in plastic clamshell container, and a red onion. Clinical Dietary Manager confirmed these items should not be stored underneath the storage racks on the floor and that area underneath should be free from debris. Individual portions of orange juice with labeled date of ,d+[DATE] were found in refrigerator, indicating that the juices were expired. The Clinical Dietary Manager confirmed the juices were expired and should not be in the refrigerator. Inside of chest freezer, individual portions of ice cream were found in freezer without labeling of date portioned or date that the items were to be used by. The Clinical Dietary Manager confirmed the ice cream was not dated or labeled properly. Inside of chest freezer, 4 of 5 large tubs of ice cream were observed to be stored without sealed covers. The Clinical Dietary Manager confirmed the large tubs of ice cream were not sealed with covers. Record review on [DATE] of facility titled Food Storage- DS-04.013 revised ,d+[DATE], stated the storerooms and walk-ins should be maintained free from dirt, dust, insects, rodents or any potential sources of contamination. The same policy also states all food should be stored on storeroom shelving that is no less than 6 from the floor . Review of FDA Food Code 2022 Section ,d+[DATE].17 Ready to Eat/Temperature Control for Safety Food, Date Marking: (A) (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S ,d+[DATE].12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days.

Based on interviews and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of four residents reviewed for falls. The facility failed to conduct neurological assessments on Resident #1 per facility protocol after Resident #1 returned from the hospital the same day of her unwitnessed fall at the facility. This failure could place residents at risk of a change in condition and not receiving proper treatment and care in a timely manner. Findings included: Review of Resident #1's face sheet, dated 10/14/24, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE] and discharged home on 10/13/24. Review of Resident #1's medical diagnoses list, dated 10/14/24, reflected she had acute on chronic systolic (congestive) heart failure, generalized muscle weakness, unsteadiness on feet, cognitive communication deficit, need for assistance with personal care, and a presence of a cardiac pacemaker. Review of Resident #1's comprehensive MDS assessment, dated 09/04/24, reflected she had a BIMS score of 9, which indicated she had moderate cognitive impairment. Resident #1 also had no falls since admission and was taking an anticoagulant (blood thinner) medication. Review of Resident #1's comprehensive care plan, dated 09/12/24, reflected she was at risk for falls, had an unwitnessed fall, and staff were required to conduct neurological checks per facility protocol. Resident #1 was also on anticoagulant therapy (Apixaban). Review of Resident #1's MAR, dated 10/14/24, reflected she took one Apixaban Oral Tablet 2.5 MG tablet by mouth on 10/01/24 at 8:00 AM. Review of Resident #1's change in condition evaluation, dated 10/14/24, reflected Resident #1 had a fall in the afternoon on 10/01/24 and was transferred to the hospital for further evaluation. Clinician and family were notified on 10/01/24 at 12:32 PM. Review of the facility's provider investigation report, dated 10/02/24, reflected Resident #1 fell from her wheelchair to the floor in her room on 10/01/24 at 12:30 PM, which was shortly before lunch meal service. Resident #1 was observed on the floor lying face down, bleeding from skin tears on both arms, had a hematoma and swollen area on the right side of her head. Resident #1 was transported to the hospital on 10/01/24 for assessment and returned the same day (10//01/24) with no major injuries or new orders. Review of Resident #1's A physician's note on 10/01/24 at 11:54 AM that reflected, Resident #1 had a fall in her room today (10/01/24). She was reported sitting in wheelchair and falling asleep and falling to the ground hitting her head. Resident #1 had a large lump right side of head. Resident #1 on Eliquis. EMS called and report given. Resident #1 sent out to hospital. Review of Resident #1's A nursing progress note on 10/01/24 at 10:20 PM that reflected, Resident #1 arrived back from hospital at approximately 10:20 PM. Large black, blue, and purple hematoma to the right side of forehead with bruising across the entre forehead. No new orders received from ER/Hospital. Review of Resident #1's electronic neurological evaluation flow sheet, dated 10/03/24 at 3:42 AM, reflected no electronic evaluations entries were completed. Review of Resident #1's neurological evaluation flow sheet, undated, reflected evaluation times/dates were as listed: -10/01/24 12:30 PM -10/01/24 10-6 -10/02/24 6-2 -10/02/24 2-10 -10/02/24 10-6 -10/03/24 6-2 -10/03/24 2-10 -10/03/24 10-6 Resident #1 missed eight neurological checks that were required to occur every two hours from 10/01/24 through 10/02/24. During an interview on 10/14/24 at 5:48 PM, the ADM stated staff must conduct neurological evaluations every shift because Resident #1 came back from the hospital around 10:00 PM on 10/01/24, which was the same day as Resident #1's unwitnessed fall incident. The ADM stated staff correctly completed the neurological checks on Resident #1. During an interview on 10/14/24 at 6:22 PM, LVN A stated staff were required to conduct neurological checks on residents every 15 minutes for the first hour, every 30 minutes for the second hour, every hour for the next four hours, every two hours for the first 24 hours, and then every shift for the second and third days. LVN A stated residents' health could be at risk because staff would miss or might not notice a resident's change in condition if staff did not conduct neurological evaluations according to facility protocol. LVN A stated nurses on duty conduct neurological evaluations. LVN A stated residents' neurological evaluations were documented on physical flowsheets. During an interview on 10/14/24 at 6:28 PM, the ADON stated floor nurses and nurses who assessed residents were responsible for conducting neurological assessments. The ADON stated she expected staff to follow the suggested frequency on the neurological flow sheet when conducting neurological evaluations on residents. The ADON stated if a resident was not monitored according to facility's protocol, the resident could be at risk of having a brain bleed, altered mental status, repeat fall and change in condition. The ADON stated the facility's IDT team oversaw weekly to ensure neurological monitoring sheets were correctly completed. The ADON stated she was unsure if Resident #1's unwitnessed fall incident was reviewed for neurological evaluations. During an interview on 10/14/24 at 6:33 PM, LVN B stated neuro evaluations were standard. LVN B stated staff were required to conduct neurological evaluations every 15 minutes for the first hour, every 30 minutes for the second hour, every hour for the next four hours, every two hours for the first 24 hours, and then every shift for the second and third days. LVN B stated staff documented neurological evaluations on physical flowsheets. LVN B stated residents could be at risk of death or have a brain bleed, which could lead to stroke, if neurological checks were not frequently completed according to facility protocol. LVN B stated residents could also be at risk of not having their change in condition not immediately noticed by staff. LVN B stated the ADON and the DON oversaw neurological check flowsheets to ensure they were correctly completed. During an interview on 10/14/24 at 6:39 PM, the DON stated she expected staff to start neurological checks and follow checking every 15 minutes for the first hour, then every 30 minutes for the second hour, then every hour for the next four hours, then every two hours for the first 24 hours, and then every shift for the second and third days. The DON stated neurological checks were completed to ensure residents were stable. The DON stated if neurological checks frequencies were not followed, residents could be at risk of a neurological issue. The DON stated Resident #1 went out and was gone the whole day on 10/01/24 and returned the night of 10/01/24. The DON stated staff were required to continue Resident #1's neurological checks from every shift after Resident #1 returned to the facility from the hospital. The DON stated the IDT team reviewed neurological sheets to ensure they were correctly completed. Review of the facility's neurological checks policy, effective 07/2015, reflected, It is the policy of this community to evaluate residents following falls for possible injury and neurological problems. Neurological checks should be done for residents with un-witnessed falls and/or injury to the head. A. Neurological checks should be done as follows: o Check every 15 minutes for the first hour, o Then every 30 minutes for the second hour, o Then every hour for the next four hours, o Then every two hours for the first 24 hours, o Then every shift for the second and third days. o Continue neurological checks if the resident is not stable or is showing evidence of change in status. o Complete the Neurological Evaluation form in Point Click Care which uses the Glasgow Coma Scale evaluation criteria. o Notify health care provider of changes in resident status as indicated. o Revise care plan as needed.

Based on observation, interview, and record review, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for one (Resident #1) of three residents reviewed for discharges. The facility failed to have a wheelchair and assistant services set up upon Resident #1's discharge to her apartment. She was unable to transfer herself and was found by EMS over 24 hours later laying in the same spot without access to food or water. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 04/29/24 at 2:00 PM and an IJ template was provided to the ADM. While the IJ was removed on 05/01/24 at 7:00 PM, facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of harm, injury, rehospitalization , and death. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including dislocation of right patella, morbid obesity, need for assistance with personal care, and muscle wasting and atrophy. She was discharged from the facility on 04/25/24. Review of Resident #1's quarterly MDS assessment, dated 03/19/24, reflected a BIMS of 15, indicating she had no cognitive impairment. Section GG (Functional Abilities and Goals) reflected she was dependent for toileting, showering/bathing, and dressing and required maximum assistance with transferring. Section M (Skin Conditions) reflected she had a stage V pressure ulcer. Review of Resident #1's admission care plan, dated 01/11/24, reflected she was at risk for falls with an intervention of providing her safe environment. It further reflected she had an ADL self-care performance deficit with interventions of requiring one staff member for assistance with bathing and dressing and requiring two staff members using a hoyer lift for transfers. Review of an email sent by SW B to an agency (HA) that helps residents apply for Medicaid and locate LTCFs, dated 03/28/24, reflected the following: [Resident #1] is looking for LTC facility, wanting to see if she can apply for Medicaid as well. She is currently discharging to (IL facility) on Monday 4/1 . Review of Resident #1's NOMNC, dated 04/22/24, reflected the effective date coverage of her current skilled nursing services would end on 04/24/24. Review of Resident #1's Physical Therapy Discharge Summary, dated 04/24/24, reflected she could transfer, stand, and walk ten feet with minimal assistance. Review of Resident #1's nursing progress noted, dated 04/25/24 and documented by LVN A, reflected the following: Comprehensive Nursing Note for [Resident #1]: AOX4. Vss. No s/s of distress. Incontinent of B&B . pending d/c @ 3:00 PM today to (independent living facility). Review of Resident #1's Discharge Summary, dated 04/25/24 at 7:48 PM and completed by SW B, reflected no home health services were recommended and a wheelchair was to be provided. Review of an e-mail from a HH agency to SW B, dated 04/25/24 at 3:24 PM (after Resident #1 had been discharged ), reflected (HH agency) was able to accept Resident #1. The e-mail chain was started that day. Review of Resident #1's EMS documentation, dated 04/26/24 at 3:28 PM and documented by EMT D, reflected the following: 12/27 seen by EMS for dislocated patella and leg pain, [Resident #1] reports emergency surgery followed by admission into (facility). [Resident #1] she was kicked out of (facility) because she hit the 100 days maximum for Medicare. [Resident #1] states staff made her leave, and she was not assessed by a physician for mobility and safety. [Resident #1] states she never refused LTC. [Resident #1] states staff forced her out of NH. AFD responded for lift assist last night a req C4 follow up today per (doctor). [Resident #1] states she is in the same diaper NH discharged her in because she is unable to get to bathroom or in/out of bed without assistance. [Resident #1] states she slid to the floor and did not fall. [Resident #1] reports last meal was yesterday around noon when she was discharged from (facility). [Resident #1] states she has been snacking on candy she had in bed since then. [Resident #1] found lying in bed, alert to EMS, AO4/GCS15. Assessment recorded above with continuous assessment on scene. [Resident #1] appears in no distress. Poor hygiene with smell of foul urine/feces. [Resident #1] states she has been unable to get out of bed to use the restroom or clean herself since discharge. [Resident #1] has trash and laundry scattered about apartment with rotting food in sink. Consult with C4 on scene for [Resident #1]'s re-admission into NH due to inability to care for self with no caregiver or home health present or planned. No answer with NH and no other options. Unable to leave [Resident #1] on scene, transport to (hospital) . Notified hospital that [Resident #1] cannot be dx home and APS is being contacted. After the documentation there were pictures EMT D took of Resident #1's apartment. Observations of these pictures revealed a heavily soaked/stained mattress and a kitchen sink filled with dishes. Review of Resident #1's hospital records, dated 04/26/24, reflected the following: Primary Diagnosis: acute debility, unable to care for self . [Resident #1] was recently discharged home from (facility) but her wheelchair was not delivered so she was essentially unable to move or care for herself. PT/OT recommending return to SNF. APS is reportedly involved in [Resident #1]'s care During an interview on 04/29/24 at 9:42 AM, SW E stated she as one of two SWs that worked at the facility. She stated the discharge process started when a resident was admitted . They discussed as a team where the resident would be discharged to, and if any DME or services would be needed. She stated upon discharge, the SWs were responsible for issuing a non-coverage form (NOMNC), explaining their right to appeal, setting home health, ordering any DME, and any other resources needed. She stated she was not Resident #1's SW. During an interview on 04/29/24 at 9:49 AM, SW B stated she had been Resident #1's SW while she was at the facility. She stated the social worker's responsibilities were mainly to focus on discharges - setting up home health, care giver support, hospice, and ordering DME. She stated she was Resident #1's SW while she was at the facility. She stated she had used up all of her Medicare days (100 days) and wanted to go back to her IL facility where her belongings were. She stated she had informed Resident #1 that it would not be a safe discharge. She stated she worked closely with HA that helped residents find long-term care facilities and they usually took a week or so until they connected with the resident after discharge. The Surveyor asked how she would care for herself for the initial week and she stated Resident #1 had told her there were caregivers at the IL that assisted two hours a day, but she had not confirmed that with the IL. She stated she told the resident it would be safer to have more assistance, but Resident #1 told her she could not afford it. She stated she was not able to order a wheelchair for her because there was a co-pay of $258 and Resident #1 did not have her wallet with her so she had no way to pay it. She stated Resident #1 told her she would pay the co-pay once she got to her apartment. She stated she even sent an e-mail to Resident #1's family member about the wheelchair so he could make sure she paid the co-pay and he was also supposed to help her apply for Medicaid. During a telephone interview on 04/29/24 at 9:56 AM, Resident #1's FM F stated he had been contacted by EMT D and was informed of the condition she was in at her apartment and it sure as hell sounded like an unsafe discharge to him. He stated her IL facility does not have care givers or anyone to assist her. He stated he lived in another state and it was hard to assist Resident #1, especially since he was so much older than she was. He stated he had not planned to fly down to assist her because he was not physically able to do so. He stated he received an e-mail from SW E regarding the wheelchair, and Resident #1 did not have a lot of disposable income, so he called the number and paid the co-pay. He stated the wheelchair was supposed to be delivered that day (04/29/24), but it would be useless since she was still in the hospital. He stated SW E did have HA contact him about applying for Medicaid back in March (2024), but Resident #1's laptop (with banking information), wallet, and cell phone had been at her apartment while she was at the facility. He stated he did not have access her banking information and told HA there was nothing they could do until she returned home. He stated it was entirely inappropriate for her to be sent home without the ability to get out of bed or go to the bathroom. He stated, How did SW E expect her (Resident #1) to pay for the wheelchair or access her banking information if she did not have any assistance or a way to get to her wallet, cell phone, or laptop? He stated EMT D had told him she should not be returning to her apartment and he was in total agreeance. During an interview on 04/29/24 at 10:12 AM, the ADM stated the discharge process starts upon admission and the goal was always to communicate with the resident for the most appropriate discharge setting. She stated if the resident requested DME or HH services, the SW was responsible for getting that set up. She stated every situation and resident was different. She stated Resident #1 was alert and oriented times 4, had a BIMS of 15, and continuously stated she wanted to go home and that it was her right to make that choice. She stated the staff had encouraged her to have home health services but she could not afford them. She stated she was told it was not a safe discharge, but in the end, she had the right to choose. She stated Resident #1 had told SW B she had a caregiver at the IL that came for two hours a day but the SW B did not confirm that because the resident was fully competent. She stated Resident #1 told SW B that she would pay the co-pay for the wheelchair as soon as she got home and normally DME was delivered within four hours. She stated Resident #1's FM F had told staff he would be flying down to assist her. She stated they did not see it as an unsafe discharge. During a telephone interview on 04/29/24 at 10:55 AM, EMT D stated Resident #1 had initially contacted the fire department the night before (04/25/24) when she fell after trying to get up to go to the bathroom. He stated the fire department assisted her back into bed and requested that EMS follow-up with her the following day (04/26/24). He stated he was glad they did because the situation was horrible. He stated Resident #1 was able to stand and pivot with assistance but was unable to get herself out of bed or walk on her own. He stated her brief was heavily soiled and the odor of urine and feces was palpable. He stated the apartment itself was deplorable with stains throughout and rotting food in the kitchen. He stated she had access to her medications that were near her bed and she told him she used her saliva to be able to take them as she had no access to food or whatever. He stated Resident #1 showed him her DC paperwork from the facility where it reflected, Recommended LTC but resident requested to go home. He stated Resident #1 was adamant stating that was a lie and no one had talked to her about LTC upon discharge. He stated she told him she initially wanted to go home when she was first admitted , but it was obvious now she was unable to care for herself. He stated Resident #1 was completely with it (mentally) and knew what she wanted. He stated he told the hospital she could not return to her apartment upon discharge as it would be completely unsafe. During an interview on 04/29/24 at 11:31 AM, PTA G stated he had been working with Resident #1 while she was at the facility. He stated she was independent with bed mobility, rolling from side to side. He stated when transferring from bed to wheelchair, she required minimal assistance while utilizing a grab bar. He stated she was able to walk up to ten steps while utilizing a walker. He stated he had made it known to SW B that Resident #1 would require a wheelchair upon discharge. He stated she should not have been discharged home without a wheelchair and in his opinion, she would not be able to live independently. During an observation and interview on 04/30/24 at 11:20 AM, revealed Resident #1 in a hospital bed. She stated she did initially tell the nursing facility she wanted to go home but she was under the impression she would have the proper medical equipment when she got home. She stated she had a walker at her apartment, but the facility did not ask her if she was able to get around using a walker. She stated the facility did not discharge her with a wheelchair because it had not been paid for. She stated it had been ordered but she owed a co-pay. She stated upon discharge the facility told her everything had been set up and taken care of for her to go home. She began crying and stated when she was alone for 24 hours without the ability to get out of bed, she felt helpless and still felt helpless. She stated she did not believe she could care for herself independently because she could not bear hardly any weight on her leg. Review of the facility's Transfer and Discharge Policy, revised 08/2023, reflected the following: Residents should be transferred and discharged by the Community in accordance with applicable Federal and State regulations. . 1. The resident should receive orientation by the social services director or designee on where he or she is being transferred or discharged and reason to minimize anxiety. The Community's policies and procedures for discharge planning should be following regarding resident preparation, education, and planning prior to transfer from the community unless the transfer is emergent. Review of the facility's Transition Care Policy, dated December 2013, reflected the following: The Transition Care Conference ensures the patient and family member are in agreement with the transfer timelines as well as the patient's status to goal and transfer disposition. An understanding of care, equipment, and home needs prior to their transfer home or an alternative care setting is another objective of this meeting, as well as pertinent discussions are the patients after care. Review of the facility's Transition of Care and Discharge Summary Policy, revised 10/23, reflected the following: When a resident discharge is anticipated, a recapitulation of the stay, final summary, and post-discharge plan should be completed. The ADM was notified on 04/29/24 at 2:00 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 05/01/24 at 3:10 PM and included: On 4/29/2024 an abbreviated survey was initiated at (facility). On 04/29/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to the health and safety. The notification of Immediate Jeopardy states as follows: F660 - The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Community Response On 4/29/24, Social Services verified with the Durable Medical Equipment (DME) Company that Resident 1 wheel chair was delivered fully assembled and ready to use at Resident 1's address on 4/29/24 delivery receipt signed by a caregiver. On 4/30/24, the community Healthcare Liaison contacted the hospital case manager and Resident 1 to inquire about discharge planning from the hospital. Resident 1 was offered to return to the community. The resident accepted and is scheduled to admit on 5/1/2024. On 4/29/24, Social Services audited actual planned discharges from 4/22/24 to the present and planned discharges scheduled to occur through 5/6/24 to verify that they include discharge date , location, DME, Home Health, and confirmation of services. Appropriate services were confirmed, and no additional residents were identified to be impacted. On 4/29/24, the Divisional Director of Clinical Operations re-educated the Administrator on the discharge planning process and policies. From 4/29/2024 to 4/30/24, the Administrator and/ or designee re-educated licensed nurses the interdisciplinary team (IDT) members, which include therapy, social services, resident programs, nursing management, and the Registered Dietician on completing the transitions discharge summary. The in-services included the Transition Care Conference policy and Transition of Care and Discharge Summary Policy, which will be re-educated before their next scheduled shift. New staff and agency staff will have the training included in orientation. The Administrator re-educated Social Services on listing the date home health has confirmed services and the planned start of care. Re-education includes notification of Adult Protective Services (APS) and Ombudsman for any discharges identified to be unsafe. This notification will be ongoing as part of a systematic change. Licensed Nurses and IDT members including as needed staff who were not available from 4/29 to 4/30/24 will be re-educated before their next scheduled shift by the Administrator and/ or designee. The training will be documented on an in-service form, and competency will be validated by a post-test. The administrator or designee is responsible for administering the posttest and ensuring compliance. On 4/29/24, the community conducted an impromptu Quality Assurance Process Improvement (QAPI) to review the discharge planning process. In attendance were the Medical Director, Administrator, Executive Director, Regional Director of Operations, Regional RAI Director, and Divisional Director of Clinical Operations. Effective 4/30/24, during the weekly Medicare meeting, the IDT will review the discharge checklist, home health services, and DME as indicated for planned discharges. Social Services will arrange for home health services and order DME as indicated. Social Services will confirm the delivery date of the ordered DME and the start of home health services. The delivery date and start dates will be documented in the medical record. IDT will provide residents with a choice to postpone discharge when services as reported not available greater than 2 days from discharge. This is an ongoing systematic change. Social Services and/ or designee will complete weekly audits of planned discharges for 90 days. The audits will be documented on an audit form and the results will be reported to the monthly QAPI Meeting for 3 months. Audit commenced on 4/29/24. The Survey Team monitored the POR on 05/01/24 as followed: During interviews conducted on 05/01/24 from 2:59 PM - 4:54 PM, with the DRE, MCS, 7LVNs, the DOR, two SWs, and the MDSC (from different shifts) all stated they were in-serviced prior to their shifts on safe discharges. All stated social services team was responsible for coordinating discharges and the facility was responsible for ensuring safe discharges. Each staff member stated they needed to ensure DME (if needed) was delivered and services (if needed) such as home health were in place prior to discharge. They stated if they thought it was going to be an unsafe discharge, they would notify the ADM and DON immediately. They stated if a resident left the facility unsafely, they would notify the Ombudsman and APS. Review of the facility's QAPI agenda, dated 04/29/24, reflected the ED, ADM, DDCO, RDO, RDCS, RRD, and MD were in attendance. Review of an e-mail received by the ADM, dated 04/29/24, reflected the wheelchair had been deliver to Resident #1's apartment on 04/29/24. Review of the facility's in-service entitled Discharge Planning conducted by the ADM, dated 04/30/24 - 05/01/24, reflected all staff from each shift were in-serviced on the following: Transition Care Conference Policy, Transition of Care and Discharge Summary Policy, and Notification of APS and Ombudsman for any discharges identified to be unsafe. Review of Planned Discharge Post-Tests , dated 04/30/24 - 05/01/24, reflected staff were completing the tests after being in-serviced. Review of the facility's resident roster, dated 05/01/24, reflected Resident #1 had been readmitted to the facility. While the IJ was removed on 05/01/24 at 7:00 PM, facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and that each resident received adequate supervision to prevent accidents for 1 (Resident #11) of 6 residents reviewed for accidents. The facility failed to ensure that the water used to prepare hot beverages for residents was maintained at a temperature appropriate to prevent scalding and burns. Water temperatures were taken on 01/24/24 from the coffee machine hot water Bunn dispenser the water temperature was 188 degrees Fahrenheit. On 09/12/23, Resident #11 spilled hot tea on herself, and she sustained a second degree burn to her right hip, which required wound care. An Immediate Jeopardy was identified on 01/25/24 at 11:50 AM. While the Immediate Jeopardy was removed on 01/26/24 at 12:50 PM, the facility remained out of compliance at a scope of pattern with no actual harm with a potential for more than minimal harm that is not immediate jeopardy, due to the facility's continuation of in-servicing and monitoring the plan of removal. These failures put residents at risk for serious injury when drinking hot beverages. Findings included: Review of Resident #11's Face Sheet dated 01/26/24 revealed she was a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included Parkinson's disease (disorder that affects the nervous system) without dyskinesia (a movement disorder that often appears as uncontrolled shakes, tics, or tremor), abnormal posture, muscle weakness, pain, and other lack of coordination. Review of Resident #11's Significant change in status MDS assessment, dated 01/11/24, reflected a BIMS score of 13 indicating no cognitive impairment. Resident #11 required partial/moderate assistance of one person for eating. Review of Resident #11's Care Plan, revised date 01/25/24 reflected: Focus: [Resident #11] is at risk for integument impairment. Resident had a history of a burn at right upper thigh from a hot liquids spill and is at risk for hot liquid spills. Goal: Resident will be free from skin breakdown through review date. Resident will be free from injury through the review date. Interventions: Resident requires set up/supervision with all meals to include ensuring a cap/lid are on all hot liquids. Focus: Resident has dx of Parkinson's, she has impaired muscle strength and coordination due to Parkinson tremors. She is at risk for hot liquid injury from hot beverages ie tea/coffee/cocoa. Goal: Resident will have no injury from hot liquids through review date. Interventions: Provide lid on hot beverages to prevent spills, staff to assist in opening the lids, setting up the tray for patient as needed. Focus: Resident had a history of a burn at right upper thigh from a hot liquids spill and is at risk for hot liquid spills. Goal: Resident will be free from injury through the review date. Interventions: Resident requires set up/supervision with all meals to include ensuring a cap/lid are on all hot liquids. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Review of the facility Incident Log date range from 08/24/23 to 01/24/24 revealed the following: Person involved in Incident: Resident #11 Date of incident: 09/12/23 Name of Associate Assigned to Resident at the time of the incident: CNA K Location of Incident: Resident Room. Nature of Incident: Miscellaneous - Scalding Type of Injury/Impairment: Burn Part(s) of Body Injured: Hip (right) Initial Actions Take: Applied First Aid, Checked for Injury, Notify emergency contact. Severity Code: 2- Harm/Injury without outside treatment and/or observation Additional Facts not Refenced Above: On the night of 9/12/23, while assigned to CNA K and LVN X, Resident #11 requested a piece of pizza and tea between 4-5AM. CNA K obtained the water for the tea from the hot water dispenser in the kitchen. She delivered the food and tea to Resident #11and when exiting the room turned off the lights and closed the door per Resident #11's request. Resident #11 dropped her tea in bed which resulted in a burn on her right hip. CNA K answered the call light, observed the accident/spill and notified LVN X. First aid was provided, RP and physician were notified. During the investigation, it was determined that Resident #11 has a history of requesting her door to be closed and lights turned off during night hours. It was also discovered that Resident #11 CNA from 6-2 that she had requested CNA K to close the door and turn off the lights. Interventions: Resident #11 will be encouraged to keep light on when eating at night. Drinks to be served with a lid when drinking hot liquids. Follow up: (10/04/23 [Administrator]) During investigation - it was determined that the hot water dispenser has been dispensing water below the recommended serving temps for hot liquids. Review of Resident #11's Hot Liquids Safety Data Collection dated 09/12/23 revealed resident was at risk of hot liquid injury. Task: Resident to use cup with lid. Review of Resident #11's progress note documented by LVN X on 09/12/23 at 5:24 AM revealed the following: Situation: The Change in Condition/s reported on this CIC Evaluation are/were: Skin wound or ulcer. Skin Status Evaluation: Skin tear. Pain Status Evaluation: Does the resident/patient have pain? Yes. Neurological Status Evaluation: Nursing observations, evaluation, and recommendations are: On observation and assessment, the skin tear looked like a blister that had popped. It would need some kind of ointment to rub on in order to heel. Review of Resident #11's progress note documented by LVN X on 09/12/23 at 17:00 [5:00PM] revealed the following: F/U hot liquid injury. alert and oriented x3, v/s stable. burn area to right hip. treatment completed as ordered. medicated x2 for pain and effective. no distress noted. Review of Resident #11's wound physician note dated 09/13/23 revealed the following: Patient present with a wound on her right hip. Burn wound of the right hip full thickness. Etiology (quality) Burn. Wound Size (L x W x D): 11.5 x 5.5 x 0.3 cm. Surface Area: 63.25 cm^2. Cluster Wound: open ulceration area of 37.95 cm^2. Exudate: Moderate Serous. Granulation tissue: 20 %. Skin: 40 %. Site 1: Surgical excisional debridement procedure: Indication for procedure: Remove Necrotic Tissue and Establish the Margins of Viable Tissue, Remove Thick Adherent Eschar and Devitalized Tissue. Consent for procedure: Treatment options-risks-benefits and the possible need for subsequent additional procedures on this wound were explained on 09/13/2023 to the patient who indicated agreement to proceed with the procedure(s). Procedure Notes: The wound was cleansed with normal saline and anesthesia was achieved using 2% lidocaine jelly. Then with clean surgical technique, 15 blade was used to surgically excise 6.32cm^2 of devitalized tissue including slough, biofilm and non-viable subcutaneous level tissues were removed at a depth of 0.3 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 10 percent to 0 percent. Hemostasis was achieved and a clean dressing was applied. Post-operative recommendations and updates to the plan of care are documented in the Assessment and Plan section below. Plan of care reviewed and addressed: The best medical estimate of the time required for this wound to heal with continued physician evaluation and intervention is 109 days. This estimate is made with an 80% degree of certainty. Review of Resident #11's progress note from Physician on 09/15/23 at 13:30 [1:30PM] revealed the following: *** Chief Complaint ***Acute Issue Pt [patient] is seen lying in bed [with] NAD exhibited. Pain reported to R [right] hip. 1st>>2nddegree burn from hot tea this am appx 0500 to R [right] thigh. Mixed intact bulla [fluid blister] [with] ruptured bulla [fluid blister] areas and exposed skin. Area is dry. Entire irregular shaped area appx 15cmx4cm. Pt reports increased pain to the area. Discussed plan [with] Pt [patient] and [family member] on the phone. Initially- Cleanse [with] NS [normal saline] and apply bacitracin [ointment] bid [twice a day], LOTA for now [with] loose brief on that time. If bullas rupture and wound begins to drain then we will need dressing. Dry at this time. Wound care team to f/u [follow-up] in am. Schedule her oxy 2.5mg q12h x 3 days and keep2.5mg q6h available, cont apap1000mg TID. Therapy Clarification from therapy regarding transfers/toileting. Going forward, the safest thing for [Resident #11] and the staff caring for her would be for [Resident #11] to be using a bed pan for toileting or a brief for incontinent episodes. She requires the hoyer lift for transfers, and it would not be feasible or safe to use the hoyer lift to transfer to the toilet or a bedside .Burn of skin - Onset: 09/12/2023. Review of facility Incident Investigation completed by Administrator, dated 09/15/23, revealed the following: Summary of Incident: On 09/12/23 between 3-5AM, [Resident #11] requested pizza and tea from [CNA K]. [CNA K] warmed up her leftover pizza and obtained her Tea from the kitchen. [CNA K] setup her tea (that had a lid) and pizza on her bedside table. [Resident #11], when attempting to grab her tea knocked it over and tea spilled on her right leg. This resulted in a second-degree burn. Investigation: 09/12/23 [Resident #11] expressed that her leg was hurting due to her spilling her tea on herself. On 09/15/23 [Resident #11] explained that [CNA K] brought her tea and she spilled it on herself. When asked what happened she said it spilled out of her hands when attempting to drink. She did mention that the room was dark and she could have grabbed the wrong end of the drink. Associated Interview: [CNA K] stated [Resident #11] requested that [I] bring her tea and pizza. [I] warmed up her left-over pizza and grabbed the water/tea bags. [I] placed it by her bed don the table and left the room. When [I] left she asked me to close the door and turn the light off. She did not call me back in the room until after she [split] the tea. [LVN X] stated [I] completed the incident report when [CNA K] came and got me telling me [Resident #11] spilled her tea. [I] notified the physician and family and performed the care as ordered. Visitor/Vendor Interview: 09/15/23 Spoke with resident family regarding the incident. She stated she did not have any concerns but wants to avoid the situation moving forward. [I] discussed interventions with her. She requested that we discuss next week as . she is pre-occupied. She was thankful that [I] I reached out and stated mom loves you and says [Administrator] will take care of me and knows we take good care of her mother. Timeline: Between 4-5:30AM: [Resident #11] request tea and pizza. Between 4-5:30AM: [CNA K] provides pizza and tea. Between 4-5:30AM: [Resident #11] spills her tea. Between 5:26AM: [CNA K] notifies [LVN X] Conclusion: Supporting statement. Unconfirmed After getting statements from all involved, [Facility] came to the conclusion that this was an accident that was the result of [Resident #11] request for her door to be closed and lights turned off potentially causing her to grab the wrong end of the cup/hands slipping. This is a consistent request of hers during night hours dating back to her days in assisting living. We are agreeance that staff should encourage [Resident #11] to leave a light on when eating/drinking. The water for the tea that [Resident #11] was drinking was obtained from our kitchen hot water brewer. The hot water brewer is set for 175 degrees. Dining Director reviewed brewing guidelines, confirmed brewer was within guidelines at 170. Immediate Actions Taken: Resident Evaluation and/or Treatment. Notifications of District/Regional Nurse and RVP/DDO. Notifications of Responsible Party, Notifications of Physician Post Investigation Actions: Care Plan updates, In-serviced/Associate Re-training, Tasks Updated, Family Updated. Review of Resident #11's wound physician note dated 11/29/23 revealed the following: Burn wound of the right hip (resolved on 11/29/23) Duration > (greater than) 74 days. Wound progress: Resolved. Anatomic location of previously existing wound examined today: Epithelialized and Resolved. Follow up only as needed. Observation and interview on 01/23/224 at 11:20 AM revealed Resident #11 lying in bed. Resident #11 stated she was doing well. Observed Resident #11 to have a sippy cup that had tea. Resident #11 denied any concerns regarding her care. Review on 01/24/24 at 10:15 AM of facility Resident Council Notes, dated 12/07/23, revealed an issue made by Resident#11 stating, Why am [I] being billed for wound care when I got burnt due to the negligence of the staff? Administrator visited Resident #11 personally and spoke to her about the bill and that she would not be charged for wound care. Follow-up observation and interview on 01/24/24 at 10:20 AM revealed Resident #11 lying in bed. Resident #11 stated last year in September 2023 she had asked CNA K for tea; she stated it was early in the morning. She stated CNA K came in her room and placed the tea on her bedside table, she stated the bedside table was above her within reach. She stated the tea was in a white styrofoam cup with a lid on. She stated CNA K turned off her lights and closed the door when she left. She stated the room was dark and could not see. She stated she tried to get her tea when she spilled it. Resident #11 stated she felt pain right away and she pushed her call light for help and a few second later CNA K entered her room. She stated CNA K called LVN X for help and they cleaned her up. She stated the burn caused a blister to her right hip. Resident #11 stated had a cover over her when the tea spilled and it still cause a burn. Resident #11 stated she received wound care for a couple of months. She stated the burn had healed. Observed Resident #11 skin to the right thigh with no visible wound or scar. Resident #11 stated she could not recall if she asked CNA K to turn off the light or to leave them on. She stated the following day CNA K entered her room and that made her upset and she notified the Administrator she no longer wanted CNA K to enter her room. She stated since the incident she had not seen CNA K. Resident #11 stated she only drinks her hot tea in her special cup with a lid on. Interview on 01/24/24 at 12:48 PM with Resident #11's Family Member-1 revealed in September 2023 she received a call from the facility notifying them of the burn that Resident #11 sustained. Resident #11's Family Member-1 stated she was informed Resident #11 had requested tea early in the morning and Resident #11 requested her lights to be turned off and when Resident #11 tried to get the tea it slipped on her. While on the phone with Resident #11's Family Member-1 another Family Member-2 got on the phone who stated when they asked the Administrator how hot the water was the Administrator responded with inappropriate temperature, Family Member-2 stated they were not satisfied with his response. Family Member-2 stated the water must had been really hot for it to cause a bad burn within second. Family Member-2 stated their concern is not just for Resident #11 but for all the resident in the facility who drink tea or coffee. Resident #11's Family Member-1 stated she did not make a big deal of the situation due to Resident #11 diagnosis of Parkinson and the incident could had been an accident. An attempt was made on 01/24/24 at 3:04 PM to contact LVN X; however, there was no response. Interview on 01/24/24/ at 3:28 PM with CNA K revealed she was the CNA assigned to Resident #11 when the burn incident happened. CNA K stated between 4-5 in the morning Resident #11 requested hot tea. She stated she got the hot water from the 2nd floor service kitchen hot water brewer and then added the tea bag. She stated she placed a lid on the cup and took it to Resident #11 room. CNA K stated she placed the teacup on the resident bedside table, within reach. She stated she notified Resident #11 of the hot tea being placed on the bed side table. She stated Resident #11 requested for the door to be closed. She stated the room was not dark, there was natural light, Resident #11 had a bedside lamp on and the bathroom light was on and the door was slightly open. She stated she continued to do her rounds when Resident #11 pushed her call light on. CNA K stated she went in the room and Resident #11 told her she had spilled her tea. She stated she called for LVN X and they cleaned Resident #11. She stated Resident #11 sustained a burn. CNA K stated she could not recall how hot the water of the tea was. CNA K stated she was in-serviced on safety measure. CNA K stated they had a service kitchen on the 2nd floor and 3rd floor, and staff obtain hot water from the hot water brewer. She stated they used the hot water brewer to make hot beverages. Interview on 01/24/24 at 3:36 PM with the ADON revealed when Resident #11 had the burn incident, she was not the nurse on duty. The ADON stated the incident happened during the night shift. She stated she was told Resident #11 requested hot tea and when Resident #11 tried to get the cup it spilled on her. The ADON stated she could not recall if she had been in-serviced on the incident; however, they put interventions in place. She stated the interventions were if Resident #11 request any hot liquids it should be given in a special cup with a lid (sippy cup). The ADON stated Resident #11 required wound care for a couple of months. She stated the wound had healed. She stated staff obtain hot water from the kitchen coffee machine hot water brewer. She stated she was unsure who was supposed to check for hot beverage temperatures. She stated they had not been told to check temperatures for hot liquid beverages. The ADON stated upon admission they complete a hot liquid assessment on any new admission residents. The ADON stated Resident #11 was the only resident who required interventions. Interview on 01/24/24 at 3:51 PM with CNA N revealed Resident #11 told her about the hot tea spilling on herself. CNA N stated Resident #11 sustained a burn. She stated when Resident #11 told her about the incident she went and spoke to CNA K. She stated CNA K stated she provided hot tea to Resident #11 and the resident spilled it on herself. CNA N stated they were in-serviced on ensuring Resident #11 gets her special cup when she requests hot beverages. She stated the 2nd floor and 3rd flood had a service kitchen which had a coffee machine with hot water Bunn dispenser. She stated they all get the hot water from the hot water Bunn dispenser when they prepare hot beverages. She stated the water that comes from the hot water Bunn dispenser was hot. She stated when someone request hot liquid beverages and she gets hot water from the hot water Bunn dispenser she waits about 10-15 minutes to let it cool down. Observation of facility 2nd floor service kitchen on 01/24/24 at 4:00 PM with the RD revealed a coffee machine with a Bunn hot water dispenser was observed. The RD stated staff obtain hot water from the coffee machine (Bunn hot water dispenser) to prepare hot beverages. The RD stated she had been checking the hot water temperature today (01/24/24) every 30 minutes due to the hot water valve being replaced today (01/24/24). Observed the RD grabbed a coffee mug and poured hot water inside the coffee mug from the Bunn hot water dispenser. Then grabbed the facility thermometer, it took her about 5 to 10 seconds to place the thermometer inside the hot water. The hot water temperature was 188 degrees Fahrenheit. The RD stated dietary staff had not been told to check Bunn hot water dispenser or hot beverage temperatures. She stated they only checked food temperatures when serving. Observed 2nd floor service kitchen temperature logbook revealed no temperature checks for hot beverages. Interview on 01/24/24 at 4:13 PM with LVN B stated she was the nurse assigned to Resident #11 the day after the incident. She stated she could not recall the dates. LVN B stated she observed Resident #11 burn the 1st day and it had a blister to the right hip. LVN B stated they did not start wound care until the blistered popped. She stated Resident #11 did complain of pain and they provided her with pain medication. She stated Resident #11 did not go to the hospital, she stated she was treated inhouse. She stated they provided wound care for a month or two until it healed. She stated she was not sure how Resident #11 burned herself; however, it happened during the night shift, she stated the night nurse on duty completed an incident report. LVN B stated she was in-serviced on how to prevent hot liquids incidents. She stated the interventions they put in place for Resident #11 was to provide her with her special up with a lid, make sure Resident #11 was able to hold the cup and make sure the water was not hot. LVN B stated she tests the hot water by placing a drop on her skin. LVN B stated she was unsure of any hot water dispenser temperature log and believed it was the dietary staff responsibility to check and log the temperatures. Interview on 01/24/24 at 4:25 PM with the DON revealed Resident #11 requested hot tea during the 10:00 PM-6:00 AM shift. She stated CNA K gave Resident #11 her tea and turned off the lights and closed the door. The DON stated when Resident #11 tried to drink the tea she spilled it over her. She stated staff immediately assisted Resident #11 and cleaned her up. She stated Resident #11 sustained a burn to her right hip. She stated Resident #11 received wound care and was on pain medication. She stated Resident #11 wound had healed and no longer required wound care. The DON stated they educated the staff on how to protect resident with hot liquid beverages, to check water temperatures and provide Resident #11 sippy cup to prevent any spills. She stated they also educated Resident #11 to not drink hot beverages in the darkness. The DON stated the hot beverages should be within temperatures and if hot beverages are too hot the CNAs must notify the dietary staff. The DON stated dietary staff should be logging hot beverages temperatures. The DON stated the water temperatures had been controlled and they had hot liquid temperature logs in each service kitchen. Interview on 01/24/24 at 4:46 PM with the Administrator revealed in September 2023 during the night shift Resident #11 requested pizza and hot tea from CNA K. He stated CNA K obtained the tea from the service kitchen hot water dispenser. He stated CNA K provided the tea in a cup with a lid and turned off the light and closed the door per Resident #11 request. The Administrator stated Resident #11 grabbed the cup of tea and spilled it on herself and resulted on a burn. He stated Resident #11 pushed the call button, CNA K came in and she called for the nurse and they performed care. He stated Resident #11 required wound care and further stated the wound had healed. The Administrator stated he conducted a full investigation and it was determined it was an accident. He stated they in-serviced all staff on using lids when drinking hot beverages, hot beverages to be monitor by the dietary department. He stated the dietary department kept a log of the temperatures. Observation and interview on 01/24/24 beginning at 4:51 PM with Dining Service Director revealed the dietary staff were not required to check the temperatures from the coffee machine hot water Bunn dispenser. She stated the maintenance staff conduct a monthly check; however, she was notified by the RD today (01/24/24) that dietary staff should monitor the hot water Bunn dispenser much closer. Observed 3rd floor service kitchen with the Dining Service Director, a coffee machine with hot water Bunn dispenser was observed. The Dining Service Director was observed to check the hot water Bunn temperature. She grabbed a coffee mug and poured hot water inside the coffee mug from the coffee machine hot water Bunn dispenser. Then grabbed the facility thermometer, it took her about 5 to 10 seconds to place the thermometer inside the hot water. The hot water temperature was 173 degrees Fahrenheit. The Dining Service Director stated she was unsure if dietary staff had been in-serviced on hot beverages, she stated she would have to ask. She stated the dietary did not have a log for the hot beverage temperature. Follow-up temperature check of facility 2nd floor service kitchen on 01/24/24 at 5:00 PM with the RD revealed the hot water temperature was 176 degrees Fahrenheit. The RD stated it was within the brewing temperatures but not serving temperatures. Interview on 01/24/24 at 5:16 PM with the Administrator revealed his expectations were for hot beverages to be within the serving guidelines 175-180 degrees Fahrenheit. A few minutes later the Administrator returned to the conference room and stated he misunderstood the question and stated hot beverages should be within the brewer temperatures 175-180 degrees Fahrenheit and serving guidelines temperatures would be 155 degrees Fahrenheit. Interview on 01/24/24 at 5:25 PM with the Maintenance Director revealed the facility had a third-party contractor who checks the facility hot water. He stated the commercial kitchen hot water are inspected quarterly. He stated they have not been told to kitchen hot water dispenser daily, he further stated it was not a requirement for the maintenance department to check temperatures. He stated normally the Dietary Manager would notify them if they had an issue in the kitchen and he would contact the third-party contractor to come inspect the issue. He stated the service kitchen on the 2nd and 3rd floor hot water dispensers had temperature fluctuations. He stated he was not asked to adjust the hot water brewer temperatures in September 2023 or as of today (01/24/24). The Maintenance Director asked if he needed to adjust the hot water brewer temperatures, because he was able to adjust them. Interview on 01/25/25 at 9:10 AM with the Administrator revealed he could not locate the in-services they completed on 09/12/23. He stated he had begun in-servicing all staff starting today (01/25/24). The Administrator stated the dietary staff did not have a log for the hot beverage temperature. Review of The American Burn Association Scald Injury Prevention Educator's Guide, https://ameriburn.org/wp-content/uploads/2017/04/scaldinjuryeducatorsguide.pdf reflected the following: .Time and Temperature Relationship to Severe Burns Water Temperature Time for a third degree burn to occur 155 degree F 1 second 140 degrees F 5 seconds Based upon the time of the exposure and the temperature of the water, the severity of the harm to the skin is identified by the degree of burn, as follows . Second- degree burns involved the first two layers of skin. These may present as deep reddening of the skin, pain, blister, glossy appearance from leaking fluid, and possible loss of some skin. Review of the facility's Safe of Hot liquids policy, revised February 2020, reflected the following: Residents shall be evaluated for safety concerns and potential for injury from hot liquids upon admission, readmission, quarterly and on change of condition. Appropriate precautions shall be implemented to maximize choice of beverages while minimizing the potential for injury. A. The potential for burns from hot liquids is considered an ongoing concern among residents with weakened motor skills, balance issues, impaired cognition, and nerve or musculoskeletal conditions. B. Residents who prefer hot beverages with meals (i.e., coffee, tea, soups, etc.) will not be restricted from these options. Instead, associated shall conduct regular Hot Liquids Safety Data Collections as indicated, and document the risk factors for scalding and burns in the care plan. D. Once risk factors for injury from hot liquids are identified, appropriate interventions shall be implemented to minimize the risk from burns. Such interventions may include: 1. Maintaining a hot liquid serving temperature of not more than 155 degrees Fahrenheit; 2. Serving hot beverages in a cup with a lid; 3. Encourage residents to sit at a table while drinking or eating hot liquids; 4. Providing protective lap covering or clothing to protect skin from accidental spills; and 5. Associate supervision or assistance with hot beverages Review of the facility's Safe Holding and Serving Temperature for Hot Beverages policy, revised 03/01/16, provided by the Administrator on 01/25/24 reflected the following: . 2. Coffee needs to be brewed at (recommended temperature per machine) 195 to 205 degrees Fahrenheit to extract the full flavor 4. Skin on the arms and legs - being less sensitive than the mouth - can suffer a burn before the danger is realized. The elderly who are immobilized in a wheelchair and confused resident are more susceptible. 5. Because of this susceptibility, follow these safety precautions: a. Serve the hot beverages between 140-155 degrees Fahrenheit. Dietary should record hot beverage temperatures for every meal c. Residents should be supervised while drinking hot beverages. d. A staff member should pour the hot beverages, in a manner that protects the resident's safety. Fill hot beverage mugs to 75% of less of their capacity. An Immediate Jeopardy was identified on 01/25/24. The Administrator was notified of the Immediate Jeopardy on 01/25/24 at 11:50 AM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 01/25/24 3:39 PM and reflected the following: -1. On 1/25/2024, the Director of Clinical Services (DCS) completed a new hot risk data collection for resident # 1 [Resident #11]. The DCS reviewed the plan of care and no additional interventions were needed. On 1/24/2024, the Dining Service Director took the hot water/coffee dispenser out of service. On 1/25/2024, the Maintenance Director contacted a third-party vendor to complete an onsite preventative maintenance check. On 1/25/2024, a Registered Dietician revised the Meal Inspection-Test Trays Form that is completed at minimum 3 times a month to include the serving temperature of coffee and hot water. -2. All residents have the potential to be impacted. On 1/25/2024 a dining service manager completed rounds to temp current serving temperatures for hot coffee and hot water on current operating dispenser in the main kitchen. This was documented on a log. -3. On 1/25/2024, a Registered Dietician completed re-education to Dining Service associates the food temperature log to include the hot coffee and hot water temperature log. On 1/25/2024, a third party Registered Dietician completed re-education to the in-house Registered Dietician and Dining Service Manager on the revised Meal Inspection- Test Trays Form that includes the hot coffee and hot water serving temperature. On 1/25/2024 to 1/26/2024, the Registered Dietician and/or designee re-educated Dining Services, Certified Nursing Assistants (C.N.As), and Nurses on the Safe Holding and Serving Temperatures for Hot Beverages and Service of Hot Beverage Guidelines. The dining service associates, C.N.A and Nurses not available on 1/25/2024 will receive re-education by the registered dietician or designee before their next scheduled shift and this will include new hires hired after 1/25/2024. Competency will be validated on a post-test. -4. The Certified Dining Manager (CDM) or designee will audit the food temperature log 5 x a week for 90 days to verify that serving temps of hot water and hot coffee are being documented and do not exceed 155 degrees. The CDM or designee will report the results of the audit monthly at the Quality Assurance Performance Improvement Meeting for 3 months. The DCS or designee will observe C.N.As and/or Nurses 3 times a week on varies shifts for 90 days to verify competency of H [TRUNCATED]

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen; specifically, the facility failed to ensure dishware were appropriately sanitized. The facility failed to ensure the dishwasher reached minimum wash and rinse temperatures of 140 degrees to wash and 180 degrees or final rinse. This failure could place residents at risk for food contamination and food borne illness. Findings included: Observation and interview, on 01/23/24 at 8:40 AM revealed Dishwasher Aide Y ran the dishwasher stating the machine was a high temp machine washing at 140-degree temperature and rinse at 180- degree temperature. Dishwasher Aide Y was not able to show the high temperature dishwasher reached the minimum wash and rinse temperatures. Dishwasher Aide Y stated it took the machine a while to reach max temperatures. Dietary Aide Y stated when he entered the facility in the mornings, he had to run the machine several times before the temperatures are reached. When Dishwasher Aide Y was asked about the dishes that he had ran prior to observation and currently running, he stated he needed re-run the dishes he had done so far. After 10 minutes the dishwasher temperatures reached no more than 140 degrees for wash, 170 degrees for rinse. Dishwasher Aide Y stated the commercial company came at least twice a week and when called on, the provider was out last Friday 01/19/22 to repair spouts, hand sink and temperatures at the dishwasher. Dishwasher Aide Y stated when temperatures are not at accurate levels this failure could place residents at risk of contamination. Dishwasher Aide Y stated the machine was not working correctly, he was responsible to alert the Chef so that he could call for a repair. Dishwasher Aide Y stated he would stop using the dishwasher until provider could be called out repair temperatures. Review of the Dish Machine Temperature Log indicated Dish machine temperatures and chemical levels must be monitored and recorded every meal period. Wash cycle must be 150-165 degrees. Final rinse temperature must be at least 180 degrees. Record review for the month of January 2024 wash cycle ran at various temperatures between 135-150 degrees, the rinse cycle ran between 175-182 degrees. Interview and observation on 01/23/24 at 8:50 AM the Executive Chef revealed commercial company comes out to provide maintenance to the dishwasher on a weekly basis and when they are called out for repairs. The Executive Chef stated the dishwasher was a high temperature machine and must run at 140 for wash and 180 for rinse. The Executive Chef stated his expectations are for the Dishwasher Aides to let the machine run to reach appropriate temperatures prior to use. The Executive Chef stated there has been in-services to remind all dishwashers to monitor the temperatures before use, record in the log, and notify him immediately with any issues. The Executive Chef further stated at this time staff will stop using the dishwasher and wash equipment by hand until provider comes out to check the dishwasher. The Executive Chef was communicating with repair company, reviewed a text which indicated the dishwasher was a high temperature machine and must reach 140 for wash cycle and 180 for rinse. Observation and interview on 01/23/24 at 11:15 AM with the Dining Service Director revealed the dishwashing staff was using the dishwasher. During observation, the dishwasher was reaching wash temperatures of 140, however did not reach adequate temperatures for rinsing. When asked why the dishwasher was in use both Dishwasher Aide Y and the Dining Service Director stated the machine takes several cycles to reach appropriate temperatures, and that staff ran the machine until temperatures are were met. During observation of Dishwasher Aide Y running the machine he was not observing the temperatures while the machine was running. Dishwasher Aide Y stated he had been working at the facility for [AGE] years and knows how to run the dishwasher. According to the Dining Service Director the machine did not usually take this long to reach appropriate temperatures therefore request for repairs would be called in. The Dining Service Director stated she expected staff to use the dishwasher properly by waiting until the appropriate temperatures are reached and to contact the Executive Chef if there was a problem so repairs could be initiated. The Dining Service Director stated they were using the dishwasher at inappropriate working temperatures. Interview on 01/25/24 at 4:42 PM with the Administrator revealed when the dishwasher was not running at its best, his expectation was to contact the provider and have them come out to repair or look at the machine (if they do not know how to fix it themselves) to ensure temperatures are reached prior to use. Staff should be checking for appropriate temperatures and sanitation prior to use. The Administrator stated not using the machine as directed could cause contamination and illness among all residents which could create an outbreak. The Administrator further stated staff should be logging accurate temperatures in the logbook and Dietary Managers should review the logbook to ensure staff are using equipment and documenting at each meal. The Administrator stated he would check with kitchen staff for any repairs for the visit on 01/23/24. He then stated they were waiting on documentation from the provider. Record review of the last repair visit dated 12/30/23 at 7:51 PM revealed regular service call The report reflected: Kitchen Results: Good ensuring wares ae safe and up to cleanliness standards. Wash Temperature 155 Fahrenheit Rinse 185 Fahrenheit monitoring wash temperature for compliance to protect guest, reputations, and machine efficiency. Rinse additive 1.5ml validating rinse additive levels. Machine Condition Good inspection machine health. Request for record review of repair visit from 01/19/24 or 01/23/24 was not provided. Record review on 01/26/24 at 8:05 AM revealed regular service call Kitchen Results: Good ensuring wares ae safe and up to cleanliness standards. Wash Temperature 145 issue found; parts replaced: Door Glides. Fahrenheit Rinse 190 Fahrenheit monitoring wash temperature for compliance to protect guest, reputations, and machine efficiency. Rinse additive 1.5ml validating rinse additive levels. Machine Condition issue found inspecting machine for health Comments: Adjusted wash paddle machine would run with no rack in the machine. After adjustment machine works properly. Also replaced door glides. Record Review on 01/26/24 at 8:09 AM Training Call, Training topic: hot water sanitation procedure. Trained on how to take rinse temperature for proper procedures and safety. Record review of the facility's Washing and Sanitizing Dishes policy and procedure, revised February 2018, reflected: .All dishes/utensils will be washed and sanitized using appropriate machine-washing procedures. Machine washing: If a commercial dishwasher is used, the following procedures should be followed: .3.Ensure that the machine reaches the proper temperatures. For high temperature dish machines, the wash water temperature must be a minimum of 150 F and the rinse water must reach 180 F. Appropriate ppm's must be measured, Chlorine levels: between 50-100 ppm, Quat levels: between 180-200 ppm. 4.Low and High temperature dish machine temperatures must be taken and recorded on the temperature log. In addition, surface temperatures are required within Skilled Nursing communities.

Based on observations and interviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 9 sharps containers, and 1 of 6 staff (CNA D) reviewed for infection control. 1. The facility failed to monitor sharps containers to prevent them from being over filled. 2. The facility failed to ensure CNA D disinfected the blood pressure cuff in between blood pressure checks for Residents #32, #34, #42 and #45. These findings could result in residents being exposed to infections and bloodborne pathogens. Findings included: 1.Observation on 1/23/24 at 11:00 AM the sharps container in the shower room on the 2nd floor was over filled to the point that the safety flap could not function. Observation on 1/23/24 at 11:10 AM the sharps container on the Wound Care Nurse procedure cart was over filled to the point that the safety flap was not functioning and a used butterfly needle, with blood in the tubing, was found on the floor beneath the sharp's container. Observation on 1/24/24 at 9:48 AM the sharps container on the medication aide cart was passed the Do Not Fill line of the container. The safety flap was still operational. Interview on 1/24/24 at 10:20 AM the Wound Care Nurse stated the risk of having an exposed needle on the floor was injury to a resident with exposure to any bloodborne pathogens that might be in the blood contained in the needle. Interview on 1/24/24 at 11:02 AM the DON stated all nurses are responsible for changing our sharps containers before they reach the Do Not Fill line. CNAs and Medication Aides were responsible for letting the nurses know when one of their sharp's boxes needed to be changed. 2. Observation on 1/23/24 from 3:20 PM to 3:31 PM of CNA C was observed checking residents vitals. CNA C used the same blood pressure cuff to check the blood pressure and pulse on Residents #32, #34, #42 and #45 without disinfecting the cuff and pulse oximeter between each resident. Interview on 1/23/24 at 4:17 PM with CNA C revealed he was the CNA assigned to the 3rd floor D Hall. He stated he completed vital checks on residents on D Hall about 30-40 minutes ago. He stated he checked for pulse, temperature, and blood pressure. CNA C stated if any of the vitals are not within range, he would notify the charge nurse. CNA C stated reusable equipment, like blood pressure cuffs, and pulse oximeter should be disinfected with wipes between each resident use (before and after use on each resident). He stated he did not observe the disinfecting wipes on the cart and he forgot to ask prior to checking vitals. He stated the risk of not disinfecting reusable equipment would be cross contamination from one resident to another. Interview on 1/25/24 at 9:16 AM with the ADON revealed she was also the Infection Preventionist at the facility. She stated her expectation was that staff would disinfect all reusable equipment between each resident use. The ADON stated staff should wipe down monitor, blood pressure cuff and any other equipment used after each resident. The ADON stated she was responsible for training staff on infection control. She stated it was the DON and her responsibility to ensure staff are disinfecting equipment's. She stated the risk would be cross contamination. Interview on 1/25/23 at 2:01PM with the DON revealed her expectation was that staff would disinfect all reusable equipment between each resident use. The DON stated failure to disinfect the blood pressure placed residents at risk of cross contamination from one resident to another. Review of the facility policy Sharps Disposal revised date 11/2019 revealed the following: This community shall discard contaminated sharps into designated containers. 1. Whoever uses contaminated sharps shall discard them immediately or as soon as feasible into designated containers. 4. Contaminated sharps containers shall be closed and placed in designated medical waste container in accordance with state and federal regulation. Record review of facility's Cleaning and Disinfecting Non-Critical Resident-Care Items policy, revised date June 2011, reflected: .non-critical items are those that come in contact with intact skin but not mucous membranes. 1. Non-critical resident-care items include bed pans, blood pressure cuffs .Reusable items are cleaned and disinfected or sterilized between residents 44140

Based on observation and interview, the facility failed to equip rooms to assure full visual privacy for each resident in 5 of 16 rooms reviewed for privacy. The facility failed to install curtains to ensure the residents in the A bed would have full visual privacy when needed. This failure could cause the resident to be exposed to anyone entering the room during cares. Findings included: Observations on 1/23/24 from 10:31 AM to 3:50 PM revealed rooms 208, 210, 223, 226, and 310 had railing on the ceiling to hold a privacy curtain but no curtains had been hung. All rooms were double occupancy rooms and the B bed had curtains to ensure full visual privacy. room [ROOM NUMBER] had a privacy curtain installed for the B bed; however, it did not extend all the way around the bed. Interview on 1/24/23 at 11:02 AM the DON stated each bed had to have curtains suspended from the ceiling that provided full visual privacy for each resident in the room. The DON stated she was unaware the A bed of each room was not equipped with privacy curtains; it had never been mentioned to her. The DON stated maintenance was responsible for hanging privacy curtains, and nursing staff were responsible for notifying them when a curtain needed to be replaced or hung. The Administrator was unable to provide a policy regarding privacy curtains. 44140

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one 1 (Resident #1) of 6 residents reviewed for quality of care. The facility failed to follow physician orders for Resident #1 to monitor blood pressure and blood sugars after a medication error was discovered and resident had to be sent to the emergency department. An Immediate Jeopardy (IJ) existed from [DATE] - [DATE]. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. These failures placed the resident at risk of not receiving adequate care and services, and decreased quality of life. Review of Resident #1's face sheet dated [DATE] reflected an [AGE] year-old female admitted to the facility with diagnoses that included: scalp laceration (cut on the head), Parkinson's Disease (central nervous system disorder that affects movement), muscle weakness, abnormality of gait and mobility, Hyperlipidemia (high cholesterol) and history of falling. Review of Resident #1's MDS reflected a BIMS of 9 indicating moderate impairment of cognitive ability. Review of Resident #1's December MAR reflected resident received the following medications at 9:00 am on [DATE]: glipizide XL10 MG (medication to treat Diabetes) and Carvedilol 25 MG (blood pressure medication). Review of Resident #1's orders reflected a physician order dated 12//,d+[DATE] at 11:00 am to Monitor BP and HR every hour for the next 6 hours r/t medication error and Monitor blood sugar every hour for the next 12 hours r/t medication error. Record review of Resident #1's December MAR reflected no blood pressure entry for 4pm and no blood sugar checks for 3 pm and 4 pm. During interview on [DATE] at 2:35 pm with LVN D, he stated he was the nurse for Resident #1 on [DATE] on the ,d+[DATE] pm shift. He stated he was not able to check Resident #1's blood pressure at 4 pm or Resident #1's blood sugar at 3pm and 4pm because Resident #1 was off the unit, and he could not find her. He stated he looked in her room, looked in her husband's room and asked staff but he could not locate resident. He stated he did not think to call the doctor and let them know he had not been able to find the resident or check her BP or blood sugar. He stated Resident #1 returned to the unit for dinner and he checker her BP and blood sugar then. He stated her sugar was a little low, but she was getting ready to eat dinner, so he waited and checked it again after she ate. He stated he continued to check her sugar as ordered and provide interventions as needed until his shift ended and then he gave report to LVN E who came on shift at 10pm. He stated he informed LVN E of the medication error and that Resident #1's blood sugar needed to be checked every hour. During an interview on [DATE] at 11:06 am, FM stated the facility did not check Resident #1's blood pressure and blood sugar like they were supposed to and then after midnight on[DATE], the facility checked her sugar, and it was in the 30's so Resident #1 was sent to the ER due to low blood sugar. FM stated Resident was in the hospital on IV medications for several days to try and stabilize her blood sugar. FM stated Resident #1's room was on the 2nd floor, and they went up to the activity room on the 3rd floor to make ornaments. She stated no staff came looking for Resident #1 and no staff called her or her another FM to see where Resident #1 was located. During an interview on [DATE] at 4:47 pm, the facility NP stated she was in the building on [DATE] and was notified of a medication error for Resident #1. She went and saw/assessed Resident #1 who was alert and in bed with family in the room. She stated she was concerned about hypotension (low blood pressure) and hypoglycemia (low blood sugar) with Resident #1 due to the medication errors. She stated her expectation when she gives orders to staff is that they will be followed. She stated she was not aware that some of the blood sugar checks, and blood pressure checks that she had ordered had been missed by the nursing staff. She stated she found out the resident had been sent to the hospital, so she found out on her own by reviewing the records that some of the blood sugar checks and blood pressure checks had been missed by the nursing staff. She stated she was concerned about the missed checks because I had not been notified that this happened and there was no documentation as to why it was not done. She further stated her concerns with the missed blood sugar checks would be exactly what happened. She became hypoglycemic. We should have been keeping a real close eye on her. It was not ideal that she ended up in the hospital. During an interview on [DATE] at 8:58 am, LVN E stated she was the nurse for Resident #1 on [DATE] on the 10 pm to 6 am shift. She stated she received report from LVN D and was made aware of Resident #1's medication error and the need to monitor Resident #1's blood sugar. She stated she saw the order in the system when she opened her computer a few minutes after 11. She stated she did not check Resident #1's blood sugar as ordered at 11pm because she got busy passing pain medications and I didn't think there was anything wrong with checking it later. She stated she saw the resident on rounds before 11 and she had crackers in her hand, so she didn't think she needed to check it. She stated she could not remember when she checked on the resident again, but she found her unresponsive and checked her sugar and it was in the 30's. She tried to give her orange juice and it was just running out of her mouth. She stated she called the DON to let her know and then called 911. She stated nurses are supposed to follow doctors orders and if they can't, they need to notify the DON or Doctor. She stated by not following orders and missing a blood sugar check a resident could potentially go into a coma - they need to check it to make sure it is stable - if it goes too low a resident could go into a state of shock or coma. During an interview on [DATE] at 9:36 am, LVN D stated when he got report at shift hand off, Resident #1 was sitting at the end of the hall with her family and then family took her off the unit and he didn't know where she was. He stated he looked around and asked some staff but did not attempt to call the family. I didn't think of calling the family to see where she was. He stated by not checking her blood sugar She could have tanked - her blood sugar could have gone so low that she could have lost consciousness and injured herself or could have even died . During an interview on [DATE] at 12:57 pm, the DON stated she had called LVN E at 11pm on [DATE] to make sure she knew Resident #1 needed to be monitored and to check her sugar. She stated LVN E told her she had just gotten report and was aware that Resident #1's blood sugar had been dropping and needed to be monitored. The DON stated Resident #1's blood sugar should have been checked at 11 pm on [DATE] and said, why should she wait if she knew there had been a problem? She stated she received a call on [DATE] at 12:37 am from LVN E and was informed that Resident #1 was found unresponsive, and her blood sugar was thirty something. She stated LVN E told her she had just taken her sugar and tried to give the resident some orange juice, but she was not able to. The DON stated she told LVN E to call the on-call doctor and see if she could get an order for glucagon. The DON stated, I got the impression that this all had just happened, not that she had checked her sugar an hour ago. The DON stated she called LVN E back at 12:45 and I asked her if she had gotten ahold of the doctor yet and she said no, so I told her to call 911 and send the resident out. The DON stated nurses are supposed to follow doctors orders and if they are not able to they need to call the doctor and notify the DON. Review of Facility policy Change of Condition for Skilled Nursing Communities, revised ,d+[DATE] reflected. When a resident is evaluated or assessed as having a change in condition, the licensed nurse should document notification to the family/resident representative, the Healthcare Provider (HCP) and other licensed nurses in order to facilitate the appropriate plan of care. 2. Upon receiving a Stop and Watch documentation or observing a difference in the resident's usual physical, emotional or cognitive patterns the licensed nurse should:2g) Implement treatment interventions, received orders and document HCP recommendations as indicated.

Based on observation, interview, and record review, the facility failed to ensure residents were free of significant medications errors for one of five residents (Resident #1) reviewed for any significant medication errors, in that: The facility gave Resident #1 medications belonging to another patient on 12/3/2023 and 12/4/2023 resulting in Resident #1 blood sugar dropping and being transferred to the emergency department. An Immediate Jeopardy (IJ) existed from 12/03/23 - 12/05/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. This failure placed residents at risk of experiencing non-therapeutic side effects from medications which could cause injury and/or death. Findings included : Review of Resident #1's face sheet dated 12/8/2023 reflected an [AGE] year-old female admitted to the facility with diagnoses that included: scalp laceration (cut on the head), Parkinson's Disease (central nervous system disorder that affects movement), muscle weakness, abnormality of gait and mobility, Hyperlipidemia (high cholesterol) and history of falling. Review of Resident #1's MDS reflected a BIMS of 9 indicating moderate impairment of cognitive ability. Review of Resident #1's MAR reflected the resident received the following medications at 9:00 am on 12/4/2023: glipizide XL10 MG (medication to treat Diabetes) and Carvedilol 25 MG (blood pressure medication). Review of Resident #1's orders reflected a physician order dated 12/4/2023 at 11:00 am to Monitor BP and HR every hour for the next 6 hours r/t medication error and Monitor blood sugar every hour for the next 12 hours r/t medication error . During an interview with LVN A on 12/8/2023 at 1:32 pm she stated she was working on 12/3/2023 in the evening when Resident #1 arrived as a new admission with a packet from the hospital. She stated she took the packet and handed it to her supervisor, RN B. LVN A stated RN B put all the medication orders in the system and then LVN A verified them to make sure they were correct. She stated she looked at the medication list but somehow I missed looking at the name of the resident on the medication list, but I checked the face sheet and history, and they all had the right name. I missed that there was a different name on the paper with the meds. She stated, I am supposed to look at all the names on everything; all the paperwork in the packet including the medication list. I did not do this. I made an assumption that everything in the packet was for that resident. (resident #1) She stated the facility practice was to have two nurses check medications to make sure they were correct, and she was the second witness for Resident #1's medication orders after RN B put them in the system. She stated not checking names on medication lists could lead to med errors and residents could get very sick . During an interview on 12/8/2023 at 2:13 pm, RN C stated she was working on 12/4/2023 when a FM for Resident #1 came to her and asked her to print out Resident #1's med list. She printed it out and a short while later, the FM came back and notified RN C that Resident #1 was not on any of the medications on the list. RN C stated she opened Resident #1 chart binder and reviewed the discharge med list from the hospital and the name on the med list was for another patient from the hospital, not Resident #1. She stated the med list was signed by two nurses on Sunday night 12/3/2023. RN C stated she alerted the DON who alerted the facility NP who was in the building and the NP assessed Resident #1. RN C stated the NP gave new orders to stop all current medications and to monitor the resident's BP, HR, and blood sugar for any changes in condition . During an interview on 12/11/2023 at 11:06 am, Resident #1s FM stated she was reviewing the hospital paperwork with RN C and found the error in the paperwork from the hospital and pointed it out to RN C who then alerted the DON, AD and NP. She stated the facility did not check Resident #1's blood pressure and blood sugar like they were supposed to and then after midnight on 12/5/2023, the facility checked her blood sugar, and it was in the 30's so Resident #1 was sent to the ER due to low blood sugar. The FM stated Resident #1 was in the hospital on IV medications for several days to try and stabilize her blood sugar. During an interview on 12/11/2023 at 3:13 pm RN B stated he was the nursing supervisor working on the evening on 12/3/2023 and he put in the medication orders for Resident #1 and then LVN A verified them. He stated Resident #1 arrived from the hospital with a packet with records and medication orders. He stated he verified the name on the history and physical and face sheet, then found the med orders and put them in. He stated he never noticed the name on the discharge medication list was not Resident #1. He stated they were supposed to verify names on all documents from the hospital. He stated he put the medication orders in the system and then LVN A verified them. He stated the facility policy was to have two nurses check the orders and they did that, but neither one of them saw the name on the medication list was not Resident #1. He stated by not checking the name it resulted in a med error for Resident #1 and she ended up going to the emergency department with low blood sugar. During an interview via a text message exchange on 12/11/2023 from 3:41 pm to 4:07 pm, the CCO for the on-call NP group stated their group had provided NP on call services to the facility. She stated when the facility called for admission orders for new residents, the on-call NP would review the orders verbally with a nurse from the facility. She stated, The nurse reads the orders out load verbally and we just approve/deny them. We do not get visibility for the discharge orders from the hospital. She said they were just provided verbally by the facility nurses and the on-call NPs did not actually put any medication orders in the system, the facility nurses do. During an interview on 12/11/2023 at 4:47 pm, the facility NP stated she had been in the building on 12/4/2023 and had been notified of a medication error for Resident #1. She stated she went and saw/assessed Resident #1 who was alert and in bed with family in the room. She stated she had been concerned about hypotension (low blood pressure) and hypoglycemia (low blood sugar) with Resident #1 due to the medication errors. She stated her expectation when she gave orders to staff was that they will be followed. She stated she was not aware that some of the blood sugar checks, and blood pressure checks that she had ordered had been missed by the nursing staff. She stated she had heard the resident had been sent to the hospital, so she found out on her own by reviewing the records that some of the blood sugar checks and blood pressure checks had been missed by the nursing staff. She stated she was concerned about the missed checks because I had not been notified that this happened and there was no documentation as to why it was not done. She further stated her concerns with the missed blood sugar checks would be exactly what happened. She became hypoglycemic. We should have been keeping a real close eye on her. It was not ideal that she ended up in the hospital. During an interview on 12/8/2023 at 12:13 pm, the AD stated as part of the order verification process upon admission the name on the orders should be verified that they are for the resident being admitted . He further stated that if that verification was not done, then there could be a medication error just like with Resident #1 and a resident could get very sick. During an interview on 12/8/2023 at 12:27 pm, the MD stated the facility had notified her of the medication error and they held an emergency QAPI meeting. She stated the hospital sent the discharge packet and had another patient's medication orders in it. She stated it was a HIPAA violation and error on the hospital's part. She stated the two nurses failed to recognize the medication orders had a different name on it than Resident #1's name and the root cause was human error. She further stated it was not a systemic error, it was an error from outside the organization and it was reported back to the hospital. She stated most med errors had little to no consequences and an individual's reaction to a med error was dependent on the individual. She stated she felt it was managed appropriately; even at the change of condition. She also stated There is always a risk of significant effect, hospitalization , and a rare complication, death. During an interview on 12/28/23 at 2:30 p.m., the ADM stated the hospital sent the wrong medication orders during Resident #1's discharge to the facility. The ADM stated the orders were primarily for Resident #1, but the last few pages were for another resident. The ADM stated the facility conducted an investigation and implemented interventions and preventions to ensure a similar incident would not occur in the future. The ADM stated Resident #1 was still residing at the facility. During an interview on 12/28/23 at 2:42 p.m., the NP stated when Resident #1 came to the facility from the hospital on 12/3/23, the discharge medication orders that were attached to the discharge paperwork were for someone else. The NP stated the nurse did not check Resident #1's discharge medication orders to ensure they were for Resident #1 and inputted the orders into Resident #1's EHR. The NP stated Resident #1 received blood pressure and blood sugar medications, which she normally did not take because she was not diabetic. The NP stated on 12/4/23, the nurse caught the error , but already administered the medications to Resident #1. The NP stated following the medication administration, nurses were assigned to check Resident #1's blood sugar and blood pressure levels. The NP stated there were some vital checks the nurses did not complete for whatever reason. The NP stated when Resident #1's blood sugar and blood pressure were checked during the night shift of 12/4/23, the nurse found Resident #1's blood sugar level was critically low . The NP stated staff sent Resident #1 to the hospital for the critically low blood sugar levels. The NP stated Resident #1 developed a secondary infection in the hospital. The NP stated Resident #1's blood sugar levels were stabilized, and she had no issues since returning from the hospital. The NP stated Resident #1's vital checks for blood sugar were conducted for a short-term because Resident #1 no longer received blood sugar and blood pressure medications. The NP stated staff no longer checked Resident #1's blood sugar levels when she returned from the hospital because she was not diabetic and did not take any medication that would affect her blood sugar levels. The NP stated staff routinely checked Resident #1's blood pressure levels. During an interview on 12/28/23 at 3:45 p.m., CNA F stated he worked for the facility for 7 years. CNA F stated he was in-serviced on BS and BP levels by the ADON and the ADON taught him s/s of hypoglycemia, how to check, how to respond in the event, and notifying the nurse on duty if a resident had a low BP. CNA F stated he checked residents' vitals immediately. CNA F stated residents' BP was checked every shift by a CNA. CNA F stated residents' BS was checked by the LVNs. During an observation and interview on 12/28/23 at 3:50 p.m., revealed LVN G was checking and verifying a newly admitted resident's hospital discharge medication orders. LVN stated he worked at the facility for 8 months. LVN stated he was in-serviced on BP and BS by the DON. LVN stated he learned how to report irregular levels. LVN stated vitals were checked every shift. LVN stated the BS was checked according to orders. LVN stated the BP was checked every shift. LVN stated vitals were checked by a CNA and BP was checked by LVNs. LVN stated charge nurses verified hospital discharge medication orders with the resident's name. During an interview on 12/28/23 at 3:58 p.m., RN H stated he worked at the facility for a month. RN stated he was in-serviced on the BP and BS levels during orientation. RN stated he learned how to check BP and BS levels and what to do in the event of hypoglycemia. RN stated residents' vitals were checked by CNAs every shift unless on BP meds. RN stated BS checks were done by LVNs, who also administered BS meds. RN stated he was trained on verifying residents' hospital discharge medication orders with the correct resident and sign and date verification whenever newly admitted and during night shift as well. During an interview on 12/28/23 at 4:02 p.m., LVN I stated she was in-serviced on BP and BS by the ADON. LVN stated she learned how to check the BP according to orders. LVN stated she checked the BS of residents with diabetes. LVN stated if residents' had irregular levels, she was trained to notify the MD. LVN stated she verified residents' hospital discharge medication orders to make sure match with residents and second verified to make sure correct verification. LVN stated CNAs checked vitals every shift. LVN stated LVNs checked the BS according to orders. During an interview on 12/28/23 at 4:06 p.m., CNA J stated she worked for the facility for two months. CNA stated she was in-serviced on BP and BS. CNA stated she could not remember who in-serviced her on the training topics. CNA stated she learned the signs and symptoms of hypoglycemia and how to respond and notify a nurse when there were signs and symptoms. CNA stated CNAs checked residents' BP every shift and whenever residents were admitted . CNA stated LVNs checked residents' BS. During an interview on 12/28/23 at 4:17 p.m., MA K stated she worked at the facility for two years. MA stated she was in-serviced on checking BP and how to verify orders by the DON and ADM. MA stated residents' BP were checked twice a day. MA stated if a resident had low BP, she was trained to notify a charge nurse, hold the residents' medicine, and check the resident's BP again. During an interview on 12/28/23 at 4:11 p.m., the ADON stated she in-serviced all nurses and taught them how to verify hospital discharge orders and made sure the nurses correctly matched the residents to the residents' discharge orders. ADON stated CNAs, MAs , and LVNs were also taught how to recognize signs and symptoms of hypoglycemia. ADON stated CNAs were also taught on how to report the signs and symptoms of hypoglycemia. ADON stated IDT meetings were conducted daily with the nurses, her, and the DON who verify and check to make sure hospital discharge medication orders correctly matched residents and were documented on the IDT checklist. ADON stated she was in-serviced by the DON on the processes. ADON stated the CNAs checked residents' BP once every shift and according to the physician's orders. ADON stated LVNs checked residents' BS twice a day, before meals and according to the physician's orders. ADON stated Resident #1 was no longer being checked for BS after she returned to the hospital because she was not taking any diabetic medication. During an observation and interview on 12/18/23 at 4:40 p.m., revealed Resident #1 was sitting in her wheelchair. Resident #1 was clean, comfortable, and her call light was sitting on her bed. Resident #1 was interacting with her family. Resident #1 and her family stated staff checked Resident #1's BP twice a day. Record review of Resident #1's December 2023 MAR/TAR revealed she received medications within required timeframes and that were active physician's orders. During an interview on 12/28/23 at 5:25 p.m., the ADM stated LVN E was suspended pending the investigation and then terminated after he completed the investigation. During an interview on 12/29/23 at 10:52 a.m., the ADM stated the facility made own POC. ADM stated there was monitoring that had been taking place daily for two weeks and then three times weekly for 12 weeks since 12/5/23. ADM stated QAPI had been conducting audits of the monitoring for the next three months and based on the audit results. ADM stated the facility had no other incidents since Resident #1's admission on 12/3/23. Record review of the facility's QAPI meeting attendance sheet, dated 12/5/23, reflected there was a QAPI meeting. The members who attended the meeting were the Executive Director/Healthcare Administrator, Director of Clinical Services, Infection Preventionist, RDCS, DDO, VP of Clinical Services, and MD. The meeting topic was regarding discharge orders entered from hospital did not match Resident #1. The incident was reported to ED/HCA, DCS, POA, and SSA. The incident investigation report was completed. The root cause analysis was completed and determined the admitting nurse and verifying nurse did not confirm name on Resident #1's orders. Resident #1 had 9 BIMS score. The clinical admission orders were reviewed and audited on 12/5/23. Record review of the facility's resident roster, dated 12/7/23, reflected residents' medication orders and names were verified and matched . An audit was completed by the ADM. Record review of the facility's in-services reflected staff were trained on the following: Medications and admissions on 12/4/23, 12/5/23 at 1:00pm, and 12/7/23: Medication errors, medication administration (including 6 rights of medication, medication reconciliation on admission including verifying name of resident, blood glucose management including documentation of ongoing monitoring, CNAs signs and symptoms of hypoglycemia, and initialing next to resident's name on discharge orders. Record review of 49 knowledge-based exams reflected staff were tested from 12/5/23 through 12/10/23 on the following: What is hypoglycemia Signs of low blood sugar What to do when they believe a resident had low blood sugar Values that were considered low blood sugar What is given to raise up a resident's blood sugar How often resident's physician order section of the medical record and electronic orders were to be reviewed Where the 24-hour physician order audit form was located and completed by a nurse What a charge nurse verifies in reviewing each order Purpose of performing medication reconciliation Medication reconciliation helps identify what factors How many nurses needed to complete medication reconciliation for a new admission Second charge nurse responsibilities Information to be gathered for an admission/readmission to reconcile the medication list Common signs and symptoms of hypoglycemia How to respond when symptomatic and unresponsive residents with hypoglycemia Record review of Resident #1's blood pressure log reflected staff assessed and documented levels daily since readmission on 12/12/23 (12/12/23 - 12/29/23). Review of the facility policy Admission and Data Collection and Orders last revised 02/23 reflected #2 The charge nurse who admits the resident is responsible for completing the Nursing Admission Data Collection, verifying orders are present for admission, additional corresponding data collections and reviewing the information sent by the discharging community, hospital and/or attending physician. and #5 The charge nurse should contact the attending physician after the resident has been admitted to the community and resident data is collected. a) Orders should be reviewed with the physician and verified.

Based on observation, interview and record review the facility has failed to ensure the resident environment remained as free of accident hazards as possible and the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Residents #1) reviewed for accidents and supervision. Facility staff failed to ensure Resident #1's wheelchair was in the locked position during a transfer, causing a fall on 8/28/23 which resulted in fractures to the pubic bone and femur. The noncompliance was identified as PNC. The noncompliance began on 8/29/23 and ended on 9/3/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of injury from accidents and hazards. The findings included: Record review of Resident #1's face sheet, dated 09/8/23, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included unspecified fracture of the lower right radius (broken wrist), history of falling, age related osteoporosis (is a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes) without current pathological fracture (a break caused by a disease, not an accident). Resident #1 was discharged on [DATE] to the hospital. Record review of Resident #1's Admission MDS assessment, dated 08/21/23, indicated Resident #1 had a BIMS of 14, which indicated being cognitively intact. Resident #1 required extensive assistance of one staff for transfers. Record review of Resident #1's care plan, dated 08/14/23, with revision on 08/31/23 (after fall on 8/29/23), indicated Resident #1 had a fall while at the facility on 8/29/23. At the time of the fall Resident #1 required assistance of one staff. Interventions added included 2-persons to assist with transfers and ensure wheelchair is locked when transferring. Record review of the facility incident report dated 8/29/23 at 4:00 p.m. indicated Resident #1 had fallen while being assisted by CNA A after a shower. The additional facts section included, On 8/29/23 [NA A's name] provided [Resident #1's name] with a shower and when transferring her to her wheelchair, the chair slipped out from under [Resident #1] resulting in [CNA A] lowering her to the ground. Charge Nurse [name] notified MD and family were notified. X-rays were ordered and originally read as negative. [Resident #1] voiced pain and was provided medication to relieve pain. During investigation, it was discovered that [CNA A] had forgotten to lock wheelchair brakes which resulted [Resident #1] needing to be lowered to ground. [CNA A] was suspended pending investigation. The report further reflected, After MD reviewed x-ray results, a CT scan was ordered and [Resident #1] was transferred to ER via non emergent transport on 8/31/23. On 9/1/23, results of CT scan were positive for a fracture to femur (bone that extends to the hip and the knee) and pubic bone. Record review of Resident #1's Progress Notes revealed on 8/29/23 at 4:54p.m. the LVN B documented, CNA reported to this nurse that resident had a near fall (in) the shower, but he was able to save her from falling, head to toe assessment completed resident complained of pain to right hip. Prn oxycodone (opioid, used to treat pain) 2.5 mg administered. The PCP was notified and responded with orders for a right hip x-ray. On 8/29/23 at 10:06 p.m. the LVN K documented in a follow-up for the fall without injuries, no swelling, bruising, or deformity noted. The resident was sitting up in bed. Complained of pain to hip. After pain medication was given, the resident stated 2 hours later she was no longer in pain. On 8/30/23 at 11 a.m. RN D documented that the x-ray results had been posted and were negative for a fracture. On 8/31/23 at 10 a.m. the facility NP documentation included, The patient was seen and examined in her room. She is sitting in her chair complaining about right hip pain and right groin pain. On examination no bruises or swelling noted to the site. Neurovascular check to right toes within normal limits. Patient is able to lift the right leg with moderate amount of pain. She had a fall on 8/29/23 evening. Per report the x-ray was negative for fracture. Personally reviewed x-ray which showed abnormal appearance of the femoral head neck junction (connection of the femoral bone head to the neck of the bone) which is suspicious for a nondisplaced (remains in proper alignment) fracture and in the appropriate clinical setting consider CT for further evaluation. Patient will be sent out to (local hospital name) for stat (immediate) CT scan of the right hip to rule out fracture since the patient is experiencing severe pain and she is not able to ambulate due to the pain. Record Review of the Facility Incident Reports from 8/1/23 through11/5/23 revealed no other incidents of falls during transfers with staff. Record review of the Provider Investigation Report dated 9/8/23 revealed the investigation summary included, on 8/29/23 around 4 p.m., Resident #1 was assisted by CNA A in a shower transfer. During the transfer, CNA A forgot to lock the wheelchair brakes which caused the wheelchair to roll away when Resident #1 was sitting down. Per CNA A, he caught Resident #1, had her lean against the wall, and grabbed the wheelchair for her to sit down. CNA A immediately reported this near fall to LVN B, who assessed the resident immediately after the incident. No redness, bruising or indication of a fall was noted except for voiced pain to Resident #1's hip. LVN B notified the physician and family. Orders were received for an x-ray and pain medications were prescribed. Record review of the facility Inservice records included on 9/1/23 and 9/2/23 for 23 CNAs and/or MAs. Training included falls, reporting falls and injuries. Fall prevention methods including rounding on residents, monitoring residents at risk, offering toileting, checking briefs, offering snacks, providing activities, low bed, call lights. Effective communication with nurses regarding resident fall/risk for falls. Resident transfers, wheelchair locked and secure prior to transfer. Mechanical lifts and a review of mechanical lift transfers, standby assistance. Facility RNs conducted twenty-eight observations, each on a different staff, utilizing check sheets for CNA and MA transfers. Safe surveys were conducted with all residents residing on the same unit. Record review of CNA A's personnel file revealed he was hired on 8/8/23. Review of training records revealed on 8/15/23 CNA A completed a course titled Safe Resident Handling and Transferring. During an interview on 11/5/23 at 12:35 p.m. with CNA C revealed she had received training with hire, about a year ago, on transfers and multiple times since including on 9/2/23 when she also was observed by an RN doing a transfer. During an interview on 11/5/23 at 12:45 p.m. with LVN D revealed she at times assist staff with transfers. LVN D stated that she has not had any concerns with staff transfers and that staff are aware of the need to lock a wheelchair before transfer. She also received training at hire and has had inservice recently regarding transferring. She is not aware of any instances of staff assisted transfers causing an injury while she was working. During an interview on 11/5/23 at 2:16 p.m. with CNA F revealed that he has worked for the facility for four months. He stated he received training on transfers at hire before working with residents and recently on 9/2/2023 another inservice and a nurse observing him doing a transfer. He stated he knows to lock the wheelchair prior to assisting resident transfer. During an interview on 11/5/23 at 2:25 p.m. with LVN F revealed he has been trained on transfers many times in the [AGE] years at the facility and has assisted CNA's frequently with transfers. LVN F stated he has done transfer observations many times and he has not witnessed a CNA transfer a resident without locking the wheelchair first. During an interview on 11/5/23 at 2:40 p.m. with CNA G revealed she has worked here for [AGE] years. She stated she knew and worked with Resident #1. She stated at the time of the incident Resident #1 was a one person transfer and there was not a problem with one staff transferring her because she was petite. CNA G stated everyone gets annual training on transfers that includes ensuring the wheelchair is locked. CNA G stated she worked with CNA A onetime and did not have concerns about his transferring of residents. She thinks he may have just made a mistake, but she was not working the day the incident occurred. She received an inservice and was observed doing a transfer on 9/2/23. During an interview on 11/5/23 at 3:19 p.m. with CNA H revealed he has received annual training on transfers since working at the facility. He stated on 9/2/23 he was inserviced on transfers and observed doing a transfer. CNA H stated all CNAs were inserviced after it was found Resident #1 was injured. During a telephone interview on 11/05/23 at 3:54 p.m. with the FM of Resident #1, he stated that he had just left the facility a few minutes before they called him and told him Resident #1 had fallen. The FM stated he was concerned he was not told initially by the facility that Resident #1's wheelchair had not been locked during a transfer. The FM stated he also did not understand how the first x-ray did not show a fracture. He stated Resident #1 complained of pain for 2 days before she was sent to the hospital where the fractures were discovered, one of which required surgery to place pins in the pelvic bone. He stated Resident #1 did not return to the facility but was currently living with her family receiving home health care and would not be interested in being interviewed. During an interview on 11/5/23 at 12:40 p.m. with the facility ED revealed CNA A was suspended pending investigation and did not return to work. The ED stated CNA A had received training on transfers when hired. The ED confirmed that at the time of the incident Resident #1's transfer requirements was one staff. The care plan was changed to include two staff after the incident. Record review of a Safe Living and Movement of Residents policy, dated 07/2018, indicated a Policy Overview In order to protect the safety and well-being of associates and residents, and to promote quality care, this community uses appropriate techniques and devices to lift and move residents.

Based on interview and record review, the facility failed to protect the residents' rights to be free from abuse for two (Resident #2 and Resident #3) of four residents reviewed for abuse, in that: -Resident #2 was not protected from alleged abuser CNA A after making a verbal complaint againt CNA A; measures were not taken to remove access by the alleged perpetrator to the alleged victim, resulting in intimidation and mental abuse. -Resident #3 was not protected from further abuse, in the form of mental abuse and potential physical abuse, when alleged perpetrator continued to have access to Resident #3 in the facility, causing Resident #3 mental distress. An IJ was identified on 08/25/2023 at 5:50 PM. While the IJ was removed on 8/27/2023 at 10:50 AM, the facility remained out of compliance at a severity level of actual harm with the potential for more than minimal harm that was not in immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for physical abuse or mental abuse by allowing perpetrators or potential perpetrators of abuse to continue. Findings included: Record review of Resident #2's face sheet, dated 07/20/2023, revealed a [AGE] year-old female with facility admitted [DATE] with diagnoses of right intertrochanteric fracture of right femur (fracture of the large bone of the right thigh in the hip area), fracture of right humerus (large bone of the upper arm), and major depressive disorder (persistently low or depressed mood), among other diagnoses. She was admitted to the facility for Physical and Occupational Therapy services after an acute care stay at a local hospital. Record review of Resident #2's MDS (standardized assessment tool that measures health status in nursing home residents) dated 07/14/2023 indicated a BIMS (assessment which measures cognitive functioning) score of 15/15, indicating resident had full cognition (full intellectual capacity), and revealed that Resident #2 had felt down, depressed, or hopeless nearly every day over the previous 2 weeks at the time the assessment was conducted. The MDS indicated that Resident #2 was not having hallucinations or delusions, she did not have any behavioral symptoms such as hitting or kicking, did not have any verbal symptoms, such as cursing or screaming at others, and did not have any behavioral symptoms directed toward others. Resident #2 required extensive assistance for bed mobility, including turning side to side in bed and positioning self while in bed, and she was always incontinent of urine and bowel. Record review of Resident #2's Care Plan, entry effective 07/21/2023, revealed that resident required extensive assistance of one person to roll over in the bed. Resident #2 had an ADL (activities of daily living, including hygiene, toileting/continence, other activities) self-care deficit and required assistance of at least one person for assistance with ADL's. Record review of Form 3613-A, Provider Investigation Report, dated and signed by ADM on 07/24/2023, revealed On 07/17/2023, (Resident #2) made the following grievance: . The Investigation did find that (CNA A) circled around Monday morning (07/17/2023) to ask (Resident #2) what went wrong during the care and why a grievance was made. (Resident #2) had grievances regarding (CNA A) peri-care on the morning of 7/15/2023. revealed that head to toe assessment of Resident #2 was done on 07/17/2023 at 10:00 AM. revealed that provider investigation findings were inconclusive. Record review of 07/17/2023 provider investigation facility form entitled (Corporate Name) Incident Investigation Form - Applicable to Skilled Nursing, Timeline section, indicated that incident involving Resident #2 and CNA A occurred at 4:00 AM on 07/16/2023, that Resident #2 made grievance on 07/16/2023 at 7-8:00 AM, and that RN A followed up with Resident #2 regarding her grievance on 07/16/2023 in the evening. Record review of form entitled (Corporate Name) Incident Investigation Form - Applicable to Skilled Nursing, dated 07/17/2023, Timeline section, indicated that RN A discussed grievance with CNA A on 07/17/2023 day shift; this same document/Timeline section, revealed that CNA A followed up with Resident #2 regarding grievance on 07/17/2023 during the day shift. Record review of (Corporate Name) form entitled Incident Investigation Form - Applicable to Skilled Nursing, dated 07/17/2023 and signed by ADM, revealed that Resident #2 stated CNA A was 'rough' during peri-care and Resident #2 was scared of CNA A. Record review of (Corporate Name) Incident Investigation form, dated 07/17/2023, revealed quoted statements from CNA A and PT A regarding the grievance and reapproach of Resident #2 by CNA A and the reapproach of Resident #2 as witnessed by PT A. Date/time of statements was not indicated. In this document, CNA A stated I went in to change her brief and she never said there was a problem .She didn't want me to change her pad and I do not know why. I went and talked to her on Monday because I thought everything was okay .and I wanted to know what was/went wrong. PT A statement included I did witness CNA A approach Resident #2 on Monday. I wouldn't say it was aggressive but it was inappropriate .I do not think CNA A understood how she was coming off to Resident #2. I do not think CNA A was trying to intimidate Resident #2 but trying to figure out why Resident #2 complained about her. A statement that CNA C's memory and opinion was congruent with PT A's statement was included on this form. A statement which read Pending CNA B interview followed these statements. No statement for CNA B, nurse aide for Resident #2 when allegations were first verbalized after incident, per Timeline section on (Corporate Name) Incident Investigation Form - Applicable to Skilled Nursing, was documented at time of investigation. Record review of (Corporate Name) Incident Investigation Form - Applicable to Skilled Nursing, dated 07/17/2023, revealed in Immediate Actions Taken: Resident was evaluated and/or treated, Associate accused/suspected was suspended, Notification was made to (Corporate) District/Regional Administrative Officers, Responsible Party was notified, Physician was notified; this same form indicated that Post Investigation Actions included In-services/Associate Re-training and Other Action (specified without detailed description as Corrective Action: CNA A) was taken. Record review of (Corporate Name) Incident Investigation Form - Applicable to Skilled Nursing, dated 07/17/2023, Conclusion, indicated that Provider findings were inconclusive and unfounded, as indicated by checked boxes; boxes associated with Confirmed or Unconfirmed were left blank. Record review of the Provider Investigation indicated that four safe surveys were conducted on four residents on unknown date by unknown person and there were no safety concerns expressed. Record review of documents in Provider Investigation indicated that Abuse and Neglect in-service was held on 07/17/2023 at 4:35 PM and signed by 15 staff persons. a Peri-care in-service was held on 07/17/2023 at 3:00 PM and signed by 15 staff persons. In-service on customer service dated 07/17/2023 at 4:35 PM revealed sign-in sheet signed by 15 staff persons. CNA A's signature did not appear on in-service sign in sheets dated 07/17/2023. During interview with Resident #2 on 08/23/2023 at 12:40 PM, Resident #2 stated that CNA A was rough with her on a night shift on 07/15/2023 or 7/16/2023. Resident #2 was able to identify CNA A by first name. Resident #2 stated that CNA A turned the light on in her room and woke her up and stated that she needed to change her brief and bedding as everything was wet. Prior to changing the brief, Resident #2 stated that CNA A had asked her to roll over. Resident #2 stated that she complied with CNA A request and rolled over. Resident #2 stated that CNA A then took her hands and shoved her over further, which indicated to Resident #2 that the CNA A was angry that she had not rolled over far enough on her own. Resident #2 stated she told CNA A that the action of shoving her over really hurt as this was her side (of her body) with fractures. Resident #2 stated she told CNA A not to change the wet pad that was underneath her on the bed as she just wanted CNA A to leave her room. Resident #2 stated CNA A left the wet pad under her and left the room. Interview with RN A on 8/23/2023 at 12:50 PM, revealed RN A was informed about the abuse allegation after Resident #2 reported it to morning CNA B when she came on duty on the morning shift of 07/16//2023 at approximately 7:00 AM. RN A stated that he spoke with Resident #2 immediately after he was informed of the grievance which had been conveyed from Resident #2 to CNA B. RN A stated that Resident #2 stated to him on 07/16/2023 at approximately 7:00 AM that CNA A was rough with her care when she attempted to change Resident #2's brief and wet bed in the early morning hours of 07/16/2023 after entering the room and turning on the light. Resident #2 stated to RN A during grievance follow-up on 07/16/2023 that she felt scared of CNA A. RN A stated CNA A is very passionate about her work and gets offended when she is accused of improper care. RN A denied that CNA A had been accused of abuse prior to the event with Resident #2. RN A stated that CNA A approached Resident #2 in a common area the following day, 07/17/2023, and stated to her That isn't what I did, referring to grievance expressed by Resident #2. RN A stated that CNA A came across in the wrong way as she attempted to relay verbally to Resident #2 that she had not been rough. RN A stated that CNA A is very efficient, works fast, and any rough behavior would not have been intentional. Resident #2 is no longer assigned to receive care from CNA A per RN A. RN A stated that he reported the incident to ADM right away after speaking with Resident #2 on 07/16/2023. Interview with Family Member #1 on 08/23/2023 at 3:51 PM, revealed that Family Member #1 and Resident #2 had spoken to the ADM on unknown date, about the allegation, in the days following the allegation. Family Member #1 stated that Resident #2 had a palpable fear that she was being retaliated against when she overheard an unknown Nurse Aide asking another staff person Who would report my friend? Family Member #1 stated that the penalty for CNA A regarding incident with Resident #2 was attending an in-service and this concerned Family Member #1, as he stated he did not feel this was a sufficient response from the facility regarding the incident. Family Member #1 stated that he did not feel the facility response was adequate based on the treatment that Resident #2 received from CNA A, and that she was left feeling scared after she alleged the mistreatment. Interview with Physical Therapist by phone on 08/24/2023 at 1:00 PM, revealed that Physical Therapist was with Resident #2 providing therapy services when Resident #2 was approached by CNA A. Physical Therapist stated that she does not remember the exact date/time. Physical Therapist stated during interview that CNA A approached Resident #2 during PT session and stated I heard you had a complaint about me, what did I do wrong?' to which Resident #2 replied 'I felt you were a little rough with me when you rolled me in the bed' . CNA A replied, according to Physical Therapist in interview, 'Well I have to roll you in order to change you' . Physical Therapist stated that she and Resident #2 felt this to be an uncomfortable situation and it caused Resident #2 distress, per Physical Therapist. Physical Therapist stated that Resident #2 told her that she did not want CNA A to come back in her room. Interview with CNA C on 08/24/2023 at 12:32 PM, revealed that she witnessed, on unknown date/time, Resident #2 as she was confronted by CNA A regarding grievance. CNA C stated that Resident #2 stated to her, at a time after she was approached by CNA A, 'She (CNA A) came up to me and accused me of reporting her' . CNA C stated that she told Resident #2 that wasn't very nice of her. CNA C stated that Resident #2 stated 'that scared me', in reference to the action of CNA A approaching her . CNA C stated that Resident #2 then stated 'I hope she doesn't come back to my room. I'm afraid of her roughing me up.' Interview with ADM on 08/24/2023 at 2:17 PM, by phone revealed that CNA A was suspended for a couple of days. ADM stated that when it came down to it, it was a he said-she said. ADM stated that CNA A was coached, after the incident on 07/17/2023, not to reapproach residents if they make accusations which involved her. ADM stated that in addition to a couple days suspension, beginning on 07/17/2023, CNA A was in-serviced on Customer Service, Peri Care (incontinent care), and Abuse/Neglect. A phone interview on 08/25/2023 at 10:52 AM with ADM, stated he was not made aware of grievance until 07/17/2023. ADM stated during phone interview on 08/24/2023 at 2:17 PM that he was made aware of Resident #2 grievance on 07/17/2023 and took action to investigate and address grievance beginning on this date. ADM stated that to his knowledge, RN A did not notify him of the grievance on 07/16/2023. ADM acknowledged that he is the facility Abuse Coordinator and that staff have been trained to report allegations of abuse or neglect to him immediately. Observation on 08/25/2023 at 2:31 PM, included incontinent peri-care and brief change for bed-bound resident by CNA G and CNA H. There were no concerns during observation. Record review of Resident #3's face sheet dated 08/11/2023 revealed a [AGE] year old female with diagnoses of depression, dementia without behavioral disturbance (decreased ability to remember without behavioral symptoms directed at others or oneself), psychotic disturbance, mood disturbance, and anxiety, among other diagnoses. Record review of Resident #3's MDS (standardized assessment tool that measures health status in nursing home residents dated 08/23/23 revealed a BIMS score of 7/15, which indicated severely impaired cognition (a deterioration or loss in intellectual capacity). Record review of Resident #3's Care Plan dated 08/11/2023 revealed that Resident #3 required staff assistance with bathing/showering, assistance with activities of daily living, and assistance to dress. The Care Plan indicated that Resident #3 had alteration in mood with interventions listed including administering medications, ordering behavioral health consults, and encouraging the resident to express feelings. Record review of Tulip submitted on 08/22/2023 at 4:12 PM, by ADM revealed that Resident #3 alleged that a nurse aide was rough with her during a shower with facility first learning of incident on 08/22/2023 at 3:30 PM, the report indicated that the perpetrator was unidentified. Resident #3's allegation of abuse revealed that Actions and Notifications taken by the facility included: assessing resident, notifying family and physician, conducting safe surveys, taking statements, and conducting in-services regarding showers, customer service, abuse, neglect, and exploitation. Provider investigation documents were requested at entrance to facility on 08/23/2023 at 11:02 AM by email to Executive Director and ADM. Executive Director stated at entrance conference that RN A would be facility contact person for anything needed to investigate intakes and Executive Director would also be available. ADM would be available by phone, per Executive Director. Executive Director stated that although intake was reported one day prior, the investigation regarding was under way. ADM was interviewed by phone on 8/23/2023 at 10:50 AM. ADM stated that incident which involved Resident #3 was reported to State intake the day prior, on 08/22/2023. ADM stated that Nurse Aide, whom had perpetrated abuse on Resident #3 during a shower, remained unidentified. ADM stated that ADON was sent in to do physical assessment on Resident #3 after allegation of abuse was communicated to him as the result of a Care Plan Meeting on 08/22/2023. During Care Plan Meeting on 08/22/2023, Family Member #2 communicated that Resident #3 had stated to him that a nurse aide was rough with her during a shower on either 08/20/2023 or 08/21/2023. ADM stated during interview of 08/23/2023 that Resident #3 Family Member is not worried that abuse occurred. Interview with Resident #5 on 8/23/2023 at 1:00 PM, revealed her own experience in the facility, then she advised that her roommate, Resident #3, had verbalized a concerning incident to her that she felt Resident #3 would want to discuss with HHS representative. Resident #5 revealed that her roommate had told her that she had been mistreated during a shower. Because her roommate, Resident #3, had been upset about the event, Resident #5 verbalized that she thought her roommate would want to discuss the concern. Resident #5 stated that she did not witness alleged abuse but had heard about it from her roommate, Resident #3. Resident #5 did not witness the alleged perpetrator to her knowledge. Resident #5 stated that she did not know what day the alleged abuse had taken place or what date/time Resident #3 had first told her about the event. Interview with Resident #3 on 08/23/2023 at 1:15 PM revealed that Resident #3 did not know the name of the staff person who had showered her on date of alleged abuse and was unable to give the date or day of the week that the shower had been given. Resident #3 described the event which had occurred in the shower: alleged perpetrator was assisting Resident #3 with her shower and asked her to turn around as she stood; alleged perpetrator was going to wash off her back side. Resident #3 stated that when she did not turn around in a timely manner, the alleged perpetrator physically turned her body around, knocking her against the shower wall. Not able to recall the date/time of the incident, Resident #3 provided a verbal description of the alleged perpetrator which included: of African or Hispanic descent, female, curly dark hair, and wearing a copper-colored hair accessory. Resident #3 stated that she told her roommate and her son after the alleged abuse took place. Resident #3 stated that she had further seen the alleged perpetrator since the date/time of the incident; Resident #3 stated that one sighting occurred at the nurse's station (date/day of week unknown) and second sighting was in the dining room as alleged perpetrator poured drinks (date/day of week unknown). Resident #3 stated that when she saw alleged perpetrator in the dining room it made her cry, and some of the staff asked her what was wrong and attempted to console her. Resident #3 stated that she had not had another shower since the alleged abuse occurred. Resident #3 became teary as she recounted the shower event, during her interview. Resident #3 stated that the alleged abuse made her feel awful and that she never had anyone treat her the way that she was treated during that shower. Request for Provider Investigation or documents which indicated progress toward investigation, , requested verbally from DON on 08/23/2023 at 3:00 PM. DON was unable to provide any investigation documents for review. CNA C was interviewed on 08/24/2023 at 12:45 PM. CNA C stated that she was aware of Resident #3 having a complaint about someone being rough with her in the shower. CNA C stated that she had no knowledge of a perpetrator or when the alleged abuse occurred, CNA C that Resident #3 is a day shower (showers on the 2:00 PM to 10:00 PM shift) and she had not showered Resident #3. Interview with RN B was held on 08/24/2023 at 1:40 PM. RN B stated that she had worked on 8/22/2023 and 08/23/2023 and was the primary nurse for Resident #3 on those days. RN B stated that she and ADON had done a skin assessment on Resident #3. RN B stated that an allegation had prompted the skin assessment but she did not know what was being alleged. RN B stated during interview on 08/24/2023 at 1:40 PM that she had heard that someone had been rough with Resident #3 during a shower and backed her up against the wall of the shower. RN B stated that she did not know who the assigned nurse aides were for Resident #3 on 08/22/2023 or 08/23/2023 or if she had had a shower on those dates. RN B stated that she had not witnessed abusive treatment toward Resident #3. Interview with ADON was done on 08/24/2023 at 2:08 PM and revealed that he and RN B did a head to toe skin assessment with Resident B on 08/22/2023. Resident #3 became agitated during skin assessment, ADON stated during 08/24/2023 interview, so skin assessment had to be done slowly and with measures taken to allow Resident #3 to calm during the procedure. ADON stated during 08/24/2023 interview that he and RN B were able to do a thorough skin assessment and did not find evidence of abuse. ADON stated that skin assessment was done at the end of the day on 08/22/2023 and he did not know who the alleged perpetrator was or who had showered Resident #3 when alleged abuse occurred. ADON stated that Nurse Aides do showers three times weekly per resident and that no Shower Aides are used in the facility. Provider Investigation documents requested on 08/24/2023 from RCS by text (her preferred method of contact for requesting documents per RCS, who was in facility on 08/24/2023 and 08/25/2023). Verbal request to RCS was made for Provider Investigation documents on 08/24/2023 at 2:02 PM. RCS stated advised investigator to speak with ADM regarding investigation documents and no Provider Investigation documents were obtained from RCS at this time. Provider Investigation documents for were requested from ADM by phone on 08/24/2023 at 2:10 PM. Email containing four safety surveys conducted with four residents on unknown date/time were received on 08/24/2023 at 2:13 PM. No other progress on investigation was submitted and a perpetrator remained unidentified for the alleged abuse regarding Resident #3. Executive Director was interviewed on 08/25/2023 at 09:55 AM and stated that the investigation regarding, Resident #3, had been started. Executive Director stated that interviews had been started with staff. Executive Director stated during interview on 08/25/2023 at 09:55 AM that there was no alleged perpetrator. Executive Director stated that Resident #3 is confused and unable to give a description of alleged perpetrator. ADM was interviewed on 08/25/2023 at 10:57 AM by phone regarding intake 445774. ADM stated that 5-day investigation report would be submitted to State intake on Tuesday, August 29, 2023. ADM stated that after initially receiving grievance on 08/22/2023, the facility staff began checking all other residents. ADM stated that family and physician were notified on 08/22/2023. ADM stated that in-services are being initiated and interviews are being completed on 08/25/2023. Resident identified perpetrator to ADM as African American female with short curly hair. ADM stated that CNA E had given Resident #3 a shower earlier in the week. ADM stated that he had spoken with various staff regarding incident or if there were any concerns regarding staff working on Resident #3's hall. Point Click Care software based electronic medical record was accessed on 08/23/2023 to aide in investigation. It was revealed in PCC that a shower had been documented on 08/22/2023, 2:00 PM to 10:00 PM shift. Shower entry in PCC was documented as Resident #3 requiring some assistance RN A was asked to identify the staff member that had documented the shower, along with their initials, on 08/22/2023 and RN A was unable to identify. Executive Director stated that he would be able to identify the staff member initials in PCC; it was requested to Executive Director that this staff member be identified and interviewed by HHS representative if they were present in the facility. CNA D was interviewed on 08/23/2023 at 2:19 PM. CNA D could not verify yes or no during interview if entry in PCC was her identification and entry when shown; CNA D stated that she was assigned to Resident #3 on date of Resident #3's last documented shower, which PCC documentation indicated to have occurred on 08/22/2023 on the 2:00 PM to 10:00 PM shift. CNA D stated that she had worked on 08/22/2023 and was assigned to Resident #3 on the 2:00 PM to 10:00 PM shift. CNA D stated that although a shower is documented as having been given, with codes 3, 2 documented in the entry (corresponding key indicated that Resident #3 required physical help in part of bathing activity, code 3, and by one person, code 2) she did not give a shower to Resident #3 as entry indicated. CNA D stated that Resident #3 had refused her shower on 08/22/2023. Two of three documented initials on entry matched CNA D. Shower entry in PCC prior to 08/22/2023 was on 08/19/2023 on the 2:00 PM to 10:00 PM shift; it was revealed that the 8,8 codes that were used in the entry indicated that the activity did not occur per documentation entry codes listed on same PCC page. Other shower entries for Resident #3 indicated that on 08/17/2023 on the 2:00 PM to 10:00 PM shift, Resident #3 was given a shower, required physical help in part of bathing activity by one person (codes 3 and 2) and that initials of person documenting belonged to a male nurse aide. Entry on 08/15/2023 indicated that activity did not occur for Resident #3 and entry on 08/14/2023 indicated that activity did not occur. There were no further shower entries in PCC electronic medical record for Resident #3 for August 2023. Second interview with Resident #3 occurred on 08/25/2023 at 10:10 AM. Resident #3 recounted the events verbally as she did during first interview; Resident #3 recounting of the shower event did not change from her first interview on 08/23/23 to her second interview on 08/25/25. Resident #3 description of the perpetrator did not change from the first interview to the second interview. During interview on 08/25/2023 at 10:10 AM, Resident #3 stated that DON had come by to see her (unknown day/date). Resident #3 stated that DON advised her to speak with ADM and find out if he had spoken with alleged perpetrator. Attempted to call Family Member #2 on 08/23/2023 at 3:30 PM. Sims message (digital phone number of caller) was only available option after Family Member #2 did not answer, and phone number was sent for call back. Attempted to interview Family Member #2 on 08/24/2023 at 10:39 AM, Sims message sent (call back number sent). Attempted to call Family Member #3 on 08/23/2023 at 4:09 PM. Message left requesting call back. Attempted to call CNA B for interview on 08/23/2023 at 3:37 PM as RN A had provided phone number for facility staff person who frequently worked with Resident #3; no answer; voicemail was not an option. Attempted to call CNA B a second time for interview on 08/23/2023 at 2:27 PM, no answer to phone call and voicemail was not an option. CNA B was not working in the facility on investigation days per RN A. Record review of facility's policy titled Abuse, Neglect, and Exploitation dated October 2022 reflected Residents have the right to be free from abuse, neglect, mistreatment, misappropriation, and exploitation. Record review of facility's ANE Policy, dated October 2022, reflected The facility should attempt to take necessary steps to verify residents are protected from subsequent episodes of abuse. Upon learning of alleged abuse, neglect, mistreatment, or exploitation, the ADM or supervisor on duty should attempt to take necessary steps to verify residents are protected from subsequent episodes of abuse, neglect, mistreatment, or exploitation .and take necessary steps to protect the residents. If the investigation is conducted by a designee, the designee should report the results of the investigation to the ADM, no time frame for reporting to ADM is specified. On 8/25/23 at 05:50 PM, an Immediate Jeopardy (IJ) was identified. The ADM was notified and provided the IJ template, and a Plan of Removal (POR) was requested at that time The Facility Plan of Removal (POR) was accepted on 08/27/2023 at 10:45 AM. Monitoring of the plan of Removal included the following: Plan of Removal On 8/25/2023, at 5:45PM, [Facility] was notified of an immediate jeopardy for F600 (Free from abuse and neglect) regarding: - The facility failed to prevent further mistreatment of Resident #2 while the investigation was in progress - The facility failed to investigate a report of abuse by Resident #3 to prevent further abuse F600 Abuse and Neglect 1. Two residents were identified as being affected by deficient practice. All residents have the potential to be affected. Resident #2 discharged on [DATE]. On 8/25/2023, Resident #3's alleged perpetrator was put on formal suspension pending further investigation. The CNA has not been in the community since noon on 8/24/23. On 8/25/2023, director of clinical services completed skin assessment and pain data collection. No concerns or pain noted. Beginning on 8/26/23 through 8/27/2023, the regional director of clinical services provided re-education to licensed nurses and CNAs regarding showers, customer service and abuse and neglect. Licensed nurses and CNAs not available will be re-educated prior to the next shift or during orientation for new hires by the DCS or designee. 2. Beginning on 8/25/2023 and continuing through 8/26/23, DCS and/or designee conducted interviews with all current residents regarding potential abuse and/or neglect. No additional allegations of abuse or neglect were identified. Beginning on 8/25/2023 and continuing through 8/26/23, DCS and/or designee conducted pain data collections on current residents, which includes verbal and non-verbal pain. Beginning on 8/25/2023 and continuing through 8/26/23, the administrator and designee reviewed current residents' last 45 days (8/25/2023 back through 7/11/2023) of progress notes, grievances, and incidents/accidents to ensure all residents were free from abuse and neglect. No additional allegations of abuse or neglect were identified. 3. On 8/25/2023 through 8/26/2023, licensed nurses and CNAs were re-educated by the director of clinical services/designee regarding: o o Abuse, neglect, and exploitation policy including retaliation with post-test o o Reporting any suspected allegation of abuse-to-abuse coordinator (Administrator) and/or backup abuse coordinator (executive director) immediately o o Staff, residents, and/or visitors may file a formal grievance and/or concerns o o Completing a grievance form and providing to the administrator/executive director and/or designee o o When a resident voices pain during care, associates will halt care, and notify a licensed nurse to address the resident's concerns Licensed nurses and CNAs not available will be re-educated prior to the next shift by the DCS or designee. On 8/25/2023, the healthcare administrator and executive director completed re-education by Regional Director of Clinical Services (RDCS) regarding completing thorough investigations dealing with abuse, neglect, or exploitation, including suspension of alleged perpetrators pending completion of the investigation. On 8/26/2023, RN weekend supervisor was re-educated by executive director and/or designee on reporting potential allegations of abuse and/or neglect to the abuse coordinator and/or backup abuse coordinator immediately. 4. Starting on 8/25/2023, progress notes, incidents/accidents, and grievances will be reviewed daily Monday-Friday by an interdisciplinary team (executive director, healthcare administrator, DCS, ADCS, RAI coordinators, CDM, resident programs, and social services) (IDT) in the clinical meeting. Saturday and Sunday to be reviewed by the weekend supervisor, to verify that residents are free from abuse and neglect. Quality improvement rounds to be completed by members of the IDT daily Monday through Friday. Results will be recorded and reviewed by the a [TRUNCATED]

Based on interview and record review, the facility failed to ensure that each resident receives adequate supervision and assistive devices to prevent elopement for one resident (Resident #4) of two reviewed with dementia who exhibited exit-seeking behaviors. Resident #4 was able to exit facility on 07/19/2023 around 1:00 PM and was left unsupervised and exposed to environmental hazards for a period of time. A past non-compliance Immediate Jeopardy was identified on 08/25/2023. The IJ was determined to have been removed due to the facility's implemented actions that corrected the non-compliance prior to the beginning of the investigation. This failure could place residents with dementia who have exhibited exit-seeking behaviors at risk for severe injury or death. Findings included: Record review of Resident #4's face sheet dated 07/20/2023 revealed an [AGE] year-old female resident admitted on [DATE] from acute care hospital with Diagnoses which included syncope and collapse, fall which required acute-care hospitalization in period just prior to facility admitted [DATE], dementia without behavioral, psychotic, mood, or anxiety disturbance, seizures and epilepsy, among other diagnosis. Primary language of Resident #4 was noted to be of Eastern European dialect per face sheet dated 07/20/2023. Record review of Resident #4's MDS dated [DATE] revealed BIMS score of 07/15, which indicated severe cognitive impairment (a deterioration or loss in intellectual capacity), wandering behavior had not been exhibited. Resident #4 required supervision level of assistance for walking in room, walking in corridor, locomotion on unit, and locomotion off unit. Resident #4 had not had any falls since 07/05/2023. Resident #4 had been admitted for OT and PT services and those services were provided during facility stay. Record review also revealed that no physical restraints were used during stay. Record review of Resident #4's Care Plan entry for Fall Risk revealed that Resident #4 focus area for fall risk was initiated on 07/05/2023, that a Goal of Resident #4 not sustaining serious fall injury was initiated on 07/19/2023, that fall interventions of OT eval (evaluate) and treat as ordered and PT evaluate and treat as ordered were established on 07/05/2023 and that other fall interventions were initiated on 07/19/2023. The Care Plan revealed wandering/elopement seeking behaviors with initiation of focus area, goal, and interventions added to Care Plan on 07/19/2023include the following: Ensuring the environment is clutter free and hazardous items are away from Resident #4, collaboration of staff to help with monitoring Resident #4, relocating Resident #4 to a room close to nurse's station, asking family members to come sit with Resident #4, providing one on one supervision. Use of wander guard (an electronic device worn as a bracelet or anklet which interfaces with an alarm if resident gets too close to an exit door) did not appear as an intervention for elopement risk on Care Plan. Resident #4 Care Plan revealed initiation of entry on 07/19/2023 with focus area of blisters to both left and right heel due to frequent ambulation; goal and interventions for blisters were initiated on 07/20/2023 and included intervention of encouraging Resident #4 to wear shoes and socks when ambulating, monitoring healing of the blisters, and monitoring feet for signs and symptoms of infection every shift, notification of medical provider if blisters opened. Care plan for Resident #4 focus area of ADL self-care performance deficit, initiated 07/05/2023 indicated an intervention initiated on 07/19/2023 of making sure shoes were comfortable and not slippery. Record review of Tulip intake revealed that on 07/19/2023 at 1:15 PM, the facility learned of an incident in which Resident #4 had eloped from the building. Resident #4 with no injuries found, completion of change of condition documentation, utilization of wander guard system/process and management of wander guard alarm, notification of physician and family, one on one care initiation, auditing like-residents, and providing hydration. The report indicated in-service of staff on change of condition process, utilization of elopement binder/procedure, wander guard system/process and management, and notifications. Record review of an e-mail (electronic mail) from the ADM dated 07/20/2023 at 12:57 PM, uploaded to Tulip, stated that Resident #4 was first noted to exit seek on 07/06/2023. Further information indicated that Resident #4 had been gone approximately 25 minutes, was a short term rehab (rehabilitation) resident, and had been wearing a wander guard. The e-mail stated that Charge Nurse (no name specified) and Aide (no name specified) saw her 15-20 minutes prior to being reported missing. Record review of PIR, submitted on 07/27/2023 at 5:08 PM, indicated that Resident #4 had a wander guard placed on 07/06/2023 when Resident #4 was initially identified as an exit-seeker. and that Resident #4 was first found to be missing by Social Services Director on 07/19/2023 (no stated time). Record review of facility Incident Investigation Incident report, Summary of Incident, dated 07/20/2023 reflected that Social Services Director had gone to Resident #4's room on 07/19/2023 (no time indicated) and did not find Resident #4 there. Social Services Director then (no time indicated) informed Charge Nurse A that Resident #4 was not in her room and a missing resident procedure was initiated (no time indicated). Record review of (facility) Incident Investigation report, Associate Interview section, dated 07/20/2023, Charge Nurse A statement indicated that Charge Nurse A, assigned to Resident #4, was notified around 1 PM that Resident #4 was missing and that Charge Nurse A had last seen Resident #4 approximately 20 minutes prior. Record review of facility Incident Investigation report, Associate Interview section, dated 07/20/2023, CNA F revealed that she has seen Resident #4 approximately 15-20 minutes prior (no time given) to the time that she was found missing (no time given). Record review of facility Incident Investigation report, Summary of Incident, dated 07/20/2023, indicated that Resident #4 was found outside the community (by not stated person) and was returned without any visible injuries (time not stated). Record review of facility Incident Investigation report, Resident Interview, dated 07/20/2023 indicated that Resident #4 was attempting to go home. Record review of facility Incident Investigation report, Post Investigation Actions, dated 07/20/2023 indicated that the following actions would be taken: care plan updates, in-services/associate retraining, audits (non-specified), wander guard system adjustment, 24/7 one on one care initiation with Resident #4. Record review of Form Scoring Report to identify residents at risk for elopement printed on 07/19/2023 at 14:23:54 CT indicted that elopement assessment for Resident #4 indicated Not at Risk for Elopement on 07/05/2023. No further assessment of elopement was indicated on this report for Resident #4. Record review of Form Scoring Report to identify a resident at risk for elopement printed 07/19/2023 at 14:25:51 CT indicated that Resident #4 was identified as Potential Elopement Risk on 07/06/2023 and on 07/19/2023. Record review of 07/19/2023 at 12:35 PM in-services included utilization of Elopement Binder to assist nursing staff familiarity with residents at risk for elopement, and Incident Reporting - Elopement. Sign in sheets reflecting date/time of in-service and nursing staff in attendance were contained with in-service content. Record review of 07/19/2023 at 4:20 PM in-service regarding resident Change of Condition related to Elopement/Missing Resident included nursing staff sign-in sheet and reference to attached policy. Instruction to notify administrative staff if an elopement/missing resident incident takes place was noted on staff sign-in sheet for this in-service. An in-service dated 07/20/2023 at 08:00 AM entitled Elopement Notifications to HCA was noted to be held for Therapy Department. Sign in sheet of this in-service reflected Therapy Department staff signatures and defined elopement, indicated presence/access of elopement binder at each nurse's station, and the statement that wander guards should be disabled by a licensed nurse only. An example of elopement followed the definition of elopement on 07/20/2023 at 08:00 AM in-service sign-in sheet for Therapy Department. The written example of elopement reflected Leaving skilled nursing to first floor AL without signing out/notifying staff. Elopement was defined on Therapy Department in-service sign in sheet dated 07/20/2023 at 08:00 AM as A situation in which a resident leaves the premises or a safe area without the community's knowledge and supervision which may represent a risk to the resident's health and safety. Concierge staff in-service sign-in sheet dated 07/20/2023 at 08:00 AM entitled Elopement Notifications to HCA reflected the same items covered in meeting as those of Therapy Department. In-service dated 07/20/2023 at 08:00 AM entitled Elopement Notifications to HCA with sign-in sheets was held for House (miscellaneous staff working in the facility) and for Dining Department and reflected items covered as: elopement definition, elopement example, elopement binder access and utilization, notification of administrative staff if an elopement occurs, and disabling of wander guard system by licensed nurse only. Record review of hard copies of 7/19/2023 and 07/20/2023 in-service sign in sheets were reviewed during investigation on 08/23/2023 through 08/25/2023. Record review of Nursing Progress Note dated 07/06/2023 at 8:55 PM by Charge Nurse B revealed that Resident #4 was exit-seeking and that wander guard had been applied to right wrist. Record review of Nursing Progress Note dated 07/14/2023 at 2:16 PM by Charge Nurse C revealed that Resident #4 made several attempts to elope, requires redirection, and has a wander guard in place. Record review of Nursing Progress Note dated 07/15/2023 at 9:21 PM by Charge Nurse D revealed that Resident #4 was wandering around the unit, wander guard in place at all times. Record review of Nursing Progress Notes of 07/16/2023 at 9:14 PM by Charge Nurse E revealed that Resident #14 had attempted to elope six times (period of time not stated). Record review of Nursing Progress Note dated 07/18/2023 at 6:30 PM revealed that Charge Nurse A had been contacted by receptionist from the first floor stating that she noted resident in the parking lot and brought her back into the building, and that resident continued exit-seeking behaviors that evening. Record review of Progress Note dated 07/20/2023 from APRN revealed that Resident #4 had an episode of elopement today and was found in a housing community nearby. She was brought back to her room and vitals were stable. Her face was flushed and she was given cold towels and ice water. She denies pain. She did have some blisters on her feet from where her shoes rubbed but no injuries. Patient reported that she was trying to get home. She had a wander guard in place that was functioning but was still able to elope. Patient (Resident #4) to get 24-hour sitter and plans to dc (discharge) home tomorrow with family. Record review of Missing Resident Drill Forms and sign-in sheets reflected drills conducted on 07/20/2023 at 12:30 PM, day shift, and 3:20 PM, evening shift. Record review of Missing Resident Drill Form reflected drill done on night shift at 07/21/2023 at 11:25 PM. Missing Resident Drill Forms Summary reflected that wander guard alarms were ignored and that wander guard alarms were not loud enough/staff reporting trouble hearing alarms. Record review of Root Cause Analysis developed during facility ad hoc (when necessary) QAPI meeting on 07/20/2023 at 1:00 PM indicated root cause analysis of elopement to be the need for wander guard enhancements. Interview with RN A on 08/23/2023 at 3:07 PM, revealed that RN A was working on day of Resident #4 elopement on 07/19/2023. RN A stated that Resident #4 was wearing a wander guard at time of elopement. RN A stated that Resident #4 had been placed on one-to-one supervision on several occasions during facility stay for exit-seeking. RN A stated that prior to elopement incident on 07/19/2023, staff would silence wander guard alarms. Since the elopement incident of 07/19/2023, RN A stated that only licensed nurses can now silence alarms. RN A stated that he believed that Resident #4 had been gone 5-10 minutes before she was found outside on 07/19/2023. Interview with CNA F was done on 08/24/2023 at 11:18 AM. CNA F stated that she was working on 07/19/2023 when elopement incident with Resident #4 occurred. CNA F stated that everybody was looking for her (Resident #4). CNA F stated that she did not know how Resident #4 got outside. CNA F stated that Resident #4 was not gone long but was not able to state how long Resident #4 was gone. Interview with Social Worker on 08/25/23 at 1:17 PM revealed that Resident #4 was found by a neighbor (unknown name) that lived near the facility. The neighbor realized that Resident #4 was confused and called the facility to report her location. It was then that she was brought back to the facility by two staff members who went to pick her up and walk her back to facility. Social Worker stated that she did not believe that Resident #4 was injured during incident, Social Worker stated that she felt that Resident #4 was just dehydrated, flushed, and sweating. Social Worker stated that Resident #4 was given water when she returned to facility. Social Worker stated that police were not involved in search and that Resident #4 was gone for about 15-20 minutes. Interview with Family Member #4 was conducted on 08/23/2023 at 5:26 PM. Family Member #4 stated that she was made aware on 07/19/2023 afternoon that Resident #4 had left the facility. Family member #4 stated that facility had called her three times during Resident #4's stay from 07/05/2023 to 07/20/2023 to report that resident was missing. Resident #4 Family Member #4 stated that Resident #4 worn a bracelet, applied by facility staff, that would help prevent elopement. Family Member #4 stated that Resident #4 had a strong will to leave the facility and on the fourth attempt she got outside. Resident #4 Family Member #4 stated that facility offered to find placement for Resident #4 in a Memory Care Unit after 07/19/2023 elopement incident. Family Member #4 stated that she brought Resident #4 to her house the next day and has hired 24-hour caregivers for Resident #4. Family Member #4 stated that after the elopement incident, she was told that the facility gave her water right away because it was hot outside and facility staff believed that Resident #4 may have been dehydrated. Family Member #4 stated that she was not aware of any other harm caused by the elopement. Family Member #4 stated that staff accounts of incident led her to believe that Resident #4 was missing for 15-30 minutes at approximately 1:30 PM on 07/19/2023. Interview with ADM on 08/25/2023 at 10:57 AM, revealed that Resident #4, during her stay from 07/05/2023 to 07/20/2023, had eloped to the outside of building one time and another time was found in a stair well. Actions taken after 07/19/2023 elopement incident included: root cause development, routine checks of wander guard when placed on residents and during duration of use by residents (order to check appears every shift on resident's treatment record to prompt nurses to check), and weekly door checks, with documentation log kept by maintenance, for properly working delayed egress mechanism. Per interview with ADM on 08/25/2023 at 10:57 AM, further actions taken after 07/19/2023 elopement incident included Missing Resident drills in immediate days following elopement and initiation of monthly Missing Resident drills. ADM stated that radios were now kept at nurse's station for enhanced communication. ADM stated that Security Guard now has a golf cart to check the premises when a resident is reported missing, and an emergency response warning is sent out to law enforcement officials when a resident is missing. ADM stated in interview on 08/23/2023 at 10:57 AM interview that elopement binders which include a copy of resident face sheet with photograph would be kept at each nurse's station and receptionist desk at entrance to facility. ADM further stated during 08/25/2023 at 10:57 AM interview that wander guard enhancements had been made which increased the alarm volume for staff when a resident wearing a wander guard gets close to the exit doors. Observations were conducted of live Missing Resident Drills on 08/23/2023 at 1630 (430pm) on floor 2 and on floor 3 with DON. No facility staff were observed silencing alarm. Two staff members on one floor were observed to continue other tasks during alarm period and drill and DON acknowledged that all staff should stop what they are doing and participate when there is a missing resident. DON stated on 08/24/2023 that a facility-wide elopement drill had been conducted since investigator observed drills of day prior, with good results. No sign-in sheet of this drill was produced when requested from DON for record review. Record review of facility Elopement Risk Policy dated 10/2022 defined elopement as a situation in which a resident leaves the premises or a safe area without the community's knowledge and supervision which may represent a risk to the resident's health and safety. Policy detail revealed that residents accepted for admission should be assessed upon admission into the Community and appropriate interventions should be established to respond to the resident's potential exit/elopement seeking behavior. Policy detail included completion of Elopement Risk Data sheet with photograph and placement in Elopement Risk Binder at Nurses Station, communication elopement risk to associates, elopement risk assessment on admission, quarterly, and as needed, and interventions will be documented in resident's Plan of Care. Policy on initiating wander guards, Resident Monitoring System policy, dated 10/2022, stated that Physician Orders should be placed for use of monitoring system, notification of Resident/Legal Representative, application according to manufacturer's instructions, monitoring of resident's comfort related to the device, verification of proper functioning. Policy revealed that placement of device should be checked every shift and documented, monitoring system should be inspected monthly and documented, and that recommendation will be made to physician for discontinuance of it has been determined that less restrictive measures can be accommodated. Record review of Elopement System Alarm Activation Policy, dated 10/2022, for wander guard alarms was reviewed. Policy stated that staff should go immediately to site of activation, alarmed door should remain alarming, the unsupervised resident should be identified or every resident with an elopement device should be accounted for, alarm will be reset by designated personnel, and if resident is unable to be located, Missing Resident policy will be enacted. Record review of Missing Resident Policy, dated 06/2017, revealed that a missing resident requires immediate attention. Missing Resident Policy, dated 06/2017, revealed that the following steps should be taken: verify if resident has signed out, obtain the time of last sighting, determine clothing that resident was wearing as well as cognitive and emotional status, obtain height and weight and other descriptive characteristics of missing resident. Missing Resident Policy, dated 06/2017, stated that the Missing Resident Response Worksheet should be initiated followed by a thorough interior search of the building. Security would then be notified to begin search of outside grounds, using security vehicle if needed. ADM and DON are to be notified as well medical provider. Lastly, provide the Missing Resident Profile with a picture of resident to local law enforcement. When a resident is located, per Missing Resident policy, dated 06/2017, the resident should be reviewed for injuries, an incident report should be completed, medical provider should be notified and resident will be transferred to higher level of care if needed. Resident will be assigned one-on-one supervision until reassessment determined future placement needs. On 08/25/2023 at 05:50 PM, a past non-compliance IJ was identified. The ADM was notified and provided the IJ template.

Based on observation, interview and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one of seven residents (Resident #1) reviewed for pressure ulcers. The facility failed to ensure treatment was initiated for one week after a DTI was identified on Resident #1's left heel on [DATE]. This failure led to a worsening of Resident #1's heel ulcer from a DTI to an unstageable pressure ulcer requiring hospitalization and placed residents at risk for developing infections and deterioration of their wounds. Findings include: Record review of the, undated, face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . It occurs due to blockage in the lymphatic system which is part of the immune system), and [CONDITION(S)] (failure of the veins to adequately circulate the blood, especially from the lower extremities). Record review of the admission MDS for Resident #1, dated [DATE], reflected a BIMS score of 15, which indicated little or no cognitive impairment. It also reflected he was at risk for development of pressure ulcers but did not have any pressure ulcers. Record review of the care plan for Resident #1, dated [DATE], reflected the following: The resident has potential/actual impairment to skin integrity. Resident will be free from skin breakdown through review date. The resident will have no worsening of skin alteration through review date. Assist with turning and reposition as needed. Reduce friction and shearing with use of lift/transfer sheets. Evaluate skin condition on a daily and weekly basis. Keep skin clean and dry. Use lotion on dry skin. Do not apply to area of skin breakdown, wound, or between toes. Monitor labs per physician order. Report abnormalities to MD. Record review of nursing progress notes for Resident #1, dated [DATE] and recorded by LVN B, reflected the following: Note Text: Wound care provided. Resident noted to have a DTI to L heel. (RN A) made aware. Record review of Weekly Skin Assessment Form for Resident #1, dated [DATE], reflected a new issue of deep tissue injury to left heel. Record review of clinical physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Weekly Pressure Injury Report and Summary reflected a wound documented for Resident #1 on the following dates with the following characteristics: [DATE] Left Heel 5.4cm X 5.7cm X UTA DTI Drainage: None Odor: None Treatment: [MEDICATION(S)] MWF Medical Device: offload, float, elevate [DATE] Left Heel 4.4cm X 5.9cm X UTA DTI Drainage: None Odor: None Treatment: [MEDICATION(S)] MWF Medical Device: offload, float, elevate Record review of the [DATE] TAR for Resident #1 reflected no treatment item for his heels. Record review of the [DATE] TAR for Resident #1 reflected [MEDICATION(S)]-Iodine Solution 10 % Apply to left heel eschar topically two times a day for wound care was signed as administered on [DATE] at 5:00 p.m., [DATE] at 9:00 a.m. and 5:00 p.m., and [DATE] at 9:00 a.m. Record review of hospital records for Resident #1, dated [DATE], reflected the resident was diagnosed with an unstageable ulcer with dry gangrene (a dry, black, shrinking area of tissue indicating that the blood supply has been cut off) on his left heel. The records reflected the following: Left heel ulcer concerning for NSTI. Seen for painful, necrotic wound. During an interview on [DATE] at 10:23 a.m., RN A stated he oversaw the wound care program at the facility. He stated the process for addressing new wounds was he and the facility physicians looked the wound over once a week, and charge nurses did the treatments as ordered. He stated the facility did not utilize a distinct wound care physician or contract with a wound clinic, but NP C and NP D did the weekly wound rounds. He stated when a resident admitted with wounds or a new wound was identified, the nurse in charge at the time sent a physician communication form to him and to the NPs. He stated the next step was for him and the NP to observe and assess the wound, including measurements. He stated the nurse who first identified a new wound should have documented they notified him and the NP. With regard to Resident #1's deep tissue injury, he did not have it on admission, and they first saw it on [DATE]. When asked why no orders had been initiated until [DATE], he stated they always jumped on a new wound right away and initiated offloading and pressure relief. He stated there was a standing order for floating heels when a heel wound was identified. He stated he did not remember any reason why the orders were not entered, but he was sure the [MEDICATION(S)] treatment was happening. When asked if he did the treatment, he stated he did not. He continued to repeat the information about Resident #1's wound was given to him and the treatments would have been done even without an order, but he did not provide additional information in response to any further questions. He was asked for any further information related to the identification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During observation and an interview at the hospital on [DATE] at 9:16 a.m., Resident #1 was seen in bed with his left leg and foot wrapped in gauze and his right foot in an inflatable boot. He was receiving IV [MEDICATION(S)] (antibiotic). He stated his heels were never floated at the facility. He stated he got very little attention at the facility. He stated he did not know when the black wound appeared on his heel, but while he was at the facility, he started feeling some pain and tenderness when it touched the sheet of his bed, and then one day, he bent over, and saw a reflection of something black in his mirror. He stated when he saw the black heel, he called the nurse. He did not remember which nurse he called and apologized for not knowing the names of any of the people who cared for him in the facility. He said the nurse did not tell him anything specific about the wound, but none of the staff acted surprised about it. He stated another girl came in to see him and said to him, you should have that checked. He stated he could not believe they would see something like that and not call someone to get something done. He stated he did not remember exactly what they did with the wound once they found it, but he did not think there was very much done. He stated he did not know if the wound was getting better now that he was in the hospital. He stated the hospital was doing some kind of surgical procedure the following day, on [DATE] to find out what was behind the black part of the wound, but he did not know exactly what the procedure was. During an interview on [DATE] at 9:37 a.m., the hospital RN stated the hospital had ruled out [CONDITION(S)] (bone infection) in the heel wound. She stated it was a deep tissue injury that was necrotic (most of the cells in this area of tissue have died due to disease, injury, or blood supply), and he was on [MEDICATION(S)] for that wound and for chronic [CONDITION(S)] on his legs. She stated he had an angiogram (an x-ray of blood vessels) scheduled the following day to determine if there was viable tissue behind the wound. During an interview on [DATE] at 11:12 a.m., NP C stated he believed RN A told him Resident #1 had a DTI on his heel on the day it was identified on [DATE], but NP C was out with COVID at that time. He stated RN A was in charge of the facility's wound care program, and RN B would usually assess a new wound, and then if it was a stable DTI would add iodine. He stated he did not have any insight into why the order for iodine or other treatment did not start until the [DATE]. He stated RN A did his wound rounds on Wednesday and Thursday of each week. He stated the nurses on the halls did their own wound care, and if anything was noted by either RN A or the nurses, RN A followed up on that with him or with NP D. He stated there was not a wound care physician that rounded at the facility and that if residents had more complex wounds than he and NP D could manage, the resident was referred to an outside clinic for visits. He stated he had no insight as to why Resident #1 was sent to the hospital on [DATE], as he was on leave that week. He stated there could be an impact on the resident if treatment was delayed in that a skin infection or pain could occur. During an interview on [DATE] at 11:52 a.m., RN E stated she had worked at the facility for three months. She stated she was familiar with Resident #1 and provided his wound care a few times while he was still in the facility. She stated she applied [MEDICATION(S)] to his heel and also performed wound care for his venous stasis wounds on his legs. She stated the eschar on the heel was dry when she treated it. She stated she performed some of the weekly head to toe skin assessments. She stated she did perform a head to toe skin assessment on Resident #1 but did not remember exactly when. She stated she worked PRN shifts so did not work regularly at the facility. She stated she remembered skin assessments with Resident #1 in June when he did not have the DTI on his heel but did not remember if she was the one who completed the skin assessments after he had the heel wound. She stated her process when she saw a new skin issue on a resident was as follows: she measured it, looked at drainage, the wound bed, documented pain, and wrote up a nursing note about it. She stated she then notified RN A and the NP using the physician communication form. She stated she slid on copy of the form under RN A's door if he was not in the office, and she left another in the physician binder at the nurse's station. She stated she would immediately make an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she was also trained to complete a change of condition on any new wound, so she would do that. She stated she was not involved in identifying Resident #1's DTI and became involved in treating it after there were already orders in place for treatment. She stated there could absolutely be a negative impact on a resident if treatment orders were delayed: the resident would not trust the care provided by the facility; it could impact their mental health; and it could cause infection or other major issues, especially if the resident was diabetic. She stated it could become really bad and lead to amputation if left alone for too long. A telephone interview was attempted with LVN B (the nurse who first identified Resident #1's DTI) on [DATE] at 12:04 p.m. A voicemail was left, but contact was not returned. During an interview on [DATE] at 12:35 p.m., NP D stated she was the NP who wrote orders for the DTI on Resident #1's heel on [DATE]. She stated a discharge home was impending for Resident #1, because he had refused care and therapy. She stated he had venous stasis ulcers on his legs, but the wound to his heel was the one she was concerned about. She stated they did a STAT X-ray to his heel to rule out [CONDITION(S)] (bone infection), and it was negative for [CONDITION(S)]. NP D stated the physician designee duties in the facility were split up between NP C and NP D, and NP C were out, so they had NP F, who did not normally work in the facility, assisting. NP D stated NP F was set to do his discharge on [DATE] to help her out and was really concerned about the DTI. She stated, once she and NP F had a conversation about the worrisome nature of his wound and his elevated white blood cell count, they decided it would be safer to discharge straight to the hospital. She stated she saw how bad the heel wound had gotten, and she knew it was out of the ordinary for there to be no orders for wound care for a week after the wound was identified. She stated the wound definitely could have worsened if it went without treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A telephone interview was attempted with NP F [DATE] at 12:57 p.m. A voicemail was left, but contact was not returned. During an interview on [DATE] at 1:09 p.m., CNA G stated she took care of Resident #1 and was responsible for most of his ADLs. She stated usually she did skin checks during bathing/showers, but Resident #1 did not take showers and preferred to clean himself with baby wipes. She stated she checked his skin when she assisted him, but he took care of himself for the most part. She stated she saw his feet once when one heel had a big black mark on it, and the other heel was fine. She stated that happened recently, just last week, sometime between [DATE] and [DATE]. She stated that day he had his socks and bandages off and asked her to use his phone to take some pictures of his wounds for him to send to his doctor. She stated if she saw a new skin issue, she reported to the nurse and then entered the information into the point of care documentation system under the skin observations tab. She stated she told her charge nurse about the wound, but the charge nurse already knew about it, so she did not document it in the skin observations tab as a new issue. During an interview on [DATE] at 1:53 p.m., the DON stated the DTI to Resident #1's heel was first identified on the 29th or 30th of June. She stated usually when a nurse identified something like that, the nurse would notify the NP and RN A, who was the wound nurse. She stated she knew the NP was notified, because she had the physician communication form signed by NP C. She stated she did not see any other orders for treatment after the wound was identified on [DATE] until [DATE]. She stated she did not know why no orders were entered into the system. She stated there should have been an order. She stated they had a COVID outbreak right at that time, and though there was no excuse for failing to obtain orders for treatment, that was probably why it did not happen on time. She stated they conducted skin assessments every week for all the residents which usually fell on a day there was a shower. She stated if there was ever a new wound discovered, the nurse who discovered it should have created a Change of Condition form in the EMR in addition to notifying RN A and the doctor or nurse practitioner. She stated every weekday, they printed a report of Change of Condition forms and went over them in morning meetings. She stated she could not remember if there was a change of condition form filled out for Resident #1's DTI, but she expected it was not, otherwise they would have discussed it the day after it was discovered. She stated she had conducted in-services on skin assessments and documentation for the previous few months, and she knew it had been an issue. She stated the failure to start treatment on Resident #1's DTI could impact him by affecting mobility, getting infected, and even up to he could lose his foot. During an interview on [DATE] at 2:40 p.m., the ADM stated RN A was the head of the wound care program at the facility. He stated monitoring wounds and wound care in the facility was RN A's responsibility as well as the nurses. He stated the wound guidelines for the facility for a DTI said to offload pressure, and the orders would typically call to treat it with [MEDICATION(S)]. When asked about the absence of treatment orders for the DTI until [DATE], he stated there were likely orders to float heels, but when shown there were no orders, he stated floating heels might have been in the CNA point of care tasks. When it was pointed out floating heels were not in tasks, he stated it would at least be in the care plan. When it was pointed out there was nothing about the DTI in the care plan, he asked if Resident #1 had orders for pressure-relieving boots and determined he did not. He stated a potential impact of a delay in treatment to a DTI was worsening of the wound. Record review of the facility procedure, revised ,d+[DATE], and titled Skin and Wound Care Protocol/Guidelines reflected the following: DTI: purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue. Blister: apply no sting barrier spray or no sting barrier wipe cover with transparent dressing or foam dressing change every 3 to 7 days and PRN dry wound bed hydrogel (gel or [MEDICATION(S)] pad) cover with foam dressing. Change each three days and PRN. Documentation should include: assessment/observations, planning, interventions, evaluations, and resident's response to therapy. At least weekly in the medical record, document the following: wound type, location, size, stage, drainage, appearance of the wound bed - epithelium, granulation, slough, necrotic tissue or eschar, condition of surrounding skin, current treatment, resident's response to treatment/progress. Heel ulcer prevention and management The most effective intervention for heal ulcers is to eliminate pressure (i.e. pressure relieving boots such as prevalon boot). local signs of infection, no topical dressing or [MEDICATION(S)] agent is necessary. Minimize. Heel ulcer prevention and management the most effective intervention for heal ulcers is to illuminate pressure i.e. pressure relieving boots such as prevalon boot. Skin prep each shift. If your ulcer has a scar in the area is dry, intact and without local signs of infection, no topical dressing or [MEDICATION(S)] agent is necessary. Minimize exposure to pressure (skin prep each shift, offload heels, i.e. pressure relieving boots such as pillows, prevalon boot or waffle boot. Monitor area for any evidence of infection ([CONDITION(S)], warmth, pain, swelling, fever, drainage) and notify the physician per protocol.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for one (1) of four (4) residents reviewed for proper supervision during personal care, when the resident was not provided with a two-person assist and rolled out of bed fracturing her femur (Resident #1). The facility did not provide a two person assisted transfer for Resident #1 when she rolled out of bed during care resulting in fracturing her femur due to not having the support and supervision needed for safety. These deficient practices could place 10 residents identified from incident reports as having had a fall in the previous two months at risk for injury from lack of supervision. Findings Included: Resident #1's face sheet dated 03/30/17 reflected a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's MDS assessment dated [DATE] reflected for bed mobility and transfers the resident needed extensive assistance of Two+ persons physical assist. Resident #1's Care Plan initiated on 02/13/17 reflected for 1 to 2 staff to assist resident for mobility and transfers. Incident Report and Investigation dated 02/18/17 reflected at 4:45 p.m. CNA A was providing direct care to Resident #1 and turned the resident on to her right side away from her. Resident #1 was in a bed with an air mattress and was unable to support herself from rolling further and rolled off the bed onto the floor. Resident #1 was sent to the hospital with leg pain and multiple lacerations/skin tears to both arms, the lower lip and left eyebrow. Resident #1 also had the possibility of a dislodged J-tube. The conclusion of the facility's investigation was that no neglect occurred because Resident #1's plan of care was being followed at the time of the incident. Review of Nursing Notes written 02/18/17 for Resident #1 reflected the resident rolled out of bed during direct care and landed face down. Immediate assessment of Resident #1 reflected leg/hip pain, multiple skin tears to both arms, cut to left eyebrow, cut to lower lip, and a cut to left nostril. J-tube was connected to pump and appeared to be pulled. Resident sent to hospital by ambulance for further evaluation and treatment. Review of Nursing Note written 02/19/17 at 6:42 a.m. reflected that Resident #1 returned from the hospital just before midnight with a splint on left leg with a [DIAGNOSES REDACTED]. Review of Hospital Records dated 02/18/17 for Resident #1 reflected a [DIAGNOSES REDACTED]. In an interview on 03/30/17 at 9:23 a.m. Resident #1's sister said a fracture of the femur occurred because Resident needed two staff to assist her for safety and only one was providing care. She said a family member was watching it on webcam but did not record the incident. She said the resident has since passed away. In an interview on 03/30/17 at 1:10 p.m. CNA A said she had been providing care to Resident #1 by herself the day of the incident. CNA A stated that she rolled on her right side (Resident had paralysis on the left side) to provide care. CNA A stated that when she started moving the resident on her right side, the resident kept rolling in the bed, and subsequently fell off the bed and onto the floor, before she could stop her. CNA A stated that her knowledge of the resident care needs was provided by the nurses. CNA A stated the nurses let the aides know what assistance the residents need. In an interview on 03/31/17 at 9:35 a.m; Rehabilitation Director (RD) looked at the evaluation for discharge from therapy services completed the day before the fall. RD stated that per the form, Resident #1 was not able to assist with turning in bed or holding herself in place. RD stated Resident #1 was totally dependent on staff and required two staff, to provide safe bed mobility while providing care. Rehabilitation Director said one staff would need to hold the resident, while the other provided care to the resident. Review of PT evaluation dated 12/23/16 reflected Resident # 1 needed maximum assist by two staff for rolling in bed. PT discharge summary dated 02/17/17 reflected Resident #1 was unable to assist with rolling side to side and was totally dependent for all bed mobility. In an interview on 03/30/17 at 12:20 p.m. MDS Nurse B and MDS Nurse C both said that the amount of assistance a resident needs is dependent on how strong the resident feels at that particular time and the size of the staff assisting the resident. According to the Facility Administrator there was a current census of 10 residents who had a fall previously.

Based on observation, interview, and record review, the facility failed to ensure that a resident maintained acceptable parameters of nutritional status, specifically body weight, for 1 of 11 residents (Resident #3) reviewed for weight loss. Resident #3 had significant weight loss and it was recommended by the dietician he receive feeding assistance and supplemental calories. The facility did not follow through with the Physician and the recommendation was not acted on for 9 days. This deficient practice could affect 6 residents who had unplanned significant weight loss and could result in further weight loss. The findings were: Review of Resident #6's face sheet revealed that Resident #3 is a [AGE] year male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly Minimum (MDS) data set [DATE], revealed that Resident #3 weighed 157 pounds (lbs) and was 68 inches tall. Using this height, his calculated Ideal Body Weight (IBW) is 150.48 lbs. Review of Resident #3's Monthly Weights revealed a 13 lb weight loss (9%) from 9/17/16 to 10/5/16 as follows: 7/23/16 159 lbs 8/3/16 157.8 lbs 9/17/16 157 lbs 10/5/16 143 lbs Resident #3's last weight of 143 lbs is 4.97% below his calculated IBW of 150.48 lbs. Review of Resident #3 ' s Progress Notes revealed a Dining Services Progress Note written on 10/3/16 by the RDN, recommending to continue assisting with meals, offer 120 ml 2 cal med pass twice daily between meals, SNP at all meals (increased calorie meal), and consider appetite stimulant X 30 days to see if effective per MD review. Review on 10/11/16 of Resident #3's Consolidated Physician Orders, revealed no orders up to that date related to the dietician ' s recommendations for feeding assistance, 2 Cal twice daily between meals, increased caloric meals, or an appetite stimulant. Review of Resident #3 ' s Care Plan dated 1/2015, revealed a plan to monitor meal intake, weights, assist with meals when needed, and offer supplemental nourishment as needed. The nutrition problem in the care plan was last reviewed on 9/22/16. Review on 10/12/16 of Resident #3 ' s Consolidated Physician Orders, revealed three new orders that were entered on 10/12/16 in the afternoon for feeding assistance at all meals, 2 Cal twice daily between meals, and increased caloric meals. Observation on 10/10/16 at 9 a.m., Resident #3 was in bed in his room alone. A breakfast plate is on his bedside table. Resident #3 is attempting to eat his breakfast, but is physically unable to effectively pick up his food and get it to his mouth. No staff assistance was provided. Observation on 10/11/16 at 8:48 a.m., Resident #3 was sitting up in bed alone, attempting to eat breakfast; but unable to get the toast to his mouth. No staff assistance was provided. Review of meal intake documentation in Resident #3 ' s electronic chart ,revealed Resident #3 ate 0-25% of his breakfast on both 10/10/16 and 10/11/16. In an interview on 10/11/16 at 1:05 p.m., when asked why Resident #3 did not have any assistance for feeding at breakfast time, CMA E stated that staff get very busy in the dining room during breakfast. In an interview on 10/11/16 at 1:07 p.m., when asked why Resident #3 did not have any assistance for feeding at breakfast, CNA D (who was feeding Resident #3 his lunch at the time of this interview) stated that Resident #3 has a private sitter that usually visits for about an hour to feed Resident #3; but that the sitter had started coming in the afternoon more recently. In an interview on 10/12/16 at 1 p.m., CMA E showed investigator Resident #3 ' s Medication Administration Record [REDACTED]. In a telephone interview on 10/12/16 at 2 p.m., the RD indicated that Resident #3 had significant weight loss in less than a month. When asked how her recommendations are implemented, the RD stated that her recommendations are entered into the electronic chart and go to the DON, who then implements dietary recommendations and coordinates with the physician any recommendations requiring a doctor ' s order. She stated she would expect recommendations to be addressed within 72 hours. During an interview on 10/12/16 at 2:45 p.m., the DON stated that there had been a delay implementing the dietary recommendations because the family, in particular Resident #3 ' s son, was wanting to send Resident #3 to the hospital. During an interview on 10/12/16 at 3:46 p.m., Resident #3 ' s son stated that he had attended a care plan meeting with the facility last week. Resident #3 ' s son stated that the facility staff discussed the need to consider hospitalization for Resident #3, but he wished to forego that option; and preferred Resident #3 stay at the facility, because he was concerned that the transfer would cause agitation and perhaps further dehydration. When asked if he was aware of the dietary recommendations made last week by the RD and whether he would have been amenable to the recommendations; he stated that he was not aware of the recommendations until today, 10/12/16, when the facility called to notify him of the new orders and that he would have certainly been agreeable to starting those recommendations last week. Review of CMS form 672 revealed there were 6 residents who had an unplanned significant weight loss.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit neglect for one (1) of five (5) residents reviewed for abuse and neglect (Resident #2). The facility failed to ensure that the facility-owned van used for resident transportation was properly equipped with a lap seatbelt to safely secure residents in wheelchairs and failed to ensure that residents being transported in wheelchairs were secured using a lap seatbelt. While Resident #2 was being transported to [MEDICAL TREATMENT] on [DATE] by Driver A, Resident #2 slumped forward, fell out of his wheelchair and hit his head on the floor of the van. Resident #2 was taken to the hospital where he later expired on [DATE] at 11:11 pm. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at an actual harm level with a scope identified as pattern. This deficient practice could place 10 residents who use wheelchairs during transportation at risk for severe injury or death due to being improperly secured in a wheelchair during transit. Findings include: Review of the facility ' s abuse and neglect policy dated [DATE] reflected that the facility " is committed to maintaining a safe environment for each resident, visitor and associate. Instances or allegations of abuse, neglect or exploitation should be treated seriously and must be reported to the Executive Director or the supervisor on duty for investigation, appropriate follow-up, and required reporting based on state regulation. " " Neglect is defined in Texas as the failure to provide for one ' s self the goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caregiver to provide such goods or services. " Review of Resident #2 ' s Face Sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2 ' s most current Minimum Data Set ((MDS) dated [DATE] reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 (a score of ,[DATE] indicating moderately impaired cognition). The MDS also indicated that Resident #2 required extensive two person assistant with transfers. Review of Resident #2 ' s Care Plan dated [DATE] reflected that Resident #2 was at risk for falls and had a fall risk score of 14 (a score of 10 or above indicating a high risk for falls). Interventions included to wear footwear that fit properly with non-skid soles, provide reminders to use ambulation and transfer assist devices, and to use an alarm " to monitor attempts to rise. " Review of the incident report involving Resident #2 dated [DATE] reflected " (Facility) driver (Driver A) picked up (Resident #2) from the Assisted Living at 10 am for transport to [MEDICAL TREATMENT]. Resident was loaded into the van in his wheelchair, and the four point straps were secured to his wheelchair. The resident was secured in his wheelchair with the van shoulder seat belt. At the entrance of (the road near the facility) the van stopped at the stop sign for a car to pass. (Driver A) stated he looked in the rearview mirror, and was speaking to (Resident #2) when he saw (Resident #2) make a wide-eyed distressed face, and then he fell forward. It appeared the resident pushed the top of the seat belt shoulder strap down and fell forward onto the floor. His one intact leg was caught in the seatbelt. (Driver A) immediately went to the resident and called 911 for help. The resident was mumbling when the EMS quickly arrived at the scene. (Driver A) notified the facility of the incident and the staff responded to the scene with the resident ' s advanced directives. Resident assessed by EMS, while staff in route, and CPR (Cardiopulmonary resuscitation) began when resident noted to be in [MEDICAL CONDITION]. EMS stated resident had a pulse and transferred him to the (emergency room ) ER for further evaluation. Follow-up: DON called (Resident #2 ' s responsible party) on ,[DATE] and she explained that the resident had been placed on a ventilator in the hospital and that on Saturday night she elected to withdraw the ventilator and the resident passed away. " During an interview on [DATE] at 4:20 pm, Driver A stated that on [DATE] around 10:00 am, he picked Resident #2 up from the facility and strapped his wheelchair into the van (using the 4 floor straps) and secured the resident using a shoulder seatbelt. Driver A stated that he brought the van to a complete stop at the entrance to the facility, because traffic was coming from both directions. As he was waiting for traffic to clear, he began to talk to Resident #2. When Resident #2 did not respond, Driver A looked in the rearview mirror and saw the resident had a wide-eyed expression on his face and then " slumped " forward and fell . Driver A stated that he put the van in park, went to the back of the van, and called 911 when he saw the resident on the floor of the van with blood underneath his head. He then called the facility. Driver A stated that he did not move the resident. Driver A stated that Resident #2 ' s shoulder seatbelt was still intact and attached to the latch on the floor and the wheelchair was still in place. He stated that when Emergency Medical Services (EMS) arrived, the paramedics asked him how to undo the restraints to the wheelchair so they could remove the wheelchair from the vehicle. Driver A stated that the van did not come to a hard stop and he was already at a complete stop before Resident #2 fell out of his chair. During an additional interview on [DATE] at 10:33 am, Driver A stated that when Resident #2 was in the van, he first strapped the wheelchair down to the floor, using the 4 point restraints on the floor of the van. Driver A stated that he then put on Resident #2 ' s shoulder strap seatbelt. He stated that the seatbelt came down from the back wall of the van, over the right shoulder of the resident, down across the resident ' s chest and then is latched to the left rear floor latch. Driver A stated that the seatbelt was positioned over the wheelchair armrest. Driver A stated that since the van was at a complete stop before the resident fell , the seatbelt would not have been locked into place. He stated that maybe Resident #2 pulled down on the seatbelt and was able to then fall forward. Driver A stated that Resident #2 fell more to his right side, face first, and his left leg was caught behind the seatbelt after he fell . During an interview on [DATE] at 3:45 pm, the Director of Nurses (DON) stated he heard the following information regarding the incident, after interviewing Driver A. The DON stated that Resident #2 was picked up by Driver A from the lobby of the facility. He stated that Driver A told him that he strapped down Resident #2 ' s wheelchair using the 4 point floor restraints and buckled in the resident using the across-the-body seatbelt. The DON stated that Driver A was in the parking lot, getting ready to turn onto the main road when he began talking to Resident #2. Resident #2 was not responding, so Driver A looked through the rearview mirror and saw the resident with a " wide-eyed " and scared expression on his face and he saw the resident fall forward. The DON stated that Driver A went to the back of the van and called 911. Driver A then called the facility to notify them of the situation. The DON stated that he ran from the facility to where the van was in the parking lot, carrying the residents advanced directives with him. When the DON arrived, he stated that Emergency Medical Services (EMS) had already arrived and had started chest compressions. The DON gave the paperwork to EMS who took Resident #2 to the hospital. The DON stated that Driver A told him that the seatbelt was still intact when he (Driver A) found the resident on the floor. The DON stated that he talked to the resident ' s wife on [DATE] who informed him that the resident had passed away at the hospital after the ventilator and pacemaker were discontinued. Review of Resident #2 ' s hospital records, the Critical Care History and Physical dated [DATE] reflected that Resident #2 had a history of [REDACTED]. The report reflected that Resident #2 presented to the hospital " post [MEDICAL CONDITION]/(pulseless electrical activity) PEA en route to ([MEDICAL TREATMENT]) HD today. Per records, the patient fell out of his wheelchair en route to his HD, with trauma, and subsequently developed PEA arrest. Patient was resuscitated and intubated and transferred here .... Patient is unresponsive. Per wife, who is patient ' s (medial power of attorney) MPOA, she is waiting for her children to arrive ... before likely withdrawing care. She does not wish for any further diagnostic or therapeutic interventions to take place, and only wants her husband to be made comfortable. " The preliminary discharge summary, dated [DATE] reflected that the date of the resident ' s discharge was [DATE]. The resident passed away at 11:11 pm. Review of the 24 hour report dated [DATE] reflected that " (Resident #2)- Expired at the hospital. Personal effects and non control meds picked up by family. " During an interview on [DATE] at 2:28 pm, a Homicide Detective who was investigating the case involving Resident #2 stated that the preliminary ruling for the cause of death was [MEDICATION NAME] force trauma to the head related to a fall. During an interview on [DATE] at 12:51 pm, a Homicide Detective who was investigating the case involving Resident #2 stated that he interviewed the Medical Examiner (ME) who conducted the autopsy, and the ME was trying to determine how the resident was able to fall out of the wheelchair. The Detective stated that the ME stated that Resident #2 ' s cause of death was still being determined because it was not yet determined if the resident had the cardiac event before or after he fell . During an interview on [DATE] at 4:15 pm, the Executive Assistant in the Transportation Department stated that on [DATE] she got a call from the receptionist who told her that Driver A had called to notify the facility that he had called 911 for Resident #2 who had fallen in the van in the parking lot. She stated that she ran outside to see what was happening. She stated that when she arrived to the van, the wheelchair in the van was still in place and still strapped in. The Executive Assistant stated that EMS arrived and removed the wheelchair from the van to have more room to assist Resident #2. She stated that the seatbelt that is used to secure the occupant in the wheelchair crosses the resident ' s body and latches to the floor. She also stated that the van was not currently at the facility; the van was in the repair shop for roof damage. During an interview on [DATE] at 4:30 pm, the Executive Assistant in the Transportation Department stated that when newly hired drivers are trained, either she or the Lead Driver (Driver C) will ride along with the new hire for as long as needed to ensure they are competent and safe. She stated that they would observe the driver during all steps in the transportation process, including securing a resident in a wheelchair. The Executive Assistant stated that the newly hired drivers also have to watch a video on restraining the wheelchair and securing the wheelchair occupant. During an interview on [DATE] at 10:40 am, the Executive Assistant in the Transportation Department, when asked if investigator could watch training video, stated that she was unable to locate the training video and thought that the last time the video was used, it was no longer functional. She had not received a replacement video yet. There was not a current video in use for training and training was being done hands-on. During an interview on [DATE] at 5:35 pm, the Executive Assistant in the Transportation Department stated that the transportation department trains the drivers to secure residents into wheelchairs using the shoulder seatbelt that straps across the resident ' s body, through the wheelchair wheels, and hooks onto the floor latch on the opposite corner. She stated that the strap should be touching the resident ' s body. During an interview on [DATE] at 9:05 am, Driver C stated that she helped to train Driver A and observed him properly secure different residents in wheelchairs into the van during training. Driver C stated that the shoulder seatbelt goes over the shoulder and is put through the armrest of the wheelchair and latched to the floor latch on the opposite side. During an interview on [DATE] at 1:24 pm, Driver C stated that there is no lap belt available in the van. During an interview on [DATE] at 12:51 pm, a Homicide Detective who was investigating the case involving Resident #2 stated that he was able to talk to Driver A on [DATE]. Driver A told the Detective that there was no lap belt in place for Resident #2 because there was no lap belt available to use in the van. The Detective stated that it sounded like a lap belt had never been available in this van. During an interview on [DATE] at 2:53 pm, the Executive Assistant in the Transportation Department stated that the 4 point securement system in the van is made by a company called Q ' Straint. However, she did not know the model or what kind of Q ' Straint system. She called the corporate office to ask them to find this information. She stated that the manufacturer ' s specifications could still not be located (these specifications were requested on [DATE]). The Executive Assistant then stated that the van does not have any kind of lap belt. There is no belt that goes across a resident ' s lap. During an interview on [DATE] at 8:51 am, a Customer Satisfaction Manager for Q ' Straint revealed that it is not recommended to use just the shoulder belt to secure a resident into a wheelchair in the vehicle. He stated that both a lap and shoulder belt should be used to secure the resident. He stated that he emailed the investigator the specifications and instructions for the Q ' Straint QRT Max and Q ' Straint QRT M-series models. He stated that the only other model is the Q ' Straint QRT Deluxe model, but that the Deluxe model used the same set of instructions as the Max (the differences are cosmetic, not mechanic). Review of an email provided by the Executive Director, dated [DATE] reflected that the facility van was equipped with the Q ' Straint Deluxe system. Review of Q ' Straint ' s online training video for the Q ' Straint QRT system, made by Q ' Straint dated [DATE] reflected that there were three different kinds of lap and shoulder belt combinations. For each kind, the lap and shoulder belt must be used simultaneously. Review of Q ' Straint ' s website (copyright ,[DATE]) reflected that a complete 4 point securement system includes occupant restraints described as follows: " a manual or combination lap and shoulder belt for securing the occupant. " During an interview on [DATE] at 8:31 am, the owner of the auto repair shop repairing the facility ' s van stated that roof damage is the only damage being repaired on the van. Observation of the facility van (in the repair shop) on [DATE] at 8:40 am revealed that the 4 point wheelchair straps located on the floor of the van were present, intact, and in good condition. There were two shoulder seatbelts observed, attached to the back wall of the van, one on each side of the emergency exit door. Further observation of the facility van (in the repair shop) on [DATE] at 10:25 am revealed that there were no lap belts attached to the shoulder belts on the back wall of the van. There was a separate lap belt that was found in the back right corner of the van. The lap belt seemed to be attached to a retractor that should be mounted onto the floor tracking with the other floor retractors and latches that secure the wheelchair. The lap belt retractor was not attached to the floor. Review of the Q ' Straint Diver/Operator Instruction Guide for the Q ' Straint Max system dated [DATE] (directly provided by the Q ' Straint company) reflected " List of items for each passenger and chair location: 4 wheelchair retractors and 1 lap and shoulder belt. " " Step 2: Attached lap and shoulder belt. Belt should bear upon the bony structure of the body and should be worn low across the front of the pelvis with the junction between the lap and shoulder belts located near the passenger ' s hip. Adjust the belts as firmly as possible consistent with user comfort. Ensure that the belt is not twisted. Use height adjustor if applicable. " " Occupant restraints should not be held away from the body by wheelchair components or parts such as the wheelchair armrests or wheels. " The facility Administrator and DON were notified on [DATE] at 1:16 pm that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on [DATE] at 5:17 pm. The final Plan of Removal was accepted by the investigator on [DATE] at 5:20 pm. Plan of Removal: " [DATE] I am enclosing the Plan of Removal in response to the Alleged Immediate Jeopardy finding of this date. While this document is being submitted as confirmation of the facility ' s on-going regulatory requirements, it should not be construed as an admission or agreement of this finding. In response to the Immediate Jeopardy finding, all residents who require transportation via wheelchair van, will be accommodated by an outside service. No community vehicle will be used for this purpose until approved lap and shoulder belts are in place. Lap belts were ordered on [DATE] at approximately 2PM; overnight delivery was requested. See attached UPS Confirmation. The item ordered is the QRT Retractable Deluxe Securement System. They were ordered from Para Driving Aids-Austin at 4250 Felter Lane Austin . 512 [PHONE NUMBER]. Nurses and Receptionists are being notified, beginning [DATE] at approximately 2PM, not to schedule wheelchair transportation via community vehicle, until further notice. Transportation associates are being notified, beginning [DATE] at approximately 2PM, not to transport any skilled nursing residents via community vehicle, until further notice. All nurses and transportation associates will be notified, by [DATE]. Upon receipt of the lap belts on [DATE], they will be installed by Para Driving who will train Transportation associates, who are on duty, on their use. The rest of the Transportation associates will be trained personally, by the Transportation Supervisor. The use of lap belts will be monitored, at least monthly by the Transportation Supervisor or her designee. The Transportation Competency Checklist will be revised, by [DATE], to include use of the lap belt, for wheelchair transportation. Likewise, the Transportation Policy will include the lap belt usage, by [DATE]. The Safety Committee will review this practice for at least 3 months, beginning with the [DATE] meeting, to ensure compliance. " The investigator monitored the current plan of removal as follows: During an interview on [DATE] at 2:07 pm, the Administrator stated that the seatbelts had been ordered. She stated that the Executive Assistant in the Transportation Department ordered the proper seat belts that fit the model and has requested overnight delivery. During an interview on [DATE] at 2:13 pm, the DON stated that he had rounded with the nurses on duty and informed them that they are not to schedule transportation with the facility van. Outside services would need to be utilized. During an interview on [DATE] at 2:23 pm, Licensed Vocational Nurse (LVN) E stated that if a resident is a wheelchair needed transportation, she would call an outside party to provide the service and would currently not use the facility van. Observation on [DATE] at 2:26 pm revealed the DON in-servicing the nurses who came on the evening shift regarding the transportation services. He was informing them that the facility van should not be used to schedule transportation for residents in wheelchairs and that they should use outside services to provide transportation. During an interview on [DATE] at 2:28 pm, the DON stated that he had just in-serviced all of the nurses on the evening shift and that he will continue these in-services throughout the day and the next day. During an interview on [DATE] at 2:30 pm, Registered Nurse (RN) F stated that since the facility transportation is currently out of service, if she needed to schedule transportation for a resident in a wheelchair, she would call one of the transportation services that has wheelchair accessible vans. During an interview on [DATE] at 2:35 pm, LVN B stated that currently, wheelchair transportation should be schedule with an outside party (an approved taxi service), not the facility van. During an interview on [DATE] at 2:38 pm, LVN G stated that currently, she would schedule transportation using a wheelchair taxi service since the facility transportation is out of service. During an interview on [DATE] at 2:43 pm, LVN H stated that the facility wheelchair van is not currently in use, so wheelchair transportation should be scheduled with an approved wheelchair taxi service. During an interview on [DATE] at 3:30 pm, Receptionist J stated that she would not schedule wheelchair transportation with the facility van right now but would call an approved taxi company. During an interview on [DATE] at 4:28 pm, Receptionist K stated that if a resident in a wheelchair currently needed transportation, she would call a taxi service with wheelchair services. Observation on [DATE] at 3:58 pm revealed that the facility van was not in use. A wheelchair accessible transportation service was picking up a resident outside of the facility. Review of the in-service dated [DATE] reflected that an in-service was conducted with the licensed nursing staff, transportation staff, and receptionists that arrange transportation regarding wheelchair transportation. " Our wheelchair vans are not available for transportation until further notice. Please schedule all wheelchair van transportation with either Acadian or out preferred wheelchair taxi services until further notice. " Review of the list of approved taxi services reflected that there were lists at the nurse ' s stations providing phone numbers and names of wheelchair taxi cab services. Review of the UPS Confirmation email dated [DATE] reflected that 2 sets of fixed lap and shoulder seat belts for wheelchair by Q ' Straint were ordered and next day air delivery was requested. On [DATE] at 5:22 pm, the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope as pattern due to the facility requiring time to train all staff, obtain and install the new van equipment, and monitor their Plan of Removal. The Administrator provided a list of 10 residents who use wheelchairs during vehicle transportation.

Based on observation, interview, and record review, the facility failed to implement policies and procedures that prohibit neglect for one (1) of five (5) residents reviewed for abuse and neglect (Resident #2). The facility failed to ensure that the facility-owned van used for resident transportation was properly equipped with a lap seatbelt to safely secure residents in wheelchairs and failed to ensure that residents being transported in wheelchairs were secured using a lap seatbelt. While Resident #2 was being transported to [MEDICAL TREATMENT] on [DATE] by Driver A, Resident #2 slumped forward, fell out of his wheelchair and hit his head on the floor of the van. Resident #2 was taken to the hospital where he later expired on [DATE] at 11:11 pm. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at an actual harm level with a scope identified as pattern. This deficient practice could place 10 residents who use wheelchairs during transportation at risk for severe injury or death due to being improperly secured in a wheelchair during transit. Findings include: Review of Resident #2 ' s Face Sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2 ' s most current Minimum Data Set ((MDS) dated [DATE] reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 (a score of ,[DATE] indicating moderately impaired cognition). The MDS also indicated that Resident #2 required extensive two person assistant with transfers. Review of Resident #2 ' s Care Plan dated [DATE] reflected that Resident #2 was at risk for falls and had a fall risk score of 14 (a score of 10 or above indicating a high risk for falls). Interventions included to wear footwear that fit properly with non-skid soles, provide reminders to use ambulation and transfer assist devices, and to use an alarm " to monitor attempts to rise. " Review of the incident report involving Resident #2 dated [DATE] reflected " (Facility) driver (Driver A) picked up (Resident #2) from the Assisted Living at 10 am for transport to [MEDICAL TREATMENT]. Resident was loaded into the van in his wheelchair, and the four point straps were secured to his wheelchair. The resident was secured in his wheelchair with the van shoulder seat belt. At the entrance of (the road near the facility) the van stopped at the stop sign for a car to pass. (Driver A) stated he looked in the rearview mirror, and was speaking to (Resident #2) when he saw (Resident #2) make a wide-eyed distressed face, and then he fell forward. It appeared the resident pushed the top of the seat belt shoulder strap down and fell forward onto the floor. His one intact leg was caught in the seatbelt. (Driver A) immediately went to the resident and called 911 for help. The resident was mumbling when the EMS quickly arrived at the scene. (Driver A) notified the facility of the incident and the staff responded to the scene with the resident ' s advanced directives. Resident assessed by EMS, while staff in route, and CPR (Cardiopulmonary resuscitation) began when resident noted to be in [MEDICAL CONDITION]. EMS stated resident had a pulse and transferred him to the (emergency room ) ER for further evaluation. Follow-up: DON called (Resident #2 ' s responsible party) on ,[DATE] and she explained that the resident had been placed on a ventilator in the hospital and that on Saturday night she elected to withdraw the ventilator and the resident passed away. " During an interview on [DATE] at 4:20 pm, Driver A stated that on [DATE] around 10:00 am, he picked Resident #2 up from the facility and strapped his wheelchair into the van (using the 4 floor straps) and secured the resident using a shoulder seatbelt. Driver A stated that he brought the van to a complete stop at the entrance to the facility, because traffic was coming from both directions. As he was waiting for traffic to clear, he began to talk to Resident #2. When Resident #2 did not respond, Driver A looked in the rearview mirror and saw the resident had a wide-eyed expression on his face and then " slumped " forward and fell . Driver A stated that he put the van in park, went to the back of the van, and called 911 when he saw the resident on the floor of the van with blood underneath his head. He then called the facility. Driver A stated that he did not move the resident. Driver A stated that Resident #2 ' s shoulder seatbelt was still intact and attached to the latch on the floor and the wheelchair was still in place. He stated that when Emergency Medical Services (EMS) arrived, the paramedics asked him how to undo the restraints to the wheelchair so they could remove the wheelchair from the vehicle. Driver A stated that the van did not come to a hard stop and he was already at a complete stop before Resident #2 fell out of his chair. During an additional interview on [DATE] at 10:33 am, Driver A stated that when Resident #2 was in the van, he first strapped the wheelchair down to the floor, using the 4 point restraints on the floor of the van. Driver A stated that he then put on Resident #2 ' s shoulder strap seatbelt. He stated that the seatbelt came down from the back wall of the van, over the right shoulder of the resident, down across the resident ' s chest and then is latched to the left rear floor latch. Driver A stated that the seatbelt was positioned over the wheelchair armrest. Driver A stated that since the van was at a complete stop before the resident fell , the seatbelt would not have been locked into place. He stated that maybe Resident #2 pulled down on the seatbelt and was able to then fall forward. Driver A stated that Resident #2 fell more to his right side, face first, and his left leg was caught behind the seatbelt after he fell . During an interview on [DATE] at 3:45 pm, the Director of Nurses (DON) stated he heard the following information regarding the incident, after interviewing Driver A. The DON stated that Resident #2 was picked up by Driver A from the lobby of the facility. He stated that Driver A told him that he strapped down Resident #2 ' s wheelchair using the 4 point floor restraints and buckled in the resident using the across-the-body seatbelt. The DON stated that Driver A was in the parking lot, getting ready to turn onto the main road when he began talking to Resident #2. Resident #2 was not responding, so Driver A looked through the rearview mirror and saw the resident with a " wide-eyed " and scared expression on his face and he saw the resident fall forward. The DON stated that Driver A went to the back of the van and called 911. Driver A then called the facility to notify them of the situation. The DON stated that he ran from the facility to where the van was in the parking lot, carrying the residents advanced directives with him. When the DON arrived, he stated that Emergency Medical Services (EMS) had already arrived and had started chest compressions. The DON gave the paperwork to EMS who took Resident #2 to the hospital. The DON stated that Driver A told him that the seatbelt was still intact when he (Driver A) found the resident on the floor. The DON stated that he talked to the resident ' s wife on [DATE] who informed him that the resident had passed away at the hospital after the ventilator and pacemaker were discontinued. Review of Resident #2 ' s hospital records, the Critical Care History and Physical dated [DATE] reflected that Resident #2 had a history of [REDACTED]. The report reflected that Resident #2 presented to the hospital " post [MEDICAL CONDITION]/(pulseless electrical activity) PEA en route to ([MEDICAL TREATMENT]) HD today. Per records, the patient fell out of his wheelchair en route to his HD, with trauma, and subsequently developed PEA arrest. Patient was resuscitated and intubated and transferred here .... Patient is unresponsive. Per wife, who is patient ' s (medial power of attorney) MPOA, she is waiting for her children to arrive ... before likely withdrawing care. She does not wish for any further diagnostic or therapeutic interventions to take place, and only wants her husband to be made comfortable. " The preliminary discharge summary, dated [DATE] reflected that the date of the resident ' s discharge was [DATE]. The resident passed away at 11:11 pm. Review of the 24 hour report dated [DATE] reflected that " (Resident #2)- Expired at the hospital. Personal effects and non control meds picked up by family. " During an interview on [DATE] at 2:28 pm, a Homicide Detective who was investigating the case involving Resident #2 stated that the preliminary ruling for the cause of death was [MEDICATION NAME] force trauma to the head related to a fall. During an interview on [DATE] at 12:51 pm, a Homicide Detective who was investigating the case involving Resident #2 stated that he interviewed the Medical Examiner (ME) who conducted the autopsy, and the ME was trying to determine how the resident was able to fall out of the wheelchair. The Detective stated that the ME stated that Resident #2 ' s cause of death was still being determined because it was not yet determined if the resident had the cardiac event before or after he fell . During an interview on [DATE] at 4:15 pm, the Executive Assistant in the Transportation Department stated that on [DATE] she got a call from the receptionist who told her that Driver A had called to notify the facility that he had called 911 for Resident #2 who had fallen in the van in the parking lot. She stated that she ran outside to see what was happening. She stated that when she arrived to the van, the wheelchair in the van was still in place and still strapped in. The Executive Assistant stated that EMS arrived and removed the wheelchair from the van to have more room to assist Resident #2. She stated that the seatbelt that is used to secure the occupant in the wheelchair crosses the resident ' s body and latches to the floor. She also stated that the van was not currently at the facility; the van was in the repair shop for roof damage. During an interview on [DATE] at 4:30 pm, the Executive Assistant in the Transportation Department stated that when newly hired drivers are trained, either she or the Lead Driver (Driver C) will ride along with the new hire for as long as needed to ensure they are competent and safe. She stated that they would observe the driver during all steps in the transportation process, including securing a resident in a wheelchair. The Executive Assistant stated that the newly hired drivers also have to watch a video on restraining the wheelchair and securing the wheelchair occupant. During an interview on [DATE] at 10:40 am, the Executive Assistant in the Transportation Department, when asked if investigator could watch training video, stated that she was unable to locate the training video and thought that the last time the video was used, it was no longer functional. She had not received a replacement video yet. There was not a current video in use for training and training was being done hands-on. During an interview on [DATE] at 5:35 pm, the Executive Assistant in the Transportation Department stated that the transportation department trains the drivers to secure residents into wheelchairs using the shoulder seatbelt that straps across the resident ' s body, through the wheelchair wheels, and hooks onto the floor latch on the opposite corner. She stated that the strap should be touching the resident ' s body. During an interview on [DATE] at 9:05 am, Driver C stated that she helped to train Driver A and observed him properly secure different residents in wheelchairs into the van during training. Driver C stated that the shoulder seatbelt goes over the shoulder and is put through the armrest of the wheelchair and latched to the floor latch on the opposite side. During an interview on [DATE] at 1:24 pm, Driver C stated that there is no lap belt available in the van. During an interview on [DATE] at 12:51 pm, a Homicide Detective who was investigating the case involving Resident #2 stated that he was able to talk to Driver A on [DATE]. Driver A told the Detective that there was no lap belt in place for Resident #2 because there was no lap belt available to use in the van. The Detective stated that it sounded like a lap belt had never been available in this van. During an interview on [DATE] at 2:53 pm, the Executive Assistant in the Transportation Department stated that the 4 point securement system in the van is made by a company called Q ' Straint. However, she did not know the model or what kind of Q ' Straint system. She called the corporate office to ask them to find this information. She stated that the manufacturer ' s specifications could still not be located (these specifications were requested on [DATE]). The Executive Assistant then stated that the van does not have any kind of lap belt. There is no belt that goes across a resident ' s lap. During an interview on [DATE] at 8:51 am, a Customer Satisfaction Manager for Q ' Straint revealed that it is not recommended to use just the shoulder belt to secure a resident into a wheelchair in the vehicle. He stated that both a lap and shoulder belt should be used to secure the resident. He stated that he emailed the investigator the specifications and instructions for the Q ' Straint QRT Max and Q ' Straint QRT M-series models. He stated that the only other model is the Q ' Straint QRT Deluxe model, but that the Deluxe model used the same set of instructions as the Max (the differences are cosmetic, not mechanic). Review of an email provided by the Executive Director, dated [DATE] reflected that the facility van was equipped with the Q ' Straint Deluxe system. Review of Q ' Straint ' s website (copyright ,[DATE]) reflected that a complete 4 point securement system includes occupant restraints described as follows: " a manual or combination lap and shoulder belt for securing the occupant. " Review of Q ' Straint ' s online training video for the Q ' Straint QRT system, made by Q ' Straint dated [DATE] reflected that there were three different kinds of lap and shoulder belt combinations. For each kind, the lap and shoulder belt must be used simultaneously. During an interview on [DATE] at 8:31 am, the owner of the auto repair shop repairing the facility ' s van stated that roof damage is the only damage being repaired on the van. Observation of the facility van (in the repair shop) on [DATE] at 8:40 am revealed that the 4 point wheelchair straps located on the floor of the van were present, intact, and in good condition. There were two shoulder seatbelts observed, attached to the back wall of the van, one on each side of the emergency exit door. Further observation of the facility van (in the repair shop) on [DATE] at 10:25 am revealed that there were no lap belts attached to the shoulder belts on the back wall of the van. There was a separate lap belt that was found in the back right corner of the van. The lap belt seemed to be attached to a retractor that should be mounted onto the floor tracking with the other floor retractors and latches that secure the wheelchair. The lap belt retractor was not attached to the floor. Review of the facility ' s abuse and neglect policy dated [DATE] reflected that the facility " is committed to maintaining a safe environment for each resident, visitor and associate. Instances or allegations of abuse, neglect or exploitation should be treated seriously and must be reported to the Executive Director or the supervisor on duty for investigation, appropriate follow-up, and required reporting based on state regulation. " " Neglect is defined in Texas as the failure to provide for one ' s self the goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caregiver to provide such goods or services. " Review of the Q ' Straint Diver/Operator Instruction Guide for the Q ' Straint Max system dated [DATE] (directly provided by the Q ' Straint company) reflected " List of items for each passenger and chair location: 4 wheelchair retractors and 1 lap and shoulder belt. " " Step 2: Attached lap and shoulder belt. Belt should bear upon the bony structure of the body and should be worn low across the front of the pelvis with the junction between the lap and shoulder belts located near the passenger ' s hip. Adjust the belts as firmly as possible consistent with user comfort. Ensure that the belt is not twisted. Use height adjustor if applicable. " " Occupant restraints should not be held away from the body by wheelchair components or parts such as the wheelchair armrests or wheels. " The facility Administrator and DON were notified on [DATE] at 1:16 pm that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on [DATE] at 5:17 pm. The final Plan of Removal was accepted by the investigator on [DATE] at 5:20 pm. Plan of Removal: " [DATE] I am enclosing the Plan of Removal in response to the Alleged Immediate Jeopardy finding of this date. While this document is being submitted as confirmation of the facility ' s on-going regulatory requirements, it should not be construed as an admission or agreement of this finding. In response to the Immediate Jeopardy finding, all residents who require transportation via wheelchair van, will be accommodated by an outside service. No community vehicle will be used for this purpose until approved lap and shoulder belts are in place. Lap belts were ordered on [DATE] at approximately 2PM; overnight delivery was requested. See attached UPS Confirmation. The item ordered is the QRT Retractable Deluxe Securement System. They were ordered from Para Driving Aids-Austin at 4250 Felter Lane Austin . 512 [PHONE NUMBER]. Nurses and Receptionists are being notified, beginning [DATE] at approximately 2PM, not to schedule wheelchair transportation via community vehicle, until further notice. Transportation associates are being notified, beginning [DATE] at approximately 2PM, not to transport any skilled nursing residents via community vehicle, until further notice. All nurses and transportation associates will be notified, by [DATE]. Upon receipt of the lap belts on [DATE], they will be installed by Para Driving who will train Transportation associates, who are on duty, on their use. The rest of the Transportation associates will be trained personally, by the Transportation Supervisor. The use of lap belts will be monitored, at least monthly by the Transportation Supervisor or her designee. The Transportation Competency Checklist will be revised, by [DATE], to include use of the lap belt, for wheelchair transportation. Likewise, the Transportation Policy will include the lap belt usage, by [DATE]. The Safety Committee will review this practice for at least 3 months, beginning with the [DATE] meeting, to ensure compliance. " The investigator monitored the current plan of removal as follows: During an interview on [DATE] at 2:07 pm, the Administrator stated that the seatbelts had been ordered. She stated that the Executive Assistant in the Transportation Department ordered the proper seat belts that fit the model and has requested overnight delivery. During an interview on [DATE] at 2:13 pm, the DON stated that he had rounded with the nurses on duty and informed them that they are not to schedule transportation with the facility van. Outside services would need to be utilized. During an interview on [DATE] at 2:23 pm, Licensed Vocational Nurse (LVN) E stated that if a resident is a wheelchair needed transportation, she would call an outside party to provide the service and would currently not use the facility van. Observation on [DATE] at 2:26 pm revealed the DON in-servicing the nurses who came on the evening shift regarding the transportation services. He was informing them that the facility van should not be used to schedule transportation for residents in wheelchairs and that they should use outside services to provide transportation. During an interview on [DATE] at 2:28 pm, the DON stated that he had just in-serviced all of the nurses on the evening shift and that he will continue these in-services throughout the day and the next day. During an interview on [DATE] at 2:30 pm, Registered Nurse (RN) F stated that since the facility transportation is currently out of service, if she needed to schedule transportation for a resident in a wheelchair, she would call one of the transportation services that has wheelchair accessible vans. During an interview on [DATE] at 2:35 pm, LVN B stated that currently, wheelchair transportation should be schedule with an outside party (an approved taxi service), not the facility van. During an interview on [DATE] at 2:38 pm, LVN G stated that currently, she would schedule transportation using a wheelchair taxi service since the facility transportation is out of service. During an interview on [DATE] at 2:43 pm, LVN H stated that the facility wheelchair van is not currently in use, so wheelchair transportation should be scheduled with an approved wheelchair taxi service. During an interview on [DATE] at 3:30 pm, Receptionist J stated that she would not schedule wheelchair transportation with the facility van right now but would call an approved taxi company. During an interview on [DATE] at 4:28 pm, Receptionist K stated that if a resident in a wheelchair currently needed transportation, she would call a taxi service with wheelchair services. Observation on [DATE] at 3:58 pm revealed that the facility van was not in use. A wheelchair accessible transportation service was picking up a resident outside of the facility. Review of the in-service dated [DATE] reflected that an in-service was conducted with the licensed nursing staff, transportation staff, and receptionists that arrange transportation regarding wheelchair transportation. " Our wheelchair vans are not available for transportation until further notice. Please schedule all wheelchair van transportation with either Acadian or out preferred wheelchair taxi services until further notice. " Review of the list of approved taxi services reflected that there were lists at the nurse ' s stations providing phone numbers and names of wheelchair taxi cab services. Review of the UPS Confirmation email dated [DATE] reflected that 2 sets of fixed lap and shoulder seat belts for wheelchair by Q ' Straint were ordered and next day air delivery was requested. On [DATE] at 5:22 pm, the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope as pattern due to the facility requiring time to train all staff, obtain and install the new van equipment, and monitor their Plan of Removal. The Administrator provided a list of 10 residents who use wheelchairs during vehicle transportation.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free from accident hazards as is possible for one (1) of five (5) residents reviewed for abuse and neglect (Resident #2). The facility failed to ensure that the facility-owned van used for resident transportation was properly equipped with a lap seatbelt to safely secure residents in wheelchairs and failed to ensure that residents being transported in wheelchairs were secured using a lap seatbelt. While Resident #2 was being transported to dialysis on [DATE] by Driver A, Resident #2 slumped forward, fell out of his wheelchair and hit his head on the floor of the van. Resident #2 was taken to the hospital where he later expired on [DATE] at 11:11 pm. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at an actual harm level with a scope identified as pattern. This deficient practice could place 10 residents who use wheelchairs during transportation at risk for severe injury or death due to being improperly secured in a wheelchair during transit. Findings include: Review of Resident #2 ' s Face Sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2 ' s most current Minimum Data Set ((MDS) dated [DATE] reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 (a score of ,[DATE] indicating moderately impaired cognition). The MDS also indicated that Resident #2 required extensive two person assistant with transfers. Review of Resident #2 ' s Care Plan dated [DATE] reflected that Resident #2 was at risk for falls and had a fall risk score of 14 (a score of 10 or above indicating a high risk for falls). Interventions included to wear footwear that fit properly with non-skid soles, provide reminders to use ambulation and transfer assist devices, and to use an alarm " to monitor attempts to rise. " Review of the incident report involving Resident #2 dated [DATE] reflected " (Facility) driver (Driver A) picked up (Resident #2) from the Assisted Living at 10 am for transport to dialysis. Resident was loaded into the van in his wheelchair, and the four point straps were secured to his wheelchair. The resident was secured in his wheelchair with the van shoulder seat belt. At the entrance of (the road near the facility) the van stopped at the stop sign for a car to pass. (Driver A) stated he looked in the rearview mirror, and was speaking to (Resident #2) when he saw (Resident #2) make a wide-eyed distressed face, and then he fell forward. It appeared the resident pushed the top of the seat belt shoulder strap down and fell forward onto the floor. His one intact leg was caught in the seatbelt. (Driver A) immediately went to the resident and called 911 for help. The resident was mumbling when the EMS quickly arrived at the scene. (Driver A) notified the facility of the incident and the staff responded to the scene with the resident ' s advanced directives. Resident assessed by EMS, while staff in route, and CPR (Cardiopulmonary resuscitation) began when resident noted to be in cardiac arrest. EMS stated resident had a pulse and transferred him to the (emergency room ) ER for further evaluation. Follow-up: DON called (Resident #2 ' s responsible party) on ,[DATE] and she explained that the resident had been placed on a ventilator in the hospital and that on Saturday night she elected to withdraw the ventilator and the resident passed away. " During an interview on [DATE] at 4:20 pm, Driver A stated that on [DATE] around 10:00 am, he picked Resident #2 up from the facility and strapped his wheelchair into the van (using the 4 floor straps) and secured the resident using a shoulder seatbelt. Driver A stated that he brought the van to a complete stop at the entrance to the facility, because traffic was coming from both directions. As he was waiting for traffic to clear, he began to talk to Resident #2. When Resident #2 did not respond, Driver A looked in the rearview mirror and saw the resident had a wide-eyed expression on his face and then " slumped " forward and fell . Driver A stated that he put the van in park, went to the back of the van, and called 911 when he saw the resident on the floor of the van with blood underneath his head. He then called the facility. Driver A stated that he did not move the resident. Driver A stated that Resident #2 ' s shoulder seatbelt was still intact and attached to the latch on the floor and the wheelchair was still in place. He stated that when Emergency Medical Services (EMS) arrived, the paramedics asked him how to undo the restraints to the wheelchair so they could remove the wheelchair from the vehicle. Driver A stated that the van did not come to a hard stop and he was already at a complete stop before Resident #2 fell out of his chair. During an additional interview on [DATE] at 10:33 am, Driver A stated that when Resident #2 was in the van, he first strapped the wheelchair down to the floor, using the 4 point restraints on the floor of the van. Driver A stated that he then put on Resident #2 ' s shoulder strap seatbelt. He stated that the seatbelt came down from the back wall of the van, over the right shoulder of the resident, down across the resident ' s chest and then is latched to the left rear floor latch. Driver A stated that the seatbelt was positioned over the wheelchair armrest. Driver A stated that since the van was at a complete stop before the resident fell , the seatbelt would not have been locked into place. He stated that maybe Resident #2 pulled down on the seatbelt and was able to then fall forward. Driver A stated that Resident #2 fell more to his right side, face first, and his left leg was caught behind the seatbelt after he fell . During an interview on [DATE] at 3:45 pm, the Director of Nurses (DON) stated he heard the following information regarding the incident, after interviewing Driver A. The DON stated that Resident #2 was picked up by Driver A from the lobby of the facility. He stated that Driver A told him that he strapped down Resident #2 ' s wheelchair using the 4 point floor restraints and buckled in the resident using the across-the-body seatbelt. The DON stated that Driver A was in the parking lot, getting ready to turn onto the main road when he began talking to Resident #2. Resident #2 was not responding, so Driver A looked through the rearview mirror and saw the resident with a " wide-eyed " and scared expression on his face and he saw the resident fall forward. The DON stated that Driver A went to the back of the van and called 911. Driver A then called the facility to notify them of the situation. The DON stated that he ran from the facility to where the van was in the parking lot, carrying the residents advanced directives with him. When the DON arrived, he stated that Emergency Medical Services (EMS) had already arrived and had started chest compressions. The DON gave the paperwork to EMS who took Resident #2 to the hospital. The DON stated that Driver A told him that the seatbelt was still intact when he (Driver A) found the resident on the floor. The DON stated that he talked to the resident ' s wife on [DATE] who informed him that the resident had passed away at the hospital after the ventilator and pacemaker were discontinued. Review of Resident #2 ' s hospital records, the Critical Care History and Physical dated [DATE] reflected that Resident #2 had a history of [REDACTED]. The report reflected that Resident #2 presented to the hospital " post cardiac arrest/(pulseless electrical activity) PEA en route to (hemodialysis) HD today. Per records, the patient fell out of his wheelchair en route to his HD, with trauma, and subsequently developed PEA arrest. Patient was resuscitated and intubated and transferred here .... Patient is unresponsive. Per wife, who is patient ' s (medial power of attorney) MPOA, she is waiting for her children to arrive ... before likely withdrawing care. She does not wish for any further diagnostic or therapeutic interventions to take place, and only wants her husband to be made comfortable. " The preliminary discharge summary, dated [DATE] reflected that the date of the resident ' s discharge was [DATE]. The resident passed away at 11:11 pm. Review of the 24 hour report dated [DATE] reflected that " (Resident #2)- Expired at the hospital. Personal effects and non control meds picked up by family. " During an interview on [DATE] at 2:28 pm, a Homicide Detective who was investigating the case involving Resident #2 stated that the preliminary ruling for the cause of death was blunt force trauma to the head related to a fall. During an interview on [DATE] at 12:51 pm, a Homicide Detective who was investigating the case involving Resident #2 stated that he interviewed the Medical Examiner (ME) who conducted the autopsy, and the ME was trying to determine how the resident was able to fall out of the wheelchair. The Detective stated that the ME stated that Resident #2 ' s cause of death was still being determined because it was not yet determined if the resident had the cardiac event before or after he fell . During an interview on [DATE] at 4:15 pm, the Executive Assistant in the Transportation Department stated that on [DATE] she got a call from the receptionist who told her that Driver A had called to notify the facility that he had called 911 for Resident #2 who had fallen in the van in the parking lot. She stated that she ran outside to see what was happening. She stated that when she arrived to the van, the wheelchair in the van was still in place and still strapped in. The Executive Assistant stated that EMS arrived and removed the wheelchair from the van to have more room to assist Resident #2. She stated that the seatbelt that is used to secure the occupant in the wheelchair crosses the resident ' s body and latches to the floor. She also stated that the van was not currently at the facility; the van was in the repair shop for roof damage. During an interview on [DATE] at 4:30 pm, the Executive Assistant in the Transportation Department stated that when newly hired drivers are trained, either she or the Lead Driver (Driver C) will ride along with the new hire for as long as needed to ensure they are competent and safe. She stated that they would observe the driver during all steps in the transportation process, including securing a resident in a wheelchair. The Executive Assistant stated that the newly hired drivers also have to watch a video on restraining the wheelchair and securing the wheelchair occupant. During an interview on [DATE] at 10:40 am, the Executive Assistant in the Transportation Department, when asked if investigator could watch training video, stated that she was unable to locate the training video and thought that the last time the video was used, it was no longer functional. She had not received a replacement video yet. There was not a current video in use for training and training was being done hands-on. During an interview on [DATE] at 5:35 pm, the Executive Assistant in the Transportation Department stated that the transportation department trains the drivers to secure residents into wheelchairs using the shoulder seatbelt that straps across the resident ' s body, through the wheelchair wheels, and hooks onto the floor latch on the opposite corner. She stated that the strap should be touching the resident ' s body. During an interview on [DATE] at 9:05 am, Driver C stated that she helped to train Driver A and observed him properly secure different residents in wheelchairs into the van during training. Driver C stated that the shoulder seatbelt goes over the shoulder and is put through the armrest of the wheelchair and latched to the floor latch on the opposite side. During an interview on [DATE] at 1:24 pm, Driver C stated that there is no lap belt available in the van. During an interview on [DATE] at 12:51 pm, a Homicide Detective who was investigating the case involving Resident #2 stated that he was able to talk to Driver A on [DATE]. Driver A told the Detective that there was no lap belt in place for Resident #2 because there was no lap belt available to use in the van. The Detective stated that it sounded like a lap belt had never been available in this van. During an interview on [DATE] at 2:53 pm, the Executive Assistant in the Transportation Department stated that the 4 point securement system in the van is made by a company called Q ' Straint. However, she did not know the model or what kind of Q ' Straint system. She called the corporate office to ask them to find this information. She stated that the manufacturer ' s specifications could still not be located (these specifications were requested on [DATE]). The Executive Assistant then stated that the van does not have any kind of lap belt. There is no belt that goes across a resident ' s lap. During an interview on [DATE] at 8:51 am, a Customer Satisfaction Manager for Q ' Straint revealed that it is not recommended to use just the shoulder belt to secure a resident into a wheelchair in the vehicle. He stated that both a lap and shoulder belt should be used to secure the resident. He stated that he emailed the investigator the specifications and instructions for the Q ' Straint QRT Max and Q ' Straint QRT M-series models. He stated that the only other model is the Q ' Straint QRT Deluxe model, but that the Deluxe model used the same set of instructions as the Max (the differences are cosmetic, not mechanic). Review of an email provided by the Executive Director, dated [DATE] reflected that the facility van was equipped with the Q ' Straint Deluxe system. Review of Q ' Straint ' s online training video for the Q ' Straint QRT system, made by Q ' Straint dated [DATE] reflected that there were three different kinds of lap and shoulder belt combinations. For each kind, the lap and shoulder belt must be used simultaneously. Review of Q ' Straint ' s website (copyright ,[DATE]) reflected that a complete 4 point securement system includes occupant restraints described as follows: " a manual or combination lap and shoulder belt for securing the occupant. " During an interview on [DATE] at 8:31 am, the owner of the auto repair shop repairing the facility ' s van stated that roof damage is the only damage being repaired on the van. Observation of the facility van (in the repair shop) on [DATE] at 8:40 am revealed that the 4 point wheelchair straps located on the floor of the van were present, intact, and in good condition. There were two shoulder seatbelts observed, attached to the back wall of the van, one on each side of the emergency exit door. Further observation of the facility van (in the repair shop) on [DATE] at 10:25 am revealed that there were no lap belts attached to the shoulder belts on the back wall of the van. There was a separate lap belt that was found in the back right corner of the van. The lap belt seemed to be attached to a retractor that should be mounted onto the floor tracking with the other floor retractors and latches that secure the wheelchair. The lap belt retractor was not attached to the floor. Review of the Q ' Straint Diver/Operator Instruction Guide for the Q ' Straint Max system dated [DATE] (directly provided by the Q ' Straint company) reflected " List of items for each passenger and chair location: 4 wheelchair retractors and 1 lap and shoulder belt. " " Step 2: Attached lap and shoulder belt. Belt should bear upon the bony structure of the body and should be worn low across the front of the pelvis with the junction between the lap and shoulder belts located near the passenger ' s hip. Adjust the belts as firmly as possible consistent with user comfort. Ensure that the belt is not twisted. Use height adjustor if applicable. " " Occupant restraints should not be held away from the body by wheelchair components or parts such as the wheelchair armrests or wheels. " The facility Administrator and DON were notified on [DATE] at 1:16 pm that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on [DATE] at 5:17 pm. The final Plan of Removal was accepted by the investigator on [DATE] at 5:20 pm. Plan of Removal: " [DATE] I am enclosing the Plan of Removal in response to the Alleged Immediate Jeopardy finding of this date. While this document is being submitted as confirmation of the facility ' s on-going regulatory requirements, it should not be construed as an admission or agreement of this finding. In response to the Immediate Jeopardy finding, all residents who require transportation via wheelchair van, will be accommodated by an outside service. No community vehicle will be used for this purpose until approved lap and shoulder belts are in place. Lap belts were ordered on [DATE] at approximately 2PM; overnight delivery was requested. See attached UPS Confirmation. The item ordered is the QRT Retractable Deluxe Securement System. They were ordered from Para Driving Aids-Austin at 4250 Felter Lane Austin . 512 [PHONE NUMBER]. Nurses and Receptionists are being notified, beginning [DATE] at approximately 2PM, not to schedule wheelchair transportation via community vehicle, until further notice. Transportation associates are being notified, beginning [DATE] at approximately 2PM, not to transport any skilled nursing residents via community vehicle, until further notice. All nurses and transportation associates will be notified, by [DATE]. Upon receipt of the lap belts on [DATE], they will be installed by Para Driving who will train Transportation associates, who are on duty, on their use. The rest of the Transportation associates will be trained personally, by the Transportation Supervisor. The use of lap belts will be monitored, at least monthly by the Transportation Supervisor or her designee. The Transportation Competency Checklist will be revised, by [DATE], to include use of the lap belt, for wheelchair transportation. Likewise, the Transportation Policy will include the lap belt usage, by [DATE]. The Safety Committee will review this practice for at least 3 months, beginning with the [DATE] meeting, to ensure compliance. " The investigator monitored the current plan of removal as follows: During an interview on [DATE] at 2:07 pm, the Administrator stated that the seatbelts had been ordered. She stated that the Executive Assistant in the Transportation Department ordered the proper seat belts that fit the model and has requested overnight delivery. During an interview on [DATE] at 2:13 pm, the DON stated that he had rounded with the nurses on duty and informed them that they are not to schedule transportation with the facility van. Outside services would need to be utilized. During an interview on [DATE] at 2:23 pm, Licensed Vocational Nurse (LVN) E stated that if a resident is a wheelchair needed transportation, she would call an outside party to provide the service and would currently not use the facility van. Observation on [DATE] at 2:26 pm revealed the DON in-servicing the nurses who came on the evening shift regarding the transportation services. He was informing them that the facility van should not be used to schedule transportation for residents in wheelchairs and that they should use outside services to provide transportation. During an interview on [DATE] at 2:28 pm, the DON stated that he had just in-serviced all of the nurses on the evening shift and that he will continue these in-services throughout the day and the next day. During an interview on [DATE] at 2:30 pm, Registered Nurse (RN) F stated that since the facility transportation is currently out of service, if she needed to schedule transportation for a resident in a wheelchair, she would call one of the transportation services that has wheelchair accessible vans. During an interview on [DATE] at 2:35 pm, LVN B stated that currently, wheelchair transportation should be schedule with an outside party (an approved taxi service), not the facility van. During an interview on [DATE] at 2:38 pm, LVN G stated that currently, she would schedule transportation using a wheelchair taxi service since the facility transportation is out of service. During an interview on [DATE] at 2:43 pm, LVN H stated that the facility wheelchair van is not currently in use, so wheelchair transportation should be scheduled with an approved wheelchair taxi service. During an interview on [DATE] at 3:30 pm, Receptionist J stated that she would not schedule wheelchair transportation with the facility van right now but would call an approved taxi company. During an interview on [DATE] at 4:28 pm, Receptionist K stated that if a resident in a wheelchair currently needed transportation, she would call a taxi service with wheelchair services. Observation on [DATE] at 3:58 pm revealed that the facility van was not in use. A wheelchair accessible transportation service was picking up a resident outside of the facility. Review of the in-service dated [DATE] reflected that an in-service was conducted with the licensed nursing staff, transportation staff, and receptionists that arrange transportation regarding wheelchair transportation. " Our wheelchair vans are not available for transportation until further notice. Please schedule all wheelchair van transportation with either Acadian or out preferred wheelchair taxi services until further notice. " Review of the list of approved taxi services reflected that there were lists at the nurse ' s stations providing phone numbers and names of wheelchair taxi cab services. Review of the UPS Confirmation email dated [DATE] reflected that 2 sets of fixed lap and shoulder seat belts for wheelchair by Q ' Straint were ordered and next day air delivery was requested. On [DATE] at 5:22 pm, the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope as pattern due to the facility requiring time to train all staff, obtain and install the new van equipment, and monitor their Plan of Removal. The Administrator provided a list of 10 residents who use wheelchairs during vehicle transportation.