Every finding on record at Caraday of Houston

Based on observations, interviews, and record review, the facility failed to ensure the residents environment remained free of accident hazards as is possible to ensure residents receiving adequate supervision to prevent accidents for 1 of 6 residents (Resident #46) reviewed for accidents and supervision.The facility failed to provide appropriate and sufficient supervision to prevent avoidable accidents when Resident #46, despite her recent history of falls and documented fall risk, was left unattended and had an unwitnessed fall. The fall resulted in fracture to Resident #46's cervical spine requiring hospitalization and surgery from 05/07/26 to 05/18/26.The facility further failed to mitigate the risk for falls and accidents when they failed to revise her care plan with post-surgical instructions upon her re-admission to the facility.An Immediate Jeopardy (IJ) situation was identified on 05/28/2026. While the IJ was removed on 05/29/2026, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems.This deficient practice could place residents at risk of harm due to not providing needed interventions to prevent falls that lead to sustaining injuries.Findings Included:Record review of Resident #46 face sheet indicated she is [AGE] year-old female. She was admitted into the facility on [DATE] and readmitted on [DATE]. Her diagnosis are cerebral infraction (A thrombotic stroke occurs when a blood clot forms in an artery in the brain disrupting blood flow and leading to brain cell death); muscle wasting and atrophy (partial or complete wasting away of a part of the body); muscle weakness; and cognitive communication deficit (communication is impaired due to underlying cognitive difficulties rather than a primary language or speech problem).Record review of Resident #46 MDS dated [DATE] has section cognitive patterns blank and did not report a BIMS summary score. Resident #46 was rated as having poor decisions and supervision required under cognitive skills for daily decision making. Resident #46 was scored a 0 under section of rejection of care. Resident #46 was reviewed for functional abilities chair- to- chair transfer indicated she needed supervision or touching assist. Under walk 10 feet resident score stated the facility did not attempt due to illness, exacerbation, or injury.Record review of Resident #46's care plan revealed: Focus - Resident #46 is a high-risk or falls as evidenced by history of falls dated: actual fall with no injury on dates 2/1/26, 2/15/26,2/23/26, 3/10/26, 5/07/26. The care plan revealed Resident #46 had a history of 5 falls with no injury. Care planned interventions for Resident #46's prior to her fall on 05/07/26 besides the wheelchair positioning listed the following; Remind Resident #46 to lock her wheelchair before rising from chair 02/01/26; Standard of Care in place unless otherwise noted: Bed in low and locked, position, call light within reach, personal items and fluids close at hand, clear clean pathways and uncluttered surroundings, nightlights on/adequate lighting 02/15/26, secure wheelchair cushion to wheelchair 02/23/26; Evaluate for injury and neurological changes, Safety education provided regarding keeping on shoes during all transfers, Environmental check for additional hazards 03/10/26; Ensure and encourage resident to maintain proper footwear prior to transfers and mobilizing in wheelchair. Encourage resident to call for assistance when needed 03/17/26, EDUCATED AND ENCURAGED TO CALL FOR STAFF ASSISTANCE TO GO TO RESTROOM. 11/13/24, EDUCATED RESIDENT NOT TO PUT BELONGINGS IN WC 11/24/24. An intervention initiated on 06/16/24 revealed, Do not leave resident in wheelchair next to the bed. The care plan did not include any updated interventions since the resident's fall on 5/7/2026. Resident #46's care plan was not revised upon her return from the hospital on [DATE] and lacked individualized fall prevention interventions, supervision requirements, post- operative cervical spine precautions, positioning requirements, transfer assistance, and monitoring needs.Record review of Incident and Accidents date range from 12/28/25- 5/28/26 states Resident #46 had a witnessed fall on 03/10/26 and unwitnessed fall on 5/7/26.Record review of the facility investigation report on 5/26/26 indicated the witness statement did not include the assigned charge nurse or CNA.Record review of LVN C statement for incident on 05/07/26 states she observed resident on the floor in the room in front of her wheelchair. Patient was assessed for injuries and vitals obtained. Patient was assisted back into her wheelchair. Orders were sent to transfer out to the emergency room. Change of condition and risk management completed.Record review of progress notes recorded on 5/07/26 at 12:00pm by attending RN states Patient is wheelchair dependent. Continue fall precautions due to mobility limitations and hemiparesis (partial weakness or reduced strength on one side of the body).Incident note on progress note dated 05/07/2026 at 1:46pm The nurse was notified by the CNA that pt was on the floor in her room in front of her wheelchair. When asked by the nurse what happened, the patient is unable to give details of the incident.Record review on 05/26/2026 of witness statement from CNA C dated on 05/07/2026 Resident #46 agreed when asked if she attempted transfer without assistance resulting in a fall.Record review of Resident #46 discharge plan from the hospital dated 05/07/2026- 05/18/2026 at 11:19am states the resident chief complaint as patient presents with fall from wheelchair on date 5/2-5/6/2026 and continues after discharge to SNF, patient had an unwitnessed fall from wheelchair. On 05/09/2026 spine surgery for cervical spinal fracture on C6- C7 facet. History of present illness reported Discharge recommendations include supervision recommendations one to one. Occupation Therapist evaluation completed on 05/12/2026 reported on assessment results Activities of Daily Living status impaired, impaired endurance, and impaired functional mobility.An observation on 5/26/26 at 10:25am, Resident #46 was lying the bed with rails up. Resident #46 was observed wearing a hard cervical collar. An attempt to conduct an interview with Resident #46 was made, she was unable to answer questions and made gurgling sounds.Phone interview on 5/26/26 at 1:25pm, Family Member A stated he learned about Resident #46's incident through a staff member. He stated he went to the facility and arrived before the ambulance. Family Member A stated the staff informed him Resident #46 was taken out of her bed and put in her wheelchair, then the nurse assigned to her had left her unattended which resulted in a fall. He stated a second nurse saw Resident #46 on the floor, and the facility called the ambulance, and she was taken to the hospital. He stated once she got to the hospital, he found out Resident #46 had sustained a fracture to her neck and needed to have two major surgeries. He stated, I feel the nursing home is not giving her the best care.Interview on 5/26/26 at 3:37pm, LVN A stated he was the charge nurse who completed Resident #46 re-admission. LVN A stated the facility did training on falls through routine in-service. LVN A stated the policy on falls and his duty was to ensure the residents were assessed. LVN A reported Resident #46 is high risk for falls and on the Falling Star Program. LVN A reported Resident #46 was on regular supervision but need full assistance to complete her ADL's. LVN A stated he completed Resident #46 re-admission orders from the hospital. LVN A stated high fall risk residents shouldn't be left alone, he personally checks on them every 15 minutes. He did not indicate Resident #46 was on increased supervision. He stated he was verbally telling the aids, there was no formal documentation. He stated Resident #46 was already on the Falling Star Program for high-risk falls.Interview on 5/26/26 at 4:43pm, CNA A she has worked with Resident #46 this past week and in the past. CNA A stated Resident #46 required full assistance including feeding and changing her. CNA A stated the facility policy on falls was if anyone witnessed a fall they would complete a visual check first and look for blood, severe visible wounds, and retrieve the nurse to do an assessment. CNA A Resident #46 cannot hold a conversation and needs full assistance. Prior to her fall, CNA A stated before she fell she was able to pick herself up and needed regular supervision. CNA A stated she did not know when she reviewed Resident #46's care plan. CNA A stated she did not know about the Falling Star program, but resident identified as high risk wore a red arm band with the words Risk Fall. CNA A stated all the residents who were high for falls had fall mats and their beds were lowered. CNA A stated before she fell she was able to pick herself up and needed regular supervision.An interview was conducted on 5/26/26 at 5:12pm, CNA B stated she had worked with the facility for one year. CNA B stated Resident #46 was total care and the staff helped her do everything. CNA B stated her charge nurse LVN A had informed her prior to the shift starting that Resident #46 was total care. Staff stated it was related to a fall Resident #46 had that led to the increased care when she returned to the facility. CNA B stated her charge nurse would let her know who was on the Falling Star Program. Staff stated the program was for residents who were high risk for falls. CNA B stated the charge nurse informed the aides verbally it was not written anywhere. CNA B stated the facility was always providing ongoing training on falls. CNA B stated she doesn't know about a care plan or how to review their interventions on one. CNA B responded she has been assigned to Resident #46 yesterday and today, and a few times last week. CNA B stated she was total care since she returned from the hospital the first time. She knows because she was told by the charge nurse. CNA B learned of the fall or Resident #46 from her change nurse (LVN A) by verbally informing her prior to her shift. CNA B stated the nurse verbally will let her know who is on the falling star program by name.On 5/26/26 an interview with LVN B was held at 5:41pm. LVN B stated she is wearing a cervical collar from a recent fall. This Surveyor asked LVN B who is responsible for submitting orders when a resident returns from the hospital. LVN B reported the admitting nurse is the one who writes in the orders. LVN B added the resident with for high fall risk should be care planned and they have a sign on the door. LVN B stated she had not worked with Resident #46 since last month and was told Resident #46 was wearing a neck brace from a fall. LVN B stated if there no order writing and or a change of status since her return.On 5/27/26 at 10:17am an interview CNA C reported she worked the day of the incident and completed witness statement on the incident report, but was not assigned to Resident #46 on fall dated 05/07/2026. CNA C stated she assisted the assigned staff (CNA D) who had called out to her. CNA C stated she saw Resident #46 was on the floor with her back on the floor. On the day of the incident CNA C stated Resident #46 was unstable and was witnessed sliding down her wheelchair. CNA C stated that she transferred Resident #46 back into her bed to prevent a fall. CNA C stated, resident did not have mobility on her rights side. Staff stated Resident #46 is on the list as high risk for falls. CNA C stated Resident #46 is nonverbal. CNA C Resident #46 had regular supervision with assisted transfers. CNA C reported she read the care plans on the resident to identify any new changes before her shift. Resident #46 is a two person assist and was told verbally by her charge nurse. CNA C stated Resident #46 normally had her wheelchair close to her bedside which is where a majority of her falls would occur.An interview on 5/27/2026 at 10:47am LVN C stated she worked with Resident #46. LVN C mentioned that Resident #46 had a stroke and then had fallen right after she had to return from the hospital. LVN C stated she noticed the resident wearing a c-collar that she kept on at all times. LVN C stated she completed the incident report dated 5/7/2026 for the fall but she was not present at the time of the fall. She stated when the incident occurred, she went to assess the resident and saw her on the floor in front of the wheelchair lying face up. Staff stated Resident #46 was unable to respond to what happened as she had just returned from the hospital less than 24 hours from having a stroke. Resident #46 was mumbling but could make out what she was saying. LVN C stated the CNA called her and informed her a resident had fallen. LVN C stated she was not the assigned charge nurse that day, but the nurse was new and stepped away to go on break. LVN C stated she did read the resident's care plan, and it explains to the staff what type of care services the resident should be receiving. Each day she reviewed electronic medical record to check what the previous aid charted and discusses this during clinical in the morning. Per LVN C she stated on the day of incident, 5/07/2026, the new nurse was assigned to Resident #46 care. LVN C stated she heard the nurse left the resident in the wheelchair and left to go to lunch. After the medication aide went into the room and saw the resident. LVN C reported assigned nurse left to lunch and was notified but she never returned to the facility to complete the assessment. In the past LVN C stated Resident #46 would try to get in her chair if resident was placed near which led to many of her falls and was in her care plan was updated not to leave her unattended with the wheelchair.An interview was held on 5/27/26 at 11:42am with the Administrator reported she completed her internal investigation for Resident #46 fall on 05/07/2026. The Administrator responded it was unsubstantiated because she could not determine what caused the fall. Her investigation reflected Resident #46 was fed, changed, dry, and at the time of the incident she did not need assistance to transfer herself. The Administrator reported Resident #46 was on regular supervision, she had 2 hours checks as the other residents. Administrator reported the RN A was assigned to Resident #46 on 05/07/26. The Administrator stated the fall on 5/7/26 led to a fracture. Administrator reported Resident #46 did not show signs of pain or discomfort at the time of the fall when the nurse assessed. Resident #46 was sent to the hospital just in case as the assessment did not indicate any signs or symptoms of injury. The Administrator stated they were unaware of the injury until the day she was discharged from the hospital. The Administrator reported they did a training covering falls, strokes and they have one training scheduled for next month. The Administrator reported a care plan provides a multitude of things such as interventions, prevention practices, and steps for staff to follow for the resident.Interview held 5/27/26 at 12:32pm with the ADON stated she was at the facility on 5/7/2026 when Resident #46 fell. ADON stated the fall was unwitnessed. ADON stated she was out so she had not had time to review Resident #46. ADON stated she trains the nurses for increased care on Resident #46. ADON stated nurses who assess the resident will make the changes to the resident care plan and determine the level of supervision and other intrinsic factors on the incident report. ADON stated it had not been 14 days therefore the MDS assessment had not been revised. ADON stated the nurses are responsible for updating the fall list and deeming the resident high risk for falls.Interview on 05/29/26 at 12:22 pm with the Administrator stated all safe were educated and have a tasks list to complete which includes a review of the care plan. Administrator the charge nurses will ensure the resident safety by providing coverage and ensuring resident safety prior to going on break which includes not leaving Resident #46 unattended. Administrator has updated the residents daily charting to ensure documentation is maintained for residents. Care plan interventions were updated and included the injury along with interventions. All staff were provided with in-services before their shift to ensure compliance.On 5/29/26 at 10:11am an interview was held with the Corporate MDS Nurse who stated her title is Director of Regional Reimbursement. The MDS Nurse reported she has been assigned to this role with the facility since April 20,2026. The MDS Nurse stated she knows Resident #46. MDS Nurse reported anyone who has access to the system can update the care plan. She stated she encourages the an IDT approach at the facility level to make changes on the care plan as they are still not fully staffed. The MDS Nurse stated that she Resident #46 fell on 5/7/26 and returned to the facility on 5/18/26 the MDS assessment was not reviewed, the facility has 14 days to make significant changes. Once the review is completed it will then trigger the cause identified which will led to the IDT meeting. The MDS Nurse stated that she does not attend IDT meeting but if the facility invited her she would attend the resident review. The MDS Nurse stated the ADON, nurses, and the DON are responsible for updating the care plan at this time. The MDS Nurse reported the time frame is 14 days to initiate change and 28 days to complete the total changes on the care plan. The MDS Nurse reported they did not know Resident #46 was injured therefore the care plan was not revised sooner. The MDS Nurse stated they needed to gather data, that is the purpose of the MDS to help with the residents' care, therefore the plan could not be updated sooner. At facility level, the staff responsibilities are after the resident's problem is triggered not before.On 5/29/26 at 12:18pm in a follow-up interview with the ADON was asked about the RN who was assigned to Resident #46 on 5/7/2026. ADON stated she was in training and was still under review. The ADON stated she had seen RN prior to her break and informed her she was going to complete a checkoff and medication review. The ADON stated she provided the RN with a three-day orientation and an electronic medical record overview of the residents. The ADON stated when the RN left, she had attempted to get hold of RN but there was no response.Record review revealed the facility policy on fall prevention dated 5/08/2026 revealed in part under high-risk protocols c. Provide intervention that address unique risk factors measured by the risk assessment tool: Medications, psychological, cognitive state, or recent change in functional status.Number 7 states in policy Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care.a. Interventions will be monitored for effectiveness.b. The plan of care will be revised as needed.An Immediate Jeopardy (IJ) was identified on 05/28/26 at 1:18PM. The Administrator was notified. The Administrator was provided with the IJ template on 05/28/26 at 2:06PM. While the immediacy was removed on 05/29/26 at 3:20 PM, the facility remained out of compliance at a scope of isolated with serious injury from a fall resulting from inadequate supervision and failure to implement care plan or follow physicians orders.The following Plan of Removal submitted by the facility was accepted on 05/29/2026 at 8:07 AMn the morning.The facility implemented the following corrective measures to remove the deficient practice:ADON and designees reviewed Resident #46 medical record, fall interventions, supervision needs, transfer status, and post- surgical precautions were immediately reviewed by the interdisciplinary team.ADON and designees reviewed residents care plan and updated to include the individualized fall prevention interventions, supervision requirements, post- operative cervical spine precautions, positioning requirements, transfer assistance, and monitoring needs. Completion date was 5/28/26ADON and designees In-serviced direct care clinical staff on Falling Star & Fall Prevention Program which included falling star identification system, fall risk assessment process, intervention for yellow star residents, post- fall protocol, quality assurance and performance improvement, staff education, regulations and guidelines, fall prevention best practices, documentation requirements. Completion date was 05/28/26 and 5/29/2026ADON and designees reviewed all other resident with potential to be affected with immediate audit who have fallen in the last 30 days which included fall risk assessments were current, residents had appropriate interventions in place, care plans reflected the resident needs, ensured safety devices and supervision interventions were implemented, staff aware of resident- specific fall prevention interventions. Completion date was 05/28/26ADON and designees held in-service education for licensed nurses, CNA's, restorative staff, and direct care staff which included accident prevention and supervision requirements, compliance with resident specific care plans, high risk fall protocol, proper supervision of resident seated in wheelchairs, frequent rounding expectations, immediate reporting and assessment of falls, post- fall procedures and documentation requirements, resident safety responsibilities during staff breaks and shift transitions. Completed on 05/28/26ADON and designees instructed all direct care staff to review high- risk fall residents at the beginning of each shift to verify interventions, safety devices, supervision measures, and care plan compliance. Education is expected to be completed prior to the next working shift. Completed on 05/28/26ADON and designees reviewed the Fall Prevention program and High- Risk Fall Protocol policy, no changes were made. Completed 05/28/26ADON and designees Adhoc QAPI was help with the IDT and Medical Director to inform them of the Immediate Jeopardy. Completed on 05/28/26PRN Nurse involved in incident on 05/7/26 was terminated on 05/07/26.Monitoring of the POR included the following:On 05/29/2026 observations were made, records were reviewed, and direct care nursing staff were interviewed.Record review of MDS resident matrix, fall prevention policy, QAPI adhoc, review of in-services fall prevention, management and use of safety devices dates completed on 5/28/26 & 5/29/26, Ensuring all care plan interventions are followed by all shifts dated 05/28/26 with signature sheet. Resident #46 care plan revision with focus problem had actual fall with major injury on 5/7/26- interventions included adding resident the Dozzie system (alerts when resident is off the bed), encourage resident to follow IDT recommendations to reduce fall risk injuries, facility fall prevention program, and PT consult for strength and mobility; completed on 05/28/26. Follow up with additional residents who are high for fall risk (5 residents reviewed). Significant change assessment completed and revised for mobility as needs total assistance, mental stability disorientated. Significant change assessment completed for 5 additional residents on 05/28/2026. Incident and accident form updated for fall on 05/07/2 and deemed under un-witnessed fall incidents dated 05/28/26.Interview with the Administrator on 5/29/26 at 12:22 pm a plan of review interview was conducted with this Surveyor. This Surveyor asked administrator was the facility's proper supervision definition means and how it will be monitored. Administrator stated she is going to ensure all the staff are educated by incorporating a task list and ensure they have read the care plan. This Surveyor requested more clarification on resident safety responsibilities during staff breaks. The Administrator stated that when staff go on breaks they are ensuring residents safety is covered and provide the additional oversite while on break. She reported the care plan was revised to include injury's to align with the interventions and updated accordingly.A second interview with LVN C on 5/29/26 at 12:56pm was conducted in person on 6am - 2pm shift. This Surveyor asked LVN C what new changes were implemented for Resident #46. LVN C reported that she is aware resident is a high fall risk, the list was updated and placed in the nurses station. Resident #46 now has the Dozzie Program installed so when the resident moves or gets off the bed it sends alerts to the staff. LVN C reported that under no circumstances should Resident #46 be left unattended when out of bed. If a staff is going on break makes the CNA's know to have coverage and check on the resident. Every time she comes in for shift report she will discuss changes of condition. Staff reported she will continue to notify the doctor and family while completing her assessment duties.Interview with CNA D on 5/29/26 at 1:11pm. CNA D stated she was educated on Resident #46 being included in the falling start program. The facility updated the list is now available at the nurse station. She stated the care plan for residents was updated and reviewed. CNA D stated she knows Resident #46 should not be left in her wheelchair unattended, if she did see the resident, she would help transfer her and report to the nurse.Interview with LVN A on 5/29/26 at 1:37pm. He reported the facility provided him with in-services. LVN A stated he was made aware of the changes on the falling star program. When him or his staff are going on break, they are to notify the nurse and let them know where he will be and how long. LVN A stated Resident #46 should not be left alone in her wheelchair unattended as she is a fall risk. If witnessed her in her wheelchair unattended he would document, call on the assigned staff, and report it to the doctor and ADON.A follow up interview was completed with CNA E on 5/29/26 at 1:58pm. CNA E stated she did training and was provided with in-services that required a quiz at the end. She stated the resident was added to the falling star list and now when she documents and alert comes out resident is a fall risk. She is going to review Resident #46 and complete her documentation on her shift of status and ensure she not left unattended. Staff stated if she did see the resident left unattended, she would notify the charge nurse.An interview with LVN D on 5/29/26 at 2:16pm stated he was trained over four areas which included falls. He stated Resident #46 should not be out of bed unattended. Staff are to be reporting if any concerns arise. If he saw resident unattended, he would relocate her to the nurses station to monitor and report on her discovery to her supervisor.On 5/29/26 at 2:22pm a phone interview was conducted with RN. RN stated he was trained on reporting and falls.Interview with CNA F on 5/29/26 at 2:27pm stated she was trained by the facility on a few policies. CNA F stated she was trained on falls. Staff said she is aware Resident #46 is not supposed to be left sitting her wheelchair unattended. Resident is to be transferred back into bed. If she saw resident left in wheelchair unattended, she would bring resident up to the nurses station and have someone watch her. Then she would notify the charge nurse and follow the chain of commands ADON and Administrator.Observation on 05/29/26 of the facility indicated residents all had their star placed visibly on the doorway. List of high risk residents was available at the nurses station and on the cart.Record review of facilities fall audit and assessment for 5 residents who met high fall risk were completed on 05/28/26 by the physician.Record review of facilities incidents and accidents date range from 04/28/26- 05/28/26 was completed on 05/28/26.

Based on interview, and record review the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis at least 8 consecutive hours a day, 7 days a week for 2 of 60 (05/18/2026 and 05/25/2026) days reviewed.The facility failed to provide RN coverage for 05/18/2026 and 05/25/2026 to meet the requirements of an RN working a full 8 hours a day.These failures could result in periods without required RN oversight and placed residents at risk for unmet care needs, delayed assessments, and inadequate supervision of licenses and unlicensed staff. Findings include:Record review of the facilities PBJ data for fiscal year 1 2026 revealed the results as 'Not Triggered' for no RN hours.Record review of the facilities RN Coverage Timesheets revealed no RN worked for 05/18/2026 and 05/25/2026.During an interview on 05/28/2026 at 3:44pm with the Administrator she stated the facility has been without a DON for approximately 30 days. She stated that when a DON was not present, the facility typically assigned other RNs to cover DON responsibilities; however, they have recently experienced staffing shortage. The Administrator reported she has posted the DON position on Indeed and anticipates a new DON start at the beginning of next month. She stated the primary risk of not having an RN in the building would be the inability to provide certain treatments, such as initiating an IV. She stated she could not identify any services a resident would be unable to receive in the absence of an RN and stated there had not been a lapse in care when an RN was not present.Record review of the facilities policy for Nursing Services-Registered Nurse (RN) revised on 05/30/2025 read.Policy: It is the intent of the facility to comply with Registered Nurse staffing requirements as per Social Security Act S1919 and S1819. Full-time is defined as working 40 or more hours a week.The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days per week. (The requirement for 8 consecutive hours of RN services can be met by any RN or multiples of RNs. The facility will designate a Registered Nurse to serve as the Director of Nursing on a full-time basis.)

Based on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #7) reviewed for infection control.- CNA X failed to change gloves, wash, or sanitize hands after cleaning Resident #7's buttocks, and before handling the clean brief and bed linens.CNA Y failed to change gloves, wash, or sanitize hands after cleaning Resident #7's peri-area during incontinent care and before handling the clean brief, bed linens, and touching Resident #7's face.These failures could place residents who required assistance with toileting needs at risk for cross contamination and infection.Record review of Resident # 7's face sheet revealed a [AGE] year-old admitted to the facility on [DATE], initially admitted on [DATE] and originally admitted on [DATE]. Resident #7's diagnoses included Quadriplegia (condition characterized by partial or complete paralysis of all four limbs and torso), disorder of the brain, Aphasia (language disorder caused by damage in a specific area of the brain), diseases of the upper respiratory tract, urinary tract infection, Neuromuscular function of the bladder (nerve damage to the bladder), gastrostomy status (a surgically created opening in the abdomen directly into the stomach with a feeding tube) and colostomy status (a surgical created opening in the abdomen to allow stool to exit, that connects the large intestine to the outside of the body, and pouch worn on the outside) and Dysphagia (swallowing disorder).Record review of the quarterly Minimum Data Set (MDS) resident assessment dated [DATE] revealed Resident # 7 had short term and long-term memory problems. Resident #7 had moderately impaired cognitive skills for daily decision making. Resident #7 required staff assistance for bed mobility, transfers, dressing, toilet use and personal hygiene.Record review of Resident # 7's undated care plan revealed in part; Problems: Resident #7 required enhanced based precautions due to colostomy and G-tube with immunosuppressive disease processes. Interventions included: Enhanced Barrier precautions - Gown and gloves required when providing direct care and if anticipating coming into contact with surfaces and materials potentially contaminated by the resident. Problem: Resident #7 had an ADL self-care performance deficit r/t TBI(traumatic brain injury). Interventions included: Toilet hygiene - moderate to max assist, dressing - total assist, mobility assistance when rolling left to right - max assist. Problem: Resident #7 had functional bladder incontinence r/t impaired mobility, inability to communicate needs and physical limitations. Interventions included: the resident uses disposable briefs. Change frequently and PRN.Observation and interview on 5/28/26 at 4:30PM, Resident #7 was alert and in bed with the head of bed raised. A sign for Enhanced barrier precautions instructions was on the door to the room. Isolation personal protective equipment was in the small cart just outside the door to the room. The door was closed. Isolation trash and linen containers were in the resident's bathroom. CNA X and CNA Y gathered supplies then washed their hands in the bathroom then put on clean gowns and clean gloves. Both CNAs unfasted Resident #7's brief, rolled the brief down between Resident #7's thighs. The CNAs rolled the resident to his left side and CNA Y tucked the tabs of the brief under Resident #7's left hip, rolled the resident to his right side and CNA X removed the soiled brief with urine. Using disposable wipes CNA X cleansed Resident #7's lower abdomen and right groin. CNA 2 cleansed Resident #7's left groin CNA X cleansed the tip of the penis and the urethral meatus using clean wipes and a separate clean wipe to cleanse the scrotum. CNA X cleansed Resident #7's buttocks with a clean wipe and cleansed the anal area with a clean wipe. CNA X positioned the clean brief beneath the resident's buttocks and fastened the tab to Resident #7's right side and CNA Y fastened the tab to the left side of the resident. CNA X and CNA Y touched the resident's gown and covered his body and touched the bedding to pull the covers over the resident. CNA Y touched Resident #7's head and face then wiped his mouth with a moistened washcloth. CNA X and CNA Y did not: remove used gloves, perform hand hygiene, put on clean gloves after cleaning the resident and before touching the clean brief, bedding, and the resident's face/head. In an interview on 5/28/26 at 4:30PM, CNA X and CNA Y both stated they were nervous because they were being observed and knew they should have: changed gloves, performed hand hygiene, and put on clean gloves after the dirty part of the peri care. CNA X and CNA Y both stated it was cross-comminating to touch clean items with dirty, used gloves and should have changed gloves before touching the clean items. CNA Y stated she should not have touched Resident #7 on the face with gloves used for incontinent care because the gloves were not clean and she didn't realize she did this. In an interview on 5/29/26 at 12:30 PM, the ADON stated the CNAs were responsible for providing peri care. The ADON stated hands should be washed and gloves changed to prevent infection. The ADON stated that once done with the cleaning portion of the procedure, the gloves are to be removed, hand hygiene performed and clean gloves put on because after cleaning the resident during peri care, the gloves would be dirty and should no longer touch anything like linen and clean briefs or the resident's skin. The ADON stated it was the facility policy to perform hand hygiene between glove changes. The ADON stated she was responsible for oversights and training regarding infection control, peri care, and hand hygiene. The ADON stated since the DON left on 5/5/26 she had been conducting staff training, including peri care, infection control, and hand hygiene.Record review of the facility policy for Perineal Care revised on date 5/1/25 read in part: Policy: It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown.12. Males.h. cleanse the scrotum using.new disposable wipe with each stroke.k. Clean and dry the bottom of the scrotum and the anal area.15. Reposition as desired and cover resident. 16. Remove gloves and discard. Perform hand hygiene.Record review of the facility policy for Hand Hygiene revised on date 4/10/25 read in part: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 7. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.Record review of the facility policy for Infection Prevention and Control Program revised on date 4/2/25 read in part: .4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #46) reviewed for care plans.The facility failed to review and revise Resident #46 care plan despite her history of four recent falls (2/1/26, 2/15/26, 2/23/26, and 3/10/26) before she had a major fall on 05/07/26 and when she was re-admitted to the facility on [DATE] with a neck fracture and with post-surgical needs.This deficient practice could place residents at risk of harm as qualified staff responsible for carrying out interventions were not notified of their roles and responsibilities of the specific are and services implemented for the resident.Findings include: Record review of Resident #46 face sheet indicated she is [AGE] year-old female. Her admitting date is recorded as 7/23/21 and readmitted on [DATE] with diagnosis of cerebral infraction (A thrombotic stroke occurs when a blood clot forms in an artery in the brain disrupting blood flow and leading to brain cell death); muscle wasting and atrophy (partial or complete wasting away of a part of the body); muscle weakness; and cognitive communication deficit (communication is impaired due to underlying cognitive difficulties rather than a primary language or speech problem).Record review of Resident #46 MDS dated [DATE] has section cognitive patterns blank and did not report a BIMS summary score. Resident #46 was rated as having poor decisions and supervision required under cognitive skills for daily decision making. Resident #46 was scored a 0 under section of rejection of care. Resident #46 was reviewed for functional abilities chair- to- chair transfer indicated she needed supervision or touching assist. Under walk 10 feet resident score stated the facility did not attempt due to illness, exacerbation, or injury.Record review of Resident #46's care plan revealed: Focus - Resident #1 is a high-risk or falls as evidenced by history of falls dated: actual fall with no injury on dates 2/1/26, 2/15/26,2/23/26, 3/10/26, 5/07/,26. The care plan revealed Resident #46 had a history of 5 falls with no injury. An intervention backdated 6/16/24 and revealed in part, Do not leave resident in wheelchair next to the bed. The care plan did not have any updated interventions since the resident's fall on 5/7/2026. Care plan did not include any updates on focused care for the cervical collar or interventions outlined for staff.Record review of Resident #46 discharge plan from the hospital dated 05/18/2026 at 11:19am states the resident chief complaint as patient presents with fall from wheelchair on date 5/2-5/6/26 and continues after discharge to SNF, patient had an unwitnessed fall from wheelchair. History of present illness reported Discharge recommendations include supervision recommendations one to one. Physicians' postoperative treatment plan stated client is to continue to wear Maimi J collar, may stand as tolerated with no bending, lifting, twisting for 2 -3 months. Occupation Therapist evaluation completed on 05/12/2026 reported on assessment results Activities of Daily Living status impaired, impaired endurance, and impaired functional mobility.A record review on 5/26/26 of Resident #46 care plan has an intervention backdated 6/16/24 and reads in part, Do not leave resident in wheelchair next to the bed. Care plan did not have any updated interventions since residents fall on 5/7/2026. Care plan revealed Resident #46 has a history of 5 falls with no injury. Care plan did not include any updates on injury from fall on 5/7/2026 to include cervical collar care.Record review of re-admission orders were not completed and dated 5/26/2026. Order submitted by LVN A stated, Resident must have cervical collar on at all times until return appointment with the sx (surgeon).An observation on 5/26/26 at 10:25am, Resident #46 was lying the bed with rails up. Resident #46 was observed wearing a hard cervical collar. The room was free from obstruction and organized but did not include a fall mat on either side of the bed. An attempt to conduct an interview with Resident #46 was made, she was unable to answer questions and made gurgling sounds.Phone interview on 5/26/26 at 1:25pm, Family Member A stated he learned about Resident #46's incident through a staff member. He stated he went to the facility and arrived before the ambulance. Family Member A stated the staff informed him Resident #46 was taken out of her bed and put in her wheelchair, then the nurse assigned to her had left her unattended which resulted in a fall. He stated a second nurse saw Resident #46 on the floor, and the facility called the ambulance, and she was taken to the hospital. He stated once she got to the hospital, he found out Resident #46 had sustained a fracture to her neck and needed to have two major surgeries. Family Member A stated he attempted to move Resident #46 to another facility but did not have power of attorney. He stated, I feel the nursing home is not giving her the best care. Family Member A stated Resident #46 was non-verbal now and before she could make sentences and now she could not.On 5/26/26 at 2:32pm observation of Resident #46 in her room call light within reach of the resident. No staff were in the room or in the hallway. Resident was lying bed without her cervical collar. C-Collar was placed on the bedside table, out of reach from resident.Interview on 5/26/26 at 3:37pm, LVN A stated he was the charge nurse who completed Resident #46 re-admission. LVN A stated the resident's comprehensive care plan identifies what is going on with the resident. He stated he reviews it daily in the resident's electronic chart. LVN A stated he verbally updates his staff during report at the beginning of each shift. LVN A stated if he were to witness a staff member not following the care plan he would address them then go check on the resident to verify if the interventions were being followed. LVN A stated the manager or the ADON are normally responsible for the updates in the care plans. LVN A stated he was assigned to Resident #46 this week and last week.Interview on 5/26/26 at 4:43pm, CNA A stated it had been a long time since she reviewed are care plan and she couldn't name a date the last time she reviewed Resident #46care plan. Staff did say she recalls seeing updates on Resident #46, she had alerts pop up on her electronic chart. CNA A [NAME] her delegated charge nurse is LVN A.An interview was conducted on 5/26/26 at 5:12pm with CNA B who stated she is familiar with Resident #46. CNA B stated Resident #46 is a total care resident which means the staff have to help her do everything. CNA B stated she had to change her brief, clean, and dry her, feed her, and put clothes on her. CNA B reported that her charge nurse (LVN A) informed her prior to the shift starting what care Resident #46 needed. CNA B stated the charge nurse informs the aids verbally as it is not written anywhere. Staff stated there are no orders or plan that are provided other than being verbally told by charge nurse on the resident's level of care. CNA B stated an intervention is used to help solve a problem. CNA B stated she did not know about care plans or how to review interventions on one. CNA B stated she has been assigned to Resident #46 yesterday and today, and last week.Interview on 05/26/26 with LVN B held at 5:41pm. LVN B stated she was familiar with Resident #46 although she has not worked with her in a while. LVN B stated the care plan notifies the CNA's of the interventions on the care plan. LVN B stated the care plan was a plan of care for the resident, a guideline for the residents and their specific needs. LVN B stated the charge nurses normally did the initial assessments and then they are discussed amongst the departments. LVN B stated the MDS Nurse updated the care plans and nurses could do baseline care plan changes.On 5/27/26 at 10:17am an interview was held with CNA C indicated interventions are in place to help care for the patient. She reported that PCC also provide alerts to help notify them if anything needs reviewing or monitoring. CNA C attends shift report at every shift report about the resident, what happened at each round, how long ago each task was conducted (feeding, changing), anything significant if they been up or asleep. CNA C stated Resident #46 care includes full assistance with a two person assist. CNA C stated she know because the charge nurse verbally told her prior to the shift but did not receive any other training or updates.An interview on 5/27/26 at 11:42am the Administrator stated The Administrator stated she was unsure if Resident #46 care plan and has not learned every resident's care plan. The Administrator stated it is normally assigned to the MDS nurse, but the facility has not held one for some time. Administrator reported a corporate MDS nurse is doing this job remotely. The Administrator stated they did train covering falls and signs of strokes after Resident #46 fell and they have one training course scheduled for next month. The Administrator stated a care plan provides a multitude of things such as interventions, prevention practices, and steps for staff to follow for the resident. She said the steps are specific to the care the resident needs. The Administrator stated the nursing staff should review the care plan daily and review any changes that have occurred. The Administrator stated it was important to follow the care plan, if the care plan was not followed there could be a gap in care services or delay in care The Administrator stated it is important to check the residents baseline, see any changes, review level of care, and communicate to the reset of the team.An interview on 5/27/26 at 12:32pm, the ADON stated she was at the facility on 5/7/2026 when Resident #46 fell. The ADON stated when reviewing a fall the nurse should complete the assessment and notify the doctor about the assessment findings. She said the nurse should place any orders, complete the risk management, assess for pain, fall type, and if unwitnessed they should complete one more task which is check for neuros. ADON reported she was out on leave therefore she had no time to review Resident #46. ADON stated that since Resident #46 return there had been a change in resident's ADL care. The ADON stated she made a request to MDS Nurse on 5/27/26 to check if Resident #46 qualified for significant change assessment on her MDS, since resident has not met her 14-day time frame. ADON stated she and the corporate nurses trained the nurses and CNA's on providing care to Resident #46. ADON stated she provided the facility staff with in-service training the day of the incident. ADON stated the staff are aware of the Falling Star Program because it will comes up on the electronic charting and the resident's care plan.A record review on comprehensive care plan policy on 5/27/26 reads in part, 1. The care planning process will include an assessment of the resident's strengths and needs. All services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality, and incorporate culturally competent and trauma-informed care as indicated. 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.Record review on 5/29/26 revealed facility trained on topic Ensuring All Care Plan Interventions are followed by all shifts dated 5/28/26.Record review on 05/29/26 facility Fall Prevention Program states in part, The assessment indicates the resident's fall risk score and the nurse will initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. Each resident's risk factors and environment hazards will be evaluated when developing the resident's comprehensive plan of care. Interventions will be monitored for effectiveness; the plan of care will be revised as needed.

Based on interview and record review, the facility failed to immediately consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #1) of 5 residents reviewed for resident rights.- Nurse A did not respond to the Dr.'s text message on 05/01/26 at 10:12 p.m. when she asked him if it looked like Resident #1 had a stroke.-Nurse B failed to report Resident #1's change in condition for approximately 12 hours and 36 minutes beginning on 05/01/26 around 10:12 p.m. NP was notified on 05/02/26 at about 10:48 a.m. and Resident #1 was not transported to the hospital until 05/02/26 at approximately 11:42 a.m.An Immediate Jeopardy (IJ) was identified on 05/09/26. The IJ template was provided to the facility on [DATE] at 1:30 p.m. While the IJ was removed on 05/11/26, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal (POR).This failure could place residents at risk of not receiving appropriate care and required notifications being made when there is a change in their condition.Findings included:Record review of Resident #1's admission Record, dated 05/06/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (lung disease), hemiplegia and hemiparesis (hemiplegia is paralysis of one side of the body, while hemiparesis is weakness on one side) following cerebral infarction (ischemic stroke and requiring targeted rehabilitation for recovery) affecting right dominant side, cognitive communication deficit (occurs when a person struggles to communicate effectively because of impairments in cognitive processes such as attention, memory, and executive function rather than problems with speech or language itself, and dysphagia (difficulty swallowing), oropharyngeal phase (initial, automatic stage of swallowing).Record review of Resident #1's MDS Assessment, dated 02/14/26, revealed a BIMS score of 14, indicating her cognition was intact. Section B, B0600, Speech clarity, was coded as 1 indicating unclear speech - slurred or mumbled words and Section B, B0700, Makes Self Understood, was coded as 1 indicating Resident #1 was usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time.Record review of Resident #1's Care Plan, undated, revealed resident had a communication problem. Interventions for the resident included allowing adequate time to respond, repeating as necessary, requesting clarification from the resident to ensure understanding, asking yes/no questions if appropriate, and using simple, brief, consistent words/cues. Additional interventions included encouraging the resident to continue stating thoughts even if resident is having difficulty and to monitor for/record cofounding problems such as a decline in cognitive status and oral motor function.Record review of Resident #1's Change in Condition Evaluation form, dated 05/02/26 at 11:00 a.m., revealed Nurse C completed the evaluation and noted Resident #1 showed signs of aphasic speech (impaired communication caused by damage to the brain's language centers, affecting speaking, understanding, reading, and writing), was easy to arouse, not able to respond as she normally did, no facial drooping, able to move left arm and leg which was normal, no respiratory distress, NP ordered to send resident to ER for evaluation and treatment.Record review of Resident #1's progress note, dated 05/06/26 at 12:59 p.m., revealed on 05/02/26 at 11:00 a.m., Nurse C entered a SBAR Summary for Providers for a CIC. CIC noted Resident #1's neurological status evaluation as abnormal speech. In addition, the CIC note indicated Nurse C was informed resident was not acting herself, was easy to arouse, not able to respond as she normally did, no facial drooping, able to move left arm and leg which was normal, no respiratory distress, NP notified and ordered to send resident to ER for evaluation and treatment.Record review of Resident #1's progress note, created date 05/06/26 at 18:58 [6:58 p.m.], revealed Nurse A created the note as a late entry. Note reflected an effective date of 05/01/26 at 21:35 [9:35 p.m.] and indicated Resident in bed watching Tv, but not as vocal as normal.Resident started singing and started speaking garbled English. Dr. [name] notified asked if she appeared to have a stroke. Unable to answer informed the on coming nurse, that the resident was not vocal and that Dr. [name] wanted to know if it appears that the resident has had a stroke. Resident viewed again and was singing no distress at the moment. Nurse agreed to monitor the resident and if any changes to notify the Dr.Record review of Resident #1's progress note, dated 05/06/26 at 12:59 p.m., revealed on 05/02/26 at 12:30 p.m., Nurse C entered EMS arrived at facility at 11:42A and placed resident on stretcher and left facility 11:48A.Record review of hospital records, dated 05/02/26 revealed Resident #1 had diagnosis of altered mental status and acute cerebrovascular accident (CVA). She returned to the facility on [DATE].During an interview on 05/07/26 at 8:37 a.m., Nurse B said he worked Friday, 05/01/26 from 10:00 p.m. to 6:00 a.m. He said Nurse A gave him resident updates verbally and told him Resident #1's speech was not clear, and it took her 30 seconds to a minute longer, compared to her regular baseline to respond. He said Nurse A told him he texted the Dr. [name] and was waiting for a response from her. He said Nurse A told him to monitor the resident during his shift. He said he monitored Resident #1 during his shift. He said he monitored her at 10:30 p.m. and resident was asleep and he checked her vital signs. He said at 1:30 a.m. resident was asleep and he touched her arm, she blinked, opened her mouth, and went back to sleep. He said at 3:15 a.m., she was asleep, he touched her arm, she opened eyes and went back to sleep. He said he went to resident's room around 5:00 a.m.-5:30 a.m. He said resident was awake and he tried to speak with her and felt resident's speech was still not clear and that she was trying to say the words, but her speech was still slurred. He said he asked Resident #1 if she was okay and she said she was fine, but it took her more than a minute to answer the question but said he understood her answer. He said he completed a full body assessment on 05/02/26 at approximately around 5:00 a.m.-5:30 a.m. (documentation could not be located). He said around 6:15 a.m. he gave Nurse C the shift change report and told him Resident #1's speech was slurred, that he could not make out the words, and it look like she had seizure activity. Nurse B said he asked Nurse C to assess the resident and then to call the doctor. He said Nurse C said he would do the assessment and would then call the doctor about resident's speech. He said he then left the facility because his shift was over. He said if resident has a physical change he would ensure treatment and care was provided to Resident #1 when there was a change consistent with professional standards of practice. During an interview on 05/07/26 at 11:31 a.m., the NP said she received a phone call from Nurse C around 10:48 a.m. on 05/02/26 about Resident #1. She said Nurse C told her Resident #1's speech was slurred and that she had a significant change with her speech. She said Resident #1's speech went from 3-4 words, for example, not feeling good, stomach hurts, get the hell out of here, but NP said now Resident #1's words were indiscernible. NP said Resident #1 now not being able to speak leads her to believe she had a stroke, but NP said she had not reviewed the hospital paperwork yet.During a telephone interview on 05/07/26 at 11:49 a.m., the Dr. said Nurse A messaged her on 05/01/26 approximately around 9:40 pm-10:00pm saying Resident #1 denies any pain, not herself, sorry to bother you. She said she messaged him back and asked if Resident #1 had any signs of a stroke, but she said she did not hear back from Nurse A. Dr. said she would have needed more information to determine what exactly was going on with Resident #1. Dr. said it was already hard to decipher Resident #1's speech and what she was saying.During an interview on 05/07/26 at 1:20 p.m., Nurse A said he did not complete Resident #1's full consultation with the Dr. on 05/01/26 nor did he complete a full-body assessment on Resident #1 before the end of his shift from 2:00P-10:00P on 05/01/26. He said he texted the Dr. on 05/01/26 at 9:37 p.m. Sorry to bother you but [resident name] is not herself, denied pain but is speaking in garbled English. He said Dr. [name] messaged him back at 10:12 p.m. and asked him, Does it look like a stroke? but he said he never responded back to her question. He said he knew the Dr. would want them to monitor the resident to make sure she was alright, and if there were any changes to let her know. He said he did not complete a full body assessment because she could move and she was not in any pain. He said it was time for shift change and he reported to oncoming Nurse B, what was going on with Resident #1.During an interview on 05/07/26 at 2:43 p.m., the ADON said when a resident had a change in condition, the nurse should complete a full head-to-toe assessment, take their vitals, call the doctor to let them know about the changes and to see if they had any recommendations or new orders, and to notify the resident's family.During a telephone interview on 05/08/26 at 8:05 a.m., Nurse C said Nurse B did not report to him that something was wrong with Resident #1's speech or that he suspected seizure activity during his shift change report or before leaving the facility. Nurse C said he was not positive but said it was roughly around 8:30 a.m.-9:00 a.m. when he received a phone call from Nurse B telling him that Nurse A called him and said a CNA (could not recall name) told him Resident #1 may have had a stroke. Nurse C said he immediately went to Resident #1's room and started talking to her. He said she opened her eyes, smiled, she was alert and oriented, she moved left arm and leg which was normal, had no facial drooping, responded to light, but the only thing was she was aphasic (disorder that impairs the ability to communicate through speech, writing, or understanding language). He said he messaged the NP, reported Resident #1's symptoms and asked NP if she wanted to send Resident #1 out to hospital and NP said yes.Record review of the facility's Notification of Changes policy, date reviewed/revised 05/13/2025, read in part .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Definitions: Life-Threatening Conditions: Examples - Heart Attack or Stroke.Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification.Circumstances requiring notification include:.2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complications.The Administrator was notified on 05/09/26 at 1:30 p.m., that an IJ was identified due to the above failures and the IJ template was provided. The following Plan of Removal (POR) was accepted on 05/10/25 at 4:27 p.m.: 5/10/2026[Facility Name]Plan of Removal - F580 Notification of ChangesThe Facility failed to report a significant change in the Resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. Immediate Corrective Action for Resident #1Resident #1 was assessed upon return on 5/5/26 from the hospital, including neurological status, vital signs, skin/body assessment, functional status, communication ability, and swallowing status.Physician/NP orders were reviewed and implemented.Care plan was updated to reflect change in condition, stroke history, communication needs, monitoring needs, and interventions. Identification of Other Residents with Potential to be Affected All residents residing in the facility have the potential to be affected by the alleged deficient practice. On 5/9/2026 An audit was conducted by the Director of Nursing (DON), Assistant Director of Nursing (ADON), or designee of current residents with recent changes in condition within the last 30 days to ensure: Appropriate nursing assessments were completed, Physician and responsible party notifications were timely, Documentation was complete, Orders and follow-up interventions were implemented appropriately. No other residents were identified with concerns. Systemic Changes Implemented The facility has implemented the following systemic changes to prevent recurrence: All Licensed nurses were re-educated by the DON/ADON/Designee on the facility policy for Change in Condition, beginning on 5/9/2026 and completed by 5/10/2026 or prior to working next scheduled shift including: Immediate head-to-toe assessment, Neurological assessment when indicated, Appropriate physician/NP and responsible party notification was initiated immediately upon recognition of the resident's acute change in status, if the physician, covering physician, on-call provider, nurse practitioner, or medical director is unable to be reached initiate emergency services (911/EMS) immediately if the resident demonstrates signs or symptoms of a medical emergency or worsening conditionDocumentation requirements, Escalation of unresolved or worsening symptoms, Shift-to-shift communication expectations. (CNA and all personal care staff were educated on the Change of condition process) Scheduled staff were trained by the ADON and Regional Nurse. Staff education will be completed by 5/10/2026 or prior to their next scheduled shift.Education included recognition of signs and symptoms of stroke/CVA and the need for immediate intervention and emergency services activation when warranted. Policies reviewed for Change in resident conditions, no changes made. The Regional Nurse reviewed the policy on 05/09/2026Adhoc QAPI held with Medical Director regarding Immediate Jeopardy. 05/09/2026Education includes nurse responsibility if the MD does not respond. On 05/11/2026, surveyor confirmed the facility implemented their plan or removal (POR) to sufficiently remove the IJ by: During observation on 05/10/26 at 1:30pm, showed how they document, new alert in the resident POC, the appropriate time to document and there is no expectation time, resident safety is based on making sure their bed is low especially for fall risk, make sure call light within reach, and everything that they need is close by, make sure everything is reachable and secured. For dignity and respect she will make sure the residents are dressed nicely, encourage them to get up, let them look in the mirror, make sure they smell good, treat them how they want to be treated or how she would want to be treated or treated her mother. Signs of a stroke, posture is not straight, face is drooping, one side is hurting, and if their speech is off.Record review revealed on 05/09/26 and 05/10/26, in-service training was initiated on Quality-of-Care requirements.Record review revealed on 05/10/26, in-service training was initiated with staff over recognizing a change in condition, reporting to the MD, and documentation of change.During an interview on 05/10/26 at 12:35am, Nurse D said she works 6:00 a.m.-2:00 p.m., she works all halls, has been at the facility working since November 2025, a change in condition is anything outside of the resident's normal baseline, even if they say their stomach is hurting today and it wasn't yesterday. First she would do vitals, assess the resident, notify the doctor but the doctor comes by daily, they will call and text the doctor regarding the change, after that she will wait for orders if any and they do whatever the doctor states, send the resident out, blood work, notify the family and the DON, they are also completing the SBAR which is the change in condition. She would document right away, and they also document the new orders and if they get new orders, new appointment and any follow-ups that were received, they also document in the progress notes for three days pertaining to the status of the resident. She ensure the resident is safe by doing rounds every two hours but depending on the severity she would also do 1 hour, they also report during shift change. The report is verbal, but they are also completing the 24-hour report and it's also in the POC. She will update the 24-hour report and then she will pass it on to the next shift, she also does clinicals in the morning. The care plan is reviewed when she come in the morning before she go to the clinical meetings. The expectation for documentation, accurate, on time, and it needs to be done. The saying is if it is not documented then it didn't happen. Signs of stoke would be drooling, numbness, weakness in limbs, elevated vitals, and slurred speech. She ensure residents are treated with dignity and respect by talking to them. Speaking to them, assisting the aides.During an interview on 05/10/26 at 12:49 p.m. CMA/CNA A, has been at the facility for 1 year, she mainly does meds and she does the entire building, and she does CNA work anywhere, change in condition is anything that is not normal behavior for that specific person, their blood pressure, anything out of baseline, urgent concerns would be to inform the nurse immediately, if a resident is showing signs of change in condition, she would go to the nurse to the nurse if the resident is having a change, she would also stay with the resident and call for the nurse, she wouldn't assess the resident, she would not notify the physician, before going into the resident room she does review the MAR, she would know the resident had a change by having a conversation, if they had a change she would be made aware verbally, she stated there is nothing that she would review before going in and speaking to the resident, they do not have a communication log because it will normally come from the nurse, she ensures residents are treated with dignity and respect by knocking, stating her name,, asking if it is okay to check blood pressure and if they are ready to take their medications.to ensure a resident is safe if fall risk, make sure they are not hanging off the bed, call light within reach, bed in low position, help repositioning. She can put a progress not on the EMAR for the resident if a change was experienced while passing meds. There isn't a form that she would complete if she were to recognize a change from the resident. For a resident with stroke would be face drooping, limbs cannot be held, and slurred speech. The expectation for documentation is to complete immediately, right away. She would also inform the nurse verbally. If she passed the message on she would not document.During an interview on 05/10/26 at 1:01 p.m., Nurse C has been at the facility roughly three years and only on the weekends 16 hours shifts on Saturday and Sunday , identify the change in condition is to look for difference in baseline and the resident may not be walking, overall look, speech has changed, when a resident is no longer at or doing their normal. If the resident is having a condition, speak to the resident, check vitals, began assessing, try to speak to resident, and notice the change as if a resident unable to speak, notify doctor, call 911, received order, notify ADON, and the administrator, completed the change in condition and then complete a transfer out form. The expectation for documentation is to complete what is seen and make it understandable for the next person, documentation should be completed within the live time to paint a picture. Resident safety was to make sure they have a safe environment, call light within reach, proper supervision, and monitoring and keep them out of harm's way. They use the dashboard for every resident they can see the care plan and review any changes, everything is normally downloaded and placed in the Kardex and will show everything that is needed regarding the resident. For dignity and respect this is the resident home and interact with them as a person and not a thing. Pull the curtains, make sure they are covered up, don't talk down to them or belittle them. Signs of stroke, facial drooping, limbs of weakness, the resident will become stiff and cannot move out of the position and change in speech. The physician is notified by text and verbal. If severe, they will contact via telephone. The facility doesn't have a 24-hour report.During an interview on 05/10/26 at 1:26 p.m., CNA B has been at the facility almost two years, works 6:00 a.m.-2:00 p.m. and is assigned to hall 300. A change in condition is identified by the resident is not their normal, getting up, not eating, and she would report it to the nurse. She report to the nurse verbally, and they have an area on the POC where she can chart, and she will complete the report.During an interview on 05/10/26 at 2:05 p.m., CNA C said she works 6:00 a.m.-2:00 p.m., she is PRN and only works the weekends, for change in condition, if she see the patient with a change and they are not the same, she is big on appetite and she will see the change and report it immediately, she would also go into the POC and new change alert and she will document what she saw, and she would stay with the patient and inform the nurse and she would let the nurse know to assess, she cannot touch them until the nurse will see them, she will ensure the resident is safe by constantly monitoring and documenting what they do throughout the shift, with dignity and respect and be polite, she ask them what they want to do, maintain privacy at all times, give them choices, signs of a stroke she would look for face drooping, in a daze, non-responsive, and mouth droopy.During an interview on 05/10/26 at 2:31 p.m., Nurse B has been at the facility about a year and half. A change in condition is anything that happens outside of the resident normal, difference in behavior, speaking, moving of the body parts. The first thing he would do the assessment is to head to toe, call the MD, call 911 and following any orders, document the change in condition, complete nursing note, notify DON and administrator, the appropriate time to document is in live time and document for understanding and clarity of the next person, for dignity and respect they inform the resident care is proper, treat them as a normal human being, when they need help assist the resident, answer call light. Signs of a stroke, face dropping, speech slurred, checking their body for limpness, checking the resident eyes or changes and pupils. For the incident: he assessed, the nurse told him about the change in condition and he informed him verbally. If nothing is documented, he starts to assess and will check the resident. So far he has only done in services. Stated that he also works 10:00 p.m-6:00 a.m.During an interview on 05/10/26 at 3:00 p.m., the Administrator said they had been at the facility about 45 days, since being identified, they have educated the staff starting with the aides/nurses on recognizing signs and symptoms of CVA and change in condition, appropriate reporting to the change, documentation of the change. In addition, they been doing rounds that started this morning to ensure staff is aware of the education and knowing what the expectation is, they have completed audits for the past 30 days for all residents to ensure no documentation was missed, change in conditions, and check if something that was noted that they could have possibly missed and she believes that it. At this time, they are going to be here for the night shift and make sure they understand the education they have received.During an interview on 05/10/26 at 3:18pm, the ADON had been at the facility for one year, they have reeducated staff on reporting change in condition, monitoring change in condition, signs and symptoms for stroke related symptoms, and documentation, they have done rounds with the staff to listen to the nurses to ensure they were doing shift to shift reports, she has done audits of all changes in conditions for the last 30 days to make sure notification was there, they do have 24 hour reports that the nurses should be completing every shift and it should be printed and completed, and she was here this morning before 6:00 a.m. so she could see the exchange of how staff are reporting, she has talked about documentation and the expectation of how it should be done and when, the timeframe that staff have for documenting is as it occurs, stop and watch is used for new alert and the alert will come on the dashboard and they will verbally inform the nurse and she will follow up to see what was done and when/how the resident was assessed. The Regional Nurse and Nurse C were ensuring the in-services were being done.During an interview on 05/11/26 at 3:16 p.m., CNA D said she works the 10:00 p.m.-6:00 a.m. shift, she is assigned to community and MCU, change in condition is identified by seeing the patient that slurred speech, anything that they see is different she will report it to the nurse. If the nurse didn't do anything, they go to the DON. The change is reported by informing the nurse, stay in the room and have someone let the nurse know, and document in POR the new alert option. For resident safety she will keep it low position and make sure they are monitored. Rounds are constant, but no more than 2 hours, they will do it sooner. For dignity and respect, she knock on the door, identify who she is and what they are going to do. She also try to make conversation and make sure they have call light within reach and make sure everything that they may reach for is near. Signs of stroke would be not talk, slurred talk. Expectation for documentation would be documented in the POC, in live time and when they see the change.During an interview on 05/11/26 at 3:23p.m., CNA E said she works 10:00 p.m.-6:00 a.m., she is assigned to MCU. She said she would identify a change in condition when she saw something different and would notify the nurse right away. After notifying, the nurse will assess and then she continue to assist with rounding, she will document in POC as soon as it occurs. She report changes just by letting the nurse know and state verbally what she has seen and document. The appropriate time to document is during the shift or closer towards the end of the shift. residents safety is by making sure they have a clear path, wheelchairs are put away properly, beds in low position if necessary. Dignity and respect, always call by their name. for stroke, she will check for face twisted a little bit or if the resident is not able to respond. She look for a lot of things because her mom had a stroke, so she takes it very seriously.During an interview on 05/11/26 at 3:34 p.m., CNA F said she works in the community but mainly in the secured unit, 2:00 p.m.-10:00 p.m. shift. She said a change in condition is identified by the resident not eating or not as active as they were, she would report to the nurse and document the change. Sometimes the doctor will come back and ask how the resident has been doing after the change has been identified. She would document by the POC and new alert. To document the appropriate time is after she is caring for the resident and she will try to complete every two hours. Resident safety is by keep everybody together so she can see them and continue to monitor the residents, make sure nothing is on the floor, don't let the ones in the wheelchair try to get up and walk on their own, keep things within reach. For dignity and respect she ensure maintain privacy during peri care, have a conversation with the resident. Some signs of a stroke would be lip drooping, one side of the limbs weak or the resident not being able to walk, and slurred speech.During an interview on 05/11/26 at 3:47 p.m., CNA G said she had been at the facility for almost two years, she works 2:00 p.m.-10:00 p.m. shift, and she is assigned to hall 300. She would identify a change in condition would be for a resident to not be normal such as a wound. She would report the change by POC using the new alert tab, she would document the change and the resident it is for to what is new or what has changed. The expectation for documentation is to put in POC and should be done immediately. After the change, she monitor the resident, notify the nurse. Stay close to make sure the resident doesn't injure themselves and make sure they are safe. Resident safety would be monitoring, document, nothing on the floor, make sure the path is clear, call light within reach and if they are used to getting up she would try to assist if they don't ask for help. For dignity and respect she speak to the resident, ask questions and tell them the care before starting, and ask them how they feel, and sleep them clean. Some examples of a stroke would be slurred speech, drooping jaw, and confusion.The Administrator was informed the Immediate Jeopardy was removed on 05/11/2026 at 4:55 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 5 residents reviewed for quality of care.-Nurse A noticed a change in Resident #1's speech on 05/01/26 around 9:30 p.m. He sent a text message to the Dr. at 9:37 p.m. and at 10:12 p.m., the Dr. asked if it looked like resident had a stroke, but Nurse A did not follow up with the Dr. The Dr. did not follow up with Nurse A.-Nurse B failed to report Resident #1's change in condition for approximately 12 hours and 36 minutes beginning on 05/01/26 around 10:12 p.m.-It took Resident #1 a total of 13 hours and 30 minutes to receive care for a possible stroke. Nurse A noticed a change in condition on 05/01/26 around 9:30 p.m. and Resident #1 was transferred to the hospital by EMS on 05/02/26 around 11:42 a.m.An Immediate Jeopardy (IJ) was identified on 05/09/26. The IJ template was provided to the facility on [DATE] at 1:30 p.m. While the IJ was removed on 05/11/26, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal (POR).This failure could place residents at risk for a delay in medical treatment, of not receiving necessary medical care, hospitalization, and death.Findings included:Record review of Resident #1's admission Record, dated 05/06/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (lung disease), hemiplegia and hemiparesis (hemiplegia is paralysis of one side of the body, while hemiparesis is weakness on one side) following cerebral infarction (ischemic stroke and requiring targeted rehabilitation for recovery) affecting right dominant side, cognitive communication deficit (occurs when a person struggles to communicate effectively because of impairments in cognitive processes such as attention, memory, and executive function rather than problems with speech or language itself, and dysphagia (difficulty swallowing), oropharyngeal phase (initial, automatic stage of swallowing).Record review of Resident #1's MDS Assessment, dated 02/14/26, revealed a BIMS score of 14, indicating her cognition was intact. Section B, B0600, Speech clarity, was coded as 1 indicating unclear speech - slurred or mumbled words and Section B, B0700, Makes Self Understood, was coded as 1 indicating Resident #1 was usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time.Record review of Resident #1's Care Plan, undated, revealed resident has a communication problem. Interventions for the resident included allowing adequate time to respond, repeating as necessary, requesting clarification from the resident to ensure understanding, asking yes/no questions if appropriate, and using simple, brief, consistent words/cues. Additional interventions included encouraging the resident to continue stating thoughts even if resident is having difficulty and to monitor for/record cofounding problems such as a decline in cognitive status and oral motor function.Record review of Resident #1's Change in Condition Evaluation form, dated 05/02/26 at 11:00 a.m., revealed Nurse C completed the evaluation and noted Resident #1 showed signs of aphasic speech (impaired communication caused by damage to the brain's language centers, affecting speaking, understanding, reading, and writing), was easy to arouse, not able to respond as she normally did, no facial drooping, able to move left arm and leg which was normal, no respiratory distress, NP ordered to send resident to ER for evaluation and treatment.Record review of Resident #1's progress note, dated 05/06/26 at 12:59:54 p.m., revealed on 05/02/26 at 11:00 a.m., Nurse C entered a SBAR Summary for Providers for a CIC. The CIC noted Resident #1's neurological status evaluation as abnormal speech. In addition, CIC note indicated Nurse C was informed resident was not acting herself, was easy to arouse, not able to respond as she normally did, no facial drooping, able to move left arm and leg which was normal, no respiratory distress, NP notified and ordered to send resident to ER for evaluation and treatment.Record review of Resident #1's progress note, created date 05/06/26 at 18:58(6:58 p.m.), revealed note was created as a late entry by Nurse A. Note reflected an effective date of 05/01/26 at 21:35 (9:35 p.m.) and indicated Resident in bed watching Tv, but not as vocal as normal.Resident started singing and started speaking garbled English. Dr. [name] notified asked if she appeared to have a stroke. Unable to answer informed the oncoming nurse that the resident was not vocal and that Dr. [name] wanted to know if it appears that the resident has had a stroke. Resident viewed again and was singing no distress at the moment. Nurse agreed to monitor the resident and if any changes to notify the Dr.Record review of Resident #1's progress note, dated 05/06/26 at 12:59 p.m., revealed on 05/02/26 at 12:30 p.m., Nurse C entered EMS arrived at facility at 11:42A and placed resident on stretcher and left facility 11:48A.Record review of hospital records, dated 05/02/26 revealed diagnosis of altered mental status and acute cerebrovascular accident (CVA). She returned to the facility on [DATE].During an interview on 05/07/26 at 8:37 a.m., Nurse B said he worked Friday, 05/01/26 from 10:00 p.m. to 6:00 a.m. He said Nurse A gave him resident updates verbally and told him Resident #1's speech was not clear, and it took her 30 seconds to a minute longer, compared to her regular baseline to respond. He said Nurse A told him he messaged the Dr. [name] and was waiting for a response from her. He said Nurse A told him to monitor the resident during his shift. He said he monitored Resident #1 during his shift. He said he monitored her at 10:30 p.m. and resident was asleep and he checked her vital signs. He said at 1:30 a.m. resident was asleep and he touched her arm, she blinked, opened her mouth, and went back to sleep. He said at 3:15 a.m., she was asleep, he touched her arm, she opened eyes and went back to sleep. He said he went to resident's room around 5:00 a.m.-5:30 a.m. He said resident was awake and he tried to speak with her and felt resident's speech was still not clear and that she was trying to say the words, but her speech was still slurred. He said he asked Resident #1 if she was okay and she said she was fine, but it took her more than a minute to answer the question but said he understood her answer. He said he completed a full body assessment on 05/02/26 at approximately around 5:00 a.m.-5:30 a.m. (documentation could not be located). He said around 6:15 a.m. he gave Nurse C the shift change report and told him Resident #1's speech was slurred, that he could not make out the words, and it look like she had seizure activity. Nurse B said he asked Nurse C to assess the resident and then to call the doctor. He said Nurse C said he would do the assessment and would then call the doctor about resident's speech. He said he then left the facility because his shift was over. He said if resident has a physical change he would ensure treatment and care was provided to Resident #1 when there was a change consistent with professional standards of practice.During an interview on 05/07/26 at 11:31 a.m., NP said she received a phone call from Nurse C around 10:48 a.m. on 05/02/26 about Resident #1. She said Nurse C told her Resident #1's speech was slurred and that she had a significant change with her speech. She said Resident #1's speech went from 3-4 words, for example, not feeling good, stomach hurts, get the hell out of here, but NP said now Resident #1's words were indiscernible. NP said Resident #1 now not being able to speak led her to believe she had a stroke, but NP said she had not reviewed the hospital paperwork yet.During a telephone interview on 05/07/26 at 11:49 a.m., Dr. said Nurse A messaged her on 05/01/26 approximately around 9:40 p.m.-10:00 p.m. saying Resident #1 denies any pain, not herself, sorry to bother you. She said she messaged him back and asked if Resident #1 had any signs of a stroke, but she said she did not hear back from Nurse A. Dr. said she would have needed more information to determine what exactly was going on with Resident #1. Dr. said it was already hard to decipher Resident #1's speech and what she was saying.During an interview on 05/07/26 at 2:43 p.m., the ADON said when a resident had a change in condition, the nurse should complete a full head-to-toe assessment, take their vitals, call the doctor to let them know about the changes and to see if they had any recommendations or new orders, and to notify resident's family.During a telephone interview on 05/08/26 at 8:05 a.m., Nurse C said Nurse B did not report to him that something was wrong with Resident #1's speech or that he suspected seizure activity during his shift change report or before leaving the facility. Nurse C said he was not positive but said it was roughly around 8:30 a.m.-9:00 a.m. when he received a phone call from Nurse B telling him that Nurse A called him and said a CNA (could not recall name) told him Resident #1 may have had a stroke. Nurse C said he immediately went to Resident #1's room and started talking to her. He said she opened her eyes, smiled, she was alert and oriented, she moved left arm and leg which was normal, had no facial drooping, responded to light, but the only thing was she was aphasic (disorder that impairs the ability to communicate through speech, writing, or understanding language). He said he messaged the NP, reported Resident #1's symptoms and asked NP if she wanted to send Resident #1 out to hospital and NP said yes.Record review of the facility's Licensed Practical Nurse job description, revised 09/2024, read in part .The primary purpose of the position is to ensure the highest quality of resident care available.Nursing Duties include. Observation of each participant and immediately reporting noted changes in their condition to the Program/Health Director.Record review of the facility's Registered Nurse job description, revised 09/2024, read in part .The primary purpose of the position is to ensure the highest quality of resident care available.Nursing Duties include. Observation of each participant and immediately reporting noted changes in their condition to DON.Record review of the facility's Provision of Quality of Care policy, date implemented 06/10/2025, read in part .Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices.1. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being.6. Policies and procedures will reflect current professional standards of practice. a. All employees are responsible for following established policies and procedures.The Administrator was notified on 05/09/26 at 1:30 p.m. that an IJ was identified due to the above failures and the IJ template was provided.The following Plan of Removal (POR) was accepted on 05/10/25 at 4:09 p.m.: 5/10/2026[Facility Name] Plan of Removal - F684 Quality of CareThe facility failed to ensure treatment and care was provided to Resident #1 consistent with professional standards of practiceCorrective Action for Resident #1 On 05/02/26, Resident #1 was transferred to the hospital due to change in speech. Resident #1 was admitted to the hospital on [DATE] and diagnosed with altered mental status and acute cerebrovascular accident. Resident #1 returned to the facility on [DATE] with updated orders and interventions. See Medication listed belowThe interdisciplinary team reviewed and updated the resident's care plan to include monitoring and interventions related to neurological changes, altered speech, and changes in condition.Resident #1 returned with the following new ordersNorvasc 5 mg Take (1) tablet by mouth daily hold if SBP<110 DBP< 60 and HR < 60 (Added to medication regimen to help better control the blood pressure)Plavix 75 mg Take (1) tablet by mouth daily ( Added to medication regimen for DAPT to help decrease the risk of future ischemic events)Resident #1 has returned to her baseline functional and cognitive status prior to hospitalization for acute CVA.Identification of Other Residents with Potential to be AffectedAll residents residing in the facility have the potential to be affected by the alleged deficient practice.On 5/9/2026 An audit was conducted by the Director of Nursing (DON), Assistant Director of Nursing (ADON), or designee of current residents with recent changes in condition within the last 30 days to ensure: All resident were audited for change in condition none were identified for undocumented changesAppropriate nursing assessments were completed,Physician and responsible party notifications were timely,Documentation was complete,Orders and follow-up interventions were implemented appropriately.No additional concerns were noted.Systemic Changes ImplementedThe facility has implemented the following systemic changes to prevent recurrence:All Direct Care Staff were re-educated by the DON/ADON/Designee on the facility policy for Change in Condition, beginning on 5/9/2026 and completed by 5/10/2026 or prior to working next scheduled shift including:Immediate head-to-toe assessment,Neurological assessment when indicated,Timely physician and responsible party notification,Documentation requirements,Escalation of unresolved or worsening symptoms,Shift-to-shift communication expectations. (CNA and all personal care staff were also educated on changes in condition process.)Education included recognition of signs and symptoms of stroke/CVA and the need for immediate intervention and emergency services activation when warranted, beginning on 5/9/2026 and completed by 5/10/2026 or prior to working next scheduled shift.Policies reviewed for Change in resident conditions, no changes made. Reviewed by the Regional Nurse on 5/9/2026.Adhoc QAPI held with Medical Director regarding the Immediate Jeopardy. 05/10/2026. On 05/11/2026, surveyor confirmed the facility implemented their plan or removal (POR) to sufficiently remove the IJ by: During observation on 05/10/26 at 1:30pm, showed how they document, new alert in the resident POC, the appropriate time to document and there is no expectation time, resident safety is based on making sure their bed is low especially for fall risk, make sure call light within reach, and everything that they need is close by, make sure everything is reachable and secured. For dignity and respect she will make sure the residents are dressed nicely, encourage them to get up, let them look in the mirror, make sure they smell good, treat them how they want to be treated or how she would want to be treated or treated her mother. Signs of a stroke, posture is not straight, face is drooping, one side is hurting, and if their speech is off.Record review revealed on 05/09/26 and 05/10/26, in-service training was initiated on Quality-of-Care requirements.Record review revealed on 05/10/26, in-service training was initiated with staff over recognizing a change in condition, reporting to the MD, and documentation of change.During an interview on 05/10/26 at 12:35am, Nurse D, works 6:00 a.m.-2:00 p.m., she works all halls, has been at the facility working since November 2025, a change in condition is anything outside of the resident's normal baseline, even if they say their stomach hurting today and it wasn't yesterday. First she would do vitals, assess the resident, notify the doctor but the doctor comes by daily, they will call and text the doctor regarding the change, after that she will wait for orders if any and they do whatever the doctor states, send the resident out, blood work, notify the family and the DON, they are also completing the SBAR which is the change in condition. She would document right away, and they also document the new orders and if they get new orders, new appointment and any follow-ups that were received, they also document in the progress notes for three days pertaining to the status of the resident. She ensure the resident is safe by doing rounds every two hours but depending on the severity she would also do 1 hour, they also report during shift change. The report is verbal, but they are also completing the 24-hour report and it's also in the POC. She will update the 24-hour report and then she will pass it on to the next shift, she also does clinicals in the morning. The care plan is reviewed when she come in the morning before she go to the clinical meetings. The expectation for documentation, accurate, on time, and it needs to be done. The saying is if it is not documented then it didn't happen. Signs of stoke would be drooling, numbness, weakness in limbs, elevated vitals, and slurred speech. She ensure residents are treated with dignity and respect by talking to them. Speaking to them, assisting the aides.During an interview on 05/10/26 at 12:49 p.m. CMA/CNA A, said she has been working at the facility for 1 year, she mainly did medication pass for the entire building, and helped as a CNA anywhere they needed her. She said a change in condition is anything that is not normal behavior for that specific person, their blood pressure, anything out of baseline, urgent concerns would be to inform the nurse immediately, if a resident is showing signs of change in condition, she would go to the nurse to the nurse if the resident is having a change, she would also stay with the resident and call for the nurse, she wouldn't assess the resident, she would not notify the physician, before going into the resident room she does review the MAR, she would know the resident had a change by having a conversation, if they had a change she would be made aware verbally, she stated there is nothing that she would review before going in and speaking to the resident, they do not have a communication log because it will normally come from the nurse, she ensures residents are treated with dignity and respect by knocking, stating her name,, asking if it is okay to check blood pressure and if they are ready to take their medications.to ensure a resident is safe if fall risk, make sure they are not hanging off the bed, call light within reach, bed in low position, help repositioning. She can put a progress not on the EMAR for the resident if a change was experienced while passing meds. There isn't a form that she would complete if she were to recognize a change from the resident. For a resident with stroke would be face drooping, limbs cannot be held, and slurred speech. The expectation for documentation is to complete immediately, right away. She would also inform the nurse verbally. If she passed the message on she would not document.During an interview on 05/10/26 at 1:01 p.m., Nurse C has been at the facility roughly three years and only on the weekends 16 hours shifts on Saturday and Sunday , identify the change in condition is to look for difference in baseline and the resident may not be walking, overall look, speech has changed, when a resident is no longer at or doing their normal. If the resident is having a condition, speak to the resident, check vitals, began assessing, try to speak to resident, and notice the change as if a resident unable to speak, notify doctor, call 911, received order, notify ADON, and the administrator, completed the change in condition and then complete a transfer out form. The expectation for documentation is to complete what is seen and make it understandable for the next person, documentation should be completed within the live time to paint a picture. Resident safety was to make sure they have a safe environment, call light within reach, proper supervision, and monitoring and keep them out of harm's way. They use the dashboard for every resident they can see the care plan and review any changes, everything is normally downloaded and placed in the Kardex and will show everything that is needed regarding the resident. For dignity and respect this is the resident home and interact with them as a person and not a thing. Pull the curtains, make sure they are covered up, don't talk down to them or belittle them. Signs of stroke, facial drooping, limbs of weakness, the resident will become stiff and cannot move out of the position and change in speech. The physician is notified by text and verbal. If severe, they will contact via telephone. The facility doesn't have a 24-hour report.During an interview on 05/10/26 at 1:26 p.m., CNA B has been at the facility almost two years, works 6:00 a.m.-2:00 p.m. and is assigned to hall 300. A change in condition is identified by the resident is not their normal, getting up, not eating, and she would report it to the nurse. She report to the nurse verbally, and they have an area on the POC where she can chart, and she will complete the report.During an interview on 05/10/26 at 2:05 p.m., CNA C said she works 6:00 a.m.-2:00 p.m., she is PRN and only works the weekends, for change in condition, if she see the patient with a change and they are not the same, she is big on appetite and she will see the change and report it immediately, she would also go into the POC and new change alert and she will document what she saw, and she would stay with the patient and inform the nurse and she would let the nurse know to assess, she cannot touch them until the nurse will see them, she will ensure the resident is safe by constantly monitoring and documenting what they do throughout the shift, with dignity and respect and be polite, she ask them what they want to do, maintain privacy at all times, give them choices, signs of a stroke she would look for face drooping, in a daze, non-responsive, and mouth droopy.During an interview on 05/10/26 at 2:31 p.m., Nurse B has been at the facility about a year and half. A change in condition is anything that happens outside of the resident normal, difference in behavior, speaking, moving of the body parts. The first thing he would do the assessment is to head to toe, call the MD, call 911 and following any orders, document the change in condition, complete nursing note, notify DON and administrator, the appropriate time to document is in live time and document for understanding and clarity of the next person, for dignity and respect they inform the resident care is proper, treat them as a normal human being, when they need help assist the resident, answer call light. Signs of a stroke, face dropping, speech slurred, checking their body for limpness, checking the resident eyes or changes and pupils. For the incident: he assessed, the nurse told him about the change in condition and he informed him verbally. If nothing is documented, he starts to assess and will check the resident. So far he has only done in services. Stated that he also works 10:00 p.m-6:00 a.m.During an interview on 05/10/26 at 3:00 p.m., the Administrator has been at the facility about 45 days, since being identified, they have educated the staff starting with the aides/nurses on recognizing signs and symptoms of CVA and change in condition, appropriate reporting to the change, documentation of the change. In addition, they been doing rounds that started this morning to ensure staff is aware of the education and knowing what the expectation is, they have completed audits for the past 30 days for all residents to ensure no documentation was missed, change in conditions, and check if something that was noted that they could have possibly missed and she believes that it. At this time, they are going to be here for the night shift and make sure they understand the education they have received.During an interview on 05/10/26 at 3:18pm, the ADON has been at the facility for one year, they have reeducated staff on reporting change in condition, monitoring change in condition, signs and symptoms for stroke related symptoms, and documentation, they have done rounds with the staff to listen to the nurses to ensure they were doing shift to shift reports, she has done audits of all changes in conditions for the last 30 days to make sure notification was there, they do have 24 hour reports that the nurses should be completing every shift and it should be printed and completed, and she was here this morning before 6:00 a.m. so she could see the exchange of how staff are reporting, she has talked about documentation and the expectation of how it should be done and when, the timeframe that staff have for documenting is as it occurs, stop and watch is used for new alert and the alert will come on the dashboard and they will verbally inform the nurse and she will follow up to see what was done and when/how the resident was assessed. The Regional Nurse and Nurse C were ensuring the in-services were being done.During an interview on 05/11/26 at 3:16 p.m., CNA D works 10:00 p.m.-6:00 a.m., she is assigned to community and MCU, change in condition is identified by seeing the patient that slurred speech, anything that they see is different she will report it to the nurse. If the nurse didn't do anything, they go to the DON. The change is reported by informing the nurse, stay in the room and have someone let the nurse know, and document in POR the new alert option. For resident safety she will keep it low position and make sure they are monitored. Rounds are constant, but no more than 2 hours, they will do it sooner. For dignity and respect, she knock on the door, identify who she is and what they are going to do. She also try to make conversation and make sure they have call light within reach and make sure everything that they may reach for is near. Signs of stroke would be not talk, slurred talk. Expectation for documentation would be documented in the POC, in live time and when they see the change.During an interview on 05/11/26 at 3:23p.m., CNA E works 10:00 p.m.-6:00 a.m., she is assigned to MCU. She would identify a change in condition by when she see something different and will notify the nurse right away. After notifying, the nurse will assess and then she continue to assist with rounding, she will document in POC as soon as it occurs. She report changes just by letting the nurse know and state verbally what she has seen and document. The appropriate time to document is during the shift or closer towards the end of the shift. residents safety is by making sure they have a clear path, wheelchairs are put away properly, beds in low position if necessary. Dignity and respect, always call by their name. for stroke, she will check for face twisted a little bit or if the resident is not able to respond. She look for a lot of things because her mom had a stroke, so she takes it very seriously.During an interview on 05/11/26 at 3:34pm CNA F works in the community but mainly in the secured unit, 2:00 p.m.-10:00 p.m. shift, a change in condition is identified by the resident not eating or not as active as they were, she would report to the nurse and document the change. Sometimes the doctor will come back and ask how the resident has been doing after the change has been identified. She would document by the POC and new alert. To document the appropriate time is after she is caring for the resident and she will try to complete every two hours. Resident safety is by keep everybody together so she can see them and continue to monitor the residents, make sure nothing is on the floor, don't let the ones in the wheelchair try to get up and walk on their own, keep things within reach. For dignity and respect she ensure maintain privacy during peri care, have a conversation with the resident. Some signs of a stroke would be lip drooping, one side of the limbs weak or the resident not being able to walk, and slurred speech.During an interview on 05/11/26 at 3:47 p.m., CNA G has been at the facility for almost two years, works 2:00 p.m.-10:00 p.m. shift, she is assigned to hall 300. She would identify a change in condition would be for a resident to not be normal such as a wound. She would report the change by POC using the new alert tab, she would document the change and the resident it is for to what is new or what has changed. The expectation for documentation is to put in POC and should be done immediately. After the change, she monitor the resident, notify the nurse. Stay close to make sure the resident doesn't injure themselves and make sure they are safe. Resident safety would be monitoring, document, nothing on the floor, make sure the path is clear, call light within reach and if they are used to getting up she would try to assist if they don't ask for help. For dignity and respect she speak to the resident, ask questions and tell them the care before starting, and ask them how they feel, and sleep them clean. Some examples of a stroke would be slurred speech, drooping jaw, and confusion.The Administrator was informed the Immediate Jeopardy was removed on 05/11/2026 at 4:55 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interviews and record review, the facility failed to promote and facilitate resident self- determination through support of resident choice for 1 of 6 residents (CR#1) reviewed for resident rights. The facility failed to ensure that CR#1had the opportunity to exercise rights regarding those things that were important in their life. The facility failed to promote self-determination by not having hot water in the facility, which prevented each from taking showers. This failure could place residents at risk of decreased self-worth due to their preferences not being met.The findings include: Record Review of CR#1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on 10/21/25 with diagnoses of Cerebral Infarction (Stroke), COPD (lung disease), Viral Hepatitis C (Liver Damage), and Type 2 Diabetes (Increase sugar levels). Record Review of CR#1's MDS Quarterly dated 9/19/25 revealed a BIMS score of 15 (which means CR#1 had normal cognitive functioning). CR#1 had impairment on one side (upper and lower extremities) and used a wheelchair for mobility; CR#1 needs partial/moderate assistance from staff for shower/bathing, which includes transferring in/out of the tub/shower. Record Review of CR#1's care plan dated 4/4/25 revealed: Problem: CR#1 has an ADL self-care performance deficit r/t impaired mobility. Date initiate 4/4/25. Rev. 5/7/25.Goal: CR#1 will maintain current level of function in through the review date. Date initiate 4/4/25. Rev. 5/7/25. Target: 10/25/25.Interventions: Bathing/Showering: CR#1 requires (limited to extensive) by (1) staff with shower. Date initiate 4/4/25. Rev. 8/20/25. Contractures: CR#1 has contractures of the left hand. Provide skin care, washing and drying hand to keep clean and prevent skin breakdown. Date initiate 4/4/25. Rev. 8/20/25. Record Review of Nursing Notes (administration Note) dated 8/5/25 at 11:05 a.m., by RN revealed, Resident complained of not receiving a hot shower due to facility plumbing problems. Plumbing problems have been resolved as of 8/4/25. Resident offered shower however informed that the shower temperature is lukewarm. Resident refuses stating quote I will wait as I want a hot shower and quote at 11:00 AM resident noted to be in hallway after taking recent hot shower. Residents stated satisfaction after hot shower .Record Review of an email from the OMB dated 9/30/25 at 3:00pm to the Admin revealed the following Correspondence: Good morning Admin, I got a message from resident we discussed regarding temperature of showers. They are stating that it is running cold and that attendant is stating that they are refusing a shower. They state they do not want to take a cold shower. Would you kindly advise? Record Review of email from the Admin to the OMB. dated 9-30-25 revealed the following Correspondence: The water is not as hot right now because the washers and kitchen is in full use. The maintenance director was notified and turned the temperature up. After lunch clean up the temperature will be at its hottest and he can have a shower then. Record review of HHSC complaint dated 8/5/25 revealed, CR#1 had not showered in several weeks and the facility staff kept saying there was no hot water. 11/20/25 3:00pm Observation Rounds with Maintenance and observed the water temps in five roomsS room [ROOM NUMBER] - Temp 106S room [ROOM NUMBER] - Temp 106S room [ROOM NUMBER] - Temp 109S room [ROOM NUMBER] - Temp 102S room [ROOM NUMBER] - Temp 108 During a telephone interview on 11/20/25 at 1:26 p.m., RN she stated the facility was always losing hot water in the residential area, specifically showers. RN stated residents did not get showers or didn't take showers because the water was too cold. She stated residents complained to the administration and the ombudsman. In an interview on 11/20/25 at 3:22 p.m., the Maint,he stated it was a pump that was inoperable that affected the entire building. He stated he was not here during this issue. He stated on 8/21/25 the circular pump in the boiler room failed and had to be replaced the same day. He stated the failure created an issue with water temps in other areas of the facility. He stated the hot water in the kitchen causes the other areas of the facility to have a cold temperature, which may have included the resident shower areas. During the interview with Maint, the Admin provided an invoice for plumbing repair. In an interview on 11/20/25 at 4:05 p.m., the Admin stated that the facility is going through a new organization and when she became aware of the water issue it was addressed immediately. She stated this issue began under the outgoing corporate ownership, not the current, which she represented. In an interview on 11/20/25 at 5:34 p.m., Resident #2 stated the hot water was out for about 3 weeks to a month and she could not bathe or shower because it was too cold. Resident #2 stated the water is getting hot now. In an interview on 11/20/25 at 5:45 p.m., Resident #3 stated he is doing well. He stated the hot water was out for about 2-3 weeks. Resident #3 stated the water is getting hot now. In an interview on 11/20/25 at 6:00 p.m., Resident #4 she stated the hot water was off for about a week, but it could have been longer, but she was certain it was at least a week. During a telephone interview on 11/21/25 at 3:48 p.m., the OMB stated that the residents are not lying about the water temp. She stated CR#1 did complain several times about the water amongst other things. She stated while CR#1 was transferred to another facility there were other residents that complained about the same issue starting on 2/15/25. The OMB stated she addressed it with the facility at that time and most recently and was told that the problem was resolved with repairs. Record Review of purchase Invoice for boiler part and installation dated 8/14/25. Record Review of the facility's Resident Rights Policy dated 6/10/25 revealed:4. Respect and dignity. The resident has the right to be treated with respect and dignity, including:c. The right to reside and receive services in the facility in the facility with reasonable accommodation of resident or other residents.8. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely. Record review of the Safe and Homelike Environment policy dated 6/15/25 revealed:1. The Facility will create and maintain, to the extent possible, home like environment that they emphasizes the institutional character of the setting.3. Housekeeping and maintenance services will be provided as necessary to maintain the sanitary, ordering the and comfortable environment.7. The facility will maintain comfortable safe temperature levels.

Based on observation, interview and record review the facility failed to maintain an effective pest control program so the facility was free of pest and rodents for 2 of 2 residents reviewed for environment. The facility failed to ensure resident rooms were free of gnats. This failure could place residents at risk of infection, skin irritation, allergies, which could result in unsanitary living conditions and decline in health and well-being. Findings include: In an observation with Resident #404, on 03/26/2025 at 9:57am revealed sightings of gnats on the walls, on pictures, lighting above Resident #404 bed, flying around And on a urinal placed on the floor. In an interview with Resident #404 on 03/26/2025 at 9:57 AM, the resident stated the gnats were horrible and there was a substance that was placed by MAINT, but it wasn't catching the gnats. In an interview with HSK on 03/26/2025 at 10:11 AM, revealed the resident room always had gnats. HSK stated they did not know why there were so many gnats in the room but all they did was clean up behind each resident. HSK stated it may be from the trash always overflowing or food that was left out. In an interview with LVN on 03/26/2025 at 10:13 AM, revealed pest control came last week to spray the facility and Resident #404's room. LVN stated when conducting rounds on the morning of, 03/26/2025, he identified gnats in the room, and they were going to have the room cleaned. LVN stated the risk could cause any resident to be uncomfortable with gnats being present in the room/facility. In an observation with Resident #404 on 03/27/2025 at 10:42 AM, revealed gnats in the room, but not as many as the day before. Gnats were observed on the pictures and Resident #404's urinal placed by the bed. In an interview with Resident #404 on 03/27/2025 at 10:43 AM, revealed the gnats seem to come and go, but the gnats were a lot worse than what was being observed. Resident #404 has been at the facility for one month. In an interview with Resident #5 who shared a room with Resident #404 on 03/27/2025 at 10:46 AM, revealed MAINT came to the room and sprayed to try and minimize the gnats. Resident #5 stated there were still gnats in the room, but he did appreciate the facility for trying to take care of the issue. In an interview with MAINT on 03/27/2025 at 12:04 PM, MAINT stated the gnats came from Resident #404 and the urine being spilled on the floors. MAINT stated Resident #404 wanted to be independent and used the urinal and placed it back on the floor. MAINT stated pest control treated the room and the facility once a month. MAINT stated he treated the room as well, once a week to try and prevent the gnats, but they were always present. MAINT stated he used a log to track every time he needed to treat the room or the facility for gnats. In an interview with the ADMN on 03/27/2025 at 2:54 PM, the ADMN stated pest control had been coming to treat the facility and resident rooms. The ADMN stated they were doing the best they could with the gnats, all while trying to encourage the resident to be independent. The ADMN believed Resident #404's urinal waste on the floor and could contribute to the gnats being uncontrolled. Record review of the facility's Pest Control Policy reflected Bed Bugs, Prevent and Managing Infestations of In record review of the facility's maintenance log, on 03/28/2025, listed the issue/concern for a member of maintenance to follow up. On 03/17/2025, 03/19/2025, 03/21/2025, 03/24/2025, 03/25/2025, gnats were noticed and treated by MAINT for rooms [ROOM NUMBERS]. The risk to any resident with gnats could be their dignity and not feeling good about the facility for their care. In record review of the facility's contract with pest control, on 03/28/2025, reflected the pest control company had been active since 07/01/2023. The contract stated pest specifically not covered to include Flying insects (flies, bees, wasps, and gnats) .Service for NON COVERED PESTS may be provided for a fee on a materials plus labor basis.

Based on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 3 medication carts reviewed for medication storage. The facility failed to ensure medications were properly stored and labled when Resident #4's medications were popped into a pull cup and left unattended. This failure could place residents at risk for drug diversion, lack of drug efficacy, and adverse reactions. Findings include: During an observation on 3/27/25 at 9:32am revealed a medication aide cart with a medication cup labeled Resident #4 (name) with at least 7 pills inside. During an interview on 3/27/25 at 9:37am CMA E stated the resident was taking a shower, and she would have to go back to give her medications. During an interview on 3/27/25 at 10:55am LVN A stated you should never leave any open pills on the cart. You never know what could happen to those pills during that time. They should be destroyed, and you start over. During an interview on 3/27/25 at 11:06am LVN B stated you should stand there and wait for the resident to be done. You should never leave them open medications on the cart. Training for CMAs was done with the pharmacist monthly. Medication administration was a part of their training. Monthly. Will do a one to one with medication aide. During an interview on 3/27/24 at 11:11am the administrator stated staff should follow the protocol. They should not be pre popping medications. During an interview on 3/27/24 at 11:11am the regional RN C stated if they knew the resident and medication, they put it in a cup then it should ok. First and last name should be labeled on the cup also timed and dated. If they were destroyed that could be costly to the resident. During an interview on 3/27/24 at 12:55 pm RN D stated medications were to be given on time. Staff should be following the medication rights, right patient, dose, route. Before giving the medication, it should be verified. No premedication popping. If premedication was done, you don't know which medication it was. If there's a blood pressure medication staff need to check before the pressure before giving it. So, based on the vitals it may not allow you to give the medication. This could cause a mix up in medication if staff premedicated and didn't know which one to pull. Record review of the facility provided policy titled, Medication and Preparation Administration revealed the following: Medications should be prepared for only one resident at a time. Facility staff should observe the 6 Rights and verify right resident, right drug, right dose, right route and right time, and right documentation for each medication being administered. Abbreviations: CNA-certified nursing assistant LVN-Licensed vocational nurse RN- registered nurse CMA-certified medication aide

Based on interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 4 residents (Resident #1 and Resident #2) reviewed for abuse. The facility failed to ensure Resident #1 and Resident #2 were not involved in a resident-to-resident altercation on 04/07/2024. This deficient practice could place residents at risk of physical injury and/or psychosocial harm. The findings were: 1. Record review of Resident #1's face sheet, dated 03/28/2025, revealed a male resident was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included: Nontraumatic Intracerebral Hemorrhage, Intraventricular (A type of stroke where bleeding occurs in the [NAME] tissue and also spills into the ventricles, the fluid filled spaces in the brain), Aphasia, Compression of Brain (A condition where increased pressure within the skull), Cerebral Edema (Swelling of the brain tissue due to an accumulation of fluid), Generalized Anxiety Disorder (A chronic mental health condition characterized by excessive and persistent worry and anxiety that is difficult to control), Bipolar II Disorder (A person experiences a pattern of depressive, not the full-blown manic episodes found in bipolar I disorder), and Cognitive Communication Deficit (Difficulties in communication arising from impairments in cognitive processes like attention, memory, and problem-solving, rather than problems with speech and language itself). Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 09, which indicated moderate cognitive impairment. Record review of Resident #1's care plan, initiated 08/02/2023, revealed [Resident #1] has impaired cognitive function/dementia or impaired thought processes related to encephalopathy (A group of conditions that cause brain dysfunction) .has a communication problem related to expressive Aphasia. 2. Record review of Resident #2's face sheet, dated 03/26/2025, revealed a male resident was admitted to the facility on [DATE] and discharged from the facility on 04/07/2024. Resident #2 had diagnoses which included: Cerebrovascular disease affecting left non-dominant side (the right side of the brain has been damaged), Hypertension (When the pressure in your blood vessels is too high), Rhabdomyolysis (A medical condition characterized by the breakdown of muscle tissue, leading to the release of harmful substances into the bloodstream), and Major Depressive Disorder (A mental health condition characterized by persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities, significantly impacting daily functioning). Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 12, which indicated moderate cognitive impairment. Record review of Resident #2's care plan, initiated 04/20/2024, revealed Problem: [Resident #2] is potential to be physically aggressive related to Anger, Poor impulse control; per family was in special education and told he has low IQ . he has a behavior problem fixation/fabrication related to low IQ . He is attention seeking and accusatory with fabrications Interventions: Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Communication: Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff when agitated. Monitor/document/report PRN any S/S of resident posing danger to self and others. Psychiatry to evaluate and treat as indicated. Psychology to evaluate and treat as indicated. Administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #2's clinical record, as of 04/07/2024, revealed an incident note documented by LVN C, dated 04/07/2024, At 1755 (5:55 PM) Dietary Aide came to the nurses desk and reported to charge nurse that when she was in the dining room she saw this resident (Resident #2) hit another resident (Resident #1) causing the resident to bleed from the face. LVN C went to the dining room and noted another resident bleeding from the left eye and asked what happened when this resident stated 'He called me a punk so I hit him in his eye '. LVN C asked this resident to leave the dining room area and return to his room. At 1756 (5:56 PM). LVN C called and reported this incident to the administrator who instructed the charge nurse to call the police. 911 was called immediately and notified of this incident. At 1810, 4 police officers and 2 fire department EMS Techs arrived to the facility and approached both residents. This resident stated to the police officers that he did hit the other resident. The police officers left the building stating that they were completing their investigation by speaking to the other resident. An officer informed the charge nurse that after completing their investigation they have determined that they will arrest this resident and transport him to jail. At 1934, the police came back into the facility and transported this resident (Resident #2) to jail via stretcher and this residents wheelchair was taken along with him . Record review of Resident #1's clinical record, dated 04/07/2024, revealed a nurse assessment was performed immediately following the incident. LVN C went to the dining room and noted resident bleeding from the left eye and asked what happened when this resident stated, 'he hit me in my eye.' LVN C attempted to assess this resident's left eye but resident refused care stating he was okay while holding his shirt up to his eye. LVN C asked this resident to leave the dining room area and return to his room. At 1810 (6:10 PM), 4 police officers and 2 fire department EMS arrived to the facility and this resident told officers that he was ok and that he did not want to file any charges on the other resident. EMS asked this resident if they could look at his eye and this resident refused to allow the EMS workers to look at his eye. This resident remained in his room and continued to deny charge nurse to assess or treat his eye. At 1938 (7:38 PM) LVN C went to this resident's room and asked this resident if he was in pain and this resident denied pain. LVN C asked this resident that since the other resident left the building did he now feel safe and this resident stated 'yes'. Record review of Resident #1's X ray results, dated 04/08/2024, revealed no evidence of facial bone dislocation or fracture. Attempted to interview with Dietary Aide revealed the Dietary Aide was no longer employed at the facility and the phone number was no longer in service. During an interview with the Administrator on 03/27/2025 at 2:18 p.m., she stated she did not witness the altercation between Resident #1 and Resident #2. She stated Resident #2 was not usually physically aggressive but reported he was a trash talker (insulting comments that are made especially to an opponent). She stated this was the first time the residents had a physical altercation. She stated Resident #2 was arrested after the incident and discharged from the facility. She stated the risk of having a physically aggressive resident in the facility was the resident could possibly harm the other residents . During an interview with Resident #1 on 03/28/2025 at 10:43 a.m., revealed he had an altercation with Resident #2 when questioned about specific details regarding the altercation, Resident #1 was unable to answer questions due to Cognitive Communication Deficit. During an interview with Resident #3 on 03/28/2025 at 12:27 p.m., she stated she witnessed the incident with Resident #1 and Resident #2. She stated Resident #2 got in Resident #1's face and hit him. She reported she could not remember if Resident #1 was bleeding or not. She stated staff members (unknown which staff members) intervened and separated the residents. She stated this was the first time she witnessed Resident #2 being physically aggressive with any residents. She stated she did feel safe at the facility. During an interview with LVN C on 03/28/2025 at 1:04 p.m., she stated the dietary aide informed her Resident #1 was cleaning the table in the dining room and Resident #2 hit Resident #1 and Resident #1 sustained a cut under his eye and he was bleeding. She stated she assessed Resident #1 and the physician was contacted and he was supposed to be sent out to the hospital but the resident refused to go to the hospital. She stated she had never observed Resident #2 be physically aggressive with any residents but she reported he did have verbal altercations with residents in the past. Record review of the facility's policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, revealed, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: .b. other residents .

Based on interview and record review, the facility failed to use the service of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week in the facility for 36 of 92 days (09/11/2023, 09/12/2023, 09/13/2023, 09/14/2023, 09/15/2023, 09/17/2023, 09/18/2023, 09/19/2023, 09/20/2023, 09/21/2023, 09/22/2023, 09/23/2023, 09/25/2023, 09/26/2023, 09/27/2023, 09/28/2023, 09/29/2023, 09/30/2023, 10/02/2023, 10/03/2023, 10/04/2023, 10/05/2023, 10/06/2023, 10/07/2023, 10/08/2023, 10/09/2023, 10/10/2023, 10/11/2023, 10/12/2023, 10/13/2023, 11/02/2023, 12/05/2023, 12/06/2023, 12/07/2023, 12/08/2023, and 12/11/2023) reviewed during a look back period from 09/11/2023 to 12/11/2023. -The facility failed to have RN coverage in the facility for eight consecutive hours on 09/11/2023, 09/12/2023, 09/13/2023, 09/14/2023, 09/15/2023, 09/17/2023, 09/18/2023, 09/19/2023, 09/20/2023, 09/21/2023, 09/22/2023, 09/23/2023, 09/25/2023, 09/26/2023, 09/27/2023, 09/28/2023, 09/29/2023, 09/30/2023, 10/02/2023, 10/03/2023, 10/04/2023, 10/05/2023, 10/06/2023, 10/07/2023, 10/08/2023, 10/09/2023, 10/10/2023, 10/11/2023, 10/12/2023, 10/13/2023, 11/02/2023, 12/05/2023, 12/06/2023, 12/07/2023, 12/08/2023, and 12/11/2023. This failure could affect the residents by placing them at risk for not having their nursing and medical needs met and receiving improper care. Findings include: Review of the facility's Timecard Detail sheets dated 12/13/2023 reflected there was not eight consecutive hours of coverage by an RN on the following days/dates: Monday 09/11/2023 Tuesday 09/12/2023 Wednesday 09/13/2023 Thursday 09/14/2023 Friday 09/15/2023 Sunday 09/17/2023 Monday 09/18/2023 Tuesday 09/19/2023 Wednesday 09/20/2023 Thursday 09/21/2023 Friday 09/22/2023 Saturday 09/23/2023 Monday 09/25/2023 Tuesday 09/26/2023 Wednesday 09/27/2023 Thursday 09/28/2023 Friday 09/29/2023 Saturday 09/30/2023 Monday 10/02/2023 Tuesday 10/03/2023 Wednesday 10/04/2023 Thursday 10/05/2023 Friday 10/06/2023 Saturday 10/07/2023 Sunday 10/08/2023 Monday 10/09/2023 Tuesday 10/10/2023 Wednesday 10/11/2023 Thursday 10/12/2023 Friday 10/13/2023 Thursday 11/02/2023 Tuesday 12/05/2023 Wednesday 12/06/2023 Thursday 12/07/2023 Friday 12/08/2023 Monday 12/11/2023 Interview with the Admin on 12/14/23 at 10:00 AM revealed she began her position at the facility on 09/26/2023. She said she was aware the facility did not have RN coverage for several days after starting her position. The Admin said she understood the facility is required to have an RN in the facility every day for eight consecutive hours a day and seven days a week. She said the RN coverage currently is being covered by the Regional Director of Clinical Services and he will be at the facility every day until the facility has a DON on board. She said she has one potential candidate for the DON position going through a third interview next week. She said she has run an ad for a PRN RN position as a backup, so she does not have to deal with the stress of RN coverage in the future. The Admin said not having RN coverage as required affects residents because an RN has more knowledge, and they are able to double check and sign off on things an RN can only sign off on. She also said if she has an RN onsite, she does not have to reach out to someone else to get things done. The Admin said she does not have a policy for RN coverage.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, comfortable, and homelike environment for one of twelve residents (Resident #2) reviewed for a safe, clean, and homelike environment. -The facility failed to ensure Resident #2 had a working light in her room above her sink. -The facility failed to ensure the residents who smoked cigarettes had a safe, comfortable seating area available as the bench in the smoking area was broken. These failures could place the residents at risk of injury from the visible nails on the bench in the smoking area and could place the residents at risk of decreased quality of like due to the lack of a well-maintained environment. Findings include: Record review of Resident #2's admission record dated 12/12/023 revealed a [AGE] year-old woman admitted on [DATE]. The admission record documented her diagnoses included dementia (group of symptoms that affects memory, thinking and interferes with daily life), unspecified psychosis (diagnosis assigned to individuals who are experiencing symptoms of schizophrenia or other psychotic symptoms, but do not meet the full diagnostic criteria for schizophrenia or another more specific psychotic disorder), repeated falls, schizoaffective disorder (mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), major depressive disorder (mental health disorder having episodes of psychological depression), HIV (virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases), anxiety disorder (group of mental illnesses that cause constant fear and worry), insomnia (trouble falling and/or staying asleep), and convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement). Record review of Resident #2's quarterly MDS dated [DATE] with an ARD of 11/13/2023 revealed a BIMS score of 15 indicating no cognitive decline. The MDS documented she required a walker for mobility. Per the MDS, Resident #2 minimal assistance with her ADL's including eating, hygiene, toileting, bathing, dressing, and/or personal hygiene. The MDS revealed she had adequate vision abilities with the use of corrective lenses. The MDS documented Resident #2 received PT services. Record review of Resident #2's care plan dated 12/19/2023 revealed she had a focus on her ADL needs with interventions including minimal assistance with locomotion, bed mobility, eating, transfers, and incontinence care. The care plan documented a focus on her behavioral concerns. There was no documented focus on her vision needs. Interview on 12/12/2023 at 9:23 AM with Resident #2, she said she had lived at the facility for nine years. Resident #2 said the light above her sink was not working. Observation on 12/12/2023 at 9:23 AM of Resident #2's call light and bedroom, the light over the sink in Resident #2's room would not turn on whether the switch was in the on or off position. Interview on 12/12/2023 at 11:25 AM with Resident #2, she said she had spoken to staff about the broken light in her room but no one from the facility had repaired it yet. Resident #2 said she could not recall who she had spoken to or how long the light had been broken. Observation on 12/13/2023 at 8:29 AM revealed the bench in the smoking area was in disrepair. The back of the bench had become partially dislodged from the base and nails were visible. A nurse and a resident were both sitting on the bench. Interview on 12/13/2023 at 12:19 PM with the Acting DON, he said he had never been informed of the malfunctioning light in Resident #2's room. The Acting DON said if he had been informed, he would have ensured it was repaired. The Acting DON said his expectations were that as soon as staff were informed that a resident's room was not homelike, the staff or an outside technician should repair the concern. Interview on 12/14/2023 at 3:47 PM with the Admin, she said the facility had no specific policy related to facility maintenance and/or repair. The Admin said the facility utilized an electronic repair request system in which repairs were requested and completed. Interview on 12/14/2023 at 4:28 PM with the Admin, she said no one had ever informed her that the bench in the smoking area was broken. The Admin said no one had ever informed her the light in Resident #2's room was not working. The Admin said the facility staff should have been aware of the light and the bench. The Admin said issues such as the bench and Resident #2's light would have been entered into the electronic repair system to ensure repair. The Admin said she had removed the bench completely and had replaced it with two chairs.

Based on observation and interview, the facility failed to ensure that drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 1 of 1 medication aide cart, 1 of 1 medication room refrigerator, and 1 of 1 nurse's carts reviewed for medications. -1 of 1 medication aide cart had two opened undated eye drops and two discontinued medications. -1 of 1 medication rooms had a water bottle(Ozarka) 700ml sport cover in the freezer section of the refrigerator. -1 of 1 nurse's medication cart had opened and undated medications. These failures could affect residents, placing them at risk for altered effectiveness of the medication and worsening of the resident's symptoms, requiring medical intervention. The findings include: During an observation on 12/13/23 at 2:20 p.m., it revealed the medication aide cart had two eye drop containers that were opened and not dated: Latanoprost sol 0.005% and Combigan sol 0.2/0.5%. During an interview on 12/13/23 at 2:20 p.m., MA B said she was not the person who opened the eye drops. MA B said when a medication aide opened an eye drop container, she should date the container with the opened date to prevent staff from administering the drops to residents past the expiration date. MA B said if any staff administered the medication past the open date, the drug might not be effective, and the resident would not get the desired outcome. MA B said she did not know how long the eye drops should be used after opening them. During an observation on 12/13/23 at 2:35 p.m., revealed the medication aide's cart had two discontinued medications: Clopidogrel 75 mg and Metoprolol [NAME] 25mg were left in the cart. During an interview on 12/13/23 at 2:35 p.m., MA T said the doctor discontinued medications because the resident brought them from home, and it was replaced with the medicines provided by the facility. MA T said the staff should have taken the discontinued medication from the cart and placed it in the box in the medication room. During an observation of the medication room on 12/13/23 at 3:00 p.m., revealed the refrigerator in the medication room had a water bottle (Ozarka) 700ml sports cover in the freezer section of the fridge. During an interview on 12/13/23 at 3:00 p.m., MA T said the refrigerator should have only the residents and facility medications, no personal food or drinks from the staff to prevent cross-contamination. During an interview on 12/13/23 at 3:18 p.m., LVN R said the refrigerator in the medication room was for medication only, not for any staff personal items, to prevent cross-contamination. During an interview on 12/13/23 at 3:20 p.m., LVN J said the water bottle should not be in the refrigerator because it was used for medications only, and staff personal items are not stored in it because of infection control. During an observation of the nurse's medication cart on 12/13/23 at 3:30 p.m., revealed the following medications were open and not dated: 2 Insulin lispro injection 100unit, BREO Ellipta 200/25 mcg, Levalbuterol inhalation solution USP 25 vials in a foil packet, and 4 of the vials was not inside the foil packet. During an interview on 12/13/23 at 3:32 p.m., LVN R said all open insulins and breathing treatments should be dated to prevent administering a medication that had passed the opened expiration date. LVN R said if the medication was administered to the resident after the medication had passed the expiration date, the medication would not provide the expected outcome. LVN R said it could have a negative effect on the resident. LVN R said the breathing treatments should be stored in the foil package to protect the medication from light. She said she had skills check offs, and medication administration and storage were part of the check-offs. LVN R said it was the nurse's responsibility to date medicines when opened and remove medication without a date from the medication cart. LVN R said The DON monitored the nurses when she did random cart checks. During an interview on 12/13/23 at 3:55 p.m., the Interim DON said the nurses should remove the medication the resident came with once the medication from the pharmacy comes in. The Interim DON said the eye drop container should be labeled with the opened date because once eye drop medicine was opened, it had an expiration date. During an interview on 12/13/ at 3:59 p.m., the Interim DON said staff personal items (water and food) should not be kept in the medication refrigerator in the medication room because of cross-contamination. During an interview on 12/13/23 at 4:01 p.m., the Interim said the insulin pen, BREO inhaler, and eye drops should be labeled with the open date so the staff would only use them up to the expiration date to prevent any adverse outcome. During interview on 12/14/23 at 3:30 p.m., the Administrator said she could not find the competency skills check off for the nurses and medication aides. Record review of the facility policy on medication storage not dated policy read in part, . facility staff should place open on date to medications label for medications with limited expiration date upon opening . food is not stored with refrigerated medications .

Based on observation, interview, and record review the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for 1 (Resident #290,) of 3 resident reviewed for respiratory care. -The facility administered oxygen to Resident #290 without a physician order. These failures placed residents who received oxygen therapy at risk of respiratory complications. Findings include: Record review of Resident #290's admission face sheet dated 10/19/23 revealed an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted [DATE]. Her diagnoses included diabetes mellitus (metabolic disease involving Hight blood glucose levels), hypertension (blood is pumping with more force than normal through arteries), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activity) and chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problem). Record review of Resident #290's 5-day MDS assessment, dated 12/08/23, revealed the BIMS score was 04, which indicated severely impaired cognition. Further review of the MDS revealed she required oxygen therapy. Record review of Resident #290's physician's order for December 2023 revealed there was no oxygen order until 12/12/23. Record review of Resident #290's hospital discharge order dated 12/04/23 read oxygen at 2L . During an observation and interview on 12/12/23 at 10:05 a.m., Resident #290 was on oxygen, and the concentrator was set to 2.5 L. The NC (nasal canula) was on the floor under the bed. Resident #290 said she could not remember how many liters of oxygen she should be on. Resident #290 said she was having some difficulty breathing at this time. During an observation on 12/12/23 at 10:07 a.m., LVN J said the O2 (oxygen) tubing was on the floor under the bed. During an interview on 12/12/23 at 10:15 a.m., LVN J said the oxygen should be on 2L continuously, and she moved the knob on the concentrator down to 2L. Then, LVN J said she would check Resident #290's physician orders and clarify if the oxygen setting should be on 2L. During an Interview on 12/12/23 at 12:09 p.m., LVN J said Resident #290 came from the hospital on12/04/23 with oxygen, and she was not the nurse who admitted Resident #290 back to the facility. LVN J said she worked with Resident #290 last week, and Resident #290 was on continuous oxygen. LVN J said Resident #290 should have an order for oxygen before administering oxygen. LVN J said she checked Resident #290's oxygen saturation, which fluctuated between 93% and 94 %. LVN J said she did not know how they dropped the ball and did not get an order for the oxygen. LVN J said the DON verified Resident #290 orders when she was admitted to the facility, and she did not realize she did not get an order for the oxygen. LVN J said Resident #290 could go into respiratory distress if Resident #290 was not getting enough oxygen or more than required because she was diagnosed with COPD. During an interview on 12/13/23 at 3:07 p.m., LVN MDS said she independently prepared the MDS and care plan. LVN MDS said she asked the interim DON to review the care plan and make corrections. LVN MDS said Resident #290 was admitted to the facility on [DATE] and she had oxygen on when she was admitted . After a couple of hours, the facility that Resident #290 came from, called and said Resident #290 had a critical lab and she was sent to the hospital. LVN MDS said Resident #290 was readmitted on [DATE] with oxygen from the hospital. LVN MDS said the resident had oxygen since she came to the facility and the interim DON verified her medications. LVN MDS said the interim DON should have clarified the oxygen order because it was on her hospital discharged orders. LVN MDS said she added the oxygen to Resident #290's MDS but forgot to care plan the oxygen use. LVN MDS said the interim DON and LVN J admitted Resident #290 and failed to get an oxygen order from the physician. LVN MDS said Resident #290 could have retained carbon dioxide, because she had COPD, which could have caused harm or she could have passed out. During an interview on 12/14/23 at 8:40 a.m., the Interim DON said Resident #290 should not be on oxygen without a physician's order. The interim DON said all the residents on oxygen should have an order from the physician for oxygen before oxygen is administered. The interim DON said the nurse who admitted Resident # 290 should have called Resident #290's physician and verified discharged orders upon admission. The interim DON stated the DON should have verified Resident #290's discharged orders, contacted her physician for any discrepancies, and made corrections the next day. The interim DON said these actions would have prevented Resident #290 from being administered oxygen for at least a week without an order. The interim DON said administering oxygen to Resident #290 could have a negative outcome depending on the oxygen setting. The Interim DON said it could have interfered with CO2 if there was too much oxygen going in since Resident #290 had a diagnosis of COPD. Record review of the facility policy dated 2001 MED - PASS, Inc. (Revised October 2010) read in part, . the purpose of this procedure is to provide guideline for safe oxygen administration . preparation: #1. Verify that there is a physician's order for this procedure . review the physician's order . for oxygen administration .

Based on interviews, and record review, the facility failed to act upon the recommendations of the pharmacist report of irregularities for 1 of 6 residents (Resident #2), reviewed for the Medication Regimen Review (MRR). -The facility failed to review and act on the pharmacist's Resident #2's to utilize the correct consent form. This failure could place residents at risk from maintaining their highest practicable level of physical, mental, and psychosocial well-being, and could place them at risk for not providing informed consent to a psychotropic medication. The findings include: Record review of Resident #2's admission record dated 12/12/023 revealed a [AGE] year-old woman admitted on [DATE]. The admission record documented her diagnoses included dementia (group of symptoms that affects memory, thinking and interferes with daily life), unspecified psychosis (diagnosis assigned to individuals who are experiencing symptoms of schizophrenia or other psychotic symptoms, but do not meet the full diagnostic criteria for schizophrenia or another more specific psychotic disorder), repeated falls, schizoaffective disorder (mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), major depressive disorder (mental health disorder having episodes of psychological depression), HIV (virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases), anxiety disorder (group of mental illnesses that cause constant fear and worry), insomnia (trouble falling and/or staying asleep), and convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement). Record review of Resident #2's November MAR dated 12/12/2023 revealed a prescription for Aripiprazole (an antipsychotic medication used for treatment of agitation that occurs with certain mental and/or mood disorders) 20mg tablet, one tablet, once daily for schizoaffective disorder. The MAR documented it was given daily at 9:00 AM on 11/1/2023 through 11/30/2023 except 11/4/2023. Per the MAR, the prescription began on 8/29/2023. Record review of Resident #2's December MAR dated 12/12/2023 revealed a prescription for Aripiprazole 20mg tablet, one tablet, once daily for schizoaffective disorder. The MAR documented it was given daily at 9:00 AM on 12/1/2023 through 12/12/20233. Per the MAR, the prescription began on 8/29/2023. Record review of Resident #2's quarterly MDS dated [DATE] with an ARD of 11/13/2023 revealed a BIMS score of 15 indicating no cognitive decline. The MDS documented she required a walker for mobility. Per the MDS, Resident #2 minimal assistance with her ADL's including eating, hygiene, toileting, bathing, dressing, and/or personal hygiene. The MDS revealed Resident #2 was prescribed an antipsychotic. Record review of Resident #2's care plan dated 12/19/2023 revealed she had a focus on her ADL needs with interventions including minimal assistance with locomotion, bed mobility, eating, transfers, and incontinence care. The care plan documented a focus on her behavioral concerns. The care plan included a focus on Resident #2's psychotropic medication use with interventions including monitoring for signs or symptoms of side effects. Record review of Resident #2's September 2023 MRR dated between 9/5/2023 and 9/7/2023 revealed the pharmacist's recommendation to use the consent form number 3713 for Aripiprazole as it was no longer appropriate to use the conventional informed consent form for antipsychotics. Record review of Resident #2's October 2023 MRR dated between 10/1/2023 and 10/3/2023 revealed the pharmacist's recommendation to use the consent form number 3713 for Aripiprazole as it was no longer appropriate to use the conventional informed consent form for antipsychotics. Record review of Resident #2's November 2023 MRR dated between 11/1/2023 and 11/3/2023 revealed the pharmacist's recommendation to use the consent form number 3713 for Aripiprazole as it was no longer appropriate to use the conventional informed consent form for antipsychotics. Interview on 12/12/2023 at 9:23 AM with Resident #2, she said she had lived at the facility for nine years. Resident #2 said she had no concerns with her medical care at the facility. Interview on 12/12/2023 at 11:25 AM with Resident #2, she said she was aware of the medications she took, and she had no concerns with those medications. Interview on 12/13/2023 at 12:19 PM with the Acting DON, he said he had been Acting DON for five total days. The Acting DON said he expected the MRR to be reviewed by the DON monthly after the pharmacist provides the recommendations. The DON said a resident's updated medication consent forms should be obtained by the DON. The DON said Resident #2's Aripiprazole consent should have been updated. The DON said the consent form 3713 detailed the previous attempts and approaches to the underlying mental illness, and without the correct form that would not be available when consent was granted. Interview on 12/14/2023 at 3:47 PM with the Acting DON, he said the facility did not have a specific policy related to MRR's or the DON's responsibility to them. The Acting DON said the facility utilized the consultant pharmacy's policy related to MRR. Telephone interview on 12/14/2023 at 12:57 PM the consultant pharmacist for the facility, she said the facility does not currently have a DON. The Pharmacist said the facility had multiple consent for psychotropic medication forms completed but they may not be uploaded. The Pharmacist said Resident #2's correct consent form could be at the facility and not uploaded to the EMR. The Pharmacist said if the facility could not produce the consent it would be a concern because certain medications require appropriate consents to ensure the resident or their representative were able to give informed consent to the medication. Interview on 12/14/2023 at 4:28 PM with the Admin, she said she expected that the MRR was reviewed, and the resident's physician was contacted to determine if the recommendations would be put in place. The Admin said she expected the facility's nurses to follow-up and a obtain the correct consent for psychotropic medications. Record review of the undated consultant pharmacy's policy related to MRR revealed the pharmacist would conduct an MRR for each resident at the facility monthly. The policy documented the purpose of the MRR was to ensure the resident's were receiving the correct medication therapy. The policy read in part .All findings and recommendations made during the MRR are reported to the director of nursing .

Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 7 % based on 2 errors out of 27 opportunities, which involved 1 of 11 residents (Resident #31) reviewed for medication errors. - MA B was going to administer Metoprolol and Lisinopril (used to treat high blood pressure) and not follow the blood pressure parameters according to the physician's orders for Resident #31. This failure could place residents at risk for increased negative side effects and a decline in health. Findings include: Record review of Resident #31's Face Sheet dated 12/14/23 revealed, a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: hypertension (condition in which the blood vessels have persistently raised pressure), major depressive disorder (medial illness that negatively affect how you feel, the way you think and how you act), and chronic obstructive pulmonary disease ( group of disease that cause airflow blockage and breathing related problem). Record review of Resident #31's annual Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS score of 10, which indicated the resident had moderately impaired cognition . Record review of Resident #31's Care Plan initialed 10/13/21 revealed, resident had cardiac disease related to CAD and HTN. Interventions: administer medication per physician orders. Record review of Resident #31's order summary report for December 2023 revealed a start date for Lisinopril 20 mg 1 tab po qd was started on 09/02/23, and the parameter read hold if SBP below 110. Metoprolol Tartrate 50 mg 1 tab po qd hold for SBP less than 110, DBP less 60, and HR less 60. Record review of Resident #31's MAR for December 2023 did not reveal any area to document the vital signs. During medication pass observation on 12/13/23 at 8:35 a.m., MA B was about to administer Lisinopril 20 mg and Metoprolol Tartrate 50 mg to Resident #31 without checking the residents blood pressure. The state surveyor stopped the medication aide before administration. During an interview on 12/13/23 at 8:38 a.m., M A B said she did not check Resident #31's blood pressure because when she started working in the facility three months ago, she told the nurse who was on duty, there was no area in MAR for documenting Resident #31's blood pressure and heart rate. MA B said the nurse told her not to take Resident #31's blood pressure because Resident #31 was on blood pressure medication for maintenance. MA B said the nurse no longer works for the facility. During an interview on 12/13/23 at 8:41 a.m., the Interim DON said MA B should check Resident #31's blood pressure before she administered blood pressure medication and documented it on the MAR. The interim DON said if the blood pressure medication had a perimeter, there should be an area in the MAR for documentation. During an observation on 12/13/23 at 8:49 a.m., MA B checked Resident #31's blood pressure on her right wrist, and Resident #31's blood pressure was 102/50with a pulse of 87. During an observation on 12/13/23 at 8:51 a.m., MA B rechecked Resident #31's blood pressure with an electronic wrist blood pressure machine on Resident #31's left wrist, and Resident #31's blood pressure was 144/93, and her pulse was 69. During an observation on 12/13/23 at 8:55 a.m., LVN J checked Resident#31's blood pressure with an electronic wrist blood pressure machine on Resident #31's left wrist, and Resident #31's blood pressure was 97/71, and pulse was 63. During an observation on 12/13/23 at 9:00 a.m., LVN J checked Resident #31's blood pressure with an electronic wrist blood pressure machine on Resident #31's left wrist, and Resident #31's blood pressure was 109/55 and pulse was 63. During an interview on 12/13/23 at 9:02 a.m., LVN J said Resident #31's blood pressure medication would be held because the blood pressure was below the parameter. LVN J said if MA B had given the blood pressure medications to Resident#31, it would have caused Resident #3's blood pressure to drop more, which could have made the resident dizzy or even fall. LVN J said she was not aware MA B was not checking Resident #31's blood pressure before she gave blood pressure medication, and she did not tell MA B not to check Resident #31's vitals. LVN J said she monitored MA B during medication administration when she made random rounds, and the DON monitored the nurses when she made random rounds. During an interview on 12/13/23 at 9:08 a.m., MA B said she would have given the medication without checking Resident #31's blood pressure if the state surveyor had not intervened. MA B said Resident #31's blood pressure could have dropped very low if she had given the blood pressure medications because it was already below the parameter. MA B said Resident #31 could have had a negative outcome. MA B said the floor nurse does monitor the medication aides during medication administration. She said she had a skills check-off, and it included checking the resident's blood pressure before administering blood pressure medication. During an interview on 12/14/23 at 9:04 a.m., the Interim DON said Resident #31's blood pressure was low, and if MA B administered BP medications to Resident #31, it could drop the BP even lower. The interim DON said the negative outcome for Resident #31 could be dizziness and weakness. The interim DON said if Resident #31's blood pressure medication had a parameter, then MA B should have checked blood pressure before administering medication. During interview on 12/14/23 at 3:30 p.m., the Administrator said she could not find the competency skills check off for the nurses and medication aides. Record review of the undated facility policy on medication administration read in part . facility staff should observe the six medication rights . right documentation for each resident . a triple check of these 5 rights is recommended . if there is any other reason to question . or directions, the physician's orders are checked .

Based on observation, interview, and record review the facility failed to ensure residents were free from any significant medication errors for 1 of 11 residents (Residents #31) reviewed for significant medication errors. - MA B failed to administer medications as ordered by the physician to Resident # 31. These failures could place residents at risk of not receiving the desired therapeutic effect of their medications and negative outcomes. Findings include: Record review of Resident #31's Face Sheet dated 12/14/23 revealed, a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: hypertension (condition in which the blood vessels have persistently raised pressure), major depressive disorder (medial illness that negatively affect how you feel, the way you think and how you act), and chronic obstructive pulmonary disease (group of disease that cause airflow blockage and breathing related problem). Record review of Resident #31's annual Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS score of 10, which indicated the resident had moderately impaired cognition. Record review of Resident #31's Care Plan initialed 10/13/21 revealed, resident had cardiac disease related to CAD and HTN. Interventions: administer medication per physician orders. Record review of Resident #31's order summary report for December 2023 revealed a start date for Lisinopril 20 mg 1 tab po qd was started on 09/02/23, and the parameter read hold if SBP below 110. Metoprolol Tartrate 50 mg 1 tab po qd hold for SBP less than 110, DBP less 60, and HR less 60. Record review of Resident #31's MAR for December 2023 did not reveal any area to document the vital signs. During medication pass observation on 12/13/23 at 8:35 a.m., MA B was about to administer Lisinopril 20 mg and Metoprolol Tartrate 50 mg to Resident #31 without checking the residents blood pressure. The state surveyor stopped the medication aide before administration. During an interview on 12/13/23 at 8:38 a.m., M A B said she did not check Resident #31's blood pressure because when she started working in the facility three months ago, she told the nurse who was on duty, there was no area in MAR for documenting Resident #31's blood pressure and heart rate. MA B said the nurse told her not to take Resident #31's blood pressure because Resident #31 was on blood pressure medication for maintenance. MA B said the nurse no longer works for the facility. During an interview on 12/13/23 at 8:41 a.m., the Interim DON said MA B should check Resident #31's blood pressure before she administered blood pressure medication and documented it on the MAR. The interim DON said if the blood pressure medication had a perimeter, there should be an area in the MAR for documentation. During an observation on 12/13/23 at 8:49 a.m., MA B checked Resident #31's blood pressure on her right wrist, and Resident #31's blood pressure was 102/50with a pulse of 87. During an observation on 12/13/23 at 8:51 a.m., MA B rechecked Resident #31's blood pressure with an electronic wrist blood pressure machine on Resident #31's left wrist, and Resident #31's blood pressure was 144/93, and her pulse was 69. During an observation on 12/13/23 at 8:55 a.m., LVN J checked Resident#31's blood pressure with an electronic wrist blood pressure machine on Resident #31's left wrist, and Resident #31's blood pressure was 97/71, and pulse was 63. During an observation on 12/13/23 at 9:00 a.m., LVN J checked Resident #31's blood pressure with an electronic wrist blood pressure machine on Resident #31's left wrist, and Resident #31's blood pressure was 109/55 and pulse was 63. During an interview on 12/13/23 at 9:02 a.m., LVN J said Resident #31's blood pressure medication would be held because the blood pressure was below the parameter. LVN J said if MA B had given the blood pressure medications to Resident#31, it would have caused Resident #3's blood pressure to drop more, which could have made the resident dizzy or even fall. LVN J said she was not aware MA B was not checking Resident #31's blood pressure before she gave blood pressure medication, and she did not tell MA B not to check Resident #31's vitals. LVN J said she monitored MA B during medication administration when she made random rounds, and the DON monitored the nurses when she made random rounds. During an interview on 12/13/23 at 9:08 a.m., MA B said she would have given the medication without checking Resident #31's blood pressure if the state surveyor had not intervened. MA B said Resident #31's blood pressure could have dropped very low if she had given the blood pressure medications because it was already below the parameter. MA B said Resident #31 could have had a negative outcome. MA B said the floor nurse does monitor the medication aides during medication administration. She said she had a skills check-off, and it included checking the resident's blood pressure before administering blood pressure medication. During an interview on 12/14/23 at 9:04 a.m., the Interim DON said Resident #31's blood pressure was low, and if MA B administered BP medications to Resident #31, it could drop the BP even lower. The interim DON said the negative outcome for Resident #31 could be dizziness and weakness. The interim DON said if Resident #31's blood pressure medication had a parameter, then MA B should have checked blood pressure before administering medication. The interim DON stated the incident with Resident #31 could have the potential for significant medication error because MA B would have administered the blood pressure medications to Resident #31 without checking her blood pressure, which was already low if the surveyor had not intervened. During interview on 12/14/23 at 3:30 p.m., the Administrator said she could not find the competency skills check off for the nurses and medication aides. Record review of the undated facility policy on medication administration read in part . facility staff should observe the six medication rights . right documentation for each resident . a triple check of these 5 rights is recommended . if there is any other reason to question . or directions, the physician's orders are checked .

Based on observation and interview, the facility failed to ensure that drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles for 1 of 1 medication aide cart and 1 of 1 medication room refrigerator reviewed for medications. -1 of 1 medication aide cart had two discontinued medications. -1 of 1 medication rooms had a water bottle (Ozarka) 700 ml sport cover in the freezer section of the refrigerator. These failures could affect residents, placing them at risk for altered effectiveness of the medication and worsening of the resident's symptoms, requiring medical intervention. The findings include: During an observation on 12/13/23 at 2:35 p.m., revealed the medication aide's cart had two discontinued medications: Clopidogrel 75 mg and Metoprolol [NAME] 25mg were left in the cart. During an interview on 12/13/23 at 2:35 p.m., MA T said the doctor discontinued medications because the resident brought them from home, and it was replaced with the medicines provided by the facility. MA T said the staff should have taken the discontinued medication from the cart and placed it in the box in the medication room. During an observation of the medication room on 12/13/23 at 3:00 p.m., revealed the refrigerator in the medication room had a water bottle (Ozarka) 700 ml sports cover in the freezer section of the fridge. During an interview on 12/13/23 at 3:00 p.m., MA T said the refrigerator should have only the residents and facility medications, no personal food or drinks from the staff to prevent cross-contamination. During an interview on 12/13/23 at 3:18 p.m., LVN R said the refrigerator in the medication room was for medication only, not for any staff personal items, to prevent cross-contamination. During an interview on 12/13/23 at 3:20 p.m., LVN J said the water bottle should not be in the refrigerator because it was used for medications only, and staff personal items are not stored in it because of infection control. During an interview on 12/13/23 at 3:55 p.m., the Interim DON said the nurses should remove the medication the resident came with once the medication from the pharmacy comes in. During an interview on 12/13/ at 3:59 p.m., the Interim DON said staff personal items (water and food) should not be kept in the medication refrigerator in the medication room because of cross-contamination. During interview on 12/14/23 at 3:30 p.m., the Administrator said she could not find the competency skills check off for the nurses and medication aides. Record review of the facility policy on medication storage not dated policy read in part, . facility staff should place open on date to medications label for medications with limited expiration date upon opening . food is not stored with refrigerated medications .

Based on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (CR #1) reviewed for comprehensive assessments. - The facility failed to ensure CR #1's comprehensive care plan reflected medication (Provera) and interventions. This failure could place residents at risk of not receiving the care and treatment listed in the care plan and could lead to a diminished quality of care. Findings include: Record review of the admission sheet for CR#1 revealed a [AGE] year old male admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with diagnoses which included paraphilia (a condition characterized by abnormal sexual desires, typically involving extreme or dangerous activities), unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), delirium due to known physiological condition and other sexual dysfunction not due to a substance or known physiological condition ( a serious change in mental abilities). Record review of CR#1's Discharge MDS, dated [DATE], revealed his staff assessment for mental status was conducted due to the resident was unable to complete the brief interview for mental status questions. He was assessed as having short term memory problems, long term memory problems, and cognitive skills for daily decision making was severely impaired never/rarely made decision. Further review of MDS revealed he required supervision from staff with transfers, dressing and toilet use. Record review of CR#1's physician order dated 9/21/22 revealed an order for Provera tablet 10 mg (medroxyprogesterone) Acetate) Give 1 tablet by mouth one time a day related to other sexual dysfunction not due to a substance or known physiological condition. Record review of CR#1's nurses notes written by LVN A on 9/21/2022 at 1:25pm read in part: .staff reports that this resident is verbalizing sexual things to them at this time. resident continues to show sexual behaviors by being verbally aggressive as to telling staff members sexual things he wants to do to them. charge nurse notified md of these behaviors. new order received for Provera 10mg po qd. order was transcribed into system at this time. RP called, message left and still waiting for call back to facility at this time . Record review of CR#1's nurses notes written by LVN B on 9/25/2022 at 6:55pm read in part: '' .Resident alert and stable, started to say verbally inappropriate words to staff by saying sexual things that he would like to do. Writer redirected resident and informed resident that it's inappropriate, Resident redirected without difficulty . Record review of CR#1's nurses notes written by LVN A on 11/22/2022 at 1:32pm read in part: .resident awake and alert with no s/s of distress noted walking around the facility. activity director reports that during an activity this resident approached another resident asking if she would be his girlfriend. activity director states that the other resident raised her hand up to let this resident know to get out of her face due to this resident being deaf but this resident continued to ask the other resident to be his girlfriend and continued by telling her to come to his room. the activity director stated that she intervened and asked this resident to leave the resident alone and return to his room. this resident then left the dining room at this time . Record review of CR#1's nurses notes written by previous DON on 11/22/2022 at 4:50pm read in part: .Resident RP called explained discharge to pysch facility per MD resident in facility sexually aggressive w/resident making statements of aggressive sexual nature Resident also chased HR down hallway yelling sexual statements Resident at nurses station scream for DICK [NAME] medication resident re-directed multiple times refusing to stop behavior . In an interview on 01/02/23 at 9:51 a.m. with CNA AA, she said CR#1 showed sexual behaviors by being verbally aggressive as to telling staff members sexual things he wanted to do to them. She said she started working in this facility in April 2022 on the memory care unit. She said she had witnessed CR#1 had sexual behaviors while in the memory care unit and continued when moved of MCU. She said interventions were to re-direct and he was put of medication. In a telephone interview on 01/02/23 at 11:32a.m., with CR#1's doctor, he said due to CR#1's sexually aggressive behavior inventions were placed to move him out of the secure unit, be in a room closer to nurses station and started him on medication. In a telephone interview on 01/02/23 at 12:05 p.m., with CR#1's RP, she said CR#1's care plan did not address the medications he was taking to control the desire and there were no interventions to address his behaviors. She said LVN A told her that the resident was having on going sexually behaviors, but those behaviors were not addressed in the care plan. In a telephone interview on 01/02/23 at 12:29 p.m., with LVA A, she said CR#1 had explicit sexual behaviors. She said CR#1 was on medication Provera. She said CR#1 was going to be discharged to a psych facility because of his sexually aggressiveness with another female resident. She said RP refused to send resident to psych facility and decided to discharge him home. Record review of CR #1's care plan initiated 11/24/2021 and revised on 12/05/2022 revealed no documentation of care plans addressing medication (Provera) and interventions for behaviors. The Care plan was revised 12 days after CR#1 was discharged from the facility by the previous DON on 12/05/2022. Attempted telephone interview on 01/02/23 at 12:20p.m., with previous DON was unsuccessful. In an interview on 01/02/23 at 1:32 p.m., with the LVN/MDS nurse, she said she updated the care plan quarterly and upon significant change of condition. She said she updated the care areas that triggered on the MDS. She said she worked on the floor and was aware of CR#1 sexually behaviors towards staff and the medications. She said she notified the previous DON so she would update the care plan. LVN/MDS nurse said she was an LVN and only RNs could create the care plan. She said it was important to update the care plan because nurses followed the care plan. Record review and interview on 1/2/23 at 1:42 p.m. the DON and, this Surveyor reviewed CR#1's physician orders, nurses notes and care plan with the DON. The DON said an RN had to initiate the care plan, but LVN/MDS nurse was responsible for updating the comprehensive care plan. She said CR#1 problem existed as he was having on going behaviors. The DON said CR#1 had psychiatric assessment on 05/02/2022 for violent behavior. Another episode in September 2022 and then in November 2022. She said CR#1 was placed on new medication (Provera). She said the care plan should have been updated to include new medication and new interventions for the behaviors. She said it was important to update the care plan because it was the plan that told how the facility would care for him. Record review of the facility's Care Plan, Comprehensive Person-Centered Policy (Revised March 2022) read in part: .Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; e. reflects currently recognized standards or practice for problem areas and conditions. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .

Caraday of Houston Based on observation, interview, and record review, the facility failed to ensure staff had the appropriate competencies and skills for 2 (DC- A and DC- B) of 6 dietary staff reviewed for Dietary support personnel. 1. The facility failed to ensure that DC- A and DC- B were working with within the active date of their food handler's certification. This failure could place residents who consumed food prepared from the kitchen at risk of food-borne illness. Findings included: During an observation of the kitchen on [DATE] at 11:36am, 3 Food Manager's Certifications were on display. Each certification was currently active and up to date. During an interview with the DM on [DATE] at 11:36am, she stated that out of 6 dietary staff members, 3 were up to date with their certifications, 1 staff member was a new hire, and DC-A and DC- B were currently working on their certification. She stated that they use to do the classes in person, but because of Covid, the in-person classes stopped, and they are now only offered online. During an interview with DC-B on [DATE] at 11:45am, she stated that had worked at the facility for about ,d+[DATE] years. On [DATE], at 9:15am, an interview was attempted with DC-B, but she was not at work. The DM stated that she would be off for the next 3 days. During an interview with DC-A on [DATE] at 9:39am, it was revealed that DC-A was currently working on her Food Manager's Course, and she did not have a reason as to why she did not have it completed sooner. When asked when it expired, she stated that it was believed to have been some time last year. During an interview with the HR on [DATE] at 11:45am, she stated that during the hiring process, she is responsible for ensuring all future employees undergo a background check, certification/licensure check, electronic medical record review, and a vaccination status check. For 3 of the dietary staff, a certification was provided. When asked about DC-B, she stated that she has her certification, but she would have to pull it up through their online portal because she did not have a printed copy. In a follow up interview with HR on [DATE] at 12:04pm, she stated that dietary aides do not have to acquire a certificate in a certain amount of time after hire and DC-A did not need to have a certificate because she is not a cook. Record Review of the facility roster reviewed on [DATE] revealed that DC-A is titled at the facility as a dietary cook. On [DATE] at 2:45pm, the policy on dietary certifications for dietary staff was requested from the administrator. The facility was not able to provide a policy on this subject because they did not have one for their facility. Record review of the requested Personnel Files form completed by the facility on [DATE] displayed that the licensure number and expiration date for DC-A was not available. For DC-B, a licensure number was provided, but the expiration date was not available. Record review of the facility's dietary certifications on [DATE] revealed that DC- A Food Manager's Certification had expired on [DATE] and DC-B's Food Manager's Certification had expired on [DATE]. During an interview with the admin on [DATE] at 12:17pm, it was stated that the DM thought that the staff were able to work under her license but was now aware that all staff is required to complete their Food Manager's Certification within 30 days of hire. Record review of the Texas Administration Code, Title 25, Part 1, Chapter 228 subchapter B updated [DATE], indicates: . Certified Food Protection Manager and Food Handler Requirements. (d) . All food employees, except for the certified food protection manager, shall successfully complete an accredited food handler training course, within 30 days of employment. (e) The food establishment shall maintain on premises a certificate of completion of the food handler training course for each food employee.

Based on observation, interview, and record review the facility failed to ensure that the resident environment remains free of accident hazards, and each resident receives adequate monitoring and supervision to prevent elopement for 1 of 8 (CR #1) residents reviewed for supervision. -The facility failed to ensure CR#1 who resided in the facility MCU was adequately supervised and monitored to prevent him from eloping from the secured unit. -The facility failed to develop and implement interventions to prevent elopement after multiple verbalizations by CR #1 of wanting to leave the facility which resulted in him eloping. An Immediate Jeopardy (IJ) situation was determined to have existed on 03/09/2022. While the IJ was removed on 03/13/2022, the facility remained out of compliance at a severity level of no actual harm, with the potential for more than minimal harm that is not immediate jeopardy, and a scope of isolated, due to the facility's need to evaluate the effectiveness of their Plan of Removal (POR). These failures could place residents on the secured unit at risk of elopement that could possibly result in serious injury or death. Findings Included: Record review of CR #1's face sheet revealed that CR #1 was a [AGE] year-old male admitted to the NF MCU on 03/02/2022 with a diagnosis of unspecified psychosis (a mental disorder characterized by a disconnection form reality). Record review of CR #1's Wandering Risk Scale dated 03/02/2022 revealed that CR #1 could follow instructions, was ambulatory, could communicate, and had a history of wandering (past hospitalization /family). Further review revealed that the NF scored CR #1 as a 7 (low risk on the wandering scale). Record review of CR #1 Physician orders revealed an order dated 03/02/2022 to admit to the NF MCU. Further record review revealed an order dated 03/02/2022 to administer melatonin tablet 5mg give 2 (two) tablets by mouth at bedtime for insomnia (disrupted sleep patterns), and Zyprexa 5mg give one table by mouth three times a day related to psychosis. Record review of CR #1's MAR dated March 02, 2022 revealed melatonin and Zyprexa was administered as ordered by the physician. Record review of CR #1's care plan dated 03/02/22 revealed CR #1 was being care planned for elopement risk/wander related to bipolar (disorder associated with episodes of mood swings ranging from depressive lows to highs) flight of thoughts. The interventions in place were the following: identify pattern of wandering, provide structural activities, and redirection. Record review of the NF staffing on 03/07/2022 for the 10pm-6am shift for the MCU revealed one CNA (CNA F), 2 CNA's one for station 1 and 1 for station 3, and 1 nurse, LVN A. Further review of the NF staffing on 03/08/2022 revealed the MCU was staffed with one staff member, CNA J for the 6am-2pm shift. Record review of CR #1's Nursing Progress Notes revealed in part: .Day 3 of new admit, resident basically stays in his room. Continues to express desire to leave facility. No attempts at exit seeking he remains on the Memory Care Unit . documented by LVN G on 03/04/2022. .elopement on 03/08/2022 . documented by LVN D. Record review of Total Fire and Safety dated 03/08/2022 revealed in part: .Service call to test magnetic locks. The magnetic locks were tested and found working properly at this time . Record review of an in-service/training documented 03/08/2022 revealed topic discussed elopement protocol. Record review of CNA H statement documented 03/08/2022 revealed in part: .I clocked in at 6:05am came to lock unit to check on a resident then came to get my supplies because I worked on the outside of station 3. Around 6:40am the medication aide and I cleaned another resident. Then around 7:50am the medication aide was passing trays on the lock unit. I went back there to help and we noticed CR #1 was not in room . Interview on 03/09/2022 at 9:05am the Administrator said they had not been able to locate CR #1. She said CR #1 was alert and oriented 1-2 (person and place) and was ambulatory. The Administrator said she arrived to the NF on 03/08/2022 at 8:00am and was informed that CR #1 could not be found. She said a search for CR #1 was conducted inside and outside of the NF premises. She said a call was placed to the Police Department at 8:55am, they put out a missing person flier, and conducted a 15-mile radius search for CR #1 but had not been able to find him. CR #1 was admitted to the NF from home on 03/02/2022. CR #1 at one time resided in a NF and was sent from a previous NH to a psych hospital. She said the previous NF refused to accept CR #1 back and therefore he was discharged home. The Administrator said CMA B reported the last time CR #1 was in the NF was at 6:15am on 03/08/2022. CMA B reported that she heard CR #1 moving around in the bathroom while administering medication to another resident that shared the same bathroom with CR #1. She said the staff was passing breakfast trays at 7:45am on the hallways, and it was discovered that CR #1 was missing. She said they had Total Fire Safety to come to the NF to check the doors on the MCU and all doors were functioning properly. All the windows had a safety lock on them, and no screens on the windows had been removed on the MCU. She said she had no clue how CR #1 eloped off the MCU. She said CR #1 left his clothes but took his laptop and charger. CR #1 liked to watch the news, and had a poor short-term memory due to a brain injury. The census on the MCU was 8 but now at 7. She said on the night shift 10pm-6am shift on 03/07/2022 there was 2 nurses, 3 aides and on the morning shift of 03/08/2022 the staffing consisted of 3 CNA's, 1 nurse, and 1 CMA. The NF utilized on the MCU one nurse and 1 CNA on the 10pm-6am. The Administrator said on 03/08/2022 she staffed the MCU with 1 CNA, 2 CNAs to cover station 1 and station 3, and one nurse to cover the MCU, station 1, and station 3. Further interview with the Administrator on 03/09/2022 at 9:05am said LVN A worked on 03/07/2022 10pm-6am reported that at the end of her shift which would have been around 6:00am on 03/08/22, CR #1 was in his bed. She said CR #1 would interact with the staff, but his conversation was limited. The Administrator said the front entrance to the NF was locked from the outside but not from the inside. Interview on 03/09/2022 at 10:30am LVN A said she worked the 10pm-6am shift on 03/07/2022. LVN A said CR #1 on the night shift of 03/07/2022 was in his room at the beginning of the shift. LVN A said around 1:30am CR #1 came out of his room and went to the T.V./ Day Room with his laptop and stayed in the T.V./Day Room for about 15 minutes and then went back to his room. LVN A said a CNA was present on the MCU and reported that she had last seen CR #1 around 5:55 or 6:00am on 03/07/2022. LVN A said CR #1 was lying in bed on top of the covers wearing a gray shirt and grayish jogging pants. LVN A said she finished checking on the other residents in the MCU and station 1 and 3 . LVN A said while finishing her documentation, CMA B came to the nurse station to let her know that she heard noise in CR #1's bathroom while administering medication to another resident who was talking loud and probably awaken CR #1. LVN A said this was around 6:15am on 03/08/2022. LVN A said she was not on the MCU per say but covered the MCU and the other halls (station 1 and 3). LVN A said this was how the NF normally staffed. LVN A said she made rounds in the MCU every 2-hours and relieved the CNA in the MCU for breaks. Interview on 03/09/2022 at 12:08pm CNA F said she worked on 03/07/2022 on the10pm-6am shift on the MCU and last saw CR #1 between 4:00am-4:30am. CNA F said CR #1 was in his room in bed. CNA F said she checked on CR #1 again around 5:30am by knocking on his door and opening it asking if he was okay. CNA F said CR #1 answered yes that he was okay. Interview on 03/09/2022 at 11:00am CMA B said she worked on 03/08/2022 on the 6am-2pm shift. CMA B said she went to the MCU around 6:00am to administer some medication to a resident that shared the same bathroom as CR #1. CMA B said while administering the medication, she heard noise in the bathroom of CR #1. CMA B said after administering the medication, she left the MCU around 6:15am to go and administering medications on another hall outside of the MCU. CMA B said around 7:45am she began to assist with passing out the breakfast trays on the halls. CMA B said when she arrived too CR #1's room on the MCU, CR #1 was not present in his room. CMA B said she did not see the CNA in the MCU and just assumed the CNA was in another room assisting another resident. CMA B said she notified the nurse LVN D. Interview on 03/09/2022 at 11:47am LVN D said she was the covering the MCU, station 1 and 3. LVN D said she worked on 03/08/2022 6am-2pm shift and was covering the same units. LVN D said when she got to work the morning of 03/08/2022, she began to make rounds starting first on station 1 taking the residents vital signs and getting blood sugars. She said she found out that CR #1 was missing from the MCU around seven-ish when she had made it to station 3 and was told by CMA B. LVN D said she told the staff to start searching for CR #1. LVN D said CR #1 never acted like or verbalized he wanted to leave the NF. She said although the MCU was staffed with one CNA on the MCU she could see straight down the hallway on the MCU through the glass double doors. LVN D said often times CR #1 would come to the double glass doors at the entrance of the MCU and just look, but then turn around and go back to his room. Observation on 03/09/2022 at 11:08am of station 3 being right by the entrance double glass doors leading into the MCU which were locked. Observation on 03/09/2022 at 11:10am MCU after being let into MCU by staff member, observation was made of the T.V./Day Room being right by the entrance door into the MCU on the left side. There were no residents present in the T.V. room at the present time. Adjacent to the T.V./Day Room was the staff break room. Observation on 03/09/2022 at 11:15am room [ROOM NUMBER] was CR #1's room. Further observation of CR #1's closet revealed that CR #1 personal belongings 2 duffle bags inside of closet with no clothes hanging in closet and no clothes inside of drawers. Interview on 03/09/2022 at 11:15am CNA C said when CR #1 arrived on the MCU on 03/02/2022, CR #1 told her that he was not going to be at the NF long therefore told her not to hang his clothes in the closet or place any of his clothes in the drawers. CNA C said CR #1 showed her his Veteran card. CNA C said CR #1 did not appear confused and requested the NF Wi-Fi and went on to sign his device on the NF Wi-Fi and asked for the remote to the T.V. CNA C said CR #1 put both his laptop and TV on CNN. CNA C said CR #1 was able to give himself a shower and shave himself. CNA C said CR #1 always wanted the room to be dark as well as the T.V./Day Room. CNA C said when staff open the blinds in the T.V./Day Room for the other residents, CR #1 would get up and go and close the blinds. CNA C said often times CR #1 would go to the entrance doors by station 3 and just lean against the wall and just watch then turn around and go back to his room. CNA C she did tell the DON about CR #1 verbalizing he did not want to be in the NF and that he was not going to be there long, the DON said CR #1 would be alright. Interview on 03/09/2022 at 12:15pm the Administrator said CR #1 was admitted to the MCU due to memory issues flight of thought and the goal was to transfer CR #1 to a group home or personal care home. The Administrator said the family of CR #1 was working with CR #1's insurance to assist in placing CR #1 into one of these homes. Interview on 03/10/2022 at 6:22pm LVN G said she worked the 2pm-10pm shift and that she was the only nurse on duty at the NF. LVN G said the NF had 1 CNA on the MCU, 2 CNA's outside of the MCU, and 1 CMA. LVN G said the NF census was 29. LVN G said she had been working at the NF since September of 2021 and the NF always staffed the MCU with one staff member (CNA). Interview on 03/11/2022 at 7:15pm am the DON said the NF had put out a $1000.00 reward for CR #1. The DON said staffing for the MCU on all the shifts was one CNA with the nurses on station 3 assisting with supervision. The DON was asked who supervised the other residents if the one CNA on the MCU was in a room assisting another resident? The DON said the nurse on station 3 could see down the hall of the MCU to watch the other residents in the MCU because it was just one hall on the MCU. The DON said during the 6am-2pm shift herself along with the nurse on the 300-Hall as well as the Unit Manager could assist the staff on the MCU when needed. The DON said on the night shift 10pm-6am shift, she staffed the MCU with 1 nurse and 1 CNA. The DON said she did not know how CR #1 eloped from the MCU. The DON said CR #1 did not show signs of elopement. The DON said during the admission process, a meeting was held with CR #1 and his family member. The DON said CR #1 expressed that he knew he would not be at the NF long and that living at the NF was only temporary. The DON said she learned later after CR #1 had eloped from the MCU, that CR #1 had tried to commit suicide while driving a vehicle and injured himself causing brain injury. The DON said she had been trying to get CR #1's hospital records. Interview on 03/11/2022 at 11:18am the DON said the CNA on duty on 03/08/2022 for the 6am-2pm shift on the MCU was CNA H. The DON said CNA H was assigned to the MCU. The DON said CNA H had been placed on leave because her statements kept changing when she realized the severity of the situation. The DON said CNA H said she was on the MCU the whole times but was sitting down in the back of the MCU. The DON said CNA H at one time had reported that she made rounds on all of the residents but did not check on CR #1 because his door was closed, and she did not want to disturb him because sometimes CR #1 would become irritated when disturbed. The DON said CNA H could have at least knocked on CR #1's door and looked in on CR #1. Interview on 03/11/2022 at 12:53pm interview with CNA H via phone said on 03/08/2022 she was scheduled to work the 6am-2pm outside of the MCU. CNA H said when she came to work, she found out later around 7:45am or 8:00am when herself and CMA B was passing the breakfast trays that a CNA had called off who was scheduled to work the MCU. CNA H said the staff schedule was 3 CNA's. CNA H said a long time ago prior to the new Administrator and DON the NF always staffed with 2 CNAs on the MCU at all times. CNA H said with the NF census being low, someone in Corporate office said the MCU would not be staffed with 2 CNA's. CNA H said when she found out that herself and CNA I were the only 2 CNAs in the NF that were working, she asked the Staffing Coordinator were they going to try and get someone else to come in and work? CNA H said the Staffing Coordinator told her no and that herself and CNA I could do it. CNA H said herself and CNA I was going back and forward to the MCU and the other units to care for the residents. CNA H said the Administrator and DON was not being honest about what all had taken place around CR #1's elopement from the MCU. CNA H said the first day CR #1 arrived to the MCU she overheard that CR #1 was saying he did not want to be at the NF. CNA H said when CNA C tried to unpack CR #1's clothes, CR #1 started to get upset saying the MCU was not the place for him and that he was in the military. CNA H said CNA C said she was going to let the DON know what CR #1 was saying because this was not going to work, placing CR #1 on the MCU. Interview on 03/11/2022 at 1:27am via phone CNA I said on 03/08/2022 on the 6am-2pm, she was scheduled to work on station 1 and CNA H was assigned to station 3. CNA I said CNA J was assigned to work on the MCU on 03/08/2022 and that was the unit she normally worked. CNA I said it was around 7:00am when she found out that the NF was short of a CNA. CNA I said she was feeding a resident on station 1 when she was told by the DON that CR #1 was missing. CNA I said prior to feeding a resident on station 1, CNA H and herself was providing care to another resident on station 1 around 6:45 or 6:50am. CNA I said she was not aware that no staff was on the MCU. CNA I said she was unsure where the nurse was at in the NF. CNA I said after providing care to the resident on station 1, she went back to station 300 and by that time the breakfast trays had arrived. CNA I said she had provided care for CR #1 in the past and CR #1 walked a lot and loved to watch TV and be on his laptop. CNA I said she did not understand why the NF was writing her up when she did not know initially there was a change in the staffing schedule. CNA I said when she did find out the change in the staffing schedule, she and CNA H began to go back and forward to the MCU to assist with the residents. CNA I said prior to CR #1 eloping from the NF, she had not been in-serviced on how to supervise or monitor a resident at risk for elopement. Interview on 03/11/2022 at 1:50pm Staffing Coordinator said he had been the Staffing Coordinator for a week and was also a CNA. The Staffing Coordinator said CNA J had called off on 03/07/2022 around 11:00pm. The Staffing Coordinator said CNA J worked the 6am-2pm shift. The Staffing Coordinator said he tried to find placement but was unsuccessful due to last minute. The Staffing Coordinator said he arrived at the NF on 03/08/2022 right before 7am. The Staffing Coordinator said he started gathering supplies to care for the residents to assist the other aides. The Staffing Coordinator said whenever there was a shortage with staffing, the Staffing Coordinator would assist with care on the units. The staffing Coordinator said it was after 7:00am when he saw CNA H and CNA I standing outside of the MCU. The Staffing Coordinator said the 10p-6a shift had already left. The Staffing Coordinator said he was explaining to both CNA's that they were the only 2 CNA's and CNA H said she had placed her personal items on the inside of the MCU. The Staffing Coordinator said he assumed that CNA H was going to work in the MCU. The Staffing Coordinator said he went to the Central Supply room to gather more supplies and as he was returning to station 1 10- 15 minutes later, he heard a code white being called (elopement). The staffing Coordinator said all the staff started searching for CR #1. The Staffing Coordinator said the NF normally staffed for the morning and evening shift with 3 CNA's, 1 CMA, and one nurse with one of the CNA's going to the MCU. The staffing Coordinator said for the night shift 10pm-6am staffed with 2 nurses and 3 CNA's. The Staffing Coordinator said the MCU was staffed with 1 CNA on the morning and evening shift. The Staffing Coordinator said at nighttime staffed with 1 nurse and one CNA for the MCU. Interview on 03/12/2022 at 12:20pm the Administrator said the NF had gone out looking for CR #1 and two service stations said they had seen CR #1 just walking around. Record review of the NF Admission Screening for Placement on Dementia Secure Unit revised 12/2020 revealed in part: .Identification of individuals whose needs necessitate placement on the Dementia Secure Unit prior to their admission to the community requires the following: Follow up with the resident to assess psychosocial well-being and for adjustment issues . The Administrator and DON were notified on 09/10/2022 at 7::12pm an IJ situation was identified due to the above failures. An IJ template was provided. The following Plan of Removal (POR) was submitted by the NF Administrator and was accepted on 03/11/2022 at 11:25am. [Facility name] Plan of Removal 03/11/2022 Immediate Actions: The facility's IDT will meet to review incident, discuss investigation, and complete a root cause analysis for this incident/situation on 3/11/22 The facility did not identify how the resident eloped from the MCU after an overview of the unit inside and out no breach was identified. The resident has not been located at this time. The local police are continuing their search along with the facility. The facility was identified two locations the resident was seen, and flyers had been distributed to different locations throughout the city. All residents on memory care unit were immediately accounted for by the DON Elopement risk assessment conducted by the charge nurse on 3/10/22 and reviewed by the DON on 3/11/22. No update needed to current resident care plan on memory care unit Education will be completed the DON/designee to ensure that when a resident is expressing a desire to leave, that this is reported, evaluated, and interventions put in place to meet the resident needs started on 3/11/22 Two staff members a combination of CNA's or CNA/LVN or 2 LVN's or 2 CNAs on memory unit every shift- starting 3/11/22. One of the staff will be always monitoring the hallway. If one staff is providing care the other will be monitoring the hallway. Lunch and breaks will be covered by the staff from the open community unit, maintaining two staff on the MCU at all times. Current resident on MCU is all one person assist. Education for this process will be conducted on 3/11/22 by the DON/designee Staff training initiated on 3/08/22 by DON - Wandering, elopement risk, elopement binder, what are elopement risk behaviors All staff will be in-serviced by DON/designee 3/11/22 on elopement risk, wandering, and what to look for in an elopement risk resident Elopement risk assessment completed on all memory care residents on 3/10/22 by the charge nurse and reviewed by the DON Medical Director notified on 3/10/22on IJ for supervision by the Administrator Facility's Plan to Ensure Immediate Compliance Two staff members will be assigned to the memory care unit every shift starting on 3/10/22. Staff will be trained on elopement, wandering and missing residents, training will be conducted by the DON/designee The doors will be checked for functionality three times daily by administrator or designee 3/11/22 DON or designee will round on memory care unit twice daily looking for changes in wandering risk or behavior 3/11/22 DON and/or Designee Elopement risk/missing residents drills will be conducted once a week X 4 weeks starting 3/11/22 DON and/or Designee will in-service Charge nurses on completing elopement/wandering assessment on new admission/readmission(s) starting on 3/11/22 DON and/designee will in-service staff that are not currently working starting on 3/11/22. The in-service will include elopement risk, wandering, what to look for in an elopement risk, and resident elopement binder. Training will include individualized interventions based on residents age, ambulatory and mental status. Social Services, Activities Director will be included in new hire training. DON/designee will follow-up within 24hrs of new admissions to ensure elopement/wandering assessments are completed. Starting 3/11/22 DON/designee to interview staff to determine if they have knowledge of any other resident who has tried or talked about eloping. Starting 3/11/22 Elopement binder in place on unit and at the nurse's station with face sheet elopement risk, staff will be reeducated on elopement binder 3/11/22 Staff will be educated by DON and/or Designee each time a resident is added or removed from the elopement binder starting on 3/11/22 Off cycle QAPI will be conducted related to the elopement and updated staffing pattern for memory care unit on 3/11/22 IDT will review the admission criteria for the memory care unit on 3/11/22 for appropriate admission criteria to ensure only resident whose needs could be met by the facility are admitted The DON/designee will be responsible for making clinical admission decisions DON will be educated by Regional Clinical Director on appropriate policy and expectation of admission to the memory care unit on 3/11/22 Monitoring was initiated on 03/12/2022 at 1:15pm: Interview on 03/12/2022 at 1:17pm CNA AA said she worked the 6am-2pm. CNA CC said she had been in-serviced on resident (s) eloping from the NF to call a CODE silver, recognizing the signs of elopement and reporting to the charge nurse right away. CNA AA said she was also in-serviced to check all the resident room and the MCU had to be staffed with 2 people at all times. Interview on 03/12/2022 at 1:25pm CMA BB said the NF had given her in-service on elopement in notifying the nurse immediately, signs of elopement such as wandering or verbalizing wanting to leave. Interview on 03/12/2022 at 1:30PM RN CC said she worked on the weekends as the weekend supervisor. RN CC said she had received in-service on elopement drill. RN CC said the in-service included assessing residents upon admission and readmission to see if they are at risk for elopement, abuse and neglect, monitoring the residents every 2 hours and twice a shift in the MCU, and to ensure that the MCU was always staffed with 2 people. Interview on 03/12/2022 at 1:32pm LVN A said she had been in-serviced on admissions and new admissions assessing residents for elopement risk or wandering. LVN A said the elopement CODE had been changed from white to silver. LVN A said an elopement risk binder is kept at each nursing station. LVN A said she was also in-service on assisting with supervising and monitoring the MCU. Observation on 01/12/2022 at 1:35pm of an elopement risk binder at each nurse station as well as at the front entrance. Interview on 03/12/2022 at 1:40pm LVN O said she worked the weekends double shift from 6am-10pm and was in orientation. LVN O said she had been in-serviced on elopement risk making sure the residents in the MCU did not elope off the MCU and that the MCU needed to be staffed with 2 people at all times. Observation 03/12/2022 at 1:42pm of the MCU being staffed with 2 CNA's. Interview on 03/12/2022 at 1:45pm CNA DD last her last in-service at the NF was on elopement monitoring residents for signs of elopement and reporting the nurse right away. CNA DD said she was also informed to do rounds on all the residents as soon as she reported on duty to work and that the elopement code had been changed to code silver. CNA DD said she normally worked the 2pm-10pm shift but was helping out on the 6am-2pm shift. Interview on 03/12/2022 at 2:05pm CNA P on the 2pm-10pm shift said she had received in-service on elopement risk and ensuring that all residents were counted for in the NF. CNA P said if a resident was missing to notify the nurse as well as Administration right away. Interview on 03/13/2022 at 3:20am via phone CNA F said she had been in-serviced on the NF elopement protocol recognizing signs of elopement such as resident wandering or verbalizing they did not want to be at the NF to inform the charge nurse immediately. Interview on 03/13/2022 at 12:00pm via phone RN K said he worked the 10p-6am shift Monday-Friday. RN K said he had received in-services on resident elopement to assess the resident (s) and report any signs of elopement to the DON and the Administrator. RN K said even a resident leave out of the door on the MCU or the NF without supervision, it was to be reported to Administration because it was still an elopement that needed to be reported. RN K said he had also been in-serviced on monitoring the MCU twice daily for signs of elopement. Interview on 03/13/2022 at 2:20pm via phone CNA L said she worked the 10pm-6am shift and had received in-services on resident elopement risk reporting signs to the nurse and monitoring residents for signs of elopement. CNA L said the elopement code had been changed to code silver. On 03/13/2022 at 10:40 AM the Administrator was notified that the IJ was removed. However, the facility remained out of compliance at a severity level of no actual harm, with the potential for more than minimal harm that is not immediate jeopardy, and a scope of isolated, 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 maintain an Infection Control Program designed to prevent, recognize, and control the onset and spread of infection to the extent possible for 3 of 3 residents (#1, #2 and #3) reviewed for infection control in that: -CNA A did not sanitize or wash her hands between resident encounters for Resident's #1, #2 and #3. -CNA's A and B did not wear proper PPE while providing care to resident's #1, #2 and #3 in the quarantine unit. -LVN A did not wear proper PPE while providing care to Resident #1. -The facility did not have signage posted on the quarantine unit entry doors. -The facility failed to implement their policy to ensure staff, who were providing care to the quarantined residents wore appropriate PPE of N95 respirator, gown, gloves, and goggles or face shield when caring for quarantined residents. An Immediate Jeopardy (IJ) was identified on 9/11/20. While the IJ was removed on 9/13/20 the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate threat and a pattern of isolated while they continued to monitor their plan of removal. These failures could affect all residents on the quarantine unit and place them at risk of contracting an infectious disease. Findings include: Record review of the Centers for Disease Control website at CDC.gov on 6/11/20 revealed, .Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year-old male who was initially admitted on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS of 07 out of 15 indicating the resident had moderately impaired cognition. He required supervision for bed mobility, transfer, locomotion in room, eating, and toilet use. He required one-person assistance with dressing and personal hygiene. Record review of Resident #1's care plan initiated on 5/21/20 revealed the following: Focus: Resident #1 is potential risk for exposure to infectious disease: COVID 19. Goal: Resident #1 will have minimal exposure to COVID 19 during the review period. Interventions: 14-day observation related to new admission. Follow facility protocol for COVID -19 screening and precautions; and observe for signs/symptoms of COVID 19; document and promptly report signs/symptoms: fever, new/worsening cough, sore throat, shortness of breath. Resident #2 Record review of Resident #2's face sheet revealed a [AGE] year-old male who was initially admitted on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #2's annual MDS assessment dated [DATE] revealed a BIMS of 07 out of 15 indicating the resident had moderately impaired cognition. He was assessed as requiring supervision with setup help for bed mobility. Transfers, walking in the room, and walking in the corridor were coed as a 6/6, which was not on the coding key for the document. He was coded as a 5/1 for dressing, which was also not on the coding key for the document. He was assessed as needing limited set up assistance for eating. He required supervision for toileting. He was not coded for Section K: swallowing disorder. Section O: Special treatments, procedures, and programs revealed the resident was coded for M. Isolation or quarantine for active infectious disease. Record review of Resident #2's care plan initiated on 9/2/20 revealed the following: Focus: Resident #2 is potential risk for COVID 19 pandemic infection. Goal: Resident #2 will not have increased potential for COVID 19 infection without intervention throughout the review period. Interventions: Educate resident and staff re: CDC guidelines for prevention of COVID 19 transmission; frequent handwashing and sanitizer use; masking during care; social admission; documentation of any signs/symptoms of concerns. Resident #3 Record review of Resident #3's face sheet revealed a [AGE] year-old male who was initially admitted on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #3's care plan initiated on 4/9/20 and revised on 4/13/20 revealed the following: Focus: Resident #2 is at risk for exposure to infectious disease: COVID 19. Goal: Resident #2 will have minimal exposure to COVID 19 during the review period. Intervention: Educate staff, client, family and visitors of COVID-19 signs/symptoms as well as precautions. Follow facility protocol for COVID -19 screening and precautions; and observe for signs/symptoms of COVID 19; document and promptly report signs/symptoms: fever, new/worsening cough, sore throat, shortness of breath. Observation on 9/11/20 at 10:44 am revealed the quarantine unit had a sign posted on the entry door that said, staff/employees only. There was no signage posted indicating the unit was a quarantined unit. The unit had one entry. The back of the unit had sealed barrier with heavy plastic sheeting that extended from the ceiling to the floor and walls. No one was able to enter through the sealed barrier. Observation on 9/11/20 at 10:45 am revealed Resident #1 in bed with his eyes closed. He was tucked in under his blanket. His bed was in the lowest position. There was a fall mat on the right side of the bed. There was a shake container on his rolling table. There was a box about 2 feet in front of Resident #1's bed, instead of at the exit to the room, that had a red biohazard waste bag. A second box with a yellow bag was adjacent to the first box. Both boxes were uncovered. In an interview on 9/11/20 at 10:46 am with CNA A, she said she had worked for the facility for 1 year and 4 months. She said she was designated to work the quarantine unit. She said the yellow bag in the box in Resident #1's room was for laundry. She said the red bag was to doff PPE. This Surveyor asked CNA A where the biohazard bag should be located. She said she did not know. Observation and interview on 9/11/20 at 10:47 am with CNA A revealed CNA A was wearing only a surgical mask. She was not wearing a gown, N95 respirator, goggles/face shield, or gloves. CNA A went into quarantine resident rooms (202, 203 and 205), and was within 6ft of the residents. PPE was located outside each resident's room. CNA A entered Resident #2's room to adjust his bed and clip his call light to his gown. She was not wearing gloves. She left Resident #2's room and walked into Resident #1's room without washing her hands or using hand sanitizer or donning gloves. She stooped down by Resident #2's bed to ask him if he wanted to eat. She was within 1 foot of the resident. Resident #2 declined, and she tucked Resident #2 in his bed with his blanket and left the room. She proceeded to Resident #3's room without washing her hands or hand sanitizing or donning gloves. She was observed within 1 foot from Resident #3 while asking him if he was okay. CNA A said she was told she did not have to wear a gown, face shield, or N95 for residents in quarantine because the residents tested negative prior to discharge from the hospital. She said residents that had one overnight stay at the hospital had to be quarantined when they returned from the hospital because they were told there was the possibility residents could contract [MEDICAL CONDITION] between the date of discharge and the date of arrival to the facility. This Surveyor asked her if readmits status was considered unknown status. She said yes. When asked to confirm, the regarding the residents in quarantine, whether the staff knew if the residents in quarantine were positive or negative, she said, Yes, we don't know, so I should be wearing full PPE. She said full PPE would include gown, N95, goggles or face shield and gloves. She said she made a mistake because she knew she was supposed to wash her hands between residents. She said she was supposed to wash her hands before and after resident care. She said only one person was allowed in the quarantine unit. She said Resident #1 required one-person assistance with feeding, repositioning, turning, bathing, and personal hygiene. She said he got a bed bath every other day. Observation and interview on 9/11/20 at 12:32 pm revealed CNA A entering the quarantine unit. She was wearing a surgical mask. She said she had been in the restroom. This Surveyor told her Resident #2 required her assistance. She entered Resident #2's quarantine room wearing only a surgical mask. She did not wash her hands or use hand sanitizer. She did not wear a gown, N95, goggles or face shield or gloves. She tried to adjust Resident #2's bed, but the mechanical frame was in disrepair. She was observed telling Resident #2, That's as far as it goes up. She placed a pillow to help increase the Resident's position, so he could eat without aspirating. She left Resident #2's room and entered Resident #1's room. She did not wash her hands. She was wearing a surgical mask. She was not wearing a gown, N95, goggles or face shield, or gloves. She looked at the lunch tray, picked up the meal ticket, and bent down to the resident's level (bed in lowest position) to ask the resident if he wanted to eat. She asked twice, and he responded no twice. She asked him if he was cold and he said yes. She tucked him in with his blanket. She left Resident #1's room and entered Resident #3's room. She did not wash her hands or use hand sanitizer. She only wore a surgical mask. She was not wearing a gown, N95, goggles or face shield or gloves. In an interview on 9/11/20 at 12:35 am with CNA A, she said she was supposed to wash her hands after doffing gloves and before and after making contact with residents. She said she made a mistake by not washing her hands. She said she was not wearing full PPE (gown, N95, goggles or face shield) because she was told she did not need to wear PPE in the quarantine unit. Observation on 9/11/20 at 12:39 am revealed the quarantine unit had a sign posted on the entry door that said, staff/employees only. There was no signage posted indicating the unit was a quarantine unit. The unit had one entry. The back of the unit had a sealed barrier with heavy plastic sheeting that extended from the ceiling to the floor and walls. No one was able to enter through the sealed barrier. Observation and interview on 9/11/20 at 12:40 pm with LVN A revealed her entering Resident #1's room wearing only a surgical mask. She washed her hands. She grabbed gloves from inside the resident's room and put them on. She did not don a gown, N95, goggles or face shield. She picked up the resident's meal ticket. She went to Resident #1's bedside, stooped down to Resident #1's bed to ask him if he wanted to eat. He said no. She was within ½ foot in distance from the resident. She asked him if he would like a shake and he said yes. She prepared the shake, doffed gloves, washed her hands, and left the room. She said she did not know the difference between isolation and quarantine. After guidance, she said unknown status would prompt her to wear full PPE (gown, N95, goggles or face shield and gloves). She said she was told by another nurse that PPE was required only for residents with positive results for COVID. She said she was responsible for the quarantine unit. She said she was also responsible and worked in the non-quarantine rooms 101-110 and 120-130. She said she started working at the facility this past Thursday, 9/3/20 and she had not received any training. LVN A headed back to work at non-quarantined units. Observation on 9/11/20 at 12: 50 pm revealed LVN A walking the hallways of unit 100. She was wearing a surgical mask. Observation and interview on 9/11/20 at 12:55 pm accompanied by LVN A revealed clean linen uncovered and left on shower cart, one soiled flat bed sheet and one 15 ounce bottle of tropical coconut conditioner left open in the community shower room located behind the first nurse's station by Unit 100. LVN A said the clean linen and soiled bed sheet should not have been left out. She said the clean linen belonged in the clean linen closet. She said the soiled bed sheet should have been placed in the soiled linen bin. She said it was important to keep clean linens and soiled linens in their appropriate place to prevent infection and cross-contamination. Interview on 9/11/20 at 1:40 pm with Administrator and ADON, the ADON said she had just started on 8/31/20. She said there were 4 residents in quarantine. She said Resident #1, #2 and #3 were re-admits from the hospital. She said Resident #4 was in quarantine because he was sent to the hospital for blood [MEDICAL CONDITION] when he was at [MEDICAL TREATMENT]. She said Resident #4 was getting ready to be moved back to his room because his quarantine days were completed. She said residents got negative tests from the hospital. She said the facility would retest residents when they were close to the 9th day, so they could come out of quarantine on the 10th day. She said residents were being monitored for COVID at every shift and it was documented on their MAR's. She said isolation meant residents were positive. She said quarantine meant monitoring symptoms or waiting on pending test results. She said when residents arrived, the facility had to have the test results from the hospital. She said if positive, the facility would not retest. She said if negative and the facility received the negative results from the hospital, the facility would not retest readmits. She said, even if residents tested negative at the hospital two days ago, they would still have to be monitored for symptoms upon readmission. The Administrator said, sometimes symptoms don't show up for 2 to 5 days. The Administrator said staff still had to wear PPE when making contact with residents in quarantine, even if readmits tested negative at the hospital prior to discharge. She said staff was supposed to be wearing gowns, N95's, goggles or face shields and gloves. The ADON said the charge nurse had oversight to ensure staff were wearing the appropriate PPE. Interview on 09/11/20 at 1:50 pm with Administrator and DON, the Administrator said that staff were to wear N95, gown, and gloves when caring for quarantine residents. She said face shields were only used if residents were positive for COVID. The Administrator said the charge nurse was supposed to monitor the quarantine unit to ensure staff was wearing appropriate PPE. The DON said he did not know if staff was supposed to wear full PPE (gown, N95, goggles or face shields and gloves) because he was new to this facility. He pointed at the Administrator and said, what she said. The Administrator said, you see all this PPE, so I don't know why they are not using it. She said she was responsible for tracking the burn rate, so she always knew how much PPE the facility had on hand. The DON said residents had to have orders for COVID testing. He said the facility did not have dedicated staff for the quarantine unit. He said all facilities were having the same staffing issues. Observation and record review on 9/11/20 at 1:55 pm of the Administrator's office revealed the facility had an abundance of PPE. Record review of the facility's tracking spreadsheet for PPE inventory on hand, not dated revealed the facility had the following PPE supplies on hand: 2,835 N95's, 990 gowns, 5150 face masks, 1000 face shields, 90 safety glasses, 1,512 KN95's, 8,150 small gloves, 5,000 medium gloves, 6,000 large gloves and 50 XL gloves. Record review of the facility's COVID policy, titled: Coronavirus Emergency Pandemic Policy Addendum dated 8/22/20 read in part . The center will be utilized - N95 (if possible)/KN95, eye protection, gloves, and isolation gown. Employees will be assigned to work the hall with probable/presumed or confirmed only. Minimize all employees from working across units or halls. Staff and residents perform appropriate hand hygiene before and after each activity. A face mask for source control does not replace the need to wear an N95 or higher-level respirator (or other PPE) when indicated, including when caring for patients with probable or confirmed COVID 19 . Record review of the facility's infection control policy titled: Infection Control - Standard Precautions dated 3/1/20 read in part . 1. Hand hygiene a. hand hygiene refers to handwashing with soap or the use of alcohol-based hand rub. B. hand hygiene is performed with alcohol-based hand rub (1) before and after contact with the resident. (3) after contact with items in the resident's room; and after removing PPE. After gloves are removed, wash hands immediately to avoid transfer of microorganisms to other residents or environments . These failures resulted in an Immediate Jeopardy (IJ). The facility Administrator, DON and ADON were notified of the IJ on 9/11/20 at 5:45 pm and a plan of removal (POR) was requested at that time. The IJ template was left with the Administrator. The POR was accepted on 9/11/2020 at 10:23 pm after one revision. The POR read in part: .Plan of Removal for Immediate Jeopardy: Identify responsible staff/what action taken: All staff working the quarantine hall that provide essential care. All staff are being in serviced on the required PPE (gown, N95, eye protection and gloves) to be worn on the quarantine hall. Who/which staff will monitor this and how often? Who will conduct the training and verify return demonstration? DON/designee will monitor the appropriate process for PPE is being followed on the quarantine hall. The monitoring will be completed daily by the DON/designee. The DON will initiate the in-service training 9/11/20. The facility will provide separate spaces to don (put on) and doff (take off) PPE when possible. Will post PPE required for quarantine on door/barrier going onto the quarantine hall. All staff are being in-service on the hand hygiene and went to wash hands/use hand sanitizer. This in-service was started will be initiated on 9/11/20 by the DON/designee. Who will verify competency to return demonstration? DON/designee will validate competency with handwashing via return demonstration. Facility will have designated staff for the quarantine hall unless required on another call hard to maintain adequate staffing . In service conducted: in-service was conducted by DON and Administrator on 9/11/20. The in-service is on infection control. The details of the in-service include: All staff are being in-serviced on the PPE required for quarantine residence. The following procedure will be followed: staff will don an N95 and eye protection will be worn on the quarantine hall throughout the shift, gown and gloves will be changed with each resident encounter. Hand hygiene will be performed prior to donning gown and exiting resident room. The in-service was attended by licensed nurses which include registered nurse license vocational nurse certified nursing assistance, certified medication aid, and licensed therapist which include physical therapist, occupational therapist and speech therapist, housekeeping, maintenance, activities. For licensed staff we are unavailable for training on this date, they will not be allowed to return to work until training is complete. This in-service will be started on 9/11/20. Monitoring: The Administrator/DON/ADON will be responsible for monitoring the implementation and effectiveness of in-service on 9/11/20. DON/designee will mentor that the appropriate process for PPE is being followed for quarantine hall. This monitoring will be completed daily by the DON/designee. The clinical nurse consultant will follow up. Administrator/DON/designee will monitor to ensure staff working the quarantine hall are [MEDICATION NAME] hand hygiene. Staff schedule will be monitored to ensure designated staff assigned to quarantine hall . Following acceptance of the facility's Plan of Removal, the facility was monitored from 9/12/20 to 9/13/20. Observation on 9/12/20 at 12:21 pm revealed the quarantine unit had a sign posted on the entry door that said, staff/employees only. The unit had one entry. The back of the unit had plastic sheeting that extended from the ceiling to the floor and walls. The signage provided written and visual instructions for donning and doffing PPE (gown, mask or respirator, goggles or face shield and gloves). Observation and interview on 9/12/20 at 12:25 pm revealed CNA B sitting in the dining area outside of the quarantine unit asleep with her head bowed down. Her surgical mask laid on her chin leaving her nose and mouth exposed. After a few minutes she woke up startled. She said she had been wearing said surgical mask all morning. She said she should have been wearing her N95 mask while working in the quarantine unit. She said she had just been trained on 9/11/20 for wearing proper PPE in the quarantine unit. She could not explain why she was not wearing an N95. She said she made a mistake. She said she knew the facility was amid an IJ because the DON had explained it in the in-service training she had yesterday. She said she felt very badly that she did not follow protocol. In an interview on 9/12/20 at 12:50 pm with Administrator, she said she in-serviced CNA's this morning. She said she had them do a return demonstration for donning and doffing PPE (gowns, N95, goggles or face shield and gloves). She said she in-serviced staff for proper hand hygiene as well. In an interview on 9/12/20 at 12:55 pm with DON, he said he was going to in-service CNA B again same day. He said she knew better. He said CNA B had just been in-serviced on proper PPE (gowns, N95, goggles or face shield and gloves). He said he made her do a return demonstration. He said, I just don't understand. In an interview on 9/12/20 at 1:05 pm with CNA F, she said she was trained to don and doff PPE. She said she was supposed to put gown, N95 mask, goggles and gloves on when entering resident's rooms in the quarantine unit. She said she was supposed to wash her hands before and after resident care. She said, preferably wash hands. She said she was supposed to wash hands and don new gloves when changing tasks while providing resident care. She said she was supposed to wash and scrub her hands for at least 20 seconds. She said the DON made her do a return demonstration of donning and doffing PPE and proper hand washing. In an interview on 9/12/20 at 1:15 pm with CNA G, he said the Administrator in-serviced him for donning and doffing PPE. He said she made him do a return demonstration. He said he was supposed to put gown first, N95, goggles and gloves. He said the gloves had to be cuffed over the gown. He said when doffing, he was supposed to remove gloves, goggles, gown and then mask. He said he was supposed to throw them in the red biohazard bag prior to leaving resident's rooms. He said he was supposed to wash his hands for at least 20 seconds before and after donning PPE. Observation and interview on 9/13/20 at 4:00 p.m. with Activity Director revealed her sitting in the quarantine unit's hallway wearing an N95. She said she just needed to wear an N95 outside of resident's rooms. She said she was in-serviced on 9/11/20 by the DON and Administrator for donning and doffing PPE and proper hand washing. She said she was supposed to wash her hands prior to entering resident's rooms. She said she was supposed to don PPE (gown, N95, face shield and gloves). She said before leaving the room, she was supposed to doff gown, face shield and gloves. She said she was supposed to throw the gown and gloves in the red biohazard bag and sanitize the face shield after each use and place it in a plastic bag. She said she was supposed to wash her hands prior to leaving resident's rooms. Observation and interview on 9/13/20 at 5:50 pm with Cook B revealed him knocking on the quarantine unit's entry door. He did not go into the unit. He was wearing a hair and beard restraint. He said his dietary manager trained him and told him he was not supposed to enter the quarantine unit. He said she told him to knock and have the staff roll the cart into the quarantine unit when he delivered resident's meal trays. Observation and interview on 9/13/20 at 5:51 pm with Activity Director revealed meals were served on Styrofoam plates and plastic utensils were provided to the residents in the quarantine unit. She said all meals delivered to the quarantine unit were served on Styrofoam plates along with plastic utensils. Observation on 9/13/20 at 5:52 pm revealed Activity Director washing her hands. She turned the faucet on, grabbed soap, scrubbed hands for 20 seconds, rinsed, dried hands with paper towel and turned off the faucet with paper towel. She donned gown. She was already wearing N95 mask. She put her face shield on and donned gloves. She entered Resident #3's room to deliver and set up dinner tray. He was watching TV covered and tucked in his blanket. She set the resident's tray on his rolling table. She doffed her gown, removed face shield and gloves. She threw gown and gloves in the red biohazard bag by the resident's door. She washed her hands prior to leaving the resident's room. She sanitized her face shield and place it in a plastic bag. She washed her hands again. She washed them properly. Observation and interview on 9/13/20 at 5:59 pm revealed Activity Director properly washing her hands to encounter Resident #2. She She donned a gown. She was already wearing N95 mask. She put on her face shield and gloves. She said Resident #2 ate independently. She rang Resident #2 door bell. She entered Resident #2's room to deliver and set up dinner tray on his rolling table. She raised Resident #2's bed upright. Resident #2 asked her to raise the bed higher. The Activity Director attempted to raise the bed higher but, the bed would only go to about a 45-degree angle. She told Resident #2 that the bed would not go any higher and she would report it to maintenance, so they could fix it. She used pillows to help Resident #2 sit up to a 90-degree angle, so he could eat with aspirating. She doffed gown, removed face shield and gloves. She threw gown and gloves in the red biohazard bag by the resident's door. She washed her hands prior to leaving the resident's room. She sanitized her face shield and placed it in a plastic bag. She washed her hands again. She washed her hands properly. Observation and interview on 9/13/20 at 6:05 pm revealed Activity Director properly washing her hands to encounter Resident #1. She donned a gown. She was already wearing N95 mask. She put on her face shield and gloves. She said Resident #1 required one-person assistance with eating. She assisted the resident. She doffed gown, removed face shield and gloves. She threw gown and gloves in the red biohazard bag by the resident's door. She washed her hands prior to leaving the resident's room. She sanitized her face shield and placed it in a plastic bag. She washed her hands again. She washed her hands properly. She said the DON was monitoring the quarantine unit about every hour to one and a half hours throughout the day. Observation on 9/13/20 at 6:15 revealed LVN B enter the quarantine unit. She was already wearing an N95 mask. She washed her hands. She turned the faucet on, grabbed soap, scrubbed hands for 20 seconds, rinsed, dried hands with paper towel and turned off the faucet with paper towel. She donned a gown. She put on her face shield and gloves. She entered Resident #1's room accompanied by the Activity Director. The Activity Director washed her hands to accompany LVN B. She turned the faucet on, grabbed soap, scrubbed hands for 20 seconds, rinsed, dried hands with paper towel and turned off the faucet with paper towel. She donned a gown. She was already wearing N95 mask. She put on her face shield and gloves. LVN B asked Resident #1 if he wanted to eat. He declined twice. She offered him pudding and he agreed to eat pudding. LVN B fed him the pudding. He ate about three quarters of the serving. The Activity Director was on the opposite side of the bed across from LVN B. In-between LVN B feeding Resident #1 pudding, the Activity Director was encouraging him to drink the shake. Resident #1 finished the shake with a lot of prompting and encouragement. LVN B, doffed gown, face shield and gloves. She threw gown and gloves in the red biohazard bag. She sanitized her face shield. LVN B washed her hands prior to exiting Resident #1's room. The Activity Director waited her turn maintaining social distancing. She doffed gown, face shield and gloves. She threw gown and gloves in the red biohazard bag. She washed her hands prior to exiting Resident #1's room. She sanitized her face shield and placed it in a plastic bag. She washed her hands again. In a follow-up interview on 9/13/20 at 7:00 pm with CNA B, she said the DON re-trained her on the same day she made the mistake to not wear proper PPE and for forgetting to wash her hands before she donned gloves to encounter residents in quarantine. She said she was required to do a return demonstration so that she could demonstrate competency. She said she knew now that she was supposed to wash her hands, don gown, N95 mask, face shield and gloves). She said the gloves were supposed to be cuffed over the gown. She said after providing care, she was supposed to doff PPE at the door. She said she was supposed to doff gown, face shield, gloves and the last thing was to wash her hands prior to exit. She said she was supposed to throw away the gown and gloves in the red biohazard bag by the door. She said she was disciplined for not wearing her mask properly. Record review of CNA B's in-service record titled: Personal Protective Equipment (PPE) Audit Tool dated 9/12/20 read in part . Identify and gather the proper PPE to don. Perform hand hygiene. Put on isolation gown. Put on NIOSH-approved N95. Put on face shield or goggles. Put on gloves. Doffing: remove gloves. Remove gown. Perform hand hygiene. Remove face shield or goggles. Remove and discard respirator (or facemask). Perform hand hygiene after removing the respirator/face mask . Record review of CNA B's disciplinary action form dated 9/12/20 read in part . failure to comply with PPE protocol . Record review of CNA B's in-service record dated 9/12/20 read in part . Objectives of the in-service: PPE, handwashing/wearing gloves and leaving unit unattended. CNA must stay on the unit; all other times must wear N95 mask always. Must don/doff PPE per guidelines . Record review of the facility's in-service record dated 9/11/20 read in part . Topic: Admission/Readmission QUARANTINE Hall. Wear PPE (gowns, gloves, mask, N95 (if possible)/KN95 and eye protection. Change gloves and gowns between every resident encounter. Eye goggle/face shields once disinfectant may be bagged and placed in the isolation cart. Eye goggles can be reused. Face shields will be discarded at the end of the shift (unless in crisis capacity and will be disinfected). N95 (if possible) are to be worn on quarantine hall. Hand hygiene will be performed prior to entering the isolation area/admission/readmission hall, lea(TRUNCATED)