Every finding on record at Cedar Creek Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for food and nutrition services. The facility failed to ensure food items were sealed and properly dated in the refrigerator and the pantry. These failures could place residents at risk for food borne illness. Findings included: During an observation on 05/29/2026 at 10:15 AM revealed in the kitchen's standing refrigerator had an opened bag of cut lettuce tied shut, not dated when it was opened, half of a watermelon wrapped in plastic wrap not dated when sliced open, and half a package of sliced ham open to air not sealed or dated with open date. During an observation and interview on 05/29/2026 at 10:18 AM revealed a box of partially used muffin mix was observed to be open and was not closed/sealed and was open to air. The Dietary Supervisor stated the box of muffin mix should have been placed in a zip top bag and dated. He further stated the dating of the bag was so it would be known when the box had been opened to ensure the quality, however they did follow the best if used by date. The Dietary Supervisor stated by placing the box in a zip top bag would prevent cross contamination and the risk of it attracting unwanted pests. During an interview on 05/29/2026 at 10:22 AM the Dietary Supervisor stated the lettuce bag and the half watermelon in refrigerator should have been dated. He further stated they had the watermelon and made salads 2 days prior. The Dietary Supervisor stated he would have preferred the bag of lettuce to be placed in a zip top bag instead of having been tied off. The Dietary Supervisor stated by dating items and sealing them it was part of quality control. During an observation and interview on 05/29/2026 at 10:25 AM [NAME] A was observed making ham sandwiches with the package of ham from the refrigerator. [NAME] A stated the ham should have been put in a zip top, closed and dated when it was opened so the staff would have known how old it was. [NAME] A further stated it could have possibly caused someone to get sick. During an interview on 05/29/2026 at 10:32 AM the Administrator stated items in the kitchen should be appropriately packed, sealed and dated. The Administrator further stated that was so staff would know when food was outdated and for it to be appropriately disposed of. Review of facility's policy, Food storage and Supplies, dated 2012, read, All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects. Procedure: 4. Open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination.

Based on observation, interview, and record review, the facility failed to ensure drugs used in the facility were labeled in accordance with currently accepted professional principles and the expiration date for 1 of 2 medication carts (short hall medication cart) reviewed for medication storage.The facility failed to ensure 3 insulin pens and 2 insulin vials were labeled with the expiration date and discarded within 28 days of opening.This failure could result in residents receiving expired insulin and lead to unstable or elevated blood sugar levels. Findings included: In an observation and interview on [DATE] at 10:47 AM with the ADON, the short hall medication cart was observed to contain the following:Novolog insulin (a medication used to manage blood sugar levels) pen dated [DATE]Open Lantus insulin vial, undatedUnopened Novolin insulin vial in the manufacturers box, undatedLantus insulin pen, undatedNovolog insulin pen, undatedThe ADON said all insulin containers should be dated for 28 days when they are removed from the refrigerator and opened, and she was unsure when the 5 insulin containers were removed from the refrigerator. She said it is the nurse's responsibility to maintain the contents of the carts, and the nurse who was responsible for the cart that day had left work early. She was unsure if the labeled date of [DATE] on the Novolog pen was the expiration date or the date the pen was opened. She said the potential harm to residents of not labeling insulin vials was receiving expired and/or ineffective insulin. In an interview with the DON on [DATE] at 2:50 PM, she said all insulin containers should be labeled with the date of expiration by the nurse as soon as they are removed from the refrigerator. She was unsure why the cart contained inaccurately labeled insulin pens/vials. She said the potential harm to residents was receiving ineffective insulin. Record review of the facility policy titled Insulin Pen Use dated 2003/ revised [DATE], reflected the following:Once you take the insulin pen out of cool storage you can use it for up to 28 days. Ensure that the pen is dated when placed into use . Do not use it after this time. Do not use the insulin after the expiration date printed on the label of the pen or on the carton .

Based on observation, interview, and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for 2 of 8 residents (Resident #6 and Resident #40) reviewed for clinical records.The facility failed to ensure Resident #6's medical diagnoses report, MDS Assessment, and Care Plan were accurately and completely documented with diagnosis of schizoaffective disorder and bipolar disorder.The facility failed to ensure the EMR contained a complete and accurate MPOA with Resident #40's signature along with a signed admission Agreement. And did not document Resident #40's progress notes with behaviors and statements made during her residence at Nursing Facility A.These failures could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records. Findings included:1. Record review of Resident #6's admission Record, dated 05/07/2026, revealed a [AGE] year-old male admitted [DATE] and re-admitted [DATE]. Resident #40 was listed as his own Responsible Party.Record review of Resident #6's Medical Diagnoses, undated and accessed 05/07/2026 at 3:14 p.m., revealed diagnoses including major depressive disorder (serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), recurrent, severe with psychotic symptoms and schizoaffective disorder (rare mental illness that affects how a person thinks, feels, and behaves).Record review of Resident #6's admission MDS assessment, dated 04/02/2026 and signed 04/03/2026 as completed, reflected a BIMS score of 13 indicating cognition intact. Resident #6 was documented as having not exhibited any behavioral symptoms and having active diagnoses of Depression and taking antipsychotic and antidepressant medications. Resident #6's functional abilities were documented as requiring supervision or touching assistance to set up or clean-up assistance He was noted to have a history of schizophrenia (chronic mental health condition that can significantly impair daily functioning and quality of life) and bipolar disorder (mental health condition characterized by significant mood swings) not documented as an active diagnosis.Record review of Resident #6's care plan, undated, revealed Resident #6 interventions documented psych services to evaluate and treat as needed. The care plan intervention was initiated on 04/22/2026. Care plan did not document diagnoses of bipolar (mental health condition characterized by significant mood swings) or schizoaffective disorder (mental health condition that typically can affect many different aspects of day-to-day life).Record review of Resident #6's EMR Diagnosis tab on 05/08/2026 did not reveal documentation of bipolar disorder.Record review of Resident #6's PL 1 Screening, dated 03/31/2026, revealed PASRR Level 1 Screening was coded No for Mental Illness and he was noted to have a Mental Illness but documented as not having one.Record review of Resident #6's EMR Misc Tab on 05/08/2026 did not reveal documentation of submission of Form 1012 (A determination that a resident with a negative PL1 screening form submitted into the LTC Portal needs further evaluation for MI).Record review of Resident #6's Psychiatry Initial Evaluation, dated 04/29/2026, revealed Psych History. History of schizophrenia and bipolar disorder (schizoaffective disorder, depressive type) per hospital records and previous collateral review.During an observation and interview of Resident #6 on 05/05/2026 at 11:34 a.m., he was noted to be standing near the doorway to his room, he was dressed well, groomed appropriately, no odors. He stated that he ate breakfast, he had been a resident at Nursing Facility A for a few weeks, he did not want to go to activities today as he felt funky and stated he could not describe this feeling. He stated the care was okay and stated he did not want to talk anymore and closed his room door. Interview ended with Surveyor. 2. Record review of Resident #40's admission Record, dated 05/07/2026, revealed a [AGE] year-old female admitted [DATE] and discharged home on 01/302026. Resident #40 was not listed as her own Responsible Party with her [Family Member B] listed as Responsible Party, POA-Medical, and Emergency Contact #1.Record review of Resident #40's Medical Diagnoses, undated and accessed 05/06/2026 at 12:28 p.m., revealed diagnoses including traumatic subdural hemorrhage (a collection of blood that forms between the brain and its outer covering, often due to head trauma) with loss of consciousness of 1 hour to 5 hours 59 minutes and Alzheimer's disease with late onset (characterized by progressive memory loss, cognitive decline, and changes in behavior). Record review of Resident #40's quarterly MDS assessment, dated 11/27/2025 and signed 12/01/2025 as completed, reflected a BIMS score of 06 indicating severe cognitive impairment.Record review of Resident #40's care plan, undated, revealed Resident #40 was resistive to care r/t [related to] wanting to go Home with (Family Member D) and Goal documented that Resident #40 will cooperate with care through next review date with interventions of Allow resident [Resident #40] to make decisions about treatment regime, to provide sense of control. The care plan focus was created and initiated on 11/10/2025 and revised on 12/26/2025. The care plan did not reveal discharge plans for Resident #40 once she stabilized and was able to make her needs and wants known.Record review of Resident #40's EMR Misc tab on 05/08/2026 did not reveal a valid MPOA document signed by Resident #40 with signature acknowledged before a notary public giving Family Member B the authority to make any and all health care decisions for her. Record review of Resident #40's EMR Physician progress notes tab on 05/08/2026 did not reveal physician certification that Resident #40 lacked the competence to make health care decisions for herself.Record review of Resident #40's EMR Documentation tab on 05/08/2026 did not reveal documentation signed by Resident #40 authorizing Family Member B as their legal guardian or an agent under a medical power of attorney.Record review of Resident #40's progress note, Administrator Note, dated 01/30/2026, revealed Residents [Resident #40] [Family Member B] has MPOA and he did not agree with resident [Resident #40] discharging home with [Family Member D] however, resident [Resident #40] insisted that she wanted to go home to her house and have her Family Member D help with her care. [Family Member D] called [Local Law Enforcement] and they arrived to [Nursing Facility A] and explained this was a civil matter and the MPOA documents clearly state [Family Member B] can make decisions for resident [Resident #40] only if she is deemed incompetent by a physicianRecord review of Resident #40's admission Agreement. dated 11/06/2025, revealed that Family Member B was documented as the Responsible Party for this agreement and enters into this admission and Financial Agreement with [Nursing Facility A] to provide care for [Resident #40] under the terms and conditions set forth below. If Resident Is Not Own Responsible Party, Resident Authorizes the below to be their agent. Responsible Party Name: [Family Member B]. Responsible Party here in is: (x all that apply).Durable Power of Attorney/Attorney in fact for Resident [Resident #40] was selected for Authority Resident authorizes Responsible Party to make: Financial Decisions. Medical decisions [Nursing Facility A] has been provided with a durable power of attorney, advance directive or other appropriate instrument). Admission, care, and discharge decisions. Other decisions related to Resident's [Resident #40] personal property and well-being. Primary contact person for this Resident [Resident #40] and signed by only Family Member B and Business Office Manager C.Record review of Resident #40's clinical Rehabilitation Notes dated 11/01/2025, revealed Resident #40's Orientation: A&O x4 (indicates a fully intact cognitive function).Record review of Resident #40's Medical Power of Attorney Designation of Health Care Agent (MPOA), dated 08/25/2025, revealed Disclosure Statement. Before Signing This Document, You Should Know These Important Facts:Except to the extent you state otherwise, this document gives the person you name as your agent the authority to make any and all health care decisions for you in accordance with your wishes.when you are unable to make the decisions for yourself. Your agent's authority is effective when your doctor certifies that you lack the competence to make health care decisions for yourself. Your agent's authority is effective when your doctor certifies that you lack the competence to make health care decisions. Once you have signed this document, you have the right to make health care decisions for yourself as long as you are able to make those decisions. This Power of Attorney Is Not Valid Unless: (1) You sign It And Have Your Signature Acknowledged Before A Notary Public; Or (2) You Sign It In The Presence Of Two Competent Adult Witnesses. Signature Acknowledged Before Notary was that of Family Member B and not of Resident #40. Resident #40 was unavailable for observation or interview as she was discharged home on [DATE].During a telephone interview on 05/05/2026 at 1:00 p.m., the Complainant revealed that Resident #40 was able to express her needs and wants and Nursing Facility A did not have a valid MPOA/POA signed by Resident #40 and she did not designate a Responsible Party to make decisions on her behalf.During an interview on 05/08/2026 at 10:22 a.m., the Activities Director stated Resident #40 engaged in numerous activities, enjoyed participating, verbalizing her needs and wants and her cognition was intact. She stated Resident #40 seemed sad at times and she would talk about missing Family Member D back home. She stated she would report Resident #40's demeanor and statements to the Director of Nursing and Social Services for follow-up and does not recall if this information was documented in the residents' EMR.During an interview on 05/08/2026 at 10:25 a.m., LVN F revealed that there was a big dispute between Resident #40 and her Family Member B regarding him being her Responsible Party. She stated that she did not know all the facts, but that the MDS Coordinator and the Assistant Director of Nursing discovered the guardianship paperwork for Resident #40 was not valid.During an interview on 05/08/2026 at 10:37 a.m., Assistant Director of Nursing revealed that Family Member B noted he had MPOA over Resident #40, but after she looked over her electronic medical record, she did not recall documentation to support valid MPOA. During an observation and interview on 05/08/2026 at 10:50 a.m., the MDS Coordinator revealed that Resident #40 could express needs and wants clearly, and would tell her directly of returning home with Family Member D. The MDS Coordinator was observed to review Resident #40's MPOA to identify valid Responsible Party documentation and stated the MPOA was not signed by Resident #40. She stated that after reviewing the MPOA that it would not be considered a valid MPOA and was inaccurate. The MDS Coordinator stated that she is responsible for ensuring medical diagnosis are reflected accurately on a resident's EMR and failure to update could result in residents not receiving the proper care. She noted that she did not review the prior clinicals for Resident #6 and this is an error on her part and Resident 6's medical diagnosis should have been updated to reflect bipolar disorder. She also noted that she is responsible for ensuring PASRR Level 1 Screenings are accurate when received. She stated that by not identifying an inaccurate PL 1 Screening can result in missed services for a resident. During an observation and interview on 05/08/2026 at 11:48 a.m. the Business Office Manager revealed that for a valid MPOA or POA the resident would need to sign it and this would allow family to speak on their behalf, make decisions on their behalf, and sign consents. The Business Office Manager was observed to review Resident #40's MPOA to identify valid Responsible Party documentation and stated it was not valid as it was not signed by Resident #40.During an observation and interview on 05/08/2026 at 11:49 a.m. the Administrator was observed to review Resident #40's MPOA to identify valid Responsible Party documentation provided at admission and stated she did not realize Resident #40 never signed it. She denied Resident #40 discussing discharge with her and noted upon admission the nursing staff had to lean on Family Member B as Resident was unable to make her needs and wants known. She stated that once Resident #40 stabilized she was coherent and she was able to make her wishes known. She noted discharge plans were discussed during the care plan meeting but stated the nursing staff did not document this in the EMR. The Administrator also noted that accuracy of records is necessary to reflect what is going on with a resident, accuracy is how care is provided and the impact on a resident could be that treatment could be missed.Record review of a facility policy titled, Documentation, undated, revealed .Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident and or soft resident file. It may include observations, investigations, and communications of the resident involving care and treatments. It has legal requirements regarding accuracy and completeness, legibility and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets (daily, weekly, monthly, discharge) . 1. The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. 2. The facility will ensure that information is comprehensive and timely and properly signed. [Procedure] 1. Place all required and appropriately signed forms in the clinical record. Items such as copies of advance directives, consent for treatment, consents for specific procedures. 2. Ensure that active diagnoses are transferred from hospital forms to the appropriate facility forms. 4. Document completed assessments in a timely manner and per policy.

Based on observation, interview, and record review, the facility failed to ensure preadmissions screening for individuals with a mental disorder and individuals with intellectual disability for 1 of 6 residents (Resident #6) reviewed for PASARR accuracy. The MDS Coordinator failed to accurately screen Resident #6 for mental illness upon admission to the facility. This failure could place residents at risk of not receiving the necessary care and services.Findings included:Record review of Resident #6's admission Record, dated 05/07/2026, revealed a [AGE] year-old male admitted [DATE] and re-admitted [DATE]. Resident #40 was listed as his own Responsible Party.Record review of Resident #6's Medical Diagnoses, undated and accessed 05/07/2026 at 3:14 p.m., revealed diagnoses including major depressive disorder (serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), recurrent, severe with psychotic symptoms and schizoaffective disorder (rare mental illness that affects how a person thinks, feels, and behaves).Record review of Resident #6's admission MDS assessment, dated 04/02/2026 and signed 04/03/2026 as completed, reflected a BIMS score of 13 indicating cognition intact. Resident #6 was documented as having not exhibited any behavioral symptoms and having active diagnoses of depression and taking antipsychotic and antidepressant medications. Resident #6's functional abilities were documented as requiring supervision or touching assistance to set up or clean-up assistance, He was noted to have a history of schizophrenia (chronic mental health condition that can significantly impair daily functioning and quality of life) and bipolar disorder (mental health condition characterized by significant mood swings) but was not documented as an active diagnosis.Record review of Resident #6's care plan, undated, revealed interventions documented psych services to evaluate and treat as needed. The care plan intervention was initiated on 04/22/2026. Care plan did not document diagnoses of bipolar or schizoaffective disorder.Record review of Resident #6's EMR Diagnosis tab on 05/08/2026 did not reveal documentation of bipolar disorder.Record review of Resident #6's EMR Misc Tab on 05/08/2026 did not reveal documentation of submission of Form 1012 (A determination that a resident with a negative PL1 screening form submitted into the LTC Portal needs further evaluation for MI).Record review of Resident #6's Psychiatry Initial Evaluation, dated 04/29/2026, revealed, Psych History. History of schizophrenia and bipolar disorder (schizoaffective disorder, depressive type) per hospital records.Record review of Resident #6's Psychiatry Initial Evaluation, dated 04/29/2026, revealed, Initial psychiatric evaluation for schizoaffective disorder insomnia anxiety. He has been a patient in this facility in the past. He has a history of schizoaffective disorder, depressive type, from previous admissions and previous collateral review. He does have some delusions and hallucinations but denies depression. He is being treated with fluoxetine 10 mg daily. He refuses other psychotropic medications at this time. Previously, [Resident #6] was last seen for psychiatric care approximately 10 months ago in June 2025. He has a documented history of schizoaffective disorder, depressive type, and major depressive disorder, recurrent. He had been hospitalized for suicidal ideation and depression. No current suicidal or homicidal ideation. Patient is not currently a danger to self or others. No self-harm behaviors.Psych History. History of schizophrenia and bipolar disorder (schizoaffective disorder, depressive type) per hospital records and previous collateral review. Currently experiencing delusions and hallucinations. Denies current depression or mania.Record review of Resident #6's PL 1 Screening, dated 03/31/2026, revealed PASRR Level 1 Screening was coded No for Mental Illness and he was noted to have a Mental Illness but documented as not having one.Record review of Resident #6's Psychiatry Follow-Up, dated 06/26/2025, revealed Patient seen for Comprehensive psychiatric evaluation for MDD, insomnia, anxiety and poor appetite.Review of hospital records indicate history of schizophrenia and bipolar (schizoaffective disorder) . Active Medical Problems MAJOR DEPRESSIVE DISORDER, RECURRENT, MILD SCHIZOAFFECTIVE DISORDER, DEPRESSIVE TYPE .MENTAL STATUS EXAM. Orientation: Oriented x4. Mood: Anxious, Depressed, Irritable Thought Content: Coherent, Paranoid, Auditory Hallucination, Visual Hallucinations. Assessment/Plan SCHIZOAFFECTIVE DISORDER DEPRESSIVE TYPE.Record review of Resident #6's Order Summary, dated 04/27/2026, revealed Secuado Transdermal Patch 24 Hour 3.8 MG/24HR (Asenapinee) Apply 1 patch transdermally one time a day for schizoaffective disorder, order/start date 4/17/2026, [PMHNP].During an observation and interview of Resident #6 on 05/05/2026 at 11:34 a.m., he was noted to be standing near the doorway to his room, he was dressed well, groomed appropriately, no odors. He stated that he ate breakfast, he had been a resident at Nursing Facility A for a few weeks, he did not want to go to activities today as he felt funky and stated he could not describe this feeling. He stated the care was okay and stated he did not want to talk anymore and closed his room door. Interview ended with Surveyor.During an interview on 05/08/2026 at 10:37 a.m., the Assistant Director of Nursing revealed that Resident #6 gets depressed, he was paranoid and therapy could be offered but does not know if he would benefit from therapy services as he does not like to engage in services.During an observation and interview on 05/08/2026 at 10:50 a.m., the MDS Coordinator revealed that she was responsible for ensuring PASRR Level 1 Screening wasaccurate when received. She stated that by not identifying an inaccurate PL 1 Screening when received could result in a full PASRR Evaluation not being conducted and residents may not receive services they may be eligible for. The MDS Coordinator noted that after reviewing Resident #6's 03/31/2026 PL 1 Screening she found that it was inaccurate and she would move to submit a new PL1 Screening and request for a PASRR Evaluation.Record review of policy titled, PASRR Level 1 Screen, date revised 3-6-2019, revealed, .PASRR is a federally mandated program requiring all states to pre screen all individuals seeking admission to a Medicaid-certified nursing facility, regardless of payor source or age. The PASRR Program is important because it provides options for individuals to choose where they live, who they live with and the training and therapy they need to live as independently as possible. PASRR Program has 3 Goals: 1. To identify individuals with Ml, ID, or DD/RC. 3. To ensure individuals receive the required services for their Ml, ID, or DD. [Procedure:] 3. The Facility will review the PL 1 Screening Form for completion and correctness prior to admission and submit the PL 1 form per regulations. If the individuals PE is positive the new PL 1 would remain positive and a new PE will be completed by the LA. An Interdisciplinary Team (IDT) meeting is required and Specialized Services (SS) must be reviewed. For positive Preadmissions only, the LA enters the PL 1 into the portal and this becomes the notification to complete the PE. Both the PL 1 and PE must be completed prior to Admission.Record review of document titled, Form 1012 Policy & Procedure with Instructions, undated, revealed, . Section C. Mental Illness (Ml) Indication. 1. Review the medical record for a diagnosis of Ml and indicate No or Yes for each Ml listed. Examples of Ml are: Schizophrenia. Mood Disorder (Bipolar Disorder, Major Depression or other mood disorder) . 5. The NF physician signs and dates Section C of the form attesting to the accuracy of the Ml diagnosis information . Section D. Nursing Facility Action - A new PL 1 is needed at this time. A full PASRR Evaluation will be conducted after the NF submits a new positive PL 1.Record review of policy titled, Documentation, undated, revealed .Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident and or soft resident file. It may include observations, investigations, and communications of the resident involving care and treatments. It has legal requirements regarding accuracy and completeness. 1. The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. 2. Ensure that active diagnoses are transferred from hospital forms to the appropriate facility forms. 4. Document completed assessments in a timely manner and per policy.

Based on interview and record review, the facility failed to ensure the development and implementation of an effective discharge planning process that focuses on the resident's discharge goals for 1 of 5 residents (Resident #40) reviewed for discharge planning.The facility failed to ensure Resident #40's discharge planning goals were reviewed and implemented once her health improved and she was able to make her discharge preferences known.This failure could result in loss of residents' autonomy and rights to determine care.The findings included:Record review of Resident #40's admission Record, dated 05/07/2026, revealed a [AGE] year-old female admitted [DATE] and discharged home on [DATE]. Resident #40 was not listed as her own Responsible Party with her [Family Member B] listed as Responsible Party, POA-Medical, and Emergency Contact #1.Record review of Resident #40's Medical Diagnoses, undated and accessed 05/06/2026 at 12:28 p.m., revealed diagnoses including traumatic subdural hemorrhage (a collection of blood that forms between the brain and its outer covering, often due to head trauma) with loss of consciousness of 1 hour to 5 hours 59 minutes and Alzheimer's disease with late onset (characterized by progressive memory loss, cognitive decline, and changes in behavior). Record review of Resident #40's quarterly MDS assessment, dated 11/27/2025 and signed 12/01/2025 as completed, reflected a BIMS score of 06 indicating severe cognitive impairment. Resident #40 was documented as not exhibited any behavioral symptoms, including wandering. Resident #40's functional abilities were documented requiring partial/moderate assistance to set up or clean-up assistance. Resident #40 was documented with active diagnoses including Non-Alzheimer's Dementia and Traumatic Brain Injury (TBI) and was documented as taking antipsychotic medication. Resident #40 was coded as unknown or uncertain of the possibility of leaving this facility and returning to live and receive services in the community with information source documented as Family.Record review of Resident #40's care plan, undated, revealed Resident #40 was resistive to care r/t [related to] wanting to go Home with (Family Member D) and Goal documented that Resident #40 will cooperate with care through next review date with interventions of Allow resident [Resident #40] to make decisions about treatment regime, to provide sense of control. The care plan focus was created and initiated on 11/10/2025 and revised on 12/26/2025. The care plan did not reveal discharge plans for Resident #40 once she stabilized and was able to make her needs and wants known. Record review of Resident #40's progress note, Administrator Note, dated 01/30/2026, revealed [Family Member D] came from out of state to visit resident. Family Member D contacted the Administrator stating that resident [Resident #40] wanted to discharge home with her and explained residents home was in North Carolina. [Family Member D] discussed with Admin [Administrator] that she had the flexibility and means to care for resident [Resident #40] and provide her 24/7 care at residents [Resident #40] home. Resident's [Resident #40] [Family Member B] MPOA, did not agree with resident [Resident #40] discharging home with [Family Member D] however, resident [Resident #40] insisted that she wanted to go home to her house and have her Family Member D help with her care. Admin [Administrator] encouraged [Family Member B] to have a conversation with [Family Member D] and he stated, We do not speak and I do not have anything to say to her. [Family Member D] called [Local Law Enforcement] and they arrived to [Nursing Facility A] and explained this was a civil matter and the MPOA documents clearly state [Family Member B] can make decisions for resident [Resident #40] only if she is deemed incompetent by a physician. [Local Law Enforcement] asked resident [Resident #40] what her wishes were and she stated, I want to go home to North Carolina with my [Family Member D] to my home. Due to no guardianship and resident rights, the physician was notified and resident was Dc'ed [discharged ] home with [Family Member D] at her request.Record review of Resident #40's admission Agreement. dated 11/06/2025, revealed that Family Member B was documented as the Responsible Party for this agreement and enters into this Admission.Agreement with [Nursing Facility A] to provide care for [Resident #40] under the terms and conditions set forth below. If Resident Is Not Own Responsible Party, Resident Authorizes the below to be their agent. Responsible Party Name: [Family Member B]. Responsible Party here in is: (x all that apply).Durable Power of Attorney/Attorney in fact for Resident [Resident #40]was selected for Authority Resident authorizes Responsible Party to make: Financial Decisions. Medical decisions [Nursing Facility A] has been provided with a durable power of attorney, advance directive or other appropriate instrument). Admission, care, and discharge decisions. Other decisions related to Resident's [Resident #40] personal property and well-being. Primary contact person for this Resident [Resident #40] and signed by only Family Member B and Business Office Manager.Record review of Resident #40's progress notes dated 01/05/2026 - 01/30/2025, revealed Resident #40's Cognitive skills for daily decision making: Organized daily routine and made safe decisions in familiar situations, but experienced some difficulty in decision making when faced with new tasks or situations. Makes self-understood: Difficulty communicating some words or finishing thoughts but is able if prompted or given time. Record review of Resident #40's Psychiatry Initial Evaluation, dated 11/12/2025, revealed Patient [Resident #40] seen for Comprehensive psychiatric evaluation for dementia, insomnia, and Resident #40's mental status exam documented Orientation: Oriented To Person, Oriented To Place, Oriented to Situation. Comprehension/Language: WNL (within normal limits) - Expressive/Receptive Language. Thought Content: Coherent. [and] Thought Process: Linear/Goal-Directed/Logical.Record review of Resident #40's clinical Rehabilitation Notes dated 11/01/2025, revealed Resident #40's Orientation: A&O x4 (indicates a fully intact cognitive function).Record review of Resident #40's Medical Power of Attorney Designation of Health Care Agent (MPOA), dated 08/25/2025, revealed Disclosure Statement. document gives the person you name as your agent the authority to make any and all health care decisions for you in accordance with your wishes.when you are unable to make the decisions for yourself. Your agent's authority is effective when your doctor certifies that you lack the competence to make health care decisions for yourself. This Power of Attorney Is Not Valid Unless: (1) You sign It And Have Your Signature Acknowledged Before A Notary Public. The signature acknowledged before notary was that of Family Member B and not of Resident #40. Record review of Resident #40's EMR Physician progress notes tab on 05/08/2026 did not reveal physician certification that Resident #40 lacked the competence to make health care decisions for herself.Record review of Resident #40's EMR Documentation tab on 05/08/2026 did not reveal documentation signed by Resident #40 authorizing Family Member B as their legal guardian or an agent under a medical power of attorney. Record review of Resident #40's EMR social service notes on 05/08/2026 did not reveal there was action taken by the facility's Social Worker [Social Services] to assist with honoring Resident #40's discharge wishes.Record review of Resident #40's EMR progress notes on 05/08/2026 did not reveal there was action to assist with honoring Resident #40's discharge wishes taken by the charge nurses, ADON, DON, or Administrator after they learned of Resident #40's wishes to discharge home to the care of Family Member D.Resident #40 was unavailable for observation or interview as she was discharged home on [DATE].During a telephone interview on 05/05/2026 at 1:00 p.m., the Complainant revealed Resident #40 was back home residing with Family Member D and was doing well since her discharge from Nursing Facility A. She noted that Resident #40 was receiving care at the facility; however, the concern was that Family Member B did not have a valid MPOA and Resident #40 did not authorize or designate a Responsible Party to make decisions on her behalf. She noted that Resident #40 was able to express her needs and wants and she was vocal about discharging and returning home with Family Member D.During an interview on 05/08/2026 at 9:29 a.m., CNA E revealed Resident #40's mood was depressed, she would refuse care and medications, and she did not like being at Nursing Facility A and was vocal about wanting to be back home with Family Member D. She stated CNAs reported to the charge Nurse each time Resident #40 expressed wanting to discharge home from Nursing Facility A. She noted Resident #40's behaviors would reduce following a telephone call with Family Member D. She noted the charge nurse was responsible for reporting Resident #40's behaviors and wishes to Social Services. She noted that Resident #40 could make her needs and wants known and over time, with therapy, her cognition improved. She noted all staff, including management, were aware of Resident #40's wishes of returning home with Family Member D.During an interview on 05/08/2026 at 9:39 a.m., Social Services revealed Resident #40 had symptoms of Parkinson's, an unsteady gait, and was confused when she admitted to Nursing Facility A. She noted Resident #40 was admitted into Nursing Facility A following a hospital discharge and was aggressive and paranoid. She noted there was an awkward situation between Family Member B and Family Member D. She noted she was informed by other staff throughout Resident #40's stay of her expressed wishes to return home with Family Member D. She noted Resident #40 was able to express her needs and wants and was able to verbalize her expressed wishes to discharge home with Family Member D. She stated she never spoke with Family Member D about Resident #40's expressed wishes to discharge back to the community as Family Member B was the primary contact for Resident #40. Social Services noted that Resident #40 would attend the care plan meetings; however, she could not recall if Resident #40's expressed wishes for discharge were discussed during this meeting or if this was documented in the discharge plan.During an interview on 05/08/2026 at 10:22 a.m., the Activities Director stated Resident #40 engaged in numerous activities, enjoyed participating, verbalizing her needs and wants and her cognition was intact. She stated Resident #40 seemed sad at times and she would talk about missing Family Member D back home. She stated she would report Resident #40's demeanor and statements to the Director of Nursing and Social Services for follow-up and does not recall if this information was documented in the residents' EMR.During an interview on 05/08/2026 at 10:25 a.m., LVN F revealed that that it required law enforcement to be contacted for Resident #40 to be discharged .During an interview on 05/08/2026 at 10:37 a.m., the Assistant Director of Nursing stated she provided the nursing staff with Resident Rights training and the impact of not allowing a resident to exercise their rights could affect their quality of life, their self-esteem, and make them feel bad. She stated she recalled Resident #40 required cuing at times, when she admitted she was very sad, she was irritated about being at Nursing Facility A, Family Member B was restricting contact with other family members. She stated Resident #40 was able to express her wants and needs, her cognition was intact, she could answer questions appropriately, and she would say she wanted to return home with Family Member D. She stated Resident #40 constantly verbalized returning home with Family Member D. She stated that Family Member B stated he had MPOA over Resident #40, but after she looked over her electronic medical record, she did not recall documentation to support valid MPOA; however, Resident #40 was not allowed to discharge. She stated that she could not recall when she reviewed Resident #40's electronic medical record and she did not document these findings.During an observation and interview on 05/08/2026 at 10:50 a.m., the MDS Coordinator revealed that the impact of not allowing a resident to exercise their rights could affect their mood, making them depressed and miserable wanting to leave. She stated she recalled Resident #40 admitted with verbal and physical aggression behaviors, she was distraught, she would cry often that she wanted to go home with Family Member D. She stated that Resident #40 could express needs and wants clearly, would tell her directly of returning home with Family Member D. She noted that she was forgetful at times, but she knew what she wanted. The MDS Coordinator stated that Resident #40 was not allowed to return home and from what she gathered, Family Member B who provided Nursing Facility A with MPOA was responsible for her discharge. The MDS Coordinator was observed to review Resident #40's MPOA to identify valid Responsible Party documentation and stated the MPOA was not signed by Resident #40. She stated that after reviewing the MPOA that it would not be considered a valid MPOA and was inaccurate.During an interview on 05/08/2026 at 11:30 a.m., the Director of Nursing revealed that she provided the nursing staff with resident rights training and there could be a negative impact on a resident if they were not allowed to exercise their rights. She noted that Resident #40 was able to make her needs and wants known, she did not believe her cognition was intact, she did not have physical or verbal aggression, she was not displaying depression. She stated on a few occasions she was overheard at the nurse's station talking to Family Member D by telephone and discussing wanting to live with her. She stated she went on leave for a few weeks following her admission and could not provide additional details of Resident #40.During an observation and interview on 05/08/2026 at 11:48 a.m. the Business Office Manager revealed that she transitioned into this role in February 2026 and she has completed resident rights training and that she was responsible for new admissions and reviewing Durable MPOA provided by family members. The Business Office Manager noted that by not verifying if legal guardianship paperwork was valid, it could prevent a resident from being able to make decisions about their care and could make them confused. The Business Office Manager was observed to review Resident #40's MPOA to identify valid Responsible Party documentation and stated it was not valid as it was not signed by Resident #40.During an observation and interview on 05/08/2026 at 11:49 a.m. the Administrator revealed that she provided the nursing staff with resident rights training and noted that not allowing a resident to exercise their rights could cause them mental anguish and a failure to thrive. The Administrator stated that she recalled Resident #40 was admitted with some verbal aggression, but when she was discharged , she was very balanced out. She noted that Resident #40 talked about returning home quite a bit. She stated Resident #40 had a valid MPOA in chart and Responsible Party was making decisions on her behalf. She noted that there was some confusion about the MPOA and law enforcement assisted with Resident #40's discharge. The Administrator was observed to review Resident #40's MPOA to identify valid Responsible Party documentation provided at admission and stated she did not realize Resident #40 never signed it. She denied Resident #40 discussing discharge with her and noted upon admission the nursing staff had to lean on Family Member B as Resident was unable to make her needs and wants known. She stated that once Resident #40 stabilized she was coherent and she was able to make her wishes known. She noted discharge plans were discussed during the care plan meeting but stated the nursing staff did not document this in the EMR.Record review of a facility policy titled, Discharge or Transfer, dated 02/12/2025, revealed .This facility may initiate transfers or discharges: B. The Transfer or discharge is appropriate because the resident's health has improved sufficiently. the facility will ensure the discharge planning process addresses each resident's discharge goals and needs.the medical record will show documentation of the basis for transfer or discharge.Discharge planning is the process of creating an individualized discharge care plan, which is part of the comprehensive care plan.and must Be developed by the interdisciplinary team and involve direct communication with the resident. Be re-evaluated regularly and updated when the resident's needs or goals change. Discharge planning must identify the discharge destination, and ensure it meets the resident's health and safety needs, as well as preferences.Record review of a facility policy titled, Resident Rights, undated, revealed . A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's Individuality. The facility must protect and promote the rights of the resident. 1. The facility must ensure that the resident can exercise his or her rights without interference. 2. The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. 3. In the case of a resident who has not been adjudged incompetent by the state court, the resident has the right to designate a representative, in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by state law. 5. The facility shall not extend the resident representative the right to make decisions on behalf of the resident beyond the extent required by the court or delegated by the resident, in accordance with applicable law. Record review of a facility document titled, Nursing Facility Resident's Rights, dated 09/01/2025, revealed, Residents of Texas nursing facilities have all the rights, bene ts, responsibilities, and privileges granted by the Constitution and laws of this state and the United States. They have the right to be free of interference. Freedom of Choice. Make your own choices regarding personal affairs, care, bene ts and services. Participation in Your Care. Participate in developing a plan of care, to refuse treatment. Transfers and Discharges. Discharge yourself from the facility unless you have been determined mentally incompetent.

Based on interview and record review, the facility failed to ensure the resident's right to formulate an advance directive for 1 (Resident #40) of 5 residents reviewed for resident rights.The facility failed to ensure a valid MPOA with Resident #40's signature acknowledged before a notary public was on file with Nursing Facility A prior to designating Family Member B as the Responsible Party.The facility failed to establish if Resident #40 wished to designate Family Member B as the Responsible Party at the time of her admission on [DATE] and thereafter when she was alert and oriented and able to make her wishes known.These failures could place residents at risk for a diminished quality of life, loss of dignity and loss of self-worth.Findings included: Record review of Resident #40's admission Record, dated 05/07/2026, revealed a [AGE] year-old female admitted [DATE] and discharged home on [DATE]. Resident #40 was not listed as her own Responsible Party with her [Family Member B] listed as Responsible Party, POA-Medical, and Emergency Contact #1.Record review of Resident #40's Medical Diagnoses, undated and accessed 05/06/2026 at 12:28 p.m., revealed diagnoses including traumatic subdural hemorrhage (a collection of blood that forms between the brain and its outer covering, often due to head trauma) with loss of consciousness of 1 hour to 5 hours 59 minutes and Alzheimer's disease with late onset (characterized by progressive memory loss, cognitive decline, and changes in behavior). Record review of Resident #40's quarterly MDS assessment, dated 11/27/2025 and signed 12/01/2025 as completed, reflected a BIMS score of 06 indicating severe cognitive impairment. Resident #40 was documented as not exhibited any behavioral symptoms, including wandering. Resident #40's functional abilities were documented requiring partial/moderate assistance to set up or clean-up assistance. Resident #40 was documented with active diagnoses including Non-Alzheimer's Dementia and Traumatic Brain Injury (TBI) and was documented as taking antipsychotic medication. Resident #40 was coded as unknown or uncertain of the possibility of leaving this facility and returning to live and receive services in the community with information source documented as Family.Record review of Resident #40's care plan, undated, revealed Resident #40 was resistive to care r/t [related to] wanting to go Home with (Family Member D) and Goal documented that Resident #40 will cooperate with care through next review date with interventions of Allow resident [Resident #40] to make decisions about treatment regime, to provide sense of control. The care plan focus was created and initiated on 11/10/2025 and revised on 12/26/2025. The care plan did not reveal discharge plans for Resident #40 once she stabilized and was able to make her needs and wants known. Record review of Resident #40's progress note, Administrator Note, dated 01/30/2026, revealed [Family Member D] came from out of state to visit resident. Family Member D contacted the Administrator stating that resident [Resident #40] wanted to discharge home with her and explained residents home was in North Carolina. [Family Member D] discussed with Admin [Administrator] that she had the flexibility and means to care for resident [Resident #40] and provide her 24/7 care at residents [Resident #40] home. Resident's [Resident #40] [Family Member B] MPOA, did not agree with resident [Resident #40] discharging home with [Family Member D] however, resident [Resident #40] insisted that she wanted to go home to her house and have her Family Member D help with her care. Admin [Administrator] encouraged [Family Member B] to have a conversation with [Family Member D]and he stated, We do not speak and I do not have anything to say to her. [Family Member D] called [Local Law Enforcement] and they arrived to [Nursing Facility A] and explained this was a civil matter and the MPOA documents clearly state [Family Member B] can make decisions for resident [Resident #40] only if she is deemed incompetent by a physician. [Local Law Enforcement] asked resident [Resident #40] what her wishes were and she stated, I want to go home to North Carolina with my [Family Member D]to my home. Due to no guardianship and resident rights, the physician was notified and resident was Dc'ed [discharged ] home with [Family Member D] at her request.Record review of Resident #40's admission Agreement. dated 11/06/2025, revealed that Family Member B was documented as the Responsible Party for this agreement and enters into this admission and Financial Agreement with [Nursing Facility A] to provide care for [Resident #40] under the terms and conditions set forth below. If Resident Is Not Own Responsible Party, Resident Authorizes the below to be their agent. Responsible Party Name: [Family Member B]. Responsible Party here in is: (x all that apply).Durable Power of Attorney/Attorney in fact for Resident [Resident #40]was selected for Authority Resident authorizes Responsible Party to make: Financial Decisions. Medical decisions ([Nursing Facility A] has been provided with a durable power of attorney, advance directive or other appropriate instrument). Admission, care, and discharge decisions. Other decisions related to Resident's [Resident #40] personal property and well-being. Primary contact person for this Resident [Resident #40] and signed by only Family Member B and Business Office Manager.Record review of Resident #40's progress notes dated 01/05/2026 - 01/30/2025, revealed Resident #40's Cognitive skills for daily decision making: Organized daily routine and made safe decisions in familiar situations, but experienced some difficulty in decision making when faced with new tasks or situations. Makes self-understood: Difficulty communicating some words or finishing thoughts but is able if prompted or given time. Record review of Resident #40's Psychiatry Initial Evaluation, dated 11/12/2025, revealed Patient [Resident #40] seen for Comprehensive psychiatric evaluation for dementia, insomnia, and Resident #40's mental status exam documented Orientation: Oriented To Person, Oriented To Place, Oriented to Situation. Comprehension/Language: WNL (within normal limits) - Expressive/Receptive Language. Thought Content: Coherent. [and] Thought Process: Linear/Goal-Directed/Logical.Record review of Resident #40's clinical Rehabilitation Notes dated 11/01/2025, revealed Resident #40's Orientation: A&O x4 (indicates a fully intact cognitive function).Record review of Resident #40's Medical Power of Attorney Designation of Health Care Agent (MPOA), dated 08/25/2025, revealed Disclosure Statement. Before Signing This Document, You Should Know These Important Facts: Except to the extent you state otherwise, this document gives the person you name as your agent the authority to make any and all health care decisions for you in accordance with your wishes.when you are unable to make the decisions for yourself. Your agent's authority is effective when your doctor certifies that you lack the competence to make health care decisions for yourself. Once you have signed this document, you have the right to make health care decisions for yourself as long as you are able to make those decisions. This Power of Attorney Is Not Valid Unless: (1) You sign It And Have Your Signature Acknowledged Before A Notary Public; Or (2) You Sign It In The Presence Of Two Competent Adult Witnesses. Signature Acknowledged Before Notary was that of Family Member B and not of Resident #40. Record review of Resident #40's EMR Misc tab on 05/08/2026 did not reveal a valid MPOA document signed by Resident #40 with signature acknowledged before a notary public giving Family Member B the authority to make any and all health care decisions for her.Record review of Resident #40's EMR Physician progress notes tab on 05/08/2026 did not reveal physician certification that Resident #40 lacked the competence to make health care decisions for herself.Record review of Resident #40's EMR Documentation tab on 05/08/2026 did not reveal documentation signed by Resident #40 authorizing Family Member B as their legal guardian or an agent under a medical power of attorney. Record review of Resident #40's EMR social service notes on 05/08/2026 did not reveal there was action taken by the facility's Social Worker [Social Services] to assist with honoring Resident #40's discharge wishes.Record review of Resident #40's EMR progress notes on 05/08/2026 did not reveal there was action to assist with honoring Resident #40's discharge wishes taken by the charge nurses, ADON, DON, or Administrator after they learned of Resident #40's wishes to discharge home to the care of Family Member D.During a telephone interview on 05/05/2026 at 1:00 p.m., the Complainant revealed Resident #40 was back home residing with Family Member D and was doing well since her discharge from Nursing Facility A. She noted that Resident #40 was receiving care at the facility; however, the concern was that Family Member B did not have a valid MPOA and Resident #40 did not authorize or designate a Responsible Party to make decisions on her behalf. She noted that Resident #40 was able to express her needs and wants and she was vocal about discharging and returning home with Family Member D.Resident #40 was unavailable for observation or interview as she was discharged home on [DATE].During an interview on 05/08/2026 at 9:29 a.m., CNA E revealed Resident #40's mood was depressed, she would refuse care and medications, and she did not like being at Nursing Facility A and was vocal about wanting to be back home with Family Member D. She stated CNAs reported to the charge Nurse each time Resident #40 expressed wanting to discharge home from Nursing Facility A. She noted Resident #40's behaviors would reduce following a telephone call with Family Member D. She noted the nurse charge was responsible for reporting Resident #40's behaviors and wishes to Social Services. She noted that Resident #40 could make her needs and wants known and over time, with therapy, her cognition improved. She noted all staff, including management, were aware of Resident #40's wishes of returning home with Family Member D.During an interview on 05/08/2026 at 9:39 a.m., Social Services revealed Resident #40 had symptoms of Parkinson's, an unsteady gait, and was confused when she admitted to Nursing Facility A. She noted Resident #40 was admitted into Nursing Facility A following a hospital discharge and was aggressive and paranoid. She noted there was an awkward situation between Family Member B and Family Member D. She noted she was informed by other staff throughout Resident #40's stay of her expressed wishes to return home with Family Member D. She stated there was no formal guardianship paperwork for Resident #40 and recalls notifying Family Member B that he would need to get legal guardianship paperwork as he did not have proper documentation and recommended that he would need Durable Power of Attorney. She noted Resident #40 was able to express her needs and wants and was able to verbalize her expressed wishes to discharge home with Family Member D. She stated she never spoke with Family Member D about Resident #40's expressed wishes to discharge back to the community as Family Member B was the primary contact for Resident #40. Social Services noted that Resident #40 would attend the care plan meetings; however, she could not recall if Resident #40's expressed wishes for discharge were discussed during this meeting or if this was documented in the discharge plan.During an interview on 05/08/2026 at 10:22 a.m., the Activities Director stated Resident #40 engaged in numerous activities, enjoyed participating, verbalizing her needs and wants and her cognition was intact. She stated Resident #40 seemed sad at times and she would talk about missing Family Member D back home. She stated she would report Resident #40's demeanor and statements to the Director of Nursing and Social Services for follow-up and does not recall if this information was documented in the resident's EMR.During an interview on 05/08/2026 at 10:25 a.m., LVN F revealed that Resident #40 was being provided with skilled services, she had dementia, she was always sweet, displayed no behaviors, and sometimes she did refuse medications. She stated there was a big dispute between Resident #40 and her Family Member B regarding him being her Responsible Party. She stated that she did not know all the facts, but that the MDS Coordinator and the Assistant Director of Nursing discovered the guardianship paperwork for Resident #40 was not valid. She stated that Family Member B would direct Nursing Facility A staff to not allow Resident #40 to have contact with Family Member D. She stated this direction was not followed as this was against Resident #40's rights. She stated that it required law enforcement to be contacted for Resident #40 to be discharged .During an interview on 05/08/2026 at 10:37 a.m., the Assistant Director of Nursing stated she provided the nursing staff with Resident Rights training and the impact of not allowing a resident to exercise their rights could affect their quality of life, their self-esteem, and make them feel bad. She stated she recalled Resident #40 required cuing at times, when she admitted she was very sad, she was irritated about being at Nursing Facility A, Family Member B was restricting contact with other family members. She stated Resident #40 was able to express her wants and needs, her cognition was intact, she could answer questions appropriately, and she would say she wanted to return home with Family Member D. She stated Resident #40 constantly verbalized returning home with Family Member D. She stated that Family Member B stated he had MPOA over Resident #40, but after she looked over her electronic medical record, she did not recall documentation to support valid MPOA; however, Resident #40 was not allowed to discharge. She stated that she could not recall when she reviewed Resident #40's electronic medical record and she did not document these findings.During an observation and interview on 05/08/2026 at 10:50 a.m., the MDS Coordinator revealed that the impact of not allowing a resident to exercise their rights could affect their mood, making them depressed and miserable wanting to leave. She stated she recalled Resident #40 admitted with verbal and physical aggression behaviors, she was distraught, she would cry often that she wanted to go home with Family Member D. She stated that Resident #40 could express needs and wants clearly, would tell her directly of returning home with Family Member D. She noted that she was forgetful at times, but she knew what she wanted. The MDS Coordinator stated that Resident #40 was not allowed to return home and from what she gathered, Family Member B who provided Nursing Facility A with MPOA was responsible for her discharge. The MDS Coordinator was observed to review Resident #40's MPOA to identify valid Responsible Party documentation and stated the MPOA was not signed by Resident #40. She stated that after reviewing the MPOA that it would not be considered a valid MPOA and was inaccurate.During an interview on 05/08/2026 at 11:30 a.m., the Director of Nursing revealed that she provided the nursing staff with resident rights training and there could be a negative impact on a resident if they were not allowed to exercise their rights. She noted that legal guardianship paperwork was reviewed by the Business Office Manager for accuracy and to determine if it was valid. She noted that Resident #40 was able to make her needs and wants known, she did not believe her cognition was intact, she did not have physical or verbal aggression, she was not displaying depression. She stated on a few occasions she was overheard at the nurse's station talking to Family Member D by telephone and discussing wanting to live with her. She stated she went on leave for a few weeks following her admission and could not provide additional details of Resident #40.During an observation and interview on 05/08/2026 at 11:48 a.m. the Business Office Manager revealed that she transitioned into this role in February 2026 and she has completed resident rights training and that she was responsible for new admissions and reviewing Durable MPOA provided by family members. She noted she was provided training by her corporate office on determining if Durable MPOA, POA, and legal guardianship documents were valid. She stated that for a valid MPOA or POA the resident would need to sign it and this would allow family to speak on their behalf, make decisions on their behalf, and sign consents. The Business Office Manager noted that by not verifying if legal guardianship paperwork was valid, it could prevent a resident from being able to make decisions about their care and could make them confused. The Business Office Manager was observed to review Resident #40's MPOA to identify valid Responsible Party documentation and stated it was not valid as it was not signed by Resident #40.During an observation and interview on 05/08/2026 at 11:49 a.m. the Administrator revealed that she provided the nursing staff with resident rights training and noted that not allowing a resident to exercise their rights could cause them mental anguish and a failure to thrive. She stated that legal guardianship/MPOA was collected within 24 hours of admission. She noted if residents could sign Nursing Facility A's admission documents, then they would sign themselves. She noted that the Business Office Manager and nursing staff were provided with all kinds of training and resources in identifying valid documentation. She noted that not verifying MPOA/guardianship paperwork was valid could negatively impact residents by not fulfilling a resident's wishes. The Administrator stated that she recalled Resident #40 was admitted with some verbal aggression, but when she was discharged , she was very balanced out. She noted that Resident #40 talked about returning home quite a bit. She stated Resident #40 had a valid MPOA in chart and Responsible Party was making decisions on her behalf. She noted that there was some confusion about the MPOA and law enforcement assisted with Resident #40's discharge. The Administrator was observed to review Resident #40's MPOA to identify valid Responsible Party documentation provided at admission and stated she did not realize Resident #40 never signed it. She denied Resident #40 discussing discharge with her and noted upon admission the nursing staff had to lean on Family Member B as Resident was unable to make her needs and wants known. She stated that once Resident #40 stabilized she was coherent and she was able to make her wishes known. She noted discharge plans were discussed during the care plan meeting but stated the nursing staff did not document this in the EMR.Record review of a facility policy titled, Resident Rights, undated, revealed . A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's Individuality. The facility must protect and promote the rights of the resident. 1. The facility must ensure that the resident can exercise his or her rights without interference. 2. The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. 3. In the case of a resident who has not been adjudged incompetent by the state court, the resident has the right to designate a representative, in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by state law. a. The resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the resident representative. 4. The facility must treat the decisions of a resident representative as the decisions of the resident to the extent required by the court or delegated by the resident, in accordance with applicable law. 5. The facility shall not extend the resident representative the right to make decisions on behalf of the resident beyond the extent required by the court or delegated by the resident, in accordance with applicable law. a. In the case of a resident representative whose decision-making authority is limited by State law or court appointment the resident retains the right to make those decision outside the representative's authority. b. The resident's wishes, and preferences must be considered in the exercise of rights by the representative. Record review of a facility document titled, Nursing Facility Resident's Rights, dated 09/01/2025, revealed, Residents of Texas nursing facilities have all the rights, bene ts, responsibilities, and privileges granted by the Constitution and laws of this state and the United States. They have the right to be free of interference, coercion, discrimination, and reprisal in exercising these rights as citizens of the United States.Freedom of Choice. Make your own choices regarding personal affairs, care, bene ts and services. Participation in Your Care. Participate in developing a plan of care, to refuse treatment, and to refuse to participate in experimental research. Transfers and Discharges. Discharge yourself from the facility unless you have been determined mentally incompetent. Record review of a facility document titled, admission Agreement, undated, revealed, OBLIGATIONS OF RESIDENT/RESPONSIBLE PARTY. Responsible Party means a person who:. b) has signed an admission agreement with the facility in which the person agrees to provide payment for the resident's care costs from the Resident's income or resources. c) Resident/Responsible Party shall: Abide by [Nursing Facility A] rules and regulations, as provided to Resident/Responsible Party upon admission. vii) Abide by rules and regulations established by licensing and contracting agencies as to charges, refunds, supplies, equipment, and medicine. ENTIRETY OF THIS AGREEMENT This Agreement, and all attachments, supersedes all other agreements, either oral or in writing, between the parties, and contains all the covenants and agreements between the parties. Resident/Responsible Party acknowledge that they have received and reviewed this agreement and the same shall be binding on Resident, Responsible Party, and Resident's heirs, executors and administrators. This Agreement may be amended only by agreement, reduced to writing and signed by both parties.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. The facility failed to document temperatures that were taken from: 12/12/25 to 12/18/25 for Breakfast, Lunch, and Dinner and 12/10/25 to 12/11/25 for Lunch and Dinner.2. The facility failed to label discard dates on containers of jalapeno peppers, ketchup, and tartar sauce.3. The facility failed to clean the air conditioner vent in the kitchen. 4. The facility failed to store raw protein food items below fully cooked foods in the freezer. These failures could place residents at risk for food borne illness. The findings included: 1. Record review of HACCP Production Sheet-All Dining Locations, dated 12/12/25 to 12/18/25 for Breakfast, Lunch, and Dinner and 12/10/25 to 12/11/25 for Lunch and Dinner, reflected no temperatures of foods were documented for the foods served to residents. Interview on 12/20/25 at 05:25PM, the CDM revealed there were a few days where the temperatures were missing from the temperature logs for foods prior to meal service. He revealed this was the cook's responsibility, but he oversaw this task and was not aware the temperatures were not being taken prior to meal service. 2., 3., 4. Interview and observation on 12/20/25 at 10:42 AM reflected there was a container of jalapenos in the refrigerator dated 12/9 with no discard date and ketchup and tartar sauce dated 12/12/25 with no discard date. The CDM revealed the cook (unnamed) oversaw labeling, but he was supposed to make sure this task was done. The CDM revealed he was looking to hire another cook, but he was taking over the cook position in the meantime. It was observed that the air conditioner vent above closed cereal containers had black substances on it. The CDM revealed this needed to be cleaned but he was not sure who oversaw this. He revealed he would find out and get this cleaned. The CDM further revealed he had not been able to catch up with the cook's duties. Interview on 12/20/25 at 05:25PM, the CDM revealed there was uncooked chicken stored above pizza dough and cookie dough and uncooked proteins should not be above fully cooked products. Interview on 12/21/25 at 10:37 AM, [NAME] A revealed she was trained to take temperatures before meal service to prevent food poisoning, but it helped to get re-educated to refresh her knowledge. She revealed she needed to ensure raw proteins were not stored on top of fully cooked food products, because the juices could leak onto fully cooked food products and cause food poisoning. She revealed foods needed to be labeled with discard dates because food could smell good, but it could be bad to serve to residents and cause food poisoning. She revealed kitchen areas needed to be clean to prevent cross contamination. She revealed cold food products needed to be less than 41 degrees Fahrenheit to prevent food poisoning. She further revealed she had been in-serviced on all of this but sometimes they get in-serviced as needed. Interview on 12/21/25 at 10:42 AM, the CDM revealed since the air conditioning vent was in the kitchen he could ensure this was clean to prevent cross contamination. He revealed to prevent food poisoning he would need to ensure all temperatures were within recommended temperature range per policy. He further revealed raw proteins needed to not be stored above fully cooked foods to prevent food poisoning and cross contamination. He revealed he would make sure discard dates were on his food products, but that staff knew to throw out food after 3 days or depending on what the food is. The CDM revealed he needed to in-service his staff on all these concerns as a refresher, but all his staff were already educated on this. Interview on 12/21/25 at 03:08 PM, the DON revealed there was no pattern for any gastrointestinal issues for residents in the facility's infection control surveillance in the last 6 months. Record review of facility's policy Cleaning Schedules, dated 2012, reflected The dietary department and all equipment in the dietary department will be cleaned on a regular scheduled basis. Record Review of facility's policy Daily Food Temperature Control, dated 2012, reflected Temperatures of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature Log. This is done to help ensure that food is safe and is served within acceptable ranges. Record Review of facility's policy Food Storage and Supplies, dated 2012, did not reflect dating food products with an expiration date as was reflected in the FDA Food Code 2022. Record Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. Record review of the FDA Food Code 2022 reflected, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3- 403.11(E) may be held at a temperature of 54 C (130 F) or above; or (2) At 5 C (41 F) or less. Record review of the FDA Food Code 2022 reflected, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. Open and hold cold (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and. Record review of the FDA Food Code 2022 reflected, 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (1) Except as specified in (1)(d) below or when combined as ingredients, separating raw animal FOODS during storage, preparation, holding, and display from:. (d) Frozen, commercially processed and packaged raw animal FOOD may be stored or displayed with or above frozen, commercially processed and packaged, ready-to-eat food.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for three (Resident #1, 3, 4) of eight residents reviewed for pharmaceutical services. 1. The facility failed to ensure that RN D documented that she administered Hydrocodone-Acetaminophen Oral Tablet to Resident #3 on Resident #3's Narcotic Sheet.2. The facility failed to ensure Resident #1's tramadol HCl Oral Tablet was documented as administered on 12/16/25 and 12/17/25 as was reflected on Resident #1's Narcotic Sheet. 3. The facility failed to ensure 1 dose of Resident #4's Lorazepam Oral Tablet was wasted when the blister pack was punctured instead of taping the blister pack. This failure could place the residents at risk for medication errors and drug diversion. The findings included: 1. Record review of Resident #3's admission record, dated 12/21/25, reflected resident was a [AGE] year-old female initially admitted [DATE] and re-admitted [DATE] with diagnoses to include dementia and chronic pain syndrome. Record review of Resident #3's quarterly MDS assessment, dated 10/30/25, reflected Resident #3 had a BIMS score of 11 out of 15, reflecting moderate cognitive impairment. It further reflected that resident experienced pain occasionally in the past 5 days with her pain intensity being 2 out of 10. Record review of Resident #3's Order Summary Report, dated 12/21/25, reflected resident's order summary included Hydrocodone-Acetaminophen Oral Tablet 10-325 MG. Give 1 table by mouth every 6 hours for Pain, with start date 10/15/25. Record review of Resident #3's December MAR, accessed 12/21/25, reflected RN D administered Hydrocodone-Acetaminophen Oral Tablet to Resident #3 on 12/21/25 at 5 AM. Record review of Resident #3's Narcotic Sheet reflected RN D did not document that she administered Hydrocodone-Acetaminophen Oral Tablet at 5 AM. Record review of Resident #3's care plan, undated, reflected Resident has a potential for uncontrolled paid due to chronic pain, initiated 02/20/25, with intervention Give pain medication as ordered by [doctor]., revised 01/31/24. Interview on 12/21/25 at 11:12 AM, RN B revealed she took over the medication cart after RN D's shift. She revealed during shift change they should have caught that Resident #3's narcotic sheet was not updated to reflect that Resident #3 was given her 5AM dose and that the number on the narcotic sheet did not match the number of narcotics in the medication cart. She revealed the narcotic counts on the resident's count sheet needed to be the same as the amount in the medication cart. Interview 12/21/25 at 12:01 PM, RN D revealed she may not have filled out that she administered Hydrocodone to Resident #3 at 5 AM on the narcotic count sheet because sometimes she got too busy to document before she left the facility, but she did reveal that Resident #3 was given her 5AM dose of Hydrocodone. She revealed the number on the narcotic count sheet should match the number of narcotics in the medication cart during shift change, so that narcotics were accounted for. Interview on 12/21/25 at 02:05 PM, Resident #3 revealed she received her pain medication at 5 AM. She revealed she got her medication on time, and her pain was managed appropriately by the facility with no concerns. 2. Record review of Resident #1's admission record, dated 12/21/25, reflected resident was a [AGE] year-old female admitted [DATE] with diagnoses to include pain, chronic obstructive pulmonary disease (lung condition caused by damage to the lungs), malignant neoplasm (a cancerous tumor) of right female breast, secondary malignant neoplasm of right lung, and malignant neoplasm of upper lobe, left bronchus or lung. Record review of Resident #1's quarterly MDS assessment, dated 12/02/25, reflected Resident #1 had a BIMS score of 12 out of 15, reflecting moderate cognitive impairment. It further reflected that resident experienced pain frequently in the past 5 days with her pain intensity being a 4 out of 10. Record review of Resident #1's Order Summary Report, dated 12/20/25, reflected resident's order summary included tramadol HCl Oral Tablet 50 MG. Give 1 tablet by mouth every evening shift related to chronic obstructive pulmonary disease, with start dated 12/05/25, and tramadol HCl Oral Tablet 50 MG. Give 50 MG by mouth every 6 hours as needed for Pain Record review of Resident #1's care plan, undated, reflected Resident requires hospice as evidenced by terminal illness: Malignant Neoplasm of Right breast, Secondary malignant Neoplasm of Right Lung and Malignant Neoplasm of upper lobe, left Bronchus or lung, initiated 12/05/25, with intervention 1. Monitor for [signs and symptoms] of increased pain, discomfort-give meds/tx. monitor for relief, revised 12/11/25. Record review of Resident #1's December MAR (accessed 12/20/25) when compared to Resident #1's narcotic sheet reflected tramadol HCl Oral Tablet 50 MG was administered on 12/16/25 at 8AM and 12/17/25 at 8AM on her narcotic sheet by LVN C, but was not reflected in her December MAR. Interview on 12/21/25 at 12:59 PM, LVN C revealed she forgot to document medications given in a residents' MAR. LVN C was unable to confirm blanks in Resident #1's MAR as she did not have access to Resident #1's medical record. LVN C revealed she sometimes will write down that she gave medication but did not get to document in MAR as the facility's workload got busy at times. LVN C further revealed it was important to document residents' administration records to keep track of what medication was administered, what time a medication was last given, and to not overdo any medication. 3. Record review of Resident #4's admission record, dated 12/21/25, reflected resident was an [AGE] year-old male admitted [DATE] with diagnoses to include anxiety disorder. Record review of Resident #4's annual MDS assessment, dated 12/05/25, reflected Resident #4 had a BIMS score of 6 out of 15, reflecting severe cognitive impairment. Record review of Resident #4's Order Summary Report, dated 12/21/25, reflected resident's order summary did not include Lorazepam. Record review of Resident #4's December MAR, dated 12/21/25, reflected Resident #4 stopped taking Lorazepam Oral tablet 0.5 MG. Give 1 tablet by mouth every 12 hours as needed for anxiety for 14 days. Record review of Resident #4's care plan, undated, reflected Resident has a mood problem r/t DX of Anxiety, initiated 07/22/25, with intervention Administer medications as ordered., dated 07/22/25. Record review and observation on 12/21/25 at 10:51 AM revealed Resident #4's blister pack covering the 30th tab of Lorazepam 1 MG was punctured with 1/2 tablet in the pack, but the blister pack was taped shut. It was revealed the order on the narcotic control sheet was: Take 1/2 tablet (0.5 MG) by mouth twice daily as needed for anxiety. It was further revealed that Resident #4's narcotic count sheet matched the number of narcotics in the medication cart and the blister pack in the medication cart was received on 10/03/25 and not used. Interview and observation on 12/21/25 at 11:12 AM, RN B revealed she was not sure if it was okay to tape a blister pack for narcotics after it was punctured. LVN E walked by this medication cart and revealed if the blister pack was punctured, they would not tape it shut as was observed with Resident #4's blister pack, but they would do a drug destruction because they did not want nurses to be taking these medications and it will also be considered taking the resident's money as the residents pay for these medications. LVN E further revealed they needed 2 nurses to witness and sign off when this happened. It was further observed that LVN E and RN B were wasting (disposing of) Lorazepam 0.5 MG tablet that was in the 30th slot of Resident #4's blister pack. Interview on 12/21/25 at 03:08 PM, the DON and ADM regarding Resident #1, the DON revealed it was important for nurses to update the residents' MARs so that nurses knew how much medication was given to residents to prevent over medication. Regarding Resident #3, the DON revealed the numbers on the residents' narcotics sheets needed to match the number of medications in the medication carts because controlled substances needed to be accounted for and she expected nurses to ensure these were updated before they leave after their shift. She further revealed nurses would be able to catch these discrepancies at shift change. Regarding Resident #4, the DON revealed blister packs for narcotics should not be taped. She revealed that if the blister pack was punctured, the narcotic should be wasted and witnessed by 2 nurses. The DON revealed this was important to ensure all narcotics were accounted for. Record review of facility's policy, Medication Administration and General Guidelines, dated 2025, reflected . 9. Except for single unit dose packet distribution systems, only the licensed or legally authorized personnel who prepare a medication may administer it. This person then records the administration on the residents MAR at the time the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ascertain that all necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications.Record review of facility's policy, Medication Storage in the Facility, dated 2025, reflected .13. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to the procedures for medication destruction, and reordered from the pharmacy, if a current order exists. (sp) Record review of facility's policy Medication Administration Procedures, dated 2003, reflected . If a controlled medication is wasted it must be documented on the controlled accountability sheet for the medication and witnessed by nurses. Both staff members must sign on the accountability sheet verifying the drug was wasted.

Based on observation, interviews, and record review, the facility failed to ensure the resident's right to secure and confidential personal and medical records for one (unknown resident) of 31 residents. The facility failed on 12/20/25 to ensure the privacy of unknown residents by not locking the laptop screen on medication cart (1 of 2), so the residents' information could not be seen and/or accessed by someone walking by. This failure puts residents at risk for confidential health information exposure, psychosocial harm and decreased quality of life. The findings included: Interview and observation on 12/20/25 at 01:12 PM, RN B left her computer screen on her medication cart unlocked and unsupervised with unknown resident information while entering a resident's room during medication pass. She revealed she was supposed to lock her screen for resident privacy. Interview on 12/21/25 at 03:08 PM, the ADM and DON revealed the laptop on the medication cart needed to be locked due to HIPAA and to protect resident's medical information. Record review of facility's policy RESIDENT RIGHTS, undated, reflected Privacy and confidentiality- The resident has a right to personal privacy and confidentiality of his or her personal and medical records. 3. The resident has a right to secure and confidential personal and medical records.

Based on observation, interview, and record review, the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 (Resident #1) of 1 resident reviewed, in that: The facility failed to maintain the temperature of Resident #1's personal refrigerator was at or below 41 degrees F 12/1/25 to 12/4/25 and was documented 12/5/25 to 12/19/25. This failure could place residents at risk of foodborne illness due to consuming foods which might be spoiled. The findings included:Record review of Resident #1's admission record, dated 12/21/25, reflected resident was a [AGE] year-old female admitted [DATE] with diagnoses to include constipation, protein-calorie malnutrition, and nausea. Record review of Resident #1's quarterly MDS assessment, dated 12/02/25, reflected Resident #1 had a BIMS score of 12 out of 15, reflecting moderate cognitive impairment. Interview and record review on 12/20/25 at 03:55 PM revealed Resident #1's Refrigerator Temperature log, dated December 2025, reflected temperatures on days 1 to 4 were 43 degrees Fahrenheit and temperatures for days 5 to 19 were not documented. Resident #1 revealed she had never gotten sick from her foods in her refrigerator. Interview on 12/20/25 at 05:20PM, the ADM and the CDM revealed the ADM instructed the ambassadors (persons in management that visited residents every morning and checked the temperatures of their refrigerators, about ensuring the residents' refrigerator temperatures should be 41 degrees Fahrenheit or less. They revealed the ambassadors will be doing a sweep on Monday of all the refrigerators to ensure all the refrigerators are within the appropriate temperature range. Record Review of facility's policy Personal Refrigerators Policy, dated 2012, reflected The refrigerator compartment should be maintained at a temperature of 35-41 degrees (Fahrenheit).

Based on observations, interviews, and record review the facility failed to ensure the drugs and biologicals used in the facility must be labeled and stored in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions and the expiration date when applicable for 1 of 8 residents (Resident #2). The facility failed to ensure RN B did not leave Resident #2's medications inside the resident's room for the resident to take unsupervised on 12/20/25. This deficient practice could affect residents who received medications for treatments and could result in less potent or an adverse effects and drug diversion. The findings included: Record review of Resident #2's admission Record, dated 12/21/25, reflected resident was a [AGE] year-old male initially admitted [DATE] and re-admitted [DATE] with diagnoses to include dementia (group of symptoms affecting memory, thinking, and social abilities, which interfere with daily life) and cortical age-related cataract (an area of the lens of the eye loses transparency). Record review of Resident #2's quarterly MDS assessment, dated 10/10/25, reflected Resident #2 had a BIMS score of 11 out of 15, reflecting moderate cognitive impairment. Record review of Resident #2's Order Summary Report, dated 12/21/25, reflected resident's order summary included Prolensa Opthalmic Solution 0.07% . Instill 1 drop in left eye one time a day for CATARACT SURGERY. With start date 12/08/25. Record review of Resident #2's care plan, undated, reflected Resident has impaired visual function, has DX of cataracts, resident wears glasses, initiated 05/29/24, with intervention to include Review medications for side effects which affect vision. PRN, revised 07/19/24. Interview and observation on 12/20/25 at 01:12 PM, RN B revealed Resident #2 had his prescribed eye drop medication at bedside. RN B revealed Resident #2 was not supposed to have his eye drops at bedside even though he may be able to administer them himself. RN B further revealed it could be possible that a resident could overdo their eye drops medication but this resident was aware so this would not happen. Interview on 12/21/25 at 03:08 PM, the DON and ADM revealed they were not aware if Resident #2 could self-administer his medications. (It was asked if they could find this care planned or if there was an assessment that he could self-administer his medications, but no records were identified.) The DON revealed if Resident #2 could not self-administer his medication, they needed to keep these medications on the medication carts and doctor's orders needed to be followed. Record review of facility's policy, Medication Administration and General Guidelines, dated 2025, reflected . 9. Except for single unit dose packet distribution systems, only the licensed or legally authorized personnel who prepare a medication may administer it. This person then records the administration on the residents MAR at the time the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ascertain that all necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications.

Based on observations, interviews, and record review, the facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for one of one kitchen. The facility failed to provide palatable food on the sampled foods on test tray: Green beans were cold Turkey was lukewarm Tater tots were overcooked, hard and had no soft potato inside This failure could place residents at risk of not being satisfied with their food or encouraged to increase their personal food intake with an outcome of weight loss and a diminished quality of life. The findings included: During the initial tour on 03/04/25 between 9:15 am and 11:30 am, Residents #11 and #24 complained about the food saying it was usually cold and lacked flavor. Resident #24 complained that the food was not restaurant quality. Confidential interviews during the Resident Meeting confirmed that the food was frequently cold and lacked taste. Several residents at this meeting noted that the meals were frequently late and often the trays sat on the hall in the carts for over 15 minutes before being handed out. The trays that go to the dining room were also delivered on a cart. One resident noted that the carts were the open type, so no insulation was provided for the plates other than the dome covers. During an observation of meal service on 03/06/25, the cook had to reheat several items of food to bring them up to the required temperature on the steam table. The last cart went out at 12:33 pm which was over an hour later than the scheduled meal service time. The cart was observed on the hall. The Administrator was observed checking each plate to ensure the correct diet was present, so the cover of the plate was removed and then placed back on the plate allowing heat to escape. A test tray had been requested for the lunch meal on 03/06/25 and had been placed on the observed cart and was delivered to the state survey room after the other trays had been delivered to the residents which was finished at 12:58 pm. The Dietary Supervisor and the Administrator were present when the food was tasted. The green beans were noted to be cold, and the turkey was lukewarm. The tater tots were noted by one state surveyor to be totally dried out and crumbled when touched with no soft potato inside. The Dietary Supervisor and the Administrator discussed ways they could improve the temperature of the food and stated they will work on this. The Administrator and Dietary Supervisor acknowledged residents could experience weight loss and a diminished quality of life if food was served cold and not palatable thereby making mealtime a less enjoyable experience. The policy titled Daily Food Temperature Control dated 2012 documented We will assure that food is served at a safe temperature. Temperatures of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature Log. This is done to help ensure that food is safe and is served within acceptable rages.

Based on interview and observation, the facility failed to ensure that residents had suitable, nourishing meals and snacks outside of scheduled meal service times. The facility failed to ensure residents were offered snacks at bedtimes. This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for, unplanned weight loss, and side effects from medication given without food, and diminished quality of life. Confidential interviews during the Resident Meeting on [DATE] revealed the facility did not offer snacks at bedtime unless the resident specifically asks for a certain snack. 3 of the 7 residents who attended the meeting and who were diabetic stated they did not receive any snacks with their names on them any time during the day to indicate they needed a snack due to diabetes. During an interview with the Dietary Supervisor (DS) on [DATE] at 12:59 pm, the DS stated they do provide snacks which are kept in the resident refrigerator located in the employee breakroom. The DS showed this refrigerator to the surveyor. Observation of the contents of the refrigerator revealed 1 sandwich with no date, 2 cups of milk dated [DATE], undated containers of what appeared to be mustard and ketchup, and a carton of sour cream with a Best By date of 10 [DATE]. There were also 6 bottles of salad dressing, a half jar of pickles and a plastic bottle of mustard with a resident's name on them along with several other items containing residents' names. The DS threw the undated sandwich and cups of milk away and stated he would have to check to see how long the sour cream should be kept past its Best By date. The refrigerator freezer at the top of the refrigerator had no door on the freezer and was noted to have a couple of inches of ice coating the bottom and sides of the freezer. The shelves of the refrigerator had white circles on them from previously stored foods. When asked who was responsible for cleaning the refrigerator and throwing out expired food, the DS stated he wasn't sure but assumed that since nursing passed out the food, they would be responsible. The DS stated he thought the Maintenance Director would be responsible for defrosting the freezer. An interview with the Maintenance Director on [DATE] at 1:11 pm revealed he thought that nursing was responsible for maintaining the refrigerator. During an interview with the Administrator on [DATE] at 1:12 pm, he stated that Housekeeping should be responsible for maintaining the refrigerator. The ADM stated they had new Housekeeping Supervisor as of [DATE] and would ensure he knew about the refrigerator. The ADM was also informed about the Resident Meeting concerns that snacks were not offered at night. The ADM stated that nursing was responsible for offering snacks but he was not aware of any snacks specifically labeled for diabetic residents or any type of list so staff would know who wanted and/or received a snack. During an interview on [DATE] at 5:30 pm, the DON stated that the nurses and CNAs pass the snacks. She stated that some would have names on them if they had been ordered by the physician. A couple of unidentified staff were present during this interview and stated they knew the residents so well, they really didn't need a list since some residents get the same snack every evening such as R #11 and R #28. On [DATE] at 8:12 am, an observation and interview with ADM revealed snacks in the resident refrigerator. There were several sandwiches and cups of yogurt with blueberries viewed in the refrigerator. The ADM stated the snacks are distributed per request but he would go ahead and offer diabetic residents the snacks but could not speak for what the nursing/CNA staff did. During an interview and observation with the DS on [DATE] at 8:16 am, the DS stated Yesterday I asked the new ADON to give me a list of all the diabetics that we have in the building and I do have two residents with weight loss. I have the list in the kitchen. Last night I had the staff make whole sandwiches for all the people on the list, saltine crackers, graham crackers and any extra desserts left from dinner. The residents who are being monitored for weight loss are Resident #3 and Resident #21. The list was provided to the surveyor and then the resident refrigerator was observed. Observation of this refrigerator revealed 12 sandwiches, 6 cups of desserts, and 3 cups of milk. Resident #11 was served her bowl of cereal and Resident #28 was served his peanut butter and jelly (PB and J) sandwich. The DS stated, The diets are liberalized so they all get the same snack except for Resident #11 who always asks for cereal and Resident #28 who always requests a PB and J sandwich. The DS stated that staff should be offering the snacks. The DS also stated that one of his dietary aides works as a C.N.A. on the ,d+[DATE] shift and she has said that most people on the list are already asleep early when snacks are being offered. The DS said he thought the best protocol would be to offer the snack and not just wait for the resident to ask. He also stated that once the snacks are delivered, dietary staff does not go back to see if the snacks were given out or check the refrigerator. The DS stated that Housekeeping was in charge of cleaning out the refrigerator. During an interview with DS on [DATE] at 9:20 am, the DS stated that he was aware the refrigerator was still full of sandwiches this morning. The DS stated they are going to make a check-off list to determine who is actually accepting the snacks. A policy on Cleaning the Refrigerator dated 2012 was provided that stated Refrigerators are maintained in a clean, sanitary condition free of offensive odors. Cleaning of the reach in refrigerator will be done on a daily or as needed basis. Procedure: Interior 1. Remove all leftover food from the shelves. Check with the Dietary Service Manager and sort out and throw away all that is not usable. Store food that will be saved in another refrigeration unit until refrigerator is cleaned and ready to be re-loaded. A policy for snacks was not provided.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. 1. The facility dietary staff failed to wash their hands between tasks and before handling food. 2. The cook used his bare hands, which had not been washed prior to meal service, take rolls from the cooking sheet pan and put them on the plates as he served lunch. These failures could place residents at risk for food borne illness. The findings included: 1. The lunch meal service was observed on 03/06/25 beginning at 11:15 am. The cook was observed taking the food temperatures using a different thermometer for each item of food. Some of the items were below the required temperature so he had to place them back in the oven. While he was waiting for items to reheat, he was observed writing some notes on some of the tickets, flipping through pages of information from a folder, gathering serving utensils and washing the thermometers with water to be used to test the temperatures again. At no time during this process, was he observed washing his hands. The evening cook (EC) who was serving as a dietary aide for lunch, was observed preparing dessert items to go on the trays and was covering bowls with plastic wrap. She moved about doing several tasks involving food preparation of the food trays without washing her hands. 2. During an observation on 03/06/25 at 12: 25 pm, the cook was observed taking a roll off the cooking sheet pan and placing it on the plate with his bare hands. An interview with the DS on 03/06/25 at 12:25 pm revealed the facility had a no-glove policy on the steam table. The DS stated the cook should have used tongs to pick up each roll rather than his bare hands. Record review of undated Dietary Department Glove Standard Protocol documented: 1. Per the Texas Food Establishment Rules, there will be no bare hand-to-food contact in the kitchen. Use of tongs, spoons, spatulas, or deli tissue paper will be used whenever possible to avoid touching a ready-to-eat food item with a bare hand. If a glove much be used, such as for sandwich assembly, hands will be washed prior to putting on the glove and immediately after removing it. 4. Gloves will not be worn on tray line. Instead, as much pre-assembly and/or prep work will be completed before meal service to minimize the potential for cross-contamination during service. Record review of the Hand Washing policy dated 2012 documented: We will ensure proper hand washing procedures are utilized. Employees are to frequently perform hand washing as outlined below. Procedure: 1. Hand Washing occurs in sinks provided for that purpose; sink areas provide hot/cold running water, soap in dispensers, and paper towels, and should have a sign posted conspicuously near or above wash basin

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 3 of 12 residents (Residents #27, #4 and #24) reviewed for infection control. 1. The facility failed to ensure proper hand hygiene was performed and the blood pressure cuff and pulse oximeter were sanitized between resident use. 2. The facility failed to ensure proper hand hygiene was performed, going from a clean area to a dirty area, and the scissors used to provide wound care were sanitized prior to use. These deficient practices could place residents who received medications and wound care at-risk for infections. The findings included: 1. a. Record review of Resident #27's face sheet dated 3/7/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included diabetes with hyperglycemia (condition in which blood sugar levels are consistently higher than normal due to the body's inability to properly produce or use insulin), hyperlipidemia (condition characterized by abnormally high levels of fats in the blood), hypertension (high blood pressure), and other specified symptoms and signs involving the circulatory and respiratory systems. b. Record review of Resident #4's face sheet dated 3/5/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia, hypertension (high blood pressure), heart failure, and shortness of breath. Observation on 3/6/25 at 8:06 a.m., revealed the ADON was seen entering a resident's room in The Long Hall to administer medications and took the digital wrist b/p (blood pressure) cuff with her. The ADON was then observed exiting the room and placed the digital wrist b/p cuff on the medication cart counter. The ADON did not practice proper hygiene and did not sanitize the digital wrist b/p cuff after use. The ADON then prepared medications for Resident #27 and obtained the resident's blood pressure with the same digital wrist b/p cuff without sanitizing it and obtained the resident's oxygen and pulse reading with a digital pulse oximeter. The ADON then returned to the medication cart and placed the digital wrist b/p cuff, and the pulse oximeter on the medication cart counter without sanitizing it and did not perform proper hand hygiene after administering medications to Resident #27. The ADON then prepared medications for Resident #4 and obtained the resident's blood pressure with the same digital wrist b/p cuff and the resident's oxygen and pulse reading with the same pulse oximeter without sanitizing it prior to use. During an interview on 3/6/25 at 9:15 a.m., the ADON stated she had forgotten to sanitize the digital wrist b/p cuff and the pulse oximeter but realized it was important because it was part of infection control. The ADON stated, a break in infection control to result in residents possibly getting an infection and transmission was always a possibility. The ADON further stated she had also forgotten to wash or sanitize her hands and it was also considered a break in infection control. 2. Record review of Resident #24's face sheet dated 3/5/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included pressure ulcer of sacral region stage 4 (wound with full thickness skin and tissue loss located over the lower back near the tailbone), pressure ulcer of left buttock stage 2 (wound partial thickness skin loss), and cervical spina bifida with hydrocephalus (a neural tube defect where the spine does not close properly in the cervical (neck) region during fetal development; hydrocephalus refers to abnormal buildup of cerebrospinal fluid in the brain leading to increased pressure.) Observation on 3/5/25 at 10:38 a.m. revealed LVN A did not perform proper hand hygiene prior to entering Resident #24's room. LVN A was observed placing the treatment cart in Resident #24's room, searched in her pocket for the keys to the medication cart, opened the cart and placed wax paper on top of the medication cart counter. LVN A then, without performing proper hand hygiene and with ungloved hands, took several gloves from a box, the supplies needed for wound care including dry gauze, two tongue depressors, an adhesive bandage and a tube of ointment and placed them on top of the wax paper. LVN A then took a pair of scissors out of her pant pocket and placed it on top of the wax paper without sanitizing it. Resident #24 was observed standing from the wheelchair and used the walker for assistance. LVN A then put on gloves, did not perform proper hand hygiene, pulled Resident #24's wheelchair back with her gloved hands and unfastened the resident's brief to expose his buttock area. LVN A then removed her gloves, did not perform proper hand hygiene and put on a new pair of gloves. LVN A then began wound care and during the care removed and put on new gloves at least 6 times without performing proper hand hygiene. LVN A took the scissors and cut a medicated gauze and placed on the resident's wound. LVN A then was observed removing her gloves, did not perform proper hand hygiene and placed the adhesive bandage over the wound with her ungloved hand. LVN A then put on a new pair of gloves, did not perform proper hand hygiene and disposed of the resident's brief in the trash can. LVN A then moved to the resident's dresser, wearing the same soiled gloves and removed a clean brief from the dresser. LVN A, observed wearing the same soiled gloves, placed the clean brief over the resident, pushed the resident's wheelchair closer to the resident and pulled the walker away from the resident so the resident could sit back down on the wheelchair. LVN A then removed her gloves and gown and placed them in the trash can. LVN A then took the supplies used during care and placed them in the trash can. LVN A then moved the resident's bedside table to the right of the resident's bed and exited the resident's room without performing proper hand hygiene. During an interview on 3/5/25 at 11:01 a.m., LVN A stated she had worked for the facility back in 2020 but then returned in September 2024. LVN A stated she usually washed her hands before care but didn't do it. LVN A stated she had learned to change her gloves as I went, but not trained about washing or sanitizing her hands between glove changes. LVN A stated she had received competency training on infection control last month from the former DON. LVN A stated she had sanitized the scissors used during wound care prior to the State Surveyor observation, but acknowledged placing the scissors back in her pocket after sanitizing it probably would not have kept the scissors clean. LVN A acknowledged she had gone from a dirty area to a clean area wearing the same soiled gloves and should have at the least changed her gloves. LVN A stated, the reason she removed her gloves when applying the adhesive bandage to Resident #24's wound was because the adhesive sticks to the glove and that was the reason I didn't use gloves. LVN A stated, Resident #24 was on enhanced barrier precautions and I know I should have used gloves, but since I only touched the outside of the bandage it was not contaminated. LVN A acknowledged, a break in infection control could result in the resident developing an infection due to cross contamination. During an interview on 3/6/25 at 10:38 a.m., the DON stated it was her expectation for the nursing staff to perform proper hand hygiene between glove changes. The DON further stated, unless the gloves were visibly soiled, then proper hand hygiene would include washing the hands with soap and water. The DON stated, when in doubt sanitize. The DON stated improper hand hygiene could result in an infection, the spread of bacteria, cross contamination, and spread of infection passed on to the next resident. The DON stated, LVN A should not have removed her gloves to apply the adhesive bandage to Resident #24's wound because the bandage has a border specifically made so that it would not stick to the gloves. A competency training was requested on hand hygiene, and infection control for the ADON and LVN A but was not provided at the time of exit on 3/7/25 at 3:00 p.m. Record review of the facility policy and procedure titled, Hand Hygiene, undated revealed in part, .Hand hygiene continues to be the primary means of preventing the transmission of infection. When to perform hand hygiene .Upon and after coming in contact with a resident's intact skin (when taking a pulse or blood pressure) . Record review of the facility policy and procedure titled, Infection Control Plan: Overview, updated 3/2023 revealed in part, .The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection .The intent of this policy is to assure that the facility develops, implements, and maintains an Infection Prevention and Control Program in order to prevent, recognize, and control, to the extend possible, the onset and spread of infection within the facility .A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions .Gloving .gloves must be changed between resident contacts, and hands washed after gloves are removed .Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves .Hand Hygiene .When hands are visibly soiled .Before and after direct resident contact .Before and after changing a dressing .After handling soiled equipment .After removing gloves .After completing duty .Resident care equipment and articles. Non-invasive resident care equipment is cleaned daily or as need(ed) between use . 41095

Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 2 resident units/halls (The Short Hall and Long Hall) reviewed for dignity. 1. The facility failed to ensure Resident #11 was provided privacy when she was administered insulin. 2. The facility failed to ensure Resident #27 was provided privacy when she was administered insulin. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth. The findings included: 1. Record review of Resident #11's face sheet dated 5/5/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted [DATE] and 1/1/25 with diagnoses that included type 2 diabetes with ketoacidosis (complication of diabetes that occurs when the body starts breaking down fat too quickly due to a lack of insulin) and need for assistance with personal care. Record review of Resident #11's most recent annual MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills and received insulin injections. Record review of Resident #11's comprehensive care plan with revision date 12/12/24 revealed the resident had a diagnosis of diabetes with interventions that included to administer diabetes medications as ordered by the doctor. Record review of Resident #11's Order Summary Report dated 3/5/25 revealed the following: - Apidra Injection Solution 100 UNIT/ML, Inject as per sliding scale subcutaneously at breakfast, lunch, and supper related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA with order date 1/17/25 and no end date Observation on 3/4/25 at 11:30 a.m. revealed LVN A entered Resident #11's bedroom on the Short Hall while the resident was seen eating lunch from the tray that was placed in front of her on the bedside table. Resident #11 could be seen in full view from the hallway. LVN A, while Resident #11 was eating, instructed Resident #11 to pull up her top to expose the resident's abdomen and injected Resident #11 with the insulin. LVN A did not close the bedroom door or pull the privacy curtain to provide privacy and the resident could be seen in full view from the hallway. During an interview on 3/4/25 at 11:34 a.m., LVN A stated she had given Resident #11 an insulin injection and had not closed the bedroom door or pulled the privacy curtain to provide privacy because she had forgotten. LVN A stated she should have provided privacy so others don't notice, it's kind of a dignity thing. During an interview on 3/4/25 at 11:42 a.m., Resident #11 stated, it did not bother her LVN A did not use the privacy curtain to provide privacy. 2. Record review of Resident #27's face sheet dated 3/7/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included type 2 diabetes with hyperglycemia (condition in which a person has excessively high blood sugar levels), bipolar disorder (mental health condition characterized by extreme mood swings that include emotional highs and lows), anxiety and depression. Record review of Resident #27's most recent quarterly MDS assessment, dated 12/25/24 revealed the resident was moderately cognitively impaired for daily decision-making skills, and received insulin injections. Record review of Resident #27's comprehensive care plan with revision date 11/19/24 revealed the resident had diabetes with interventions that included to administer diabetes medications as ordered by the physician. Record review of Resident #27's Order Summary Report dated 3/7/25 revealed the following: - Novolog FlexPen Subcutaneous Solution Pen Injector 100 UNIT/ML, Inject 12 units subcutaneously three times a day related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA, hold for glucose less than 100, with order date 6/14/24 and no end date Observation on 3/6/25 at 4:23 p.m. revealed LVN B took supplies into Resident #27's room on the Long Hall and obtained the resident's blood sample via a finger stick to check her glucose level. Resident #27's bedroom door was left open, and the privacy curtain was not utilized as LVN B obtained the blood sample in full view of the hallway. LVN B then left the resident's bedside, prepared the insulin pen to inject Resident #27 with insulin and returned to the resident's bedside. LVN B instructed Resident #27 to lift her top and expose the resident's upper abdomen, where LVN B injected the resident with insulin. LVN B did not provide privacy and left the bedroom door open and did not utilize the privacy curtain leaving the resident exposed in full view of the hallway. During an interview on 3/6/25 at 4:29 p.m., LVN B stated, since Resident #27 did not have a roommate, it would be ok not to close the bedroom door. LVN B further stated, but at least I should have drawn the privacy curtain, for privacy. I wouldn't have any trouble pulling up my shirt to expose my stomach, but I understand. LVN B then stated, I know this resident (Resident #27) and I know she would not mind; she's had stuff done out in the open. She doesn't mind if no one else is around. During an interview on 3/6/25 at 4:33 p.m., Resident #27 stated, they (Nursing Staff) do it all the time, sometimes in the hallway. Resident #27 further stated it did not bother her because that's how they always do it. During an interview on 3/6/25 at 10:29 a.m., the DON stated it was her expectation for the nursing staff, when providing care, to provide privacy and should pull the privacy curtain at a bare minimum and should have closed the door. The DON stated, it is an invasion of privacy, and it is their home, I would not expect you to have the front door open. A policy and procedure was requested in reference to privacy and dignity but was not provided at exit.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 12 residents (Resident #4) reviewed for care plans: The facility failed to develop a person-centered care plan with interventions that addressed Resident #4's physician orders for the use of oxygen therapy. This failure could place residents at risk for not having their needs and preferences met. The findings included: Record review of Resident #4's face sheet dated 5/5/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia, heart failure, pneumonia, and shortness of breath. Record review of Resident #4's most recent significant change MDS assessment dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills and required oxygen therapy. Record review of Resident #4's Order Summary Report dated 5/5/25 revealed the following: - Check O2 sat every shift and as needed with order date 12/6/24 and no end date - May use oxygen at 2 l/m via nasal canula or mask every shift related to SHORTNESS OF BREATH, with order date 12/12/24 and no end date -Oxygen may be used at 2 liters for O2 sats below 90 percent on RA and shortness of breath every 8 hours as needed for Sats below 90 percent on RA and SOB, with order date 2/6/23 and no end date Record review of Resident #4's comprehensive care plan with revision date 2/11/25 revealed the resident was on oxygen therapy with interventions that included: OXYGEN SETTINGS: (Specify: The resident has, O2 via nasal prongs/mask @ (X) L continuously/(FREQ). Humidified (Specify). Observation on 3/4/25 at 10:43 a.m. revealed Resident #4 sleeping in bed and the oxygen concentrator was operating via a nasal cannula at 3 liters. During an interview on 3/7/25 at 8:28 a.m., the MDS Coordinator stated the development of an MDS, and the comprehensive care plan was a team effort. The MDS Coordinator stated the comprehensive care plan offered a picture of the resident and how to take care of them. The MDS Coordinator stated, Resident #4's comprehensive care plan should have been specific to the resident's use of oxygen and should have been updated when the resident's order for use of oxygen was changed, which was back in December. During an interview on 3/7/25 at 10:35 a.m., the DON stated the purpose of the comprehensive care plan was so that everybody would be aware of how to care for the resident and to catch any risks the resident may have and mitigate and prevent them from occurring. The DON stated, Resident #4's use of oxygen should have been specific to the resident, but it was not. The DON stated, Resident #4's comprehensive care plan did not provide specifics regarding the resident's use of oxygen and should have included the amount of oxygen used, and the duration and/or frequency the oxygen was used. Record review of the policy and procedure titled Comprehensive Care Planning undated revealed in part, .The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment .The comprehensive care plan will describe the following .The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

Based on the observation, interview, and record review the facility failed to ensure that the resident's environment remained free of accidents and hazards as was possible and each resident received adequate supervision to prevent accidents for 1 of 6 residents (Resident #4) reviewed for accidents. The facility failed to ensure Resident #4's fall mat was utilized per physician's orders. This failure could place residents at risk for accidents and injuries related to risk for falls. The findings included: Record review of Resident #4's face sheet dated 3/5/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia, abnormalities of gait and mobility, muscle wasting, muscle weakness and lack of coordination. Record review of Resident #4's most recent significant change MDS assessment dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills and was dependent on staff for bed mobility and transfers. Record review of Resident #4's Order Summary Report dated 3/5/25 revealed the following: - fall mat in place while in bed every shift related to OTHER LACK OF COORDINATION, with order date 1/10/25 and no stop date Record review of Resident #4's comprehensive care plan with revision date 2/11/25 revealed the resident was at risk for falls related to confusion, vision and hearing problems and decline in health, with interventions that included: floor mat on the floor beside bed. During an observation on 3/6/25 at 9:59 a.m., Resident #4 was seen lying in bed, and the fall mat was folded up and leaning against the wall at the foot of the bed. During an observation and interview on 3/6/25 at 10:14 a.m., Resident #4 was seen lying on the bed, and the fall mat was folded up and leaning against the wall at the foot of the bed. A female staff who identified herself as the Hospice Aide stated she was about to provide the resident with a bed bath. CNA C observed Resident #4 in the bed and the fall mat folded up and leaning against the wall at the foot of the bed. CNA C stated she made initial rounds at the beginning of the shift, which began at 6:00 a.m., and rounds included checking for fall mat use. CNA C, while the Hospice Aide was in the resident room believed the Hospice Aide may have removed the fall mat. The Hospice Aide stated the fall mat was folded up against the wall before she entered Resident #4's room. CNA C stated it was the responsibility of the CNA's and the nurses to ensure the fall mat was on the floor to prevent the resident from injury related to falls. During an interview on 3/6/25 at 11:02 a.m., the DON stated, the whole point of the fall mat was that when the resident was in the bed, the fall mat should be on the floor next to the bed to prevent injury from falls. The DON stated, the CNA staff, nursing staff and all staff in general were responsible for ensuring the fall mats were used, but ultimately the responsibility fell on the DON. A policy and procedure was requested from the DON regarding accidents and hazards but was not provided at the time of exit.

Based on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 of 1 resident (Resident #4), reviewed for quality of care. Resident #4's oxygen nasal cannula was not covered or protected from the elements when not in use. This failure could place residents who received respiratory care at risk of developing respiratory complications and a decreased quality of care. The findings included: Record review of Resident #4's face sheet dated 3/5/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia, hypertension (high blood pressure), heart failure, and shortness of breath. Record review of Resident #4's most recent significant change MDS dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills and required oxygen therapy. Record review of Resident #4's Order Summary Report dated 3/5/25 revealed the following: - Administer oxygen as needed for oxygen level less than 92 percent with order date 7/20/24 and no end date. - Change nasal or mask canula (used on the oxygen concentrator) as needed with order date 12/13/24 and no end date. Record review of Resident #4's comprehensive care plan with revision date 2/11/25 revealed the resident used oxygen therapy with interventions that included to provide extension tubing or portable oxygen apparatus for those residents who were ambulatory. Observation on 3/4/25 at 10:43 a.m. revealed Resident #4 was on the bed sleeping and the oxygen concentrator was operating via the nasal cannula. Further observation revealed the tubing attached to the oxygen concentrator with the nasal canula was dated 3/3/25. Observation on 3/5/25 at 8:13 a.m. revealed Resident #4 was not in the bedroom and the oxygen concentrator was operating with the tubing to the nasal cannula attached to the oxygen concentrator on the floor next to the bed. The oxygen concentrator tubing was dated 3/3/25. Observation on 3/5/25 at 2:59 p.m. revealed Resident #4 was sleeping on the bed and the oxygen concentrator was not operating at the time. The tubing attached to the oxygen concentrator with the nasal cannula dated 3/3/2025 was observed stored in a clear plastic bag next to the resident's bed. Observation on 3/6/25 at 8:15 a.m., during the medication pass, revealed Resident #4 was on the bed and the oxygen concentrator was operating with the tubing to the nasal cannula dated 3/3/2025 attached to the oxygen concentrator, and the part of the cannula that attaches to the resident's nostrils were inside the top open drawer of the resident's nightstand on the right side of the bed. During an observation and interview on 3/6/25 at 8:46 a.m., the ADON, who was providing medications to Resident #4 noticed the nasal cannula was not being worn by the resident and stated, we have to put the oxygen on you, it's gonna go in your nose, it's your oxygen. The ADON was observed taking the nasal cannula that was inside the top drawer of the resident's nightstand and placed it on the resident's nares. During an interview on 3/6/25 at 9:15 a.m., the ADON acknowledged Resident #4's nasal canula attached to the oxygen concentrator was seen on the top open drawer of Resident #4's nightstand and not stored in a bag. The ADON acknowledged the tubing on the nasal canula was dated 3/3/25. The ADON stated, the oxygen concentrator tubing should have been replaced after it was found on the nightstand and not stored in a bag. The ADON stated the oxygen tubing with the tubing and nasal canula were supposed to be changed weekly and as needed. The ADON stated she made rounds and part of that task was to ensure the oxygen concentrators and tubing were connected and operating according to the prescribed physician's orders and ensure the tubing is off the floor and when not in use, stored in a bag. The ADON stated she needed to change the oxygen tubing with the canula and replace it with a new one. During an interview on 3/6/25 at 10:59 a.m., the DON stated, it was her expectation, the tubing to the nasal canula used on the oxygen concentrator was supposed to be stored in a bag when not in use. The DON further stated, the tubing to the nasal canula was to remain clean and if it was not stored properly could result in the resident getting an infection, or particles of dirt could get into the lungs and result in a respiratory illness. The DON stated, all staff should be looking for proper storage and use of the tubing to the nasal canula when making rounds, but stated it was ultimately her, the DON's responsibility it was being done. Record review of the facility policy and procedure titled, Oxygen Administration with revision date 3/21/23 revealed in part, .Oxygen therapy includes the administration of oxygen (O2) in liters/minute (l/min) by cannula or face mask to treat hypoxemic conditions caused by pulmonary or cardiac diseases .The administration, monitoring of responses, and safety precautions associated with it are performed by the nurse .Attach the tubing to the regulator and the delivery device to be used .Change the tubing (including any nasal prongs or mask) that is in use on one patient when it malfunctions or becomes visibly contaminated .

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 2 resident units/halls (The Long Hall), and 1 of 3 medication carts reviewed for storage of drugs and biologicals. 1. The facility failed to ensure Resident #22 did not have a jar of mentholated ointment (a topical analgesic and decongestant) at the bedside. 2. The facility failed to ensure the medication cart on The Long Hall was locked and secured. These deficient practices could place residents at risk of medication misuse or drug diversion. The findings included: 1. Record review of Resident #22's face sheet dated 3/6/25 revealed a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included dementia, anxiety disorder (a mental health condition characterized by excessive fear, worry, or nervousness that is persistent and interferes with daily life), acute upper respiratory infection (sudden infection affecting the respiratory system, including the nose, throat, airways, and lungs), chronic pain, and allergic rhinitis (an allergic reaction that causes inflammation of the nasal passages and symptoms like sneezing, runny or stuffy nose). Record review of Resident #22's most recent quarterly MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills. Record review of Resident #22's Order Summary Report dated 3/6/25 revealed the following: - Fluticasone Propionate Nasal Suspension 50 MCG/ACT, 2 spray in both nostrils one time a day related to ALLERGIC RHINITIS, with order date 6/7/23 and no end date - Loratadine Tablet 10 MG, Give 10 mg by mouth one time a day related to ALLERGIC RHINITIS, with order date 11/20/23 and no end date - Ocean Nasal Spray Nasal Solution (Saline), 1 spray in both nostrils one time a day for flush with ocean spray prior to Flonase related to ALLERGIC RHINITIS, with order date 11/20/23 and no end date Record review of Resident #22's comprehensive care plan with revision date 1/22/25 revealed the resident had COPD (Chronic Obstructive Pulmonary Disease; a chronic inflammatory lung disease that causes obstruction of airflow to the lungs with symptoms that include shortness of breath, chronic cough, wheezing and excess mucus production). Further review of Resident #22's comprehensive care plan revealed interventions that included to give medications as ordered by the physician. Observation on 3/4/25 at 10:46 a.m., during initial tour revealed Resident #22, who was not in the bedroom, was observed with a small jar of mentholated ointment in plain view on the resident's nightstand to the left of the bed. During an observation and interview on 3/4/25 at 11:46 a.m., Resident #22 stated she received all her medications from the nurses and was not allowed to administer any medications to herself. The mentholated jar of ointment continued in plain site on Resident #22's nightstand to the left of the bed. Resident #22 could not or would not elaborate on why the mentholated jar of ointment was on the nightstand. Observation on 3/6/25 at 11:27 a.m., revealed Resident #22, who was not in the bedroom, was observed with the same small jar of mentholated ointment in plain view on the resident's nightstand to the left of the bed. During an interview on 3/6/25 at 11:31 a.m., the DON stated there were no residents residing in the facility who were able to self-medicate. The DON further stated, residents were not supposed to have medications at the bedside because they could be taken inappropriately, or used in excess by the residents or other residents could gain access to the medication. The DON stated the facility had residents who wandered. The DON stated it was the responsibility of the nursing staff, the CNA's and anybody making rounds to ensure medications were not left at the bedside. 2. Observation and interview on 3/6/25 at 4:21 p.m. during the medication pass, revealed LVN B notified the State Surveyor she was ready to be observed administering an insulin injection. LVN B was followed from The Short Hall where the State Surveyor was sitting in a room, to the other side of the building to The Long Hall where LVN B's medication cart was parked. As the State Surveyor and LVN B came to the medication cart, the cart could be seen unlocked. LVN B acknowledged the medication cart was unlocked and unattended and stated, any resident might be able to open it and access things; anybody, not just a resident. During an interview on 3/6/25 at 4:36 p.m., the DON stated, she expected the medication carts to remain locked and secured because it was a risk for a wandering resident to take a medication inappropriately. Record review of the facility policy and procedure titled, Storage of Medication, dated 2003 revealed in part, .Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Medication rooms, carts, and medication supplies are locked and attended by person with authorized access .

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit neglect of residents for 1 of 6 residents (#1) whose care was reviewed for neglect. RN E did not perform CPR to Resident #1 who requested full code status. RN E left resident #1s side while her vital signs were diminishing. Resident # 1 was pronounced deceased on [DATE] at 12:35 a.m. These failures resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as isolated until all residents were assessed and staff was in-serviced. These deficient practices could affect 19 residents in the facility who were Full Code and result in their wishes not being met leading to death. Findings: Review of Resident #1's admission orders [REDACTED]. CPR Status was documented as Yes indicating Full Code. Review of resident #1's admission orders [REDACTED]. Review of resident #1's Blood Glucose Monitoring Data Sheet dated [DATE]-21, 2016 revealed unstable blood sugar readings. Resident # 1 blood Glucose readings ranged between 35 and 397. Review of Resident #1's Postmortem assessment dated [DATE] indicated at 12:35 a.m., Resident #1 had no respirations, no apical pulse, pupils were fixed and dilated, and body temperature that indicated hypothermia. Review of resident #1's, face sheet dated [DATE] revealed she had [DIAGNOSES REDACTED]. During an interview on [DATE] at 2:00 p.m., NA G said she took care of Resident #1, whose room was on the short hall, during the night shift on [DATE] that started at 10:00 p.m. NA G said staff working during that shift included herself, RN E as the Charge Nurse, CNA F, and LVN H on her first day of work at this facility. NA G further revealed she had clocked back in from lunch at approximately 1:30 a.m. NA G stated she and CNA F crossed paths in the hallway after she clocked back in from lunch and CNA F informed her I think we lost (Resident #1). NA G stated she went into resident #1's bedroom and observed RN E standing over resident. NA G stated I pretty much thought she had no life when I walked in the room initially. NA G stated she had worked in nursing for over [AGE] years and had experienced many deaths; you just know. NA G further stated I did touch her hand at one point (Resident #1), it was cool to touch. NA G further revealed RN E stated Resident #1 was dead before EMS arrived. NA G further revealed she did not witness RN E perform CPR on resident #1. During an interview on [DATE] at 2:25 p.m., RN E said she took care of Resident #1 during the night shift on [DATE] that started at 10:00 p.m. RN E said staff working during that shift included herself, an LVN orientee, and two CNAs she could not remember by name. RN E stated she was documenting behind the nurses station when CNA (could not remember name) informed her Resident #1 wanted insulin at approximately 12:30 a.m. RN E further revealed she checked Resident #1's blood sugar, stating the blood sugar reading was 35. RN E indicated Resident #1 was lethargic and sluggish and further stated Resident #1's vital signs were stable. RN E stated she instructed LVN orientee to call 911 due to Resident #1's sluggish state. RN E stated all this activity is occurring between 12:30 a.m. and 1:00 a.m., I do not know what time EMS arrived. RN E further revealed she did not initiate CPR on Resident #1. She stated there was no need, she was sluggish, cool to touch, vital signs decreasing when EMS arrived and took over. During a subsequent telephone interview on [DATE] at 2:30 p.m. with RN E, she stated she first saw Resident #1 around 10:,[DATE]:45p.m. on [DATE]. RN E stated Resident #1 was sound asleep, no problems at that point. RN E stated she touched Resident #1's arm and called her name. RN E stated Resident #1 went mmm, and I turned and left. RN E stated the next time she observed Resident #1 was about 12ish, not really sure. RN E stated Resident #1 told CNA she wanted insulin. RN E further stated I went to Resident #1's room, called her name. She was sluggish, lethargic; blood sugar reading at that time was 35. RN E indicated she walked back out into the hallway and requested LVN H obtain a sugar packet. RN E stated CNA (name unknown) helped Resident #1 sit up as RN E gave Resident #1 a sugar packet under her tongue. RN E stated Resident #1 was responsive determined by RN E pinching her, calling her name; RN E stated Resident #1 mumbled. RN E further stated Resident #1 became more heavy, lethargic, you know heavy, so I asked LVN orientee to call EMS. RN E stated she took Resident #1's vital signs three times before EMS arrived. RN E further revealed she did not document the second and third set of vital signs or the blood sugar reading in the medical record. RN E stated she did not provide emergency treatment or CPR for Resident #1. She further revealed she did not obtain oxygen with decreasing vital signs. RN E revealed she raised the head of the bed, further stating In my experience as an RN, it is helpful to raise the head of the bed up to 45 degrees for comfort for a resident with decreasing vital signs. RN E stated she was not at Resident #1's side when EMS arrived. RN E stated I made sure she was comfortable and went to the nurse's station. RN E further stated Nobody was with Resident #1 at that point; she was alive when I left her. RN E revealed Resident #1 was a full code and stated I did not perform CPR because she was not dead; she was comfortable when I left her to go to the nurse's station. RN E stated I forgot to document the vital signs, which are why they are not in the chart. During an interview on [DATE] at 2:55 p.m., CNA F said she took care of Resident #1 during the night shift on [DATE] that started at 10:00 p.m. CNA F said staff working during that shift included herself, RN E as the Charge Nurse, LVN H on her first day of work at this facility, and NA G. CNA F stated I returned from my lunch break at approximately 12:30 a.m., and CNA G went to lunch. CNA F further stated I went to check on Resident #1 at approximately 12:35 a.m., she had a low blood sugar the night before. CNA F further revealed she walked into Resident #1's room and thought she was asleep. She attempted to arouse Resident #1 and she would not respond. She was on her back leaning to her left, I got no response when I called her name and shook her. CNA F stated she notified RN E and LVN H immediately. CNA F stated RN E instructed her to obtain two packets of sugar, RN E checked Resident #1's blood sugar. CNA F stated it was 30 something. CNA F further revealed she assisted Resident #1 up in bed; RN E gave the resident two packs of sugar. CNA F further revealed Resident #1's body was limp, I was holding her in my arms, I did not think the resident was breathing. RN E instructed LVN H to call EMS at that time, CNA F was sent for a stethoscope. CNA F further revealed she ran into NA G in the hall and stated I think we lost resident #1. CNA F revealed she and NA G returned to resident #1's bedroom and RN E was handed the stethoscope further stating I did not see RN E use the stethoscope on Resident # 1. CNA F further stated RN E said, I think she is gone, she is not breathing, and she does not have a pulse. CNA F further revealed LVN H returned to the room and informed RN E Resident #1 was a full code; EMS was on the way. CNA F further revealed RN E did not perform CPR or request anyone else to provide CPR for Resident #1. CNA F further revealed the facility crash cart or the AED was not in the Resident's room. During an interview on [DATE] at 2:15p.m., Resident #1's attending physician stated Resident # 1 had a very difficult diabetes; Type I, failure of the pancreas. The attending physician confirmed Resident # 1's previous admission to this facility was dated [DATE] with a standing order for [MEDICATION NAME] for [DIAGNOSES REDACTED]. The attending physician confirmed he did not prescribe [MEDICATION NAME] for episodes of [DIAGNOSES REDACTED] on Resident #1's last admission on [DATE], further revealing [MEDICATION NAME] possibly would have been effective, we will not know. During an interview on [DATE] at 2:38 p.m. with EMT/Paramedic K, she stated RN E, and LVN H were at the nurse's station when they walked into the building. She further revealed EMT L and EMT M were shown to Resident #1's bedroom and she returned to the truck for supplies approximately 30 seconds later. EMT K revealed when she went to Resident #1's bedroom, EMT L stated the resident was cold to touch; she has been down a while (without life for an extended amount of time). EMT K further revealed they attached a defibrillator and confirmed Asystole ([MEDICAL CONDITION] rhythm in which there is no electrical activity on the electrocardiogram monitor). EMT K further stated I felt her skin, she was cold, all extremities. The only warm area was under her back. Her eyes were closed, I opened them, and they were fixed and dilated. EMT K revealed the emergency crew did not provide Resident #1 CPR, she was dead on arrival (DOA). EMT K further revealed her cellular telephone displayed 1:37 a.m. when she received the call for assistance at the facility. EMT K further revealed the time of dispatch was 1:40 a.m., in route at 1:43 a.m., on the scene at 1:44 a.m., and back in service after the call at 3:00 a.m. During an interview on [DATE] at 4:10 p.m. with the DON, she confirmed no incident report or investigation was initiated for the night of Resident #1's death. The DON further revealed RN E stated the Resident was still alive when EMS walked in the door, I did not have a reason to make an incident report or investigate neglect. I assumed Resident #1 was alive as reported by RN E when EMS arrived. Review of RN E's documentation in Resident #1's Nurse Notes dated [DATE] at 2:58 a.m., revealed: CNA went to pt's (Resident #1) room and pt. was cold and clammy but responsive. CNA called nurse to check blood sugar. Nurse and orientee went to pt's room-Pt. lethargic barely responding t5o (to) tactile stimuli, blood sugar checked. Reading = 35. This nurse asked orientee to call 911-done. This nurse stayed at bedside v/s which continued to decline. Staff instructed to bring crash cart as EMT arrived to facility pt went into [MEDICAL CONDITION]. Pt care taken over by EMT and they began CPR (however, interview with EMT K revealed CPR was not initiated by emergency responders). EMT continue (continued) CPR to revive pt. This nurse advised t5o (to) call MD to pronice (pronounce) resident. This nurse received telephone order to pronce (pronounce) pt. via policy. Resident pronounced focis (focus) assessment: Resident had no carotidid (carotid) pulse, no apical pulse, no radial pulse. Further review of RN E's documentation in Resident #1's Nurse Notes dated [DATE] at 3:36 a.m., revealed: Continuation of previous note: no femoral pulse, no popliteal pulse, pedal pulse, and B/P unattainable. Family notified. Awaiting arrival to facility. Review of the facility Job Description for Charge Nurse dated 2010, revealed knowledge base included: Ability to organize work flow, respond to emergencies and note detail. Record review of RN E's CPR Certification revealed a CPR certification obtained on [DATE] with an expiration date of February 2018. Record review of Employee Punch Report revealed on [DATE], CNA F start meal time 11:58 p.m. and end meal time at12:40 a.m.; and NA G start meal time at 12:59 a.m. and end meal time at 1:30 a.m. Record review of undated policy provided by the facility revealed policy on Resident Rights stating in part: Exercise of Rights-The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. (Choice of CPR) Planning and Implementing Care- The resident has the right to be informed of, and participate in, his or her treatment, including: The right to receive the services and/or items included in the plan of care. (Choice of CPR) Self Determination- The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice. (Choice of CPR) Record review of the facility Nursing Policy & Procedure Manual 2003, Revised [DATE] Cardiopulmonary Resuscitation revealed in part: Cardiopulmonary resuscitation (CPR) is a method of providing systemic circulation by manual chest compression and oxygen by mouth-to-mouth breathing or providing air to the lungs via ambu bag. The procedure is performed to prevent death following cardiac or [MEDICAL CONDITION] arrest. Once initiate, it is continued until spontaneous circulation and respirations are restored, or until emergency services assume responsibility for resuscitation. Goals: Breathing and pulse will be reestablished in the resident. Procedure: 2. Ensure that the first responder calls EMS and returns to the scene with an AED (defibrillator). 3. After EMS has been called, implement the CPR protocol. 22. Document all care given and residents ' response to treatment. 23. The facility will document all code blue episodes. Record review of the facility policy and procedure Abuse/Neglect dated 2003, revised [DATE] revealed: Definition of Neglect: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Recoed review of employee Punch Report date range [DATE] - [DATE] revealed RN E was on duty [DATE] from 9:42 p.m. - 6:11 a.m., and on [DATE] from 4:46 p.m. to 10:18 p.m. Record review of Payroll Input/Personnel Action Form dated [DATE] revealed RN E was terminated from employment from this facility on [DATE] for CPR Policy Violation. The facility Administrator was notified on [DATE] at 3:15 p.m. of an Immediate Jeopardy for Quality of Care, failure to initiate CPR on a Full Code resident. A Plan of Removal was provided by the Administrator on [DATE] and included the following steps to be taken by the facility: 1. The DON, ADON, and regional nurse will verify all code status of all residents on [DATE]. To determine the code status of a resident, open the clinical record binder and the red or green sheet will be the first page of the resident chart: - If Full Code - there will be a green sheet of paper stating full code. - If DNR - there will be a red sheet of paper stating DNR with a copy of the DNR order. - All nursing staff has access to the chart. 2. The DON, ADON, and regional nurse will observe 100% of residents with a full code status on [DATE] to ensure that no resident is in distress and is in need of CPR at this time. 3. All nursing staff will be in-serviced by the DON, ADON, or regional nurse beginning on [DATE] and all staff not in-serviced on [DATE] will not be allowed to assume their duties until in-serviced regarding the following: - How to determine a resident ' s code status. - When to initiate CPR. - Continue CPR until relieved by other personnel or ordered ceased by a physician. - If the resident is in declining status, heart rate becomes less than 60 per minute, or respirations are less than 8 per minute, bather the emergency cart and AED and bring to the resident and continue to monitor closely. If heart rate or breathing ceases start CPR. Monitoring: 1. The DON and/or designee will question 8 nursing staff per week: - How to determine a resident ' s code status. - If a full code resident ceases breathing or is without a heartbeat, what should they do. 2. The DON and/or a designee will perform a mock code at least 1 time per week for 4 weeks then randomly thereafter. The mock code will consist of: - Mannequin will be the resident - A code blue will be announced - A mock call will be placed to EMS - Staff will locate and bring to the emergency cart and AED. - The AED pads will be placed in the correct area of the resident ' s body but not stuck to the resident. - The DON will then question the nurse or nurses what they would do if the resident was not breathing, was without a heartbeat, or both. Interviews with facility nurses and CNAs on [DATE] from 5:20 p.m. to 6:00 p.m. confirmed 2 nurses and 3 CNAs had received training in responding to CPR emergencies and on locations of residents' code status information. Nurses were able to verbalize steps to be taken immediately when residents were found to have no pulse and/or respirations. 100% of employed nursing staff members were in-serviced prior to starting their shifts. On [DATE] at 4:30 p.m., the Administrator was informed the IJ Plan of Removal was accepted. However, the facility remained out of compliance with a severity of actual harm with a scope identified as isolated. Information provided by the facility on [DATE] revealed there were 19 residents in the facility that had requested a full code status.

Based on interview and record review, the facility failed to investigate all alleged violations involving neglect for 1 of 6 residents (#1) whose care was reviewed for neglect. The Administrator and the DON did not investigate RN E's failure to perform CPR for resident #1 as possible neglect. These deficient practices could affect 19 residents in the facility who were Full Code and result in their wishes not being met leading to death. RN E did not perform CPR to Resident #1 who requested full code status. RN E left resident #1s side while her vital signs were diminishing. Resident # 1 was pronounced deceased on [DATE] at 12:35 a.m. These failures resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as isolated until all residents were assessed and staff was in-serviced. This deficient practice could affect 19 residents in the facility that were a Full Code status. Findings: Review of Resident #1's admission orders [REDACTED]. CPR Status was documented as Yes indicating Full Code. Review of resident #1's admission orders [REDACTED]. Review of resident #1's Blood Glucose Monitoring Data Sheet dated [DATE]-21, 2016 revealed unstable blood sugar readings. Resident # 1 blood Glucose readings ranged between 35 and 397. Review of Resident #1's Postmortem assessment dated [DATE] indicated at 12:35 a.m., Resident #1 had no respirations, no apical pulse, pupils were fixed and dilated, and body temperature that indicated hypothermia. Review of resident #1's, face sheet dated [DATE] revealed she had [DIAGNOSES REDACTED]. During an interview on [DATE] at 2:00 p.m., NA G said she took care of Resident #1, whose room was on the short hall, during the night shift on [DATE] that started at 10:00 p.m. NA G said staff working during that shift included herself, RN E as the Charge Nurse, CNA F, and LVN H on her first day of work at this facility. NA G further revealed she had clocked back in from lunch at approximately 1:30 a.m. NA G stated she and CNA F crossed paths in the hallway after she clocked back in from lunch and CNA F informed her I think we lost (Resident #1). NA G stated she went into resident #1's bedroom and observed RN E standing over resident. NA G stated I pretty much thought she had no life when I walked in the room initially. NA G stated she had worked in nursing for over [AGE] years and had experienced many deaths; you just know. NA G further stated I did touch her hand at one point (Resident #1), it was cool to touch. NA G further revealed RN E stated Resident #1 was dead before EMS arrived. NA G further revealed she did not witness RN E perform CPR on resident #1. During an interview on [DATE] at 2:25 p.m., RN E said she took care of Resident #1 during the night shift on [DATE] that started at 10:00 p.m. RN E said staff working during that shift included herself, an LVN orientee, and two CNAs she could not remember by name. RN E stated she was documenting behind the nurses station when CNA (could not remember name) informed her Resident #1 wanted insulin at approximately 12:30 a.m. RN E further revealed she checked Resident #1's blood sugar, stating the blood sugar reading was 35. RN E indicated Resident #1 was lethargic and sluggish and further stated Resident #1's vital signs were stable. RN E stated she instructed LVN orientee to call 911 due to Resident #1's sluggish state. RN E stated all this activity is occurring between 12:30 a.m. and 1:00 a.m., I do not know what time EMS arrived. RN E further revealed she did not initiate CPR on Resident #1. She stated there was no need, she was sluggish, cool to touch, vital signs decreasing when EMS arrived and took over. During a subsequent telephone interview on [DATE] at 2:30 p.m. with RN E, she stated she first saw Resident #1 around 10:,[DATE]:45p.m. on [DATE]. RN E stated Resident #1 was sound asleep, no problems at that point. RN E stated she touched Resident #1's arm and called her name. RN E stated Resident #1 went mmm, and I turned and left. RN E stated the next time she observed Resident #1 was about 12ish, not really sure. RN E stated Resident #1 told CNA she wanted insulin. RN E further stated I went to Resident #1's room, called her name. She was sluggish, lethargic; blood sugar reading at that time was 35. RN E indicated she walked back out into the hallway and requested LVN H obtain a sugar packet. RN E stated CNA (name unknown) helped Resident #1 sit up as RN E gave Resident #1 a sugar packet under her tongue. RN E stated Resident #1 was responsive determined by RN E pinching her, calling her name; RN E stated Resident #1 mumbled. RN E further stated Resident #1 became more heavy, lethargic, you know heavy, so I asked LVN orientee to call EMS. RN E stated she took Resident #1's vital signs three times before EMS arrived. RN E further revealed she did not document the second and third set of vital signs or the blood sugar reading in the medical record. RN E stated she did not provide emergency treatment or CPR for Resident #1. She further revealed she did not obtain oxygen with decreasing vital signs. RN E revealed she raised the head of the bed, further stating In my experience as an RN, it is helpful to raise the head of the bed up to 45 degrees for comfort for a resident with decreasing vital signs. RN E stated she was not at Resident #1's side when EMS arrived. RN E stated I made sure she was comfortable and went to the nurse's station. RN E further stated Nobody was with Resident #1 at that point; she was alive when I left her. RN E revealed Resident #1 was a full code and stated I did not perform CPR because she was not dead; she was comfortable when I left her to go to the nurse's station. RN E stated I forgot to document the vital signs, which are why they are not in the chart. During an interview on [DATE] at 2:55 p.m., CNA F said she took care of Resident #1 during the night shift on [DATE] that started at 10:00 p.m. CNA F said staff working during that shift included herself, RN E as the Charge Nurse, LVN H on her first day of work at this facility, and NA G. CNA F stated I returned from my lunch break at approximately 12:30 a.m., and CNA G went to lunch. CNA F further stated I went to check on Resident #1 at approximately 12:35 a.m., she had a low blood sugar the night before. CNA F further revealed she walked into Resident #1's room and thought she was asleep. She attempted to arouse Resident #1 and she would not respond. She was on her back leaning to her left, I got no response when I called her name and shook her. CNA F stated she notified RN E and LVN H immediately. CNA F stated RN E instructed her to obtain two packets of sugar, RN E checked Resident #1's blood sugar. CNA F stated it was 30 something. CNA F further revealed she assisted Resident #1 up in bed; RN E gave the resident two packs of sugar. CNA F further revealed Resident #1's body was limp, I was holding her in my arms, I did not think the resident was breathing. RN E instructed LVN H to call EMS at that time, CNA F was sent for a stethoscope. CNA F further revealed she ran into NA G in the hall and stated I think we lost resident #1. CNA F revealed she and NA G returned to resident #1's bedroom and RN E was handed the stethoscope further stating I did not see RN E use the stethoscope on Resident # 1. CNA F further stated RN E said, I think she is gone, she is not breathing, and she does not have a pulse. CNA F further revealed LVN H returned to the room and informed RN E Resident #1 was a full code; EMS was on the way. CNA F further revealed RN E did not perform CPR or request anyone else to provide CPR for Resident #1. CNA F further revealed the facility crash cart or the AED was not in the Resident's room. During an interview on [DATE] at 2:15p.m., Resident #1's attending physician stated Resident # 1 had a very difficult diabetes; Type I, failure of the pancreas. The attending physician confirmed Resident # 1's previous admission to this facility was dated [DATE] with a standing order for [MEDICATION NAME] for [DIAGNOSES REDACTED]. The attending physician confirmed he did not prescribe [MEDICATION NAME] for episodes of [DIAGNOSES REDACTED] on Resident #1's last admission on [DATE], further revealing [MEDICATION NAME] possibly would have been effective, we will not know. During an interview on [DATE] at 2:38 p.m. with EMT/Paramedic K, she stated RN E, and LVN H were at the nurse's station when they walked into the building. She further revealed EMT L and EMT M were shown to Resident #1's bedroom and she returned to the truck for supplies approximately 30 seconds later. EMT K revealed when she went to Resident #1's bedroom, EMT L stated the resident was cold to touch; she has been down a while (without life for an extended amount of time). EMT K further revealed they attached a defibrillator and confirmed Asystole ([MEDICAL CONDITION] rhythm in which there is no electrical activity on the electrocardiogram monitor). EMT K further stated I felt her skin, she was cold, all extremities. The only warm area was under her back. Her eyes were closed, I opened them, and they were fixed and dilated. EMT K revealed the emergency crew did not provide Resident #1 CPR, she was dead on arrival (DOA). EMT K further revealed her cellular telephone displayed 1:37 a.m. when she received the call for assistance at the facility. EMT K further revealed the time of dispatch was 1:40 a.m., in route at 1:43 a.m., on the scene at 1:44 a.m., and back in service after the call at 3:00 a.m. During an interview on [DATE] at 4:10 p.m. with the DON, she confirmed no incident report or investigation was initiated for the night of Resident #1's death. The DON further revealed RN E stated the Resident was still alive when EMS walked in the door, I did not have a reason to make an incident report or investigate neglect. I assumed Resident #1 was alive as reported by RN E when EMS arrived. Review of RN E's documentation in Resident #1's Nurse Notes dated [DATE] at 2:58 a.m., revealed: CNA went to pt's (Resident #1) room and pt. was cold and clammy but responsive. CNA called nurse to check blood sugar. Nurse and orientee went to pt's room-Pt. lethargic barely responding t5o (to) tactile stimuli, blood sugar checked. Reading = 35. This nurse asked orientee to call 911-done. This nurse stayed at bedside v/s which continued to decline. Staff instructed to bring crash cart as EMT arrived to facility pt went into [MEDICAL CONDITION]. Pt care taken over by EMT and they began CPR (however, interview with EMT K revealed CPR was not initiated by emergency responders). EMT continue (continued) CPR to revive pt. This nurse advised t5o (to) call MD to pronice (pronounce) resident. This nurse received telephone order to pronce (pronounce) pt. via policy. Resident pronounced focis (focus) assessment: Resident had no carotidid (carotid) pulse, no apical pulse, no radial pulse. Further review of RN E's documentation in Resident #1's Nurse Notes dated [DATE] at 3:36 a.m., revealed: Continuation of previous note: no femoral pulse, no popliteal pulse, pedal pulse, and B/P unattainable. Family notified. Awaiting arrival to facility. Review of the facility Job Description for Charge Nurse dated 2010, revealed knowledge base included: Ability to organize work flow, respond to emergencies and note detail. Record review of RN E's CPR Certification revealed a CPR certification obtained on [DATE] with an expiration date of February 2018. Record review of Employee Punch Report revealed on [DATE], CNA F start meal time 11:58 p.m. and end meal time at12:40 a.m.; and NA G start meal time at 12:59 a.m. and end meal time at 1:30 a.m. Record review of undated policy provided by the facility revealed policy on Resident Rights stating in part: Exercise of Rights-The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. (Choice of CPR) Planning and Implementing Care- The resident has the right to be informed of, and participate in, his or her treatment, including: The right to receive the services and/or items included in the plan of care. (Choice of CPR) Self Determination- The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice. (Choice of CPR) Record review of the facility Nursing Policy & Procedure Manual 2003, Revised [DATE] Cardiopulmonary Resuscitation revealed in part: Cardiopulmonary resuscitation (CPR) is a method of providing systemic circulation by manual chest compression and oxygen by mouth-to-mouth breathing or providing air to the lungs via ambu bag. The procedure is performed to prevent death following cardiac or [MEDICAL CONDITION] arrest. Once initiate, it is continued until spontaneous circulation and respirations are restored, or until emergency services assume responsibility for resuscitation. Goals: Breathing and pulse will be reestablished in the resident. Procedure: 2. Ensure that the first responder calls EMS and returns to the scene with an AED (defibrillator). 3. After EMS has been called, implement the CPR protocol. 22. Document all care given and residents ' response to treatment. 23. The facility will document all code blue episodes. Recoed review of Employee Punch Report date range [DATE] - [DATE] revealed RN E was on duty [DATE] from 9:42 p.m. - 6:11 a.m., and on [DATE] from 4:46 p.m. to 10:18 p.m. Record review of Payroll Input/Personnel Action Form dated [DATE] revealed RN E was terminated from employment from this facility on [DATE] for CPR Policy Violation. The facility Administrator was notified on [DATE] at 3:15 p.m. of an Immediate Jeopardy for Quality of Care, failure to initiate CPR on a Full Code resident. A Plan of Removal was provided by the Administrator on [DATE] and included the following steps to be taken by the facility: 1. The DON, ADON, and regional nurse will verify all code status of all residents on [DATE]. To determine the code status of a resident, open the clinical record binder and the red or green sheet will be the first page of the resident chart: - If Full Code - there will be a green sheet of paper stating full code. - If DNR - there will be a red sheet of paper stating DNR with a copy of the DNR order. - All nursing staff has access to the chart. 2. The DON, ADON, and regional nurse will observe 100% of residents with a full code status on [DATE] to ensure that no resident is in distress and is in need of CPR at this time. 3. All nursing staff will be in-serviced by the DON, ADON, or regional nurse beginning on [DATE] and all staff not in-serviced on [DATE] will not be allowed to assume their duties until in-serviced regarding the following: - How to determine a resident ' s code status. - When to initiate CPR. - Continue CPR until relieved by other personnel or ordered ceased by a physician. - If the resident is in declining status, heart rate becomes less than 60 per minute, or respirations are less than 8 per minute, bather the emergency cart and AED and bring to the resident and continue to monitor closely. If heart rate or breathing ceases start CPR. Monitoring: 1. The DON and/or designee will question 8 nursing staff per week: - How to determine a resident ' s code status. - If a full code resident ceases breathing or is without a heartbeat, what should they do. 2. The DON and/or a designee will perform a mock code at least 1 time per week for 4 weeks then randomly thereafter. The mock code will consist of: - Mannequin will be the resident - A code blue will be announced - A mock call will be placed to EMS - Staff will locate and bring to the emergency cart and AED. - The AED pads will be placed in the correct area of the resident ' s body but not stuck to the resident. - The DON will then question the nurse or nurses what they would do if the resident was not breathing, was without a heartbeat, or both. Interviews with facility nurses and CNAs on [DATE] from 5:20 p.m. to 6:00 p.m. confirmed 2 nurses and 3 CNAs had received training in responding to CPR emergencies and on locations of residents' code status information. Nurses were able to verbalize steps to be taken immediately when residents were found to have no pulse and/or respirations. 100% of employed nursing staff members were in-serviced prior to starting their shifts. On [DATE] at 4:30 p.m., the Administrator was informed the IJ Plan of Removal was accepted. However, the facility remained out of compliance with a severity of actual harm with a scope identified as isolated. Information provided by the facility on [DATE] revealed there were 19 residents in the facility that had requested a full code status.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit neglect for 1 of 6 residents (#1) whose care was reviewed for neglect. RN E did not perform CPR to Resident #1 who requested full code status. These failures resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as isolated until all residents were assessed and staff was in-serviced. These deficient practices could affect 19 residents in the facility who were Full Code and result in their wishes not being met leading to death. Findings: Record review of the facility policy and procedure Abuse/Neglect dated 2003, revised [DATE] revealed: Definition of Neglect: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of Resident #1's admission orders [REDACTED]. CPR Status was documented as Yes indicating Full Code. Review of resident #1's admission orders [REDACTED]. Review of resident #1's Blood Glucose Monitoring Data Sheet dated [DATE]-21, 2016 revealed unstable blood sugar readings. Resident # 1 blood Glucose readings ranged between 35 and 397. Review of Resident #1's Postmortem assessment dated [DATE] indicated at 12:35 a.m., Resident #1 had no respirations, no apical pulse, pupils were fixed and dilated, and body temperature that indicated hypothermia. Review of resident #1's, face sheet dated [DATE] revealed she had [DIAGNOSES REDACTED]. During an interview on [DATE] at 2:00 p.m., NA G said she took care of Resident #1, whose room was on the short hall, during the night shift on [DATE] that started at 10:00 p.m. NA G said staff working during that shift included herself, RN E as the Charge Nurse, CNA F, and LVN H on her first day of work at this facility. NA G further revealed she had clocked back in from lunch at approximately 1:30 a.m. NA G stated she and CNA F crossed paths in the hallway after she clocked back in from lunch and CNA F informed her I think we lost (Resident #1). NA G stated she went into resident #1's bedroom and observed RN E standing over resident. NA G stated I pretty much thought she had no life when I walked in the room initially. NA G stated she had worked in nursing for over [AGE] years and had experienced many deaths; you just know. NA G further stated I did touch her hand at one point (Resident #1), it was cool to touch. NA G further revealed RN E stated Resident #1 was dead before EMS arrived. NA G further revealed she did not witness RN E perform CPR on resident #1. During an interview on [DATE] at 2:25 p.m., RN E said she took care of Resident #1 during the night shift on [DATE] that started at 10:00 p.m. RN E said staff working during that shift included herself, an LVN orientee, and two CNAs she could not remember by name. RN E stated she was documenting behind the nurses station when CNA (could not remember name) informed her Resident #1 wanted insulin at approximately 12:30 a.m. RN E further revealed she checked Resident #1's blood sugar, stating the blood sugar reading was 35. RN E indicated Resident #1 was lethargic and sluggish and further stated Resident #1's vital signs were stable. RN E stated she instructed LVN orientee to call 911 due to Resident #1's sluggish state. RN E stated all this activity is occurring between 12:30 a.m. and 1:00 a.m., I do not know what time EMS arrived. RN E further revealed she did not initiate CPR on Resident #1. She stated there was no need, she was sluggish, cool to touch, vital signs decreasing when EMS arrived and took over. During a subsequent telephone interview on [DATE] at 2:30 p.m. with RN E, she stated she first saw Resident #1 around 10:,[DATE]:45p.m. on [DATE]. RN E stated Resident #1 was sound asleep, no problems at that point. RN E stated she touched Resident #1's arm and called her name. RN E stated Resident #1 went mmm, and I turned and left. RN E stated the next time she observed Resident #1 was about 12ish, not really sure. RN E stated Resident #1 told CNA she wanted insulin. RN E further stated I went to Resident #1's room, called her name. She was sluggish, lethargic; blood sugar reading at that time was 35. RN E indicated she walked back out into the hallway and requested LVN H obtain a sugar packet. RN E stated CNA (name unknown) helped Resident #1 sit up as RN E gave Resident #1 a sugar packet under her tongue. RN E stated Resident #1 was responsive determined by RN E pinching her, calling her name; RN E stated Resident #1 mumbled. RN E further stated Resident #1 became more heavy, lethargic, you know heavy, so I asked LVN orientee to call EMS. RN E stated she took Resident #1's vital signs three times before EMS arrived. RN E further revealed she did not document the second and third set of vital signs or the blood sugar reading in the medical record. RN E stated she did not provide emergency treatment or CPR for Resident #1. She further revealed she did not obtain oxygen with decreasing vital signs. RN E revealed she raised the head of the bed, further stating In my experience as an RN, it is helpful to raise the head of the bed up to 45 degrees for comfort for a resident with decreasing vital signs. RN E stated she was not at Resident #1's side when EMS arrived. RN E stated I made sure she was comfortable and went to the nurse's station. RN E further stated Nobody was with Resident #1 at that point; she was alive when I left her. RN E revealed Resident #1 was a full code and stated I did not perform CPR because she was not dead; she was comfortable when I left her to go to the nurse's station. RN E stated I forgot to document the vital signs, which are why they are not in the chart. During an interview on [DATE] at 2:55 p.m., CNA F said she took care of Resident #1 during the night shift on [DATE] that started at 10:00 p.m. CNA F said staff working during that shift included herself, RN E as the Charge Nurse, LVN H on her first day of work at this facility, and NA G. CNA F stated I returned from my lunch break at approximately 12:30 a.m., and CNA G went to lunch. CNA F further stated I went to check on Resident #1 at approximately 12:35 a.m., she had a low blood sugar the night before. CNA F further revealed she walked into Resident #1's room and thought she was asleep. She attempted to arouse Resident #1 and she would not respond. She was on her back leaning to her left, I got no response when I called her name and shook her. CNA F stated she notified RN E and LVN H immediately. CNA F stated RN E instructed her to obtain two packets of sugar, RN E checked Resident #1's blood sugar. CNA F stated it was 30 something. CNA F further revealed she assisted Resident #1 up in bed; RN E gave the resident two packs of sugar. CNA F further revealed Resident #1's body was limp, I was holding her in my arms, I did not think the resident was breathing. RN E instructed LVN H to call EMS at that time, CNA F was sent for a stethoscope. CNA F further revealed she ran into NA G in the hall and stated I think we lost resident #1. CNA F revealed she and NA G returned to resident #1's bedroom and RN E was handed the stethoscope further stating I did not see RN E use the stethoscope on Resident # 1. CNA F further stated RN E said, I think she is gone, she is not breathing, and she does not have a pulse. CNA F further revealed LVN H returned to the room and informed RN E Resident #1 was a full code; EMS was on the way. CNA F further revealed RN E did not perform CPR or request anyone else to provide CPR for Resident #1. CNA F further revealed the facility crash cart or the AED was not in the Resident's room. During an interview on [DATE] at 2:15p.m., Resident #1's attending physician stated Resident # 1 had a very difficult diabetes; Type I, failure of the pancreas. The attending physician confirmed Resident # 1's previous admission to this facility was dated [DATE] with a standing order for [MEDICATION NAME] for [DIAGNOSES REDACTED]. The attending physician confirmed he did not prescribe [MEDICATION NAME] for episodes of [DIAGNOSES REDACTED] on Resident #1's last admission on [DATE], further revealing [MEDICATION NAME] possibly would have been effective, we will not know. During an interview on [DATE] at 2:38 p.m. with EMT/Paramedic K, she stated RN E, and LVN H were at the nurse's station when they walked into the building. She further revealed EMT L and EMT M were shown to Resident #1's bedroom and she returned to the truck for supplies approximately 30 seconds later. EMT K revealed when she went to Resident #1's bedroom, EMT L stated the resident was cold to touch; she has been down a while (without life for an extended amount of time). EMT K further revealed they attached a defibrillator and confirmed Asystole ([MEDICAL CONDITION] rhythm in which there is no electrical activity on the electrocardiogram monitor). EMT K further stated I felt her skin, she was cold, all extremities. The only warm area was under her back. Her eyes were closed, I opened them, and they were fixed and dilated. EMT K revealed the emergency crew did not provide Resident #1 CPR, she was dead on arrival (DOA). EMT K further revealed her cellular telephone displayed 1:37 a.m. when she received the call for assistance at the facility. EMT K further revealed the time of dispatch was 1:40 a.m., in route at 1:43 a.m., on the scene at 1:44 a.m., and back in service after the call at 3:00 a.m. During an interview on [DATE] at 4:10 p.m. with the DON, she confirmed no incident report or investigation was initiated for the night of Resident #1's death. The DON further revealed RN E stated the Resident was still alive when EMS walked in the door, I did not have a reason to make an incident report or investigate neglect. I assumed Resident #1 was alive as reported by RN E when EMS arrived. Review of RN E's documentation in Resident #1's Nurse Notes dated [DATE] at 2:58 a.m., revealed: CNA went to pt's (Resident #1) room and pt. was cold and clammy but responsive. CNA called nurse to check blood sugar. Nurse and orientee went to pt's room-Pt. lethargic barely responding t5o (to) tactile stimuli, blood sugar checked. Reading = 35. This nurse asked orientee to call 911-done. This nurse stayed at bedside v/s which continued to decline. Staff instructed to bring crash cart as EMT arrived to facility pt went into [MEDICAL CONDITION]. Pt care taken over by EMT and they began CPR (however, interview with EMT K revealed CPR was not initiated by emergency responders). EMT continue (continued) CPR to revive pt. This nurse advised t5o (to) call MD to pronice (pronounce) resident. This nurse received telephone order to pronce (pronounce) pt. via policy. Resident pronounced focis (focus) assessment: Resident had no carotidid (carotid) pulse, no apical pulse, no radial pulse. Further review of RN E's documentation in Resident #1's Nurse Notes dated [DATE] at 3:36 a.m., revealed: Continuation of previous note: no femoral pulse, no popliteal pulse, pedal pulse, and B/P unattainable. Family notified. Awaiting arrival to facility. Review of the facility Job Description for Charge Nurse dated 2010, revealed knowledge base included: Ability to organize work flow, respond to emergencies and note detail. Record review of RN E's CPR Certification revealed a CPR certification obtained on [DATE] with an expiration date of February 2018. Record review of Employee Punch Report revealed on [DATE], CNA F start meal time 11:58 p.m. and end meal time at12:40 a.m.; and NA G start meal time at 12:59 a.m. and end meal time at 1:30 a.m. Record review of undated policy provided by the facility revealed policy on Resident Rights stating in part: Exercise of Rights-The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. (Choice of CPR) Planning and Implementing Care- The resident has the right to be informed of, and participate in, his or her treatment, including: The right to receive the services and/or items included in the plan of care. (Choice of CPR) Self Determination- The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice. (Choice of CPR) Record review of the facility Nursing Policy & Procedure Manual 2003, Revised [DATE] Cardiopulmonary Resuscitation revealed in part: Cardiopulmonary resuscitation (CPR) is a method of providing systemic circulation by manual chest compression and oxygen by mouth-to-mouth breathing or providing air to the lungs via ambu bag. The procedure is performed to prevent death following cardiac or [MEDICAL CONDITION] arrest. Once initiate, it is continued until spontaneous circulation and respirations are restored, or until emergency services assume responsibility for resuscitation. Goals: Breathing and pulse will be reestablished in the resident. Procedure: 2. Ensure that the first responder calls EMS and returns to the scene with an AED (defibrillator). 3. After EMS has been called, implement the CPR protocol. 22. Document all care given and residents ' response to treatment. 23. The facility will document all code blue episodes. Recoed review of Employee Punch Report date range [DATE] - [DATE] revealed RN E was on duty [DATE] from 9:42 p.m. - 6:11 a.m., and on [DATE] from 4:46 p.m. to 10:18 p.m. Record review of Payroll Input/Personnel Action Form dated [DATE] revealed RN E was terminated from employment from this facility on [DATE] for CPR Policy Violation. The facility Administrator was notified on [DATE] at 3:15 p.m. of an Immediate Jeopardy for Quality of Care, failure to initiate CPR on a Full Code resident. A Plan of Removal was provided by the Administrator on [DATE] and included the following steps to be taken by the facility: 1. The DON, ADON, and regional nurse will verify all code status of all residents on [DATE]. To determine the code status of a resident, open the clinical record binder and the red or green sheet will be the first page of the resident chart: - If Full Code - there will be a green sheet of paper stating full code. - If DNR - there will be a red sheet of paper stating DNR with a copy of the DNR order. - All nursing staff has access to the chart. 2. The DON, ADON, and regional nurse will observe 100% of residents with a full code status on [DATE] to ensure that no resident is in distress and is in need of CPR at this time. 3. All nursing staff will be in-serviced by the DON, ADON, or regional nurse beginning on [DATE] and all staff not in-serviced on [DATE] will not be allowed to assume their duties until in-serviced regarding the following: - How to determine a resident ' s code status. - When to initiate CPR. - Continue CPR until relieved by other personnel or ordered ceased by a physician. - If the resident is in declining status, heart rate becomes less than 60 per minute, or respirations are less than 8 per minute, bather the emergency cart and AED and bring to the resident and continue to monitor closely. If heart rate or breathing ceases start CPR. Monitoring: 1. The DON and/or designee will question 8 nursing staff per week: - How to determine a resident ' s code status. - If a full code resident ceases breathing or is without a heartbeat, what should they do. 2. The DON and/or a designee will perform a mock code at least 1 time per week for 4 weeks then randomly thereafter. The mock code will consist of: - Mannequin will be the resident - A code blue will be announced - A mock call will be placed to EMS - Staff will locate and bring to the emergency cart and AED. - The AED pads will be placed in the correct area of the resident ' s body but not stuck to the resident. - The DON will then question the nurse or nurses what they would do if the resident was not breathing, was without a heartbeat, or both. Interviews with facility nurses and CNAs on [DATE] from 5:20 p.m. to 6:00 p.m. confirmed 2 nurses and 3 CNAs had received training in responding to CPR emergencies and on locations of residents' code status information. Nurses were able to verbalize steps to be taken immediately when residents were found to have no pulse and/or respirations. 100% of employed nursing staff members were in-serviced prior to starting their shifts. On [DATE] at 4:30 p.m., the Administrator was informed the IJ Plan of Removal was accepted. However, the facility remained out of compliance with a severity of actual harm with a scope identified as isolated. Information provided by the facility on [DATE] revealed there were 19 residents in the facility that had requested a full code status.

Based on interview and record review, the facility failed to provide services that meet professional standards of quality for 1 of 6 residents (#1) whose care was reviewed. RN E did not perform CPR to Resident #1 who requested full code status. RN E left resident #1's side while her vital signs were diminishing. Resident # 1 was pronounced deceased on [DATE] at 12:35 a.m. These failures resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as isolated until all residents were assessed and staff was in-serviced. These deficient practices could affect 19 residents in the facility who were Full Code and result in their wishes not being met leading to death. Findings: Review of the Texas Nursing Board Nursing Practice Act- Chapter 301 Subchapter A General Provisions revealed in part: Nursing Practice Act - Chapter 301 Subchapter A. General Provisions In this chapter: Professional nursing means the performance of an act that requires substantial specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of professional nursing. The term does not include acts of medical [DIAGNOSES REDACTED]. Professional nursing involves: (A) the observation, assessment, intervention, evaluation, rehabilitation, care and counsel, or health teachings of a person who is ill, injured, infirm, or experiencing a change in normal health processes; (E) The administration, supervision, and evaluation of nursing practices, policies, and procedures. Review of Resident #1's admission orders [REDACTED]. CPR Status was documented as Yes indicating Full Code. Review of resident #1's admission orders [REDACTED]. Review of resident #1's Blood Glucose Monitoring Data Sheet dated [DATE]-21, 2016 revealed unstable blood sugar readings. Resident # 1 blood Glucose readings ranged between 35 and 397. Review of Resident #1's Postmortem assessment dated [DATE] indicated at 12:35 a.m., Resident #1 had no respirations, no apical pulse, pupils were fixed and dilated, and body temperature that indicated hypothermia. Review of resident #1's, face sheet dated [DATE] revealed she had [DIAGNOSES REDACTED]. During an interview on [DATE] at 2:00 p.m., NA G said she took care of Resident #1, whose room was on the short hall, during the night shift on [DATE] that started at 10:00 p.m. NA G said staff working during that shift included herself, RN E as the Charge Nurse, CNA F, and LVN H on her first day of work at this facility. NA G further revealed she had clocked back in from lunch at approximately 1:30 a.m. NA G stated she and CNA F crossed paths in the hallway after she clocked back in from lunch and CNA F informed her I think we lost (Resident #1). NA G stated she went into resident #1's bedroom and observed RN E standing over resident. NA G stated I pretty much thought she had no life when I walked in the room initially. NA G stated she had worked in nursing for over [AGE] years and had experienced many deaths; you just know. NA G further stated I did touch her hand at one point (Resident #1), it was cool to touch. NA G further revealed RN E stated Resident #1 was dead before EMS arrived. NA G further revealed she did not witness RN E perform CPR on resident #1. During an interview on [DATE] at 2:25 p.m., RN E said she took care of Resident #1 during the night shift on [DATE] that started at 10:00 p.m. RN E said staff working during that shift included herself, an LVN orientee, and two CNAs she could not remember by name. RN E stated she was documenting behind the nurses station when CNA (could not remember name) informed her Resident #1 wanted insulin at approximately 12:30 a.m. RN E further revealed she checked Resident #1's blood sugar, stating the blood sugar reading was 35. RN E indicated Resident #1 was lethargic and sluggish and further stated Resident #1's vital signs were stable. RN E stated she instructed LVN orientee to call 911 due to Resident #1's sluggish state. RN E stated all this activity is occurring between 12:30 a.m. and 1:00 a.m., I do not know what time EMS arrived. RN E further revealed she did not initiate CPR on Resident #1. She stated there was no need, she was sluggish, cool to touch, vital signs decreasing when EMS arrived and took over. During a subsequent telephone interview on [DATE] at 2:30 p.m. with RN E, she stated she first saw Resident #1 around 10:,[DATE]:45p.m. on [DATE]. RN E stated Resident #1 was sound asleep, no problems at that point. RN E stated she touched Resident #1's arm and called her name. RN E stated Resident #1 went mmm, and I turned and left. RN E stated the next time she observed Resident #1 was about 12ish, not really sure. RN E stated Resident #1 told CNA she wanted insulin. RN E further stated I went to Resident #1's room, called her name. She was sluggish, lethargic; blood sugar reading at that time was 35. RN E indicated she walked back out into the hallway and requested LVN H obtain a sugar packet. RN E stated CNA (name unknown) helped Resident #1 sit up as RN E gave Resident #1 a sugar packet under her tongue. RN E stated Resident #1 was responsive determined by RN E pinching her, calling her name; RN E stated Resident #1 mumbled. RN E further stated Resident #1 became more heavy, lethargic, you know heavy, so I asked LVN orientee to call EMS. RN E stated she took Resident #1's vital signs three times before EMS arrived. RN E further revealed she did not document the second and third set of vital signs or the blood sugar reading in the medical record. RN E stated she did not provide emergency treatment or CPR for Resident #1. She further revealed she did not obtain oxygen with decreasing vital signs. RN E revealed she raised the head of the bed, further stating In my experience as an RN, it is helpful to raise the head of the bed up to 45 degrees for comfort for a resident with decreasing vital signs. RN E stated she was not at Resident #1's side when EMS arrived. RN E stated I made sure she was comfortable and went to the nurse's station. RN E further stated Nobody was with Resident #1 at that point; she was alive when I left her. RN E revealed Resident #1 was a full code and stated I did not perform CPR because she was not dead; she was comfortable when I left her to go to the nurse's station. RN E stated I forgot to document the vital signs, which are why they are not in the chart. During an interview on [DATE] at 2:55 p.m., CNA F said she took care of Resident #1 during the night shift on [DATE] that started at 10:00 p.m. CNA F said staff working during that shift included herself, RN E as the Charge Nurse, LVN H on her first day of work at this facility, and NA G. CNA F stated I returned from my lunch break at approximately 12:30 a.m., and CNA G went to lunch. CNA F further stated I went to check on Resident #1 at approximately 12:35 a.m., she had a low blood sugar the night before. CNA F further revealed she walked into Resident #1's room and thought she was asleep. She attempted to arouse Resident #1 and she would not respond. She was on her back leaning to her left, I got no response when I called her name and shook her. CNA F stated she notified RN E and LVN H immediately. CNA F stated RN E instructed her to obtain two packets of sugar, RN E checked Resident #1's blood sugar. CNA F stated it was 30 something. CNA F further revealed she assisted Resident #1 up in bed; RN E gave the resident two packs of sugar. CNA F further revealed Resident #1's body was limp, I was holding her in my arms, I did not think the resident was breathing. RN E instructed LVN H to call EMS at that time, CNA F was sent for a stethoscope. CNA F further revealed she ran into NA G in the hall and stated I think we lost resident #1. CNA F revealed she and NA G returned to resident #1's bedroom and RN E was handed the stethoscope further stating I did not see RN E use the stethoscope on Resident # 1. CNA F further stated RN E said, I think she is gone, she is not breathing, and she does not have a pulse. CNA F further revealed LVN H returned to the room and informed RN E Resident #1 was a full code; EMS was on the way. CNA F further revealed RN E did not perform CPR or request anyone else to provide CPR for Resident #1. CNA F further revealed the facility crash cart or the AED was not in the Resident's room. During an interview on [DATE] at 2:15p.m., Resident #1's attending physician stated Resident # 1 had a very difficult diabetes; Type I, failure of the pancreas. The attending physician confirmed Resident # 1's previous admission to this facility was dated [DATE] with a standing order for [MEDICATION NAME] for [DIAGNOSES REDACTED]. The attending physician confirmed he did not prescribe [MEDICATION NAME] for episodes of [DIAGNOSES REDACTED] on Resident #1's last admission on [DATE], further revealing [MEDICATION NAME] possibly would have been effective, we will not know. During an interview on [DATE] at 2:38 p.m. with EMT/Paramedic K, she stated RN E, and LVN H were at the nurse's station when they walked into the building. She further revealed EMT L and EMT M were shown to Resident #1's bedroom and she returned to the truck for supplies approximately 30 seconds later. EMT K revealed when she went to Resident #1's bedroom, EMT L stated the resident was cold to touch; she has been down a while (without life for an extended amount of time). EMT K further revealed they attached a defibrillator and confirmed Asystole ([MEDICAL CONDITION] rhythm in which there is no electrical activity on the electrocardiogram monitor). EMT K further stated I felt her skin, she was cold, all extremities. The only warm area was under her back. Her eyes were closed, I opened them, and they were fixed and dilated. EMT K revealed the emergency crew did not provide Resident #1 CPR, she was dead on arrival (DOA). EMT K further revealed her cellular telephone displayed 1:37 a.m. when she received the call for assistance at the facility. EMT K further revealed the time of dispatch was 1:40 a.m., in route at 1:43 a.m., on the scene at 1:44 a.m., and back in service after the call at 3:00 a.m. During an interview on [DATE] at 4:10 p.m. with the DON, she confirmed no incident report or investigation was initiated for the night of Resident #1's death. The DON further revealed RN E stated the Resident was still alive when EMS walked in the door, I did not have a reason to make an incident report or investigate neglect. I assumed Resident #1 was alive as reported by RN E when EMS arrived. Review of RN E's documentation in Resident #1's Nurse Notes dated [DATE] at 2:58 a.m., revealed: CNA went to pt's (Resident #1) room and pt. was cold and clammy but responsive. CNA called nurse to check blood sugar. Nurse and orientee went to pt's room-Pt. lethargic barely responding t5o (to) tactile stimuli, blood sugar checked. Reading = 35. This nurse asked orientee to call 911-done. This nurse stayed at bedside v/s which continued to decline. Staff instructed to bring crash cart as EMT arrived to facility pt went into [MEDICAL CONDITION]. Pt care taken over by EMT and they began CPR (however, interview with EMT K revealed CPR was not initiated by emergency responders). EMT continue (continued) CPR to revive pt. This nurse advised t5o (to) call MD to pronice (pronounce) resident. This nurse received telephone order to pronce (pronounce) pt. via policy. Resident pronounced focis (focus) assessment: Resident had no carotidid (carotid) pulse, no apical pulse, no radial pulse. Further review of RN E's documentation in Resident #1's Nurse Notes dated [DATE] at 3:36 a.m., revealed: Continuation of previous note: no femoral pulse, no popliteal pulse, pedal pulse, and B/P unattainable. Family notified. Awaiting arrival to facility. Review of the facility Job Description for Charge Nurse dated 2010, revealed knowledge base included: Ability to organize work flow, respond to emergencies and note detail. Record review of RN E's CPR Certification revealed a CPR certification obtained on [DATE] with an expiration date of February 2018. Record review of Employee Punch Report revealed on [DATE], CNA F start meal time 11:58 p.m. and end meal time at12:40 a.m.; and NA G start meal time at 12:59 a.m. and end meal time at 1:30 a.m. Record review of undated policy provided by the facility revealed policy on Resident Rights stating in part: Exercise of Rights-The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. (Choice of CPR) Planning and Implementing Care- The resident has the right to be informed of, and participate in, his or her treatment, including: The right to receive the services and/or items included in the plan of care. (Choice of CPR) Self Determination- The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice. (Choice of CPR) Record review of the facility Nursing Policy & Procedure Manual 2003, Revised [DATE] Cardiopulmonary Resuscitation revealed in part: Cardiopulmonary resuscitation (CPR) is a method of providing systemic circulation by manual chest compression and oxygen by mouth-to-mouth breathing or providing air to the lungs via ambu bag. The procedure is performed to prevent death following cardiac or [MEDICAL CONDITION] arrest. Once initiate, it is continued until spontaneous circulation and respirations are restored, or until emergency services assume responsibility for resuscitation. Goals: Breathing and pulse will be reestablished in the resident. Procedure: 2. Ensure that the first responder calls EMS and returns to the scene with an AED (defibrillator). 3. After EMS has been called, implement the CPR protocol. 22. Document all care given and residents ' response to treatment. 23. The facility will document all code blue episodes. Recoed review of Employee Punch Report date range [DATE] - [DATE] revealed RN E was on duty [DATE] from 9:42 p.m. - 6:11 a.m., and on [DATE] from 4:46 p.m. to 10:18 p.m. Record review of Payroll Input/Personnel Action Form dated [DATE] revealed RN E was terminated from employment from this facility on [DATE] for CPR Policy Violation. The facility Administrator was notified on [DATE] at 3:15 p.m. of an Immediate Jeopardy for Quality of Care, failure to initiate CPR on a Full Code resident. A Plan of Removal was provided by the Administrator on [DATE] and included the following steps to be taken by the facility: 1. The DON, ADON, and regional nurse will verify all code status of all residents on [DATE]. To determine the code status of a resident, open the clinical record binder and the red or green sheet will be the first page of the resident chart: - If Full Code - there will be a green sheet of paper stating full code. - If DNR - there will be a red sheet of paper stating DNR with a copy of the DNR order. - All nursing staff has access to the chart. 2. The DON, ADON, and regional nurse will observe 100% of residents with a full code status on [DATE] to ensure that no resident is in distress and is in need of CPR at this time. 3. All nursing staff will be in-serviced by the DON, ADON, or regional nurse beginning on [DATE] and all staff not in-serviced on [DATE] will not be allowed to assume their duties until in-serviced regarding the following: - How to determine a resident ' s code status. - When to initiate CPR. - Continue CPR until relieved by other personnel or ordered ceased by a physician. - If the resident is in declining status, heart rate becomes less than 60 per minute, or respirations are less than 8 per minute, bather the emergency cart and AED and bring to the resident and continue to monitor closely. If heart rate or breathing ceases start CPR. Monitoring: 1. The DON and/or designee will question 8 nursing staff per week: - How to determine a resident ' s code status. - If a full code resident ceases breathing or is without a heartbeat, what should they do. 2. The DON and/or a designee will perform a mock code at least 1 time per week for 4 weeks then randomly thereafter. The mock code will consist of: - Mannequin will be the resident - A code blue will be announced - A mock call will be placed to EMS - Staff will locate and bring to the emergency cart and AED. - The AED pads will be placed in the correct area of the resident ' s body but not stuck to the resident. - The DON will then question the nurse or nurses what they would do if the resident was not breathing, was without a heartbeat, or both. Interviews with facility nurses and CNAs on [DATE] from 5:20 p.m. to 6:00 p.m. confirmed 2 nurses and 3 CNAs had received training in responding to CPR emergencies and on locations of residents' code status information. Nurses were able to verbalize steps to be taken immediately when residents were found to have no pulse and/or respirations. 100% of employed nursing staff members were in-serviced prior to starting their shifts. On [DATE] at 4:30 p.m., the Administrator was informed the IJ Plan of Removal was accepted. However, the facility remained out of compliance with a severity of actual harm with a scope identified as isolated. Information provided by the facility on [DATE] revealed there were 19 residents in the facility that had requested a full code status.

Based on interview and record review, the facility failed to provide the necessary care and services to attain and maintain the highest practicable physical well-being in accordance with the care plan for 1 of 6 residents (resident #1) whose care was reviewed for Code Status. RN E did not perform CPR to Resident #1 who requested full code status. RN E left resident #1s side while her vital signs were diminishing. Resident # 1 was pronounced deceased on [DATE] at 12:35 a.m. These failures resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as isolated until all residents were assessed and staff was in-serviced. These deficient practices could affect 19 residents in the facility who were Full Code and result in their wishes not being met leading to death. Findings: Review of Resident #1's admission orders [REDACTED]. CPR Status was documented as Yes indicating Full Code. Review of resident #1's admission orders [REDACTED]. Review of resident #1's Blood Glucose Monitoring Data Sheet dated [DATE]-21, 2016 revealed unstable blood sugar readings. Resident # 1 blood Glucose readings ranged between 35 and 397. Review of Resident #1's Postmortem assessment dated [DATE] indicated at 12:35 a.m., Resident #1 had no respirations, no apical pulse, pupils were fixed and dilated, and body temperature that indicated hypothermia. Review of resident #1's, face sheet dated [DATE] revealed she had [DIAGNOSES REDACTED]. During an interview on [DATE] at 2:00 p.m., NA G said she took care of Resident #1, whose room was on the short hall, during the night shift on [DATE] that started at 10:00 p.m. NA G said staff working during that shift included herself, RN E as the Charge Nurse, CNA F, and LVN H on her first day of work at this facility. NA G further revealed she had clocked back in from lunch at approximately 1:30 a.m. NA G stated she and CNA F crossed paths in the hallway after she clocked back in from lunch and CNA F informed her I think we lost (Resident #1). NA G stated she went into resident #1's bedroom and observed RN E standing over resident. NA G stated I pretty much thought she had no life when I walked in the room initially. NA G stated she had worked in nursing for over [AGE] years and had experienced many deaths; you just know. NA G further stated I did touch her hand at one point (Resident #1), it was cool to touch. NA G further revealed RN E stated Resident #1 was dead before EMS arrived. NA G further revealed she did not witness RN E perform CPR on resident #1. During an interview on [DATE] at 2:25 p.m., RN E said she took care of Resident #1 during the night shift on [DATE] that started at 10:00 p.m. RN E said staff working during that shift included herself, an LVN orientee, and two CNAs she could not remember by name. RN E stated she was documenting behind the nurses station when CNA (could not remember name) informed her Resident #1 wanted insulin at approximately 12:30 a.m. RN E further revealed she checked Resident #1's blood sugar, stating the blood sugar reading was 35. RN E indicated Resident #1 was lethargic and sluggish and further stated Resident #1's vital signs were stable. RN E stated she instructed LVN orientee to call 911 due to Resident #1's sluggish state. RN E stated all this activity is occurring between 12:30 a.m. and 1:00 a.m., I do not know what time EMS arrived. RN E further revealed she did not initiate CPR on Resident #1. She stated there was no need, she was sluggish, cool to touch, vital signs decreasing when EMS arrived and took over. During a subsequent telephone interview on [DATE] at 2:30 p.m. with RN E, she stated she first saw Resident #1 around 10:,[DATE]:45p.m. on [DATE]. RN E stated Resident #1 was sound asleep, no problems at that point. RN E stated she touched Resident #1's arm and called her name. RN E stated Resident #1 went mmm, and I turned and left. RN E stated the next time she observed Resident #1 was about 12ish, not really sure. RN E stated Resident #1 told CNA she wanted insulin. RN E further stated I went to Resident #1's room, called her name. She was sluggish, lethargic; blood sugar reading at that time was 35. RN E indicated she walked back out into the hallway and requested LVN H obtain a sugar packet. RN E stated CNA (name unknown) helped Resident #1 sit up as RN E gave Resident #1 a sugar packet under her tongue. RN E stated Resident #1 was responsive determined by RN E pinching her, calling her name; RN E stated Resident #1 mumbled. RN E further stated Resident #1 became more heavy, lethargic, you know heavy, so I asked LVN orientee to call EMS. RN E stated she took Resident #1's vital signs three times before EMS arrived. RN E further revealed she did not document the second and third set of vital signs or the blood sugar reading in the medical record. RN E stated she did not provide emergency treatment or CPR for Resident #1. She further revealed she did not obtain oxygen with decreasing vital signs. RN E revealed she raised the head of the bed, further stating In my experience as an RN, it is helpful to raise the head of the bed up to 45 degrees for comfort for a resident with decreasing vital signs. RN E stated she was not at Resident #1's side when EMS arrived. RN E stated I made sure she was comfortable and went to the nurse's station. RN E further stated Nobody was with Resident #1 at that point; she was alive when I left her. RN E revealed Resident #1 was a full code and stated I did not perform CPR because she was not dead; she was comfortable when I left her to go to the nurse's station. RN E stated I forgot to document the vital signs, which are why they are not in the chart. During an interview on [DATE] at 2:55 p.m., CNA F said she took care of Resident #1 during the night shift on [DATE] that started at 10:00 p.m. CNA F said staff working during that shift included herself, RN E as the Charge Nurse, LVN H on her first day of work at this facility, and NA G. CNA F stated I returned from my lunch break at approximately 12:30 a.m., and CNA G went to lunch. CNA F further stated I went to check on Resident #1 at approximately 12:35 a.m., she had a low blood sugar the night before. CNA F further revealed she walked into Resident #1's room and thought she was asleep. She attempted to arouse Resident #1 and she would not respond. She was on her back leaning to her left, I got no response when I called her name and shook her. CNA F stated she notified RN E and LVN H immediately. CNA F stated RN E instructed her to obtain two packets of sugar, RN E checked Resident #1's blood sugar. CNA F stated it was 30 something. CNA F further revealed she assisted Resident #1 up in bed; RN E gave the resident two packs of sugar. CNA F further revealed Resident #1's body was limp, I was holding her in my arms, I did not think the resident was breathing. RN E instructed LVN H to call EMS at that time, CNA F was sent for a stethoscope. CNA F further revealed she ran into NA G in the hall and stated I think we lost resident #1. CNA F revealed she and NA G returned to resident #1's bedroom and RN E was handed the stethoscope further stating I did not see RN E use the stethoscope on Resident # 1. CNA F further stated RN E said, I think she is gone, she is not breathing, and she does not have a pulse. CNA F further revealed LVN H returned to the room and informed RN E Resident #1 was a full code; EMS was on the way. CNA F further revealed RN E did not perform CPR or request anyone else to provide CPR for Resident #1. CNA F further revealed the facility crash cart or the AED was not in the Resident's room. During an interview on [DATE] at 2:15p.m., Resident #1's attending physician stated Resident # 1 had a very difficult diabetes; Type I, failure of the pancreas. The attending physician confirmed Resident # 1's previous admission to this facility was dated [DATE] with a standing order for [MEDICATION NAME] for [DIAGNOSES REDACTED]. The attending physician confirmed he did not prescribe [MEDICATION NAME] for episodes of [DIAGNOSES REDACTED] on Resident #1's last admission on [DATE], further revealing [MEDICATION NAME] possibly would have been effective, we will not know. During an interview on [DATE] at 2:38 p.m. with EMT/Paramedic K, she stated RN E, and LVN H were at the nurse's station when they walked into the building. She further revealed EMT L and EMT M were shown to Resident #1's bedroom and she returned to the truck for supplies approximately 30 seconds later. EMT K revealed when she went to Resident #1's bedroom, EMT L stated the resident was cold to touch; she has been down a while (without life for an extended amount of time). EMT K further revealed they attached a defibrillator and confirmed Asystole ([MEDICAL CONDITION] rhythm in which there is no electrical activity on the electrocardiogram monitor). EMT K further stated I felt her skin, she was cold, all extremities. The only warm area was under her back. Her eyes were closed, I opened them, and they were fixed and dilated. EMT K revealed the emergency crew did not provide Resident #1 CPR, she was dead on arrival (DOA). EMT K further revealed her cellular telephone displayed 1:37 a.m. when she received the call for assistance at the facility. EMT K further revealed the time of dispatch was 1:40 a.m., in route at 1:43 a.m., on the scene at 1:44 a.m., and back in service after the call at 3:00 a.m. During an interview on [DATE] at 4:10 p.m. with the DON, she confirmed no incident report or investigation was initiated for the night of Resident #1's death. The DON further revealed RN E stated the Resident was still alive when EMS walked in the door, I did not have a reason to make an incident report or investigate neglect. I assumed Resident #1 was alive as reported by RN E when EMS arrived. Review of RN E's documentation in Resident #1's Nurse Notes dated [DATE] at 2:58 a.m., revealed: CNA went to pt's (Resident #1) room and pt. was cold and clammy but responsive. CNA called nurse to check blood sugar. Nurse and orientee went to pt's room-Pt. lethargic barely responding t5o (to) tactile stimuli, blood sugar checked. Reading = 35. This nurse asked orientee to call 911-done. This nurse stayed at bedside v/s which continued to decline. Staff instructed to bring crash cart as EMT arrived to facility pt went into [MEDICAL CONDITION]. Pt care taken over by EMT and they began CPR (however, interview with EMT K revealed CPR was not initiated by emergency responders). EMT continue (continued) CPR to revive pt. This nurse advised t5o (to) call MD to pronice (pronounce) resident. This nurse received telephone order to pronce (pronounce) pt. via policy. Resident pronounced focis (focus) assessment: Resident had no carotidid (carotid) pulse, no apical pulse, no radial pulse. Further review of RN E's documentation in Resident #1's Nurse Notes dated [DATE] at 3:36 a.m., revealed: Continuation of previous note: no femoral pulse, no popliteal pulse, pedal pulse, and B/P unattainable. Family notified. Awaiting arrival to facility. Review of the facility Job Description for Charge Nurse dated 2010, revealed knowledge base included: Ability to organize work flow, respond to emergencies and note detail. Record review of RN E's CPR Certification revealed a CPR certification obtained on [DATE] with an expiration date of February 2018. Record review of Employee Punch Report revealed on [DATE], CNA F start meal time 11:58 p.m. and end meal time at12:40 a.m.; and NA G start meal time at 12:59 a.m. and end meal time at 1:30 a.m. Record review of undated policy provided by the facility revealed policy on Resident Rights stating in part: Exercise of Rights-The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. (Choice of CPR) Planning and Implementing Care- The resident has the right to be informed of, and participate in, his or her treatment, including: The right to receive the services and/or items included in the plan of care. (Choice of CPR) Self Determination- The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice. (Choice of CPR) Record review of the facility Nursing Policy & Procedure Manual 2003, Revised [DATE] Cardiopulmonary Resuscitation revealed in part: Cardiopulmonary resuscitation (CPR) is a method of providing systemic circulation by manual chest compression and oxygen by mouth-to-mouth breathing or providing air to the lungs via ambu bag. The procedure is performed to prevent death following cardiac or [MEDICAL CONDITION] arrest. Once initiate, it is continued until spontaneous circulation and respirations are restored, or until emergency services assume responsibility for resuscitation. Goals: Breathing and pulse will be reestablished in the resident. Procedure: 2. Ensure that the first responder calls EMS and returns to the scene with an AED (defibrillator). 3. After EMS has been called, implement the CPR protocol. 22. Document all care given and residents ' response to treatment. 23. The facility will document all code blue episodes. Recoed review of Employee Punch Report date range [DATE] - [DATE] revealed RN E was on duty [DATE] from 9:42 p.m. - 6:11 a.m., and on [DATE] from 4:46 p.m. to 10:18 p.m. Record review of Payroll Input/Personnel Action Form dated [DATE] revealed RN E was terminated from employment from this facility on [DATE] for CPR Policy Violation. The facility Administrator was notified on [DATE] at 3:15 p.m. of an Immediate Jeopardy for Quality of Care, failure to initiate CPR on a Full Code resident. A Plan of Removal was provided by the Administrator on [DATE] and included the following steps to be taken by the facility: 1. The DON, ADON, and regional nurse will verify all code status of all residents on [DATE]. To determine the code status of a resident, open the clinical record binder and the red or green sheet will be the first page of the resident chart: - If Full Code - there will be a green sheet of paper stating full code. - If DNR - there will be a red sheet of paper stating DNR with a copy of the DNR order. - All nursing staff has access to the chart. 2. The DON, ADON, and regional nurse will observe 100% of residents with a full code status on [DATE] to ensure that no resident is in distress and is in need of CPR at this time. 3. All nursing staff will be in-serviced by the DON, ADON, or regional nurse beginning on [DATE] and all staff not in-serviced on [DATE] will not be allowed to assume their duties until in-serviced regarding the following: - How to determine a resident ' s code status. - When to initiate CPR. - Continue CPR until relieved by other personnel or ordered ceased by a physician. - If the resident is in declining status, heart rate becomes less than 60 per minute, or respirations are less than 8 per minute, bather the emergency cart and AED and bring to the resident and continue to monitor closely. If heart rate or breathing ceases start CPR. Monitoring: 1. The DON and/or designee will question 8 nursing staff per week: - How to determine a resident ' s code status. - If a full code resident ceases breathing or is without a heartbeat, what should they do. 2. The DON and/or a designee will perform a mock code at least 1 time per week for 4 weeks then randomly thereafter. The mock code will consist of: - Mannequin will be the resident - A code blue will be announced - A mock call will be placed to EMS - Staff will locate and bring to the emergency cart and AED. - The AED pads will be placed in the correct area of the resident ' s body but not stuck to the resident. - The DON will then question the nurse or nurses what they would do if the resident was not breathing, was without a heartbeat, or both. Interviews with facility nurses and CNAs on [DATE] from 5:20 p.m. to 6:00 p.m. confirmed 2 nurses and 3 CNAs had received training in responding to CPR emergencies and on locations of residents' code status information. Nurses were able to verbalize steps to be taken immediately when residents were found to have no pulse and/or respirations. 100% of employed nursing staff members were in-serviced prior to starting their shifts. On [DATE] at 4:30 p.m., the Administrator was informed the IJ Plan of Removal was accepted. However, the facility remained out of compliance with a severity of actual harm with a scope identified as isolated. Information provided by the facility on [DATE] revealed there were 19 residents in the facility that had requested a full code status.