Every finding on record at Cherokee Trails Nursing Home

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 1 of 1 facility (2 of 7 mechanical lift slings) and 1 of 4 residents (Resident #55) reviewed for hazards:1. The facility failed to ensure items labeled keep out of reach of children and a razor were not kept in a basin in Resident #55's room on the secured unit.2. The facility failed to remove faded, worn and damaged mechanical lift slings from service. This failure could result in a loss of quality of life due to injuries.Findings included:1. Record review of a facility face sheet dated 5/19/26 for Resident #55 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: myocardial infarction (heart attack) and dementia.Record review of a Quarterly MDS assessment dated [DATE] for Resident #55 indicated she had severe cognitive impairment by Staff Assessment for Mental Status. She was dependent or required maximum assistance with most ADLs. Record review of a comprehensive care plan dated 9/2/25 for Resident #55 indicated she had cognitive impairment. During an observation on 5/18/26 at 10:17 am a bath basin was observed in Resident #55's room on the secured unit, and the following items were observed in the basin: A safety razor vitamin A & D ointment (labeled keep out of reach of children) an aerosol can of dry shampoo (labeled keep out of reach of children) a bottle of mouth rinse (labeled keep out of reach of children)During an interview on 5/18/26 at 2:30 pm, LVN B said the hospice aide must have left them in the resident's room. She said the items could be dangerous for cognitively impaired residents that wandered.During an interview on 5/19/26 at 9:50 am, the Administrator said the facility did not have a policy for safe environment.During an interview on 05/20/2026 11:09 am, the Administrator said if razors and items labeled keep out of reach of children were left in resident rooms in the secured unit, it could be a potential safety concern for residents. She said the facility had begun in-servicing staff and hospice staff. She also said going forward she would ensure Department Managers would look for safety concerns during their rounds. 2. During an interview and observation of the facility's laundry room on 05/19/2026 10:30 am, the Laundry Technician said she had worked at the facility for 12 years. The Laundry Supervisor said she washed the lift slings and hung them up to air dry. She said that she used bleach in the wash cycle if slings are soiled with bowel movement. Two of the seven mechanical lift slings hanging on the wall racks drying in the clean linen area had faded straps, light in color (light gray, light teal and light purple) not bright and vivid colors as the other mechanical lift slings hanging on the rack. One of the mechanical lift slings care labels was faded, illegible and attached by a few threads of stitching. The Laundry Supervisor said she had received in-servicing on mechanical lift sling care in the past, but it had been a long time. She said she considered the two lift slings still useable. She said that if a lift sling broke it could cause a fall with injury. During an observation and interview on 05/19/26 at 11:00 am, the Administrator observed the 2 mechanical lift slings. She said the risk to the resident was injury if the lift sling broke during transfer and caused a fall. The Administrator said she would remove the damaged slings from service. She said that if the lift sling broke it could cause a fall with injury. During an interview on 05/19/26 at 2:15 pm, the ADON said she was responsible for removing damaged slings from service. She said the straps on the mechanical lift slings were faded and care tags were illegible. She said she would in serviced nursing staff when to remove lift slings from service. The ADON said the straps could break on damaged lift slings and cause a fall with resulting injuries. During an interview on 05/19/26 at 3:15 pm, the Housekeeping-Laundry Supervisor said he had completed an in-service with laundry staff on sling care that included not bleaching and hanging them to dry. He said that if a sling broke it could cause injury to a resident due to a fall.Record review of the facility's policy titled admission Criteria for Secured Continuous Care Unit dated 5/16/2024 read: .The secure unit provides a safe living environment for residents with dementia who wander without regard for their own safety . Record review of the facility's policy titled Quality of Life-Homelike Environment revised May 2017 reflected, .Residents are provided with a safe, clean, comfortable and homelike environment .Record review of the facility's policy titled Hydraulic Lift (Hoyer Lift) revised September 2024 reflected, .Note: Follow Manufacturer recommendations.Record review of the manufacturer's guidelines Full Body Slings - Instructions for use accessed at www.medline.com on 05/19/26 read .Always inspect slings prior to each use. Signs of rips, tears, or frays indicate sling wear which is unsafe and could result in injury. Signs of color fading, bleached areas, or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury. Missing or illegible care labels. Any slings with signs of wear or improper laundering should be immediately removed from use .Record review of the manufacturer's instructions for Proactive full body slings accessed https://proactivemedical.com/products/lifts-slings/patient-slings/full-body-sling/ accessed 05/19/2026 indicated, .Proactive medical products . Guideline for Identifying Deteriorated Slings Accelerated Deterioration from Bleach, High Temperature Wash or Drying Slings, especially loop straps that have been damaged from being laundered in unsuitable conditions (bleach, high heat wash or dry) may appear to be in good condition but the actual tensile strength of the material may be compromised and pose a safety risk and should not be used for lifting a patient or resident. This Guide is intended to help staff and caregivers better identify slings that have been exposed to above laundry conditions and subsequent loss of tensile strength. We encourage any sling identified with the following characteristics to be removed from service immediately as a preventive measure. Proactive Medical slings have been designed and tested for laundry wash conditions of 170 degrees and air dry or dry at low temperature. The slings should never be bleached. Commercial washer and dryers are not recommended. Care instructions on the sling label should always be followed. Laundry equipment should be properly maintained and repaired when necessary. Completely Faded / Missing / Illegible Tag while the main body of the sling fabric is still intact and in relatively good condition. Colors are not faded or show very little fading .

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff, in 1 of two medications rooms (the front one hundred hallway medication room) reviewed for environmental concerns.The facility failed to ensure the medication room floor and under sink area, were free of roach droppings, and there was no open hole underneath the sink.These failures could place residents, staff and visitors at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, unsafe and creating a contamination risk (Additionally, cockroach droppings and skin proteins (tropomyosin) can trigger allergic reactions and worsen asthma or other respiratory conditions). Findings included:During an observation and interview on 05/20/2026 9:00 AM, roach droppings were scattered on the floor from entrance into the room for about three feet next to the sink in the medication room. An open hole 24 inches across and 12 inches long was observed with pipes exposed to the wall in the back portion of the cabinet that houses the sink . Roach droppings cover the bottom of the cabinet, up the sides of the cabinet and spill out of the cabinet into the floor. There were no active roaches seen. MA D stated, that is the worst thing I have ever seen. MA D said there were roach droppings and they were disgusting. MA D said she was aware that the medication room was dirty, but she had not looked underneath the sink and had not noticed the roach droppings on the floor. MA D said she was aware that droppings could cause allergies and spread infections. During an observation and interview on 05/20/2026 at 9:10 AM, the Housekeeping/Laundry Supervisor said he had his staff clean the medication room, when requested by nursing, but not routinely. He said he would clean the area right away. He said that the roach droppings were unsanitary. The Housekeeping/Laundry Supervisor said the condition of the medication room was unacceptable.During an observation of the medication room and interview on 05/20/2026 at 10:00 AM, the DON said she had just started working at the facility on Monday 05/18/2026. She said she had not been inside the medication room or was made aware of the unsanitary condition of the floor and underneath the sink. She said she would be providing an in- service to nursing staff to report needed cleaning and repairs needed to administration. She said the droppings were unsanitary and could spread infection.During an observation and interview on 05/20/2026 at 10:30 AM, the Administrator looked at pictures taken by this surveyor of the medication room and roach droppings. She said she was not aware of the hole underneath the sink roach droppings. The Administrator said or the droppings were unsanitary, could spread infection and cause allergic reactions. She said the DON and the ADON were responsible for oversight of the medication room and they should be setting up a time with housekeeping for routine cleanings.During an observation on 05/202/2026 at 1:45 PM, the hole underneath the medication room sink had been repaired and patched. The roach droppings had been cleaned from the floor and underneath the sink. Record review of the facility's policy titled Quality of Life-Homelike Environment revised May 2017 reflected, .Residents are provided with a safe, clean, comfortable and homelike environment . Record Review of Pest control requirements in Long Term Care, accessed 5/20/2026 at www. Orkin.com Roaches carry germs that can cause pneumonia, diarrhea and food poisoning. Cockroach droppings can also inflame allergies or asthmatic conditions.Risks of Cockroach Droppings in a Long-Term Care Facility Storage AreaCockroach droppings (cast skins) in a long-term care facility's storage area can pose serious health, safety, and compliance risks.1. Pathogen and Allergen ExposureCockroaches can carry and spread over 30 types of harmful bacteria, including E. coli, Salmonella, and Staphylococcus, which can contaminate surfaces, stored food, or medical supplies Assured Environments+1. In a storage area, droppings can settle on shelves, packaging, or equipment, creating a contamination risk for residents, staff, and visitors. Additionally, cockroach droppings and skin proteins (tropomyosin) can trigger allergic reactions and worsen asthma or other respiratory conditions Assured Environments+1.2. Impact on Vulnerable ResidentsLong-term care residents often have weakened immune systems or chronic health conditions. Exposure to cockroach allergens or pathogens can lead to infections, respiratory distress, or other complications Orkin+1. Even indirect contact with contaminated storage items can be harmful.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety for facility's only kitchen reviewed for food storage. 1. The facility did not ensure foods in the refrigerator, freezer and dry storage area were appropriately stored, labeled and dated when opened or removed from their original packaging or opened on 5/18/26. 2. The facility did not ensure food in the freezer was appropriately labeled and dated when removed from original packaging on 5/18/26. 3. The facility did not ensure food was not kept on the floor in kitchen and dry storage area on 5/18/26 and 5/19/26. 4. The facility did not ensure [NAME] C appropriately performed hand hygiene while preparing food for meal service on 5/19/26. This failure could place residents who received their meals from the kitchen at risk of food-borne illness.Findings include:During an observation on 5/18/26 at 9:45 am the following observations were made: In dry storage a zip top plastic bag was observed on shelving with what appeared to be vanilla wafer cookies inside. There was no label indicating contents, no open date, and no use by date. In dry storage there was a large, opened bag of flour sitting on the floor. In freezer there was a bag of what appeared to be thick slices of ham opened, bag was tied in a knot. There was no label of contents, no opened date, and no use by date. In freezer there was a bag of what appeared to be raisin bread, and the bag was tied in a knot. There was no label with contents, and there was no open date or use by date. In refrigerator there was a carton of thickened sweet tea with no opened date, no use by date, and the carton was not closed with the lid, lid was missing and carton was open to air. In kitchen against back wall, there was a box of sweet potatoes sitting on the floor with a large, unopened bag of sugar sitting on top of it. During an observation on 5/19/26 at 8:30 am, the box of sweet potatoes was still observed on the floor in the kitchen against the back wall with a large, unopened bag of sugar sitting on top of it.During an observation on 05/19/2026 between 11:00 am and 11:45 am [NAME] C was observed pureeing foods and checking food temperatures. [NAME] C was observed removing gloves after temping food, she then was observed to rinse her hands at the dishwashing sink, but she did not use soap. She then put on clean gloves and began placing food on steam table. She was again observed removing gloves and putting on clean gloves without washing hands and continue setting up food for meal service. After removing gloves again, she was observed to go to handwashing sink and rinse hands off, again, using no soap and then proceeded to wipe hands on her pants to dry them and put on clean gloves. Paper towels and soap were observed next to the handwashing sink. During an interview on 5/18/26 at 9:55 am, [NAME] A said the meat in the freezer was pork chops, and she had just put in there this morning, and the bread was also left over from breakfast this morning and she just forgot to date and label them when she put them in the freezer. During an interview on 05/19/2026 at 1:34 pm, [NAME] C said she was changing gloves so often because she was unsure when she touched the trash can if her hands were dirty. She said she had never been observed by state before and was nervous. She said she did not use soap at the sink because there was no soap. She said wiping her hands on her pants to dry them was not good because there could be germs on her pants. She said washing hands was important in the kitchen to prevent cross-contamination. She said she was not aware of a set schedule to clean the oven, but they would clean it when the dietary manager told them to. During an interview on 5/20/2026 at 9:58 am, the Dietary Manager said that if foods were not properly stored, dated and labeled; food preparation areas were not properly cleaned; and staff did not properly wash their hands, residents could be at risk of illness due to food contamination. She said going forward, she would be providing more education and in-services. She said they have a weekly cleaning schedule posted, and she would be responsible to monitor cleaning going forward to ensure everything was clean. During an interview on 05/20/2026 11:12 am, the Administrator said if proper procedures related to hand hygiene, food storage and labeling, and sanitation were not followed, there was a risk for infection control concerns and food safety concerns for residents that consumed food out of the kitchen. She said going forward, she would be providing more education and in-services for kitchen staff, and she would personally perform spot checks in the kitchen to make unannounced observations. Record review of the facility's policy titled Hand Hygiene revised 2/11/22 read: .Hand hygiene technique when using soap and water: a. Wet hands with water. Avoid using hot water to prevent drying of skin. b. Apply to hands the amount of soap recommended by the manufacturer. c. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. d. Rinse hands with water. e. Dry thoroughly with a single-use towel. f. Use clean towel to turn off the faucet . and .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . Record review of the facility's policy titled Equipment Cleaning Procedures revised in 1/2013 read: .Routine cleaning will be practiced on a regular basis in order to keep all dietary equipment and the environment safe, sanitary, and in compliance with state and federal regulations . and .Clean ovens and ranges weekly . and .All equipment should be cleaned as needed. Equipment that becomes soiled between scheduled cleanings must be properly cleaned and sanitized . Record review of the facility's policy titled Storage of Frozen and Refrigerated Foods revised on 10/2017 read: .Refrigerated products that are opened must be labeled with an opened on date. The use by date is 7 days from when the product was opened, unless there is a manufacturer's use by, expiration or sell by date . and .Foods prepared in the building and properly cooled will be dated as to the date prepared and use by date which will by 7 days from the date prepared . and .Packaged frozen items that are opened and not used in their entirety must be properly sealed, labeled and dated for continued storage . and .All refrigerated and frozen items in storage will contain a minimum label of common name of product and dated as noted above . Record review of the facility's policy titled Dry Food and Supplies Storage revised on 11/15/2017 read .The focus of protection for dry storage is to keep non-refrigerated foods, disposable dishware, and napkins in a clean, dry area, which is free from contaminants . and .Food and food products should always be kept off the floor and clear of ceiling sprinklers, sewer/waste, disposal pipes, and vents to maintain food quality and prevent contamination . and .Items must be stored at least 6 off the floor. Foods should be off the floor and clear of ceiling sprinklers, sewer pipes and vents. This allows for easy cleaning and discourages pest harborage . and .All opened products must be resealed effectively and properly labeled, dated and rotated for use . and .Use by, Best by and Sell by dates should routinely be checked to ensure that items which have expired are discarded appropriately .

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions for 2 of 2 medication storage refrigerators reviewed for labeling and storage (medication storage refrigerator in the medication room on mid- hallway 100 and medication refrigerator for the front hallway 100). The facility failed to monitor and record temperatures of the refrigerator used for medication storage daily as required per facility policy for medication storage. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications.Findings included: During an observation and interview on 05/20/2026 9:00 AM of the medication storage refrigerator in the medication room on front hallway 100, revealed 3 Insulin pens and three insulin vials requiring 36 to 46 degrees refrigeration. There was no temperature log for the refrigerator in the medication room. MA D said there should be a log, and the staff should check and adjust the temperature every day. During an observation and interview on 05/20/2026 9:15 AM of the medication storage refrigerator in the medication room on mid- hallway 100 revealed 3 Insulin pens requiring 36 to 46 degrees in the refrigeration, and there was no temperature log in the medication room. MA D said there should be a log, and the staff should check and adjust the temperature every day. She said the temperature could be too cold or too hot and effect the medications effectiveness. Record review of the May 2026 refrigerator log for the medication refrigerator for the front hallway 100 refrigerator, revealed the following days had no temperature logged: 5/18/26 and 5/19/2026. Record review of the April 2026 refrigerator log for the medication refrigerator for the front hallway 100 refrigerator, revealed the following days had no temperature logged:04/04/2026, 04/05/2026, 04/06/2026, 04/20/2026, 04/22/2026, and 04/23/2026. During a record review of the May 2026 refrigerator log for the mid hallway 100 medication refrigerator, the following days had no temperature logged:05/04/2026, 05/07/2026, 05/08/2026, 05/16/2026, 05/17/2026 and 05/18/2026 During a record review of the April 2026 refrigerator log for the mid hallway 100 medication refrigerator the following days had no temperature logged: 04/10/2026, 04/14/2026, 04/15/2026, 04/16/2026, 04/17/2026, 04/18/2026, 04/19/2026 and 04/20/2026. During an interview 05/20/2026 11:00 AM with the DON she said she had just started at the facility this week and had already started in-services with staff on obtaining and logging temperatures for the medication refrigerators. She said not following the facility's policy and manufacturers medication recommendations could result in loss of medication effectiveness of medications stored too cold or too hot. During an interview 05/20/2026 11:02 AM with the Administrator, she said the ADON and the DON were responsible for training the nursing staff on medication storage and logging storage temperatures. She said not storing medications as required could result in loss of medication effectiveness of stored too cold or too hot. Record review of the facility's Medication Storage Policy dated 1/20/2021 Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored, dated and labeled according to the manufacturers recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security .6b. Temperatures are maintained at 36-46 degrees. Charts are kept on each refrigerator levels are recorded daily by the Charge nurse or designee.

Based on interview and record review, the facility failed to ensure an accurate MDS was completed for 1 of 4 residents reviewed for accuracy of assessments. (Resident #33). The facility failed to ensure the comprehensive MDS assessment dated [DATE] for Resident #33 wasn't miscoded for Parenteral/IV feeding (a method of delivering nutrients directly into the bloodstream for patients who cannot use their digestive system). This failure could place residents at risk of receiving inappropriate care and services.Findings included:Record review of a facility face sheet dated 5/19/26 for Resident #33 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of type 2 diabetes (uncontrolled blood sugar).Record review of a Comprehensive MDS assessment dated [DATE] for Resident #33 indicated section K (swallowing/nutrition) was incorrectly coded for Resident #33, indicating that he had received parenteral/IV feeding while a resident in the last 7 days (4/1/26 - 4/7/26).Record review of an electronic medical record for Resident #33 on 5/19/26 indicated no record of him receiving parenteral/IV feedings.During an interview on 05/20/2026 at 9:01 am, the Administrator said have a policy for MDS, they went by the RAI manual.During an interview on 5/19/26 at 3:45 pm, the MDS nurse said Resident #33 had not had parenteral or IV feedings. She said he was supposed to have had received IV antibiotics, but instead got them IM and it was just miscoded. She said she would do a modification.During an interview on 05/20/2026 at 10:20 am, the MDS nurse said Resident #33 was supposed to have received IV antibiotics, but instead ended up receiving IM antibiotics at a doctor's office, but she could not find the documentation. She said she wasn't sure how she clicked the wrong thing, but she said from then on she would pay more attention and question everyone else's recommendations to ensure they were completely accurate before submitting the MDS. She said it could negatively affect the resident care if the MDS was not coded correctly as the care plan was generated from the MDS assessments. During an interview on 5/20/26 at 10:45 am, the Regional Reimbursement Coordinator said she did not review each MDS assessment as she had too many buildings and did not have time to review each one. She said she did spot checks to ensure accuracy. She said assessments were completed by MDS nurse and sent to Precision (an asset management company) to review for recommendations. She said if assessments were not coded accurately, it could result in incorrect payments, incorrect quality measures and incorrect care plans. She said she would be implementing a PIP to ensure accuracy of assessments going forward. During an interview on 05/20/2026 at 11:06 am, the Administrator said if MDS assessments were not coded correctly, that it could present an inaccurate view of the resident, and could affect resident care. She said, going forward, she would be reviewing the 802 report and performing spot checks for accuracy. Record review of CMS's RAI Version 3.0 Manual, dated October 2025, read: .The results of the assessment, which must accurately reflect the resident's status and needs, are to be used to develop, review, and revise each resident's comprehensive plan of care.

Based on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS admission assessment was transmitted to the CMS System within 14 days after completion for 1 of 6 residents (Resident #27) reviewed for admission MDS assessments.The facility failed to ensure Resident #27's Quarterly MDS assessments dated 1/5/2026 were transmitted within 14 days of completion.This failure could place residents at risk of not having records completed and submitted in a timely manner as required.Findings included:Record review of an admission Record for Resident #27 dated 5/19/2026 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of type 2 diabetes, dementia (decline in memory, thinking, reasoning and problem solving), bipolar (extreme mood swings) and anemia (decreased production of red blood cells in the body).Record review of a Quarterly MDS Assessment for Resident #27 dated 1/5/2026 was completed on 1/19/2026 indicated she had a BIMS score of 99 due to not being able to complete the interview. She was dependent on staff for ADLs.Record review of a Quarterly MDS Assessment for Resident #27 dated 1/5/2026 that was completed on 1/19/2026 was inactivated. Record review of a Quarterly MDS Assessment for Resident #27 dated 1/5/2026 was completed on 2/20/2026 and accepted on 2/20/2026.Record review of a Quarterly MDS Assessment for Resident #27 dated 1/5/2026 was completed on 2/20/2026 was inactivated.Record review of a CMS MDS Submission Report Final Validation dated 2/20/2026 for the facility indicated an assessment for Resident #27 dated 1/5/2026 had a warning that indicated: Resident information mismatch: submitted valued for the items listed do not match the values in the iQIES database. If the record was accepted, the resident information in the database updated. Verify that the new database was updated. Verify that the new information is correct. Assessment completed late: (assessment completion date) is more than 14 days after A2300 (assessment reference date). Record review of a CMS MDS Submission Report Final Validation dated 2/19/2026 for the facility indicated an assessment for Resident #27 dated 1/5/2026 had a warning that indicated it was rejected: This modification/inactivation record does not match a previously accepted record in the iQIES system. One or more of the items submitted in Section X of this record did not match the corresponding items of an existing record in the database.Record review of a care plan for Resident #27 dated 7/14/2025 indicated she had ADL self-care performance deficit and was at risk of not having their needs met in a timely manner. Interventions included ADL assistance required she was dependent on staff x1 except for transfers and she needed two staff. During an interview on 5/19/2026 at 2:51 pm, the MDS Coordinator said she had been employed at the facility for 2 years. She said the Regional Reimbursement Coordinator conducted an audit but was unsure of how often she did it. She said the Regional Reimbursement Coordinator would look to see if something did not go through on the batch report and would audit that assessment. She said in February 2026, the Regional Reimbursement Coordinator notified her that the assessment for Resident #27 was not completed for the assessment on 1/5/2026 until a month later because the problem was not identified until then in February 2026. She said a modification was done because that assessment was rejected and then the previous assessment was inactivated when the system would not accept the modification, so they copied the information from the original assessment, and it was accepted February 2026. She said they had 14 days until RN signature and then the assessment was submitted. She said each time she ran a batch the validation report was ran as well. She said she did not look at the validation report at that time. She said the validation report was to make sure the assessment was submitted correctly and it would let them know what was missing or needed. She said she believed she did not have a good contract number for hospice and that was why it was rejected. She said there could be a risk of the IDT team members not being aware of what was going on with the residents in the facility if they were not completed timely, they would not be aware. During a phone interview on 5/19/2026 at 3:30 pm, the Regional Reimbursement Coordinator said a batch was created with the assessment for Resident #27 from 1/5/2026 on 1/20/2026, the MDS Coordinator for the facility submitted the batch, and there was some glitch with the system. She said she had a validation ID for the batch and when she looked in SIMPLE, it was not there. She said the MDS Coordinator for the facility did a correction to resubmit the assessment and did not understand that she could not do a correction because it was never submitted. She said the MDS Coordinator for the facility copied and created a new assessment from the original assessment dated [DATE], and submitted that one which was accepted. She said she found Resident #27's name on a missing assessment report in SIMPLE back in February 2026, and then contacted the MDS Coordinator at the facility and told her she was missing an assessment for Resident #27. She said she tried to correct it to resubmit it, but it would not allow her to submit it, because it had to be inactivated. She said they had 14 days to complete and sign the assessment, and fourteen additional days after signatures to submit. She said she conducted monthly audits and did a percentage on the facilities. She said if a problem were identified then she would instruct the facility to develop a plan to prevent recurring in the future. She said if the assessments were not completed in a timely manner, they would not show up on the quality measure reports, matrix, or care plan completions, and care could be delayed. During an interview on 5/20/2026 at 1:27 pm, the Administrator said the MDS Coordinator was responsible for completing the resident assessments in the facility. She said she was not aware of Resident #27 having an assessment that was submitted late. She said, going forward, she would review the assessments monthly along with the DON and Regional Reimbursement Coordinator to ensure assessments were completed. She said they referred to the RAI manual for the timeframes on submitting the assessments. She said if the assessments were not completed timely, then the staff would not have a clear picture of what was going on with the residents, including the care plans and Kardex that the nurse aides used. She said she expected her staff to follow the RAI manual. She said the facility did not have a policy for MDS assessments.Record Review of the CMS RAI Version 3.0 Manual dated October 2025, indicated, in .Chapter 2.8, page 2-22: Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days) .

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #5) reviewed for infection control.The facility failed to ensure LVN F and CNA E wore the appropriate PPE when wound care was provided to Resident #5 who was on EBP on 5/20/2026.This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included:Record review of an admission Record for Resident #5 dated 5/20/2026 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia following cerebral infarction (paralyzed on one side of his body following a stroke), hypertension, major depression (persistent sadness or loss of interest in doing things) and bipolar (extreme mood swings).Record review of a Quarterly MDS Assessment for Resident #5 dated 5/6/2026 indicated he did not have any impairment in thinking with a BIMS score of 13. He was not at risk of developing pressure ulcers/injuries and did not have any unhealed pressure ulcers.Record review of a care plan for Resident #5 dated 5/14/2026 indicated the resident had a wound to his right foot. Interventions included to clean bottom of his right foot everyday shift for 14 days. The care plan did not reflect Resident #5 required EBP.Record review of active physician orders for Resident #5 dated 5/20/2026 indicated an order for wound care to cleanse the bottom of his right foot with wound cleanser, pat dry, apply calcium alginate (dressing used to aid in wound healing) and cover with dry dressing every day shift for 14 days. There was no physician order for EBP.During an observation on 5/20/2026 at 9:54 am, Agency LVN F and CNA E were at the door of Resident #5 to perform wound care. Signage was noted on the door for EBP and PPE, that consisted of gowns and gloves, was in the hallway outside of the door. Both staff entered the room, washed their hands, and applied gloves. Neither staff donned (put on) a gown. Agency LVN F cleaned the overbed table of Resident #4, placed a piece of wax paper down on the table as a barrier, and placed the wound care supplies that consisted of: a bottle of wound cleanser, 4x4 gauze, calcium alginate, and an adhesive dressing on the wax paper. The Agency LVN F removed her gloves and placed them in the trash, sanitized her hands, and applied clean gloves. CNA E assisted by holding Resident #5's leg. Agency LVN F removed the dressing from Resident #5's foot that was dated 5/19/2026 and placed it in the trash. Agency LVN F sprayed wound cleanser and cleaned the wound with 4 x4 gauze and placed the gauze in the trash. Agency LVN F removed her gloves and placed them in the trash; sanitized her hands and applied clean gloves. Agency LVN F patted the wound dry with gauze and removed her gloves removed and placed them in the trash; sanitized her hands and applied clean gloves. Agency LVN F applied a piece of calcium alginate to the wound bed and covered it with a dry dressing. Agency LVN F removed her gloves and placed them in the trash and sanitized her hands. Agency LVN F applied clean gloves, removed the trash, and exited the room. CNA E removed her gloves and washed her hands.During an interview on 5/20/2026 at 10:12 am, LVN F said she worked for an agency and assisted in the facility as needed. She said during the wound care provided to Resident #5, she was supposed to wear a gown when wound care was provided. She said she just forgot. She said he had a wound infection on his foot. She said she did not see the sign on the door for EBP. She said EBP was for infection control to keep germs from spreading and others from getting it. She said infections could be spread to other residents if staff did not wear their gowns when care was provided. During an interview on 5/20/2026 at 10:16 am, CNA E said she had been employed at the facility since 2016. She said during the care that was provided to Resident #5, she forgot to put on a gown. She said PPE was outside in the hallway. She said she was aware Resident #5 was on EBP and should have worn a gown during the care provided. She said residents with signs on the doors and residents with wounds would be on EBP. She said staff could be at risk of spreading infections to other residents if they did not wear the appropriate PPE when care was provided. She said she had been trained on EBP. She said she had a competency skills check off about a week ago. Record review of a Nursing Assistance Clinical Skills Checklist and Competency Evaluation for CNA E dated 5/7/2025 indicated she demonstrated competency on donning and removing PPE.During an interview on 5/20/2026 at 10:23 am, the ADON said she was responsible for infection control and was the IP for the facility. She said the interim DON conducted skills check offs about a week ago in the facility with staff. She said Resident #5 was on EBP for the wound to his foot. She said EBP was required for residents with wounds, urinary catheters, and any artificial openings with ports. She said staff should wear gowns, gloves, and masks when they provided care to residents on EBP. She said there should be a sign on the door and PPE in the hallways for the residents on EBP. She said there was a risk of spreading infections if staff did not wear the appropriate PPE for residents who were on EBP. During an interview on 5/20/2026 at 1:10 pm, the DON said she started at the facility on 5/18/2026. She said the ADON would be responsible for training staff on infection control and was the IP for the facility. She said EBP was required for residents who had wounds, g-tubes, IV's, tracheostomies (artificial opening in the neck with a tube to help breathe), PICC lines, urinary catheters, ostomies (a surgical opening in the abdomen that allows stool or urine to exit the body), and any openings from the body to the outside. She said Resident #5 was on EBP for his wound. She said staff should wear gowns and gloves when they were in the room providing care. She said if staff did not wear the appropriate PPE, then residents could be at risk of infections. During an interview on 5/20/2026 at 1:27 pm, the Administrator said the nursing managers were responsible for training staff on infection control, but she was responsible. She said the facility conducted monthly in-services that included infection control. She said EBP was in place to help prevent the spread of germs to one another. She said residents that required EBP were residents that had wounds or any artificial openings. She said staff should wear gowns and gloves when care was provided. She said if staff did not wear the appropriate PPE, then there was a risk of spreading germs. She said Resident #5 had a wound and was on EBP. Record review of the facility's policy titled Infection Prevention and Control Program revised 11/6/2024 indicated, .This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. 6. Enhanced Barrier Precautions: EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: b. Wounds and/or indwelling medical devices regardless of MDRO colonization status. During high-contact resident care activities: wound care: any skin opening requiring a dressing. Gloves and gowns prior to the high-contact activity .

Based on interview and record review the facility failed to ensure each resident was treated with respect and dignity for 2 of 7 residents (Residents #1 and #2) reviewed for Resident Rights. The facility failed to ensure 09/10/2025, at 7:15 p.m., Resident #1 and Resident #2 were treated with dignity and respect when CNA A spoke rudely about taking them outside.This failure could place residents who smoke at risk of emotional distress and diminished quality of life.Findings included: 1.Record review of an admission Record dated 2/11/26 for Resident #1 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Hepatic Encephalopathy (brain dysfunction caused by liver failure), Acute Respiratory Failure (lungs cannot adequately exchange gases), and morbid obesity. Record review of a quarterly MDS dated [DATE] indicated Resident #1 had intact cognition with a BIMS of 14. She required setup/cleanup assistance with eating, oral hygiene, and personal hygiene; she required supervision with upper body dressing; she required moderate assistance with toileting hygiene and shower/bath; she required maximal assistance with lower body dressing and putting on/taking off footwear. Record review of a comprehensive care plan dated 6/13/24 indicated Resident #1 was a smoker and was at risk for injury. Interventions were in place including assist resident to and from smoking area as needed. 2.Record review of an admission Record dated 2/11/26 for Resident #2 indicated he was a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses of Cellulitis of Left Lower Limb (infection in leg), Severe Sepsis with Septic Shock (infection in the blood that causes low blood pressure), and non-pressure chronic ulcers. Record review of a quarterly MDS dated [DATE] indicated Resident #2 had moderately impaired cognition with a BIMS of 12. He was independent in all ADL's. Record review of a comprehensive care plan revised on 3/18/25 indicated Resident #2 smoked and required supervision smoking due to noncompliance with facility policy. Interventions were in place to observe resident during smoking for unsafe smoking practices and report to nurse. During an interview on 2/10/26 at 1:35 p.m., Resident #1 said on the day of the incident CNA A took residents outside for smoke break. Resident #1 said CNA A told Resident #2 something to the effect of you're always hassling me about smoking and then turned toward her and said, and you do me the same damn way. Resident #1 said the comment upset her and she felt talked down to. Resident #1 said she reported the incident to the ADM the next day. During an interview on 2/10/26 at 3:15 p.m., Resident #2 said during a smoking break, CNA A made an inappropriate comment to him about taking residents outside to smoke. Resident #2 said he could not remember what CNA A said, but it made him feel it was a burden to take residents outside to smoke During a group interview on 2/10/26 at 4:00 p.m., 3 of 7 residents who smoke reported hearing staff say it was a hassle taking them outside to smoke but were unable to recall dates, times, or names of staff and reported no distress from the incident(s). All residents said they got their scheduled smoking breaks on time. During an interview on 2/11/26 at 2:00 p.m., CNA A said she could not recall the specific date in question, but she never used inappropriate language around residents nor told them their care was a hassle. CNA A said she no longer worked for the facility and had moved on from the incident. During an interview on 2/11/26 at 2:30 p.m., the DON said his primary focus as the new DON had been reiterating with staff they were there to serve the residents. The DON said he expected staff to maintain professional behavior at work which included not cursing or using inappropriate language. The DON said a CNA talking down to or using inappropriate language around a resident could put the resident at risk for emotional distress. During an interview on 2/11/26 at 3:00 p.m., The ADM said she was responsible for investigating allegations of abuse and neglect in the facility. The ADM said she investigated the allegation that CNA A used inappropriate language and talked down to Residents #1 and #2. CNA A said the investigation included interviews with other residents who smoked and were present at the time of the incident. The ADM said she was unable to confirm the allegation that CNA A used inappropriate language or talked down to the residents. The ADM said CNA A was terminated following the incident due to multiple reasons with customer service being one of them. Review of a facility associate disciplinary memorandum dated 9/15/25 indicated CNA A was discharged on 9/15/25. The explanation revealed .spoke to residents in a manner that could be perceived as inappropriate language/talking down to residents. Review of a facility termination form dated 9/16/25 indicated CNA A was involuntarily terminated on 9/15/26 for inappropriate behavior. Review of an undated facility policy titled Statement of Resident Rights indicated .You have the right to:.3) Be treated with courtesy, consideration, and respect.

Based on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 3 of 12 residents (Residents #18, #28, and #45) reviewed for accidents/hazards. The facility failed to remove worn and damaged mechanical lift slings from service from 03/17/2025 through 03/19/2025. This failure could place residents at risk of a loss of quality of life due to injuries. Findings included: 1. Record review of a facility face sheet dated 3/18/25 for Resident #18 indicated that she was a [AGE] year-old female admitted to the facility 8/7/23 with diagnoses including essential hypertension (uncontrolled blood pressure) and chronic peripheral venous insufficiency (poor circulation to the extremities). Record review of a Quarterly MDS assessment dated [DATE] for Resident #18 indicated that she had a BIMS score of 13, which indicated she was cognitively intact. She was dependent for all transfers and most ADLs. Record review of a comprehensive care plan dated 8/18/23 for Resident #18 indicated she had ad ADL Self-Care Performance Deficit and required a Hoyer lift for all transfers.2. 2.Record review of a face sheet for Resident #28 dated 03/18/2025 indicated he admitted to the facility 03/24/2019 and was [AGE] years old with diagnoses of Alzheimer's disease, cerebral infarction (stroke), and blindness. Record review of a Quarterly MDS Assessment for Resident #28 dated 01/10/2025 indicated he had severe impairment in thinking with a BIMS score of 3. He was dependent on 2 staff from chair/bed to chair transfers. Record review of a care plan for Resident #28 revised on 01/21/2025 indicated he had an ADL self-care performance deficit related to impaired balance that included interventions for transfers and he required 2 staff for transfers. During an observation on 03/18/2025 at 12:00 pm Resident #28 was sitting in his wheelchair with mechanical lift sling underneath him, the straps were faded light in color. 3. Record review of a facility face sheet dated 3/19/25 for Resident #45 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] and was subsequently readmitted on [DATE] with diagnoses of hepatic encephalopathy and morbid obesity. Record review of a Quarterly MDS assessment dated [DATE] for Resident #45 indicated that she had a BIMS score of 14 which indicated she was cognitively intact. She was dependent for all transfers. Record review of a comprehensive care plan dated 9/5/23 for Resident #45 indicated she had an ADL self-care performance deficit and required a Hoyer lift for transfers. During an observation and interview on 3/18/25 at 8:54 am Resident #18 was observed in her room sitting up in a motorized wheelchair with a mechanical lift sling underneath her. The strap colors were faded, and all were almost white in color. CNA B was in room with the resident and said they had just gotten her up with the lift to get her ready to leave for an appointment. She said she would check the slings to make sure they were not too thin before using them to transfer a resident. She said the CNAs do not really use the strap colors, they just call them strap 1, strap 2, etc. CNA B said she had been employed here about [AGE] years. When asked what the risks to residents could be if a worn sling was used, she replied I think it could be dangerous, they might snap and break. During an observation and interview on 3/18/2025 at 10:30 am, three mechanical lift lift slings were hanging to air dry in the clean area of the laundry room. All three Hoyer slings were faded and light in color. One sling, the straps were unraveling and had threads pulling away. The Laundry Aide said she had been employed at the facility off and on, for over [AGE] years and she bleaches the Hoyer slings if they have been soiled. She said she received training to air dry the lift slings; she hung them to dry. She said she was not aware that the bleach could fade and damage the slings making them unsafe for use. She said she inspected the slings for loose strings, rips, and tears before hanging them for drying. She said she took the damaged slings to the ADON and DON if they needed to be removed from service when she had concerns about holes or [NAME]. She said if a sling that was unsafe was used for residents, it could tear causing the resident to fall and get hurt. During an observation and interview on 3/18/25 at 1:45 pm CNAs D and E were observed to transfer Resident #45 using a mechanical lift sling that was faded in color and had no label. CNA D said she checks for any rips or tears on slings before using them to ensure safety. She said she did not think there was anything wrong with the colors of the loops on this sling. CNA E said she agreed with CNA D. During an interview on 3/18/2025 at 10:45 AM, the Laundry/Housekeeping Supervisor said the ADON was responsible for reordering new lift slings to replace them as needed. He said if staff found a lift sling that was ripped or torn, they would take to her and then she would give them a new one. He said the slings were washed by themselves and if a sling that was unsafe was used for residents, it could tear causing the resident to fall and get hurt. During an interview on 3/18/2025 at 1:31 PM, the ADON said the lift slings should be checked about every 6 months and checked every time they were washed. She said she was not aware of the manufacturer's guidelines for the lift slings that the slings should not in be use if they had been bleached and were faded. She said they planned to conduct an audit and the facility had ordered new slings for the facility. She said there could be risk for injury if the faded and [NAME] slings were being used. During an interview on 3/18/2025 at 3:10 PM, the Administrator said staff knew to report any torn or ripped mechanical lift slings and to throw them away. She said it was the responsibility of the DON or ADON to make sure they were not using worn or damaged lift slings. She said she was not aware that the laundry aide was bleaching the slings. She said the faded slings could not be in use and there would be a potential risk for falls or injuries. Record review of a facility policy titled Resident Rights, revised 02/20/2021 indicated: .8. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely . Record review of the manufacturer instruction for Medline full body slings undated indicated, .Full body slings are made of durable materials and are ideal for patient transferring and toileting activities. Always inspect slings prior to each use. Signs of color fading, bleached areas, indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use . Record review of the manufacturer instructions for Proactive full body slings accessed https://proactivemedical.com/products/lifts-slings/patient-slings/full-body-sling/ accessed 03/18/2025 indicated, .Proactive medical products . Guideline for Identifying Deteriorated Slings Accelerated Deterioration from Bleach, High Temperature Wash or Drying Slings, especially loop straps that have been damaged from being laundered in unsuitable conditions (bleach, high heat wash or dry) may appear to be in good condition but the actual tensile strength of the material may be compromised and pose a safety risk and should not be used for lifting a patient or resident. This Guide is intended to help staff and caregivers better identify slings that have been exposed to above laundry conditions and subsequent loss of tensile strength. We encourage any sling identified with the following characteristics to be removed from service immediately as a preventive measure. Proactive Medical slings have been designed and tested for laundry wash conditions of 170F degrees and air dry or dry at low temperature. The slings should never be bleached. Commercial washer and dryers are not recommended. Care instructions on the sling label should always be followed. Laundry equipment should be properly maintained and repaired when necessary. Completely Faded / Missing / Illegible Tag while the main body of the sling fabric is still intact and in relatively good condition. Colors are not faded or show very little fading . 46273

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and sanitary environment 3 of 12 residents (Residents #6, #9, and #19) reviewed for resident rights. The facility failed to provide Resident #6 a safe, clean, and sanitary environment on 3/17/2025 when the mattress on his bed was torn and his toilet seat was broken. The facility failed to provide Resident #9 a safe, clean, and sanitary environment on 3/17/25 when a foul sour odor was observed in her room. The facility failed to provide Resident #19 a safe, clean, and sanitary environment on 3/17/25 when his toilet had no toilet seat. These failures could place residents and visitors at risk for exposure to an unclean, unsanitary environment, risk of falls and other injuries due to an unsafe environment. Findings include: 1. Record review of a facility face sheet dated 3/19/25 revealed Resident #6 was a [AGE] year-old male that admitted to the facility in 9/10/2012 with a diagnosis of atherosclerotic heart disease (blockage of arteries in the heart). Record review of a facility annual MDS assessment dated [DATE] revealed Resident #6 had a BIMS score of 5 indicating severe cognitive impairment and was independent with activities of daily living. Record review of a comprehensive care plan dated 7/18/2024 revealed Resident #6 had the potential for falls related to cognitive impairment, antihypertensive drug use, incontinence, unaware of safety needs, vision and hearing problems with goal to not sustain a fall related injury by utilizing fall precautions and was at risk for infections with goal to not experience signs and symptoms of infection. During an observation and interview on 3/17/25 at 9:13 AM Resident # 6 had a broken toilet seat and the mattress was ripped at the head exposing the foam. He said he had not noticed his seat being broken and bed torn. He said he had not had any complications from the broken items. During an interview on 3/17/25 at 10:15 am CNA D said that when things were broken in the past, she would notify the maintenance director and put it in the maintenance logbook, but things would not get fixed. She said that maintenance director was no longer at the facility, and they had a new one and she would let him know about the things that needed to be fixed. She said that a broken toilet seat could cause injury and a torn mattress could not be properly cleaned and could cause injury or infections. 2. Record review of a facility face sheet dated 3/18/25 for Resident #9 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including emphysema (lung disease causing trouble breathing) and type 2 diabetes. Record review of a Quarterly MDS assessment dated [DATE] for Resident #9 indicated that she had a BIMS score of 14 which indicated she was cognitively intact. Assessment indicated no behaviors or rejection of care. During an observation and interview on 3/17/25 at 9:24 am Resident #9 was observed sitting in a wheelchair in her room. There was a very foul sour smell observed in her room. Resident did not speak much and only said everything was OK and she had no complaints. During an observation and interview on 3/17/25 at 2:45 pm Resident #9's room was still observed to have a sour smell. HR was in the hallway, and she was asked to come smell the room. She smelled the linens and the resident's shoes but could not find the smell. She found an avocado in a plastic produce bag inside of a plastic grocery store bag hidden under some other personal items that was covered in a green powdery substance that appeared to be mold. During an interview on 3/18/25 at 9:05 am CNA E said Resident #9 would not really let staff clean the room like it needed to be done and there was no telling what was in there. During an interview on 3/18/25 at 9:50 am Housekeeping Supervisor said housekeeping staff were responsible for cleaning resident rooms daily and said if there was a lingering odor observed that staff would try to find the cause, but some residents would hide things. He said if a resident gave the staff problems related to cleaning the rooms, then staff were to go to nursing staff to help intervene. He said Resident #9 liked to hide things. He said there was some old food found in her room yesterday (3/17/25) and if she had eaten it, she could have gotten sick. He said the foul odor could cause residents, staff, and visitors to feel uncomfortable. 3. Record review of a facility face sheet dated 3/19/25 for Resident #19 indicated that he was a [AGE] year-old man admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnosis including vascular dementia. Record review of a Quarterly MDS dated [DATE] for Resident #19 indicated he had a BIMS score of 6, which indicated severely impaired cognition. He was always incontinent of bowel and bladder and required partial to moderate assistance with toilet transfers. Record review of a comprehensive care plan dated 6/30/21 for Resident #19 indicated that he had an ADL self-care performance deficit and required extensive assist of one to two persons with toilet use. During an observation and interview on 3/17/25 at 9:40 am Resident #19's toilet was observed with no toilet seat. During an interview on 3/17/25 at 1:56 pm the Maintenance Director said he had only been at the facility a few days and had not had a chance to review the logs and would be getting with the staff to discuss restarting the logbook. He said he could not speak on what occurred before him but would fix the broken toilet seat and exchange the mattress right away. During an interview on 3/18/25 at 3:00 pm the Administrator said that in the past the maintenance director was not completing task and he was no longer employed as of last week. She said they hired a new maintenance director and will make environmental rounds and retrain staff on using the logbook so things can be fixed. She said she would oversee the ambassadors for each hall to ensure all areas are clean and functional. She said when areas and items were broken or in disrepair it could cause injuries or infections. Record review of maintenance logbook revealed no request in the book for 2024 or 2025. Record review of a facility policy titled Resident Room Cleaning, undated, read: .Daily cleaning of resident rooms helps to provide a sanitary environment, prevent odors, and prolong the useful life of furniture, equipment, paint, and floor finish . Record review of a facility Resident Rights document dated 2/23/2016 indicated, .8. Safe environment. The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely .

Based on interview and record review, the facility failed to provide effective communications mandatory training for 4 of 14 employees (ADON, AD, CNA A and CNA F) reviewed for training, in that: The facility failed to ensure effective communication training was provided to the ADON, AD, CNA A and CNA F annually. This failure could place residents at risk of miscommunication and social isolation due to lack of staff training. Findings include: Record review of the personnel file for the ADON indicated she was hired at the facility on 4/16/2020 and did not have annual training on effective communication. Training was last completed on 2/19/2024. Record review of the personnel file for the AD indicated she was hired at the facility on 9/29/2023 and did not have annual training on effective communication. Training was last completed on 2/19/2024. Record review of the personnel file for CNA A indicated she was hired at the facility on 9/3/2020 and did not have annual training on effective communication. Training was last completed on 2/23/2024. Record review of the personnel file for CNA F indicated she was hired at the facility on 2/8/2024 and did not have annual training on effective communication. Training was last completed on 2/9/2024. During an interview on 3/19/2025 at 9:22 AM, HR said she had been employed at the facility for a year. She said she was responsible for ensuring staff received the required trainings on hire. She said she was not sure who was responsible for ensuring staff received annual trainings. She said she used a guide that staff were given during orientation that included all the required trainings. During a follow up interview on 3/19/2025 at 10:33 AM, HR said if staff did not receive the required trainings on hire and annually thereafter, residents could be at risk of getting hurt and staff not receiving proper communication. During an interview on 3/19/2025 at 10:45 AM, the interim Administrator said the required trainings were the responsibility of HR. She said she was not aware that some of the employees did not have their annual trainings. She said the facility recently changed to a different online training program and they did not recognize that all the trainings were not being done. She said they updated the training profiles of all staff to include the missing trainings. She said there could be a risk of staff not receiving the proper training and residents not receiving proper care. Record review of a facility assessment dated [DATE] indicated, .Our facility's training program includes an orientation process and ongoing training for all new and existing staff including managers, nursing and other direct care staff, individuals providing services under contractual arrangement, and volunteers consistent with their expected roles. The content at a minimum includes Effective communication . Record review of a facility policy titled Training Requirements dated 11/29/2023 indicated, .It is the policy of this facility to develop, implement, and maintain an effective training program for all new hire and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 5. Training requirements should be met prior to staff and volunteers independently providing services to residents, annually and as necessary based on the facility assessment. 6. Training content includes, at a minimum: a. Effective communication for direct care staff .

Based on interview and record review, the facility failed to provide the required compliance and ethics training for 3 of 14 employees (CNA A, CNA B and CNA F) reviewed for training in that: The facility failed to ensure annual compliance and ethics training was provided to CNA A, CNA B, and CNA F. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training. Findings included: Record review of the personnel file for CNA A indicated she was hired on 9/3/2020 and had not completed annual training on compliance and ethics. Training was last completed on 2/23/2024. Record review of the personnel file for CNA B indicated she was hired on 5/23/2023 and had not completed annual training on compliance and ethics. Training was last completed on 5/23/2023. Record review of the personnel file for CNA F indicated she was hired on 2/8/2024 and had not completed annual training on compliance and ethics. Training was last completed on 2/9/2024. During an interview on 3/19/2025 at 9:22 AM, HR said she had been employed at the facility for a year. She said she was responsible for ensuring staff received the required trainings on hire. She said she was not sure who was responsible for ensuring staff received annual trainings. She said she used a guide that staff were given during orientation that included all the required trainings. During a follow up interview on 3/19/2025 at 10:33 AM, HR said if staff did not receive the required trainings on hire and annually thereafter, residents could be at risk of getting hurt and staff not receiving proper communication. During an interview on 3/19/2025 at 10:45 AM, the interim Administrator said the required trainings were the responsibility of HR. She said she was not aware that some of the employees did not have their annual trainings. She said the facility recently changed to a different online training program and they did not recognize that all the trainings were not being done. She said they updated the training profiles of all staff to include the missing trainings. She said there could be a risk of staff not receiving the proper training and residents not receiving proper care. Record review of a facility assessment dated [DATE] indicated, .Our facility's training program includes an orientation process and ongoing training for all new and existing staff including managers, nursing and other direct care staff, individuals providing services under contractual arrangement, and volunteers consistent with their expected roles. The content at a minimum includes compliance and ethics . Record review of a facility policy titled Training Requirements dated 11/29/2023 indicated, .It is the policy of this facility to develop, implement, and maintain an effective training program for all new hire and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 5. Training requirements should be met prior to staff and volunteers independently providing services to residents, annually and as necessary based on the facility assessment. 6. Training content includes, at a minimum: e. Written standards, policies, and procedures for the facility's compliance and ethics program .

Based on interview and record review, the facility failed to provide mandatory effective behavioral health training for 3 of 14 employees (CNA A, CNA B and CNA F) reviewed for training, in that: The facility failed to ensure annual effective behavioral health training was provided to CNA A, CNA B and CNA F. This failure could place residents with behaviors at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. Findings included: Record review of the personnel file for CNA A indicated she was hired on 9/3/2020 and had not completed annual training on behavioral health. Training was last completed on 2/23/2024. Record review of the personnel file for CNA B indicated she was hired on 5/23/2023 and had not completed annual training on behavioral health. Training was last completed on 5/23/2023. Record review of the personnel file for CNA F indicated she was hired on 2/8/2024 and had not completed annual training on behavioral health. Training was last completed on 2/9/2024. During an interview on 3/19/2025 at 9:22 AM, HR said she had been employed at the facility for a year. She said she was responsible for ensuring staff received the required trainings on hire. She said she was not sure who was responsible for ensuring staff received annual trainings. She said she used a guide that staff were given during orientation that included all the required trainings. During a follow up interview on 3/19/2025 at 10:33 AM, HR said if staff did not receive the required trainings on hire and annually thereafter, residents could be at risk of getting hurt and staff not receiving proper communication. During an interview on 3/19/2025 at 10:45 AM, the interim Administrator said the required trainings were the responsibility of HR. She said she was not aware that some of the employees did not have their annual trainings. She said the facility recently changed to a different online training program and they did not recognize that all the trainings were not being done. She said they updated the training profiles of all staff to include the missing trainings. She said there could be a risk of staff not receiving the proper training and residents not receiving proper care. Record review of a facility assessment dated [DATE] indicated, .Our facility's training program includes an orientation process and ongoing training for all new and existing staff including managers, nursing and other direct care staff, individuals providing services under contractual arrangement, and volunteers consistent with their expected roles. The content at a minimum includes caring for residents who are cognitively impaired . Record review of a facility policy titled Training Requirements dated 11/29/2023 indicated, .It is the policy of this facility to develop, implement, and maintain an effective training program for all new hire and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 5. Training requirements should be met prior to staff and volunteers independently providing services to residents, annually and as necessary based on the facility assessment. 6. Training content includes, at a minimum: f. Behavioral health including informed trauma care .

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #153) and 1 of 5 staff (MDS Coordinator) reviewed for infection control. The MDS Coordinator failed to wear appropriate PPE for enhanced barrier precautions when providing care to Resident #153 on 3/18/2025. This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings included: Record review of an Admission Record dated 3/18/2025 for Resident #153 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of osteomyelitis of left ankle and foot (bone infection), dementia, hypertension, acquired absence of left foot and right leg below knee (surgical removal). Record review of active physician orders for Resident #153 dated 3/18/2025 did not indicate an order for enhanced barrier precautions. Record review of an Admission/5 Day MDS for Resident #153 dated 3/17/2025 indicated it was not complete and in progress. Record review of a care plan for Resident #153 dated 3/12/2025 indicated he had a pressure ulcer and was at risk for infection. Interventions included to provide wound care per physician's order. Monitor and document for signs and symptoms of infection. Record review of a list of residents on enhanced barrier precautions undated indicated Resident #153 was listed with the reason for a wound. During an observation on 3/18/2025 at 09:34 AM in the room of Resident #153, RN C was present to perform wound care. There was a sign on his door for EBP. RN C sanitized her hands and donned (put on) a gown and gloves. The MDS Coordinator was present to assist, and she sanitized her hands and put on gloves, but not a gown and sat on the floor in the resident's room. Resident #153 was sitting up in a wheelchair and the MDS Coordinator lifted Resident #153's left leg and RN C performed wound care following physician orders and infection control with proper glove changes and sanitized her hands. After wound care was completed, RN C removed her gloves and placed them in the trash and sanitized her hands. The MDS Coordinator removed her gloves and placed them in the trash and sanitized her hands. During an interview on 3/18/2025 at 2:50 PM, the MDS Coordinator said residents who were on EBP, staff should wear a gown and gloves when care was provided and that included residents who had wounds. She said during the care provided to Resident #153, she should have worn a gown and only had on gloves. She said she did not think about him being on EBP and did not notice the sign on his door or the container of ppe that was outside of his door. She said she should not have been sitting on the floor while assisting him. She said there could be a risk of passing germs to other residents if staff did not wear gown and gloves when care was provided. During a joint interview on 3/19/2025 at 10:37 AM, the ADON and DON said they were both responsible for training staff on infection control. The ADON said she trained staff monthly on infection control and about every 2-3 months on EBP that included all staff. She said a resident who had wounds would be on EBP and Resident #153 was. She said when staff provided care to him, they should wear a gown and gloves at minimum. She said she was not aware the MDS Coordinator did not wear proper ppe when assisting with wound care on yesterday 3/18/2025 and she should have worn a gown and not have been sitting on the floor. She said residents could be at risk for infections and planned to inservice the MDS Coordinator and provide training with her. She said she had a training a few months ago on EBP with all staff. Record review of a facility inservice training on EBP dated 3/18/2025 indicated the MDS Coordinator received the training as indicated by her signature. Record review of a facility inservice training on EBP dated 1/31/2025 indicated the MDS Coordinator received the training as indicated by her signature. During an interview on 3/19/2025 at 10:45 AM, the interim Administrator said she had been at the facility for a couple of months. She said the ADON and DON were responsible for training staff on infection control in the facility. She said when care was provided to residents who were on EBP, staff should wear a gown and gloves. She said residents on EBP included residents with wounds. She said there could be a risk of cross contamination and infections if staff did not wear the proper ppe when care was provided. Record review of a facility policy titled Infection Prevention and Control Program revised 11/6/2024 indicated, .This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection as per accepted national standards and guidelines. 6. Enhanced Barrier Precautions: EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: b. Wounds; During high-contact resident care activities: wound care: any skin opening requiring a dressing. Gloves and gowns prior to the high-contact care activity .

Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for 3 of 14 employees (AD, DOR, and CNA B) reviewed for training. The facility failed to ensure the AD, DOR, and CNA B were trained on HIV annually. This failure could place residents at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. Findings include: Record review of the personnel file for the AD indicated she was hired at the facility on 9/29/2023 and did not have annual training on HIV. Training was last completed on 2/19/2024. Record review of the personnel file for the DOR indicated she was hired at the facility on 6/1/2023 and did not have annual training on HIV. Training was last completed on 2/19/2024. Record review of the personnel file for CNA B indicated she was hired at the facility on 5/23/2023 and did not have annual training on HIV. Training was last completed on 5/23/2023. During an interview on 3/19/2025 at 9:22 AM, HR said she had been employed at the facility for a year. She said she was responsible for ensuring staff received the required trainings on hire. She said she was not sure who was responsible for ensuring staff received annual trainings. She said she used a guide that staff were given during orientation that included all the required trainings. During a follow up interview on 3/19/2025 at 10:33 AM, HR said if staff did not receive the required trainings on hire and annually thereafter, residents could be at risk of getting hurt and staff not receiving proper communication. During an interview on 3/19/2025 at 10:45 AM, the interim Administrator said the required trainings were the responsibility of HR. She said she was not aware that some of the employees did not have their annual trainings. She said the facility recently changed to a different online training program and they did not recognize that all the trainings were not being done. She said they updated the training profiles of all staff to include the missing trainings. She said there could be a risk of staff not receiving the proper training and residents not receiving proper care. Record review of a facility assessment dated [DATE] indicated, .Our facility's training program includes an orientation process and ongoing training for all new and existing staff including managers, nursing and other direct care staff, individuals providing services under contractual arrangement, and volunteers consistent with their expected roles. The content at a minimum includes infection control and dementia management . Record review of a facility policy titled Training Requirements dated 11/29/2023 indicated, .It is the policy of this facility to develop, implement, and maintain an effective training program for all new hire and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 5. Training requirements should be met prior to staff and volunteers independently providing services to residents, annually and as necessary based on the facility assessment. 6. Training content includes, at a minimum: h. HIV; i. Dementia management and care of the cognitively impaired .

Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for 1 of 14 employees (DM) reviewed for training. The facility failed to ensure the DM was trained on dementia training annually. This failure could place residents at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. Findings include: Record review of the personnel file for the DM indicated she was hired at the facility on 2/15/2024 and did not have annual training on dementia. Training was last completed on 2/16/2024. During an interview on 3/19/2025 at 9:22 AM, HR said she had been employed at the facility for a year. She said she was responsible for ensuring staff received the required trainings on hire. She said she was not sure who was responsible for ensuring staff received annual trainings. She said she used a guide that staff were given during orientation that included all the required trainings. During a follow up interview on 3/19/2025 at 10:33 AM, HR said if staff did not receive the required trainings on hire and annually thereafter, residents could be at risk of getting hurt and staff not receiving proper communication. During an interview on 3/19/2025 at 10:45 AM, the interim Administrator said the required trainings were the responsibility of HR. She said she was not aware that some of the employees did not have their annual trainings. She said the facility recently changed to a different online training program and they did not recognize that all the trainings were not being done. She said they updated the training profiles of all staff to include the missing trainings. She said there could be a risk of staff not receiving the proper training and residents not receiving proper care. Record review of a facility assessment dated [DATE] indicated, .Our facility's training program includes an orientation process and ongoing training for all new and existing staff including managers, nursing and other direct care staff, individuals providing services under contractual arrangement, and volunteers consistent with their expected roles. The content at a minimum includes infection control and dementia management . Record review of a facility policy titled Training Requirements dated 11/29/2023 indicated, .It is the policy of this facility to develop, implement, and maintain an effective training program for all new hire and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 5. Training requirements should be met prior to staff and volunteers independently providing services to residents, annually and as necessary based on the facility assessment. 6. Training content includes, at a minimum: h. HIV; i. Dementia management and care of the cognitively impaired .

Based on observation and interview, the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 2 of 2 days reviewed (3/17/2025 and 3/18/2025) for nurse staffing posting. The facility failed to post the daily staffing information in a prominent place on 3/17/2025 and 3/18/2025. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts. Findings included: During an observation on 3/17/2025 at 10:58 AM, the daily staff posting was not in or around the front entrance. The daily staff posting was dated 3/17/2025 and on a wall by the SW office that was not clearly visible to see. During an observation 3/18/25 at 2:35 PM, the daily staff posting was dated 3/18/2025 and on a wall by the SW office that was clearly visible to see. During an interview on 3/19/2025 at 10:33 AM, HR said she was responsible for putting up the daily staff posting. She said the staff posting was put up so people would know about the current staff in the facility. She said she had always put the posting on the wall and if someone entered the facility, they would not be able to see it. She said she did not know the posting had to be visible for all to see when they entered the facility. She said she would move it. During an interview on 3/19/2025 at 10:45 AM, the interim Administrator said she had been at the facility for a couple of months. She said HR was responsible for putting up the daily staff posting. She said it was placed on the wall. She said she was not aware the staff posting had to be in a place that was visible for all to see who entered the facility including residents. She said the facility did not have a policy for the daily staff posting.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents reviewed for accident (Resident #1). The facility failed to put interventions in place to prevent Resident #1 from sliding out of the wheelchair during transport on 2/19/24 and ensure that she was secured by the shoulder and lap belt harness, resulting in Resident #1 sliding out of her wheelchair during transport. The facility failed to ensure the transport staff were aware of how to properly position the shoulder and lap belt harness to ensure Resident #1 did not have forward bodily movement in the event of the driver had to quickly stop the van. An Immediate Jeopardy (IJ) situation was identified on 9/24/24 at 4:00p.m. The IJ template was provided to the facility on [DATE] at 4:00 p.m. While the IJ was removed on 9/25/24 at 4:30 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. Failure to properly secure residents on the van placed all residents at risk of falls which could lead to injury or death. Findings included: Record review of Resident #1's face sheet dated 9/23/24 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were cerebrovascular disease (conditions that affect blood flow to the brain), essential hypertension (high blood pressure), chronic kidney disease stage 4 (kidneys do not filter wastes from the blood). Record review of Resident #1's admission MDS assessment dated [DATE] indicated severe cognitive impairment with a BIMS score of 00. Review of Resident #1's functional abilities and goals indicated she was supervision or touching assistance for sit to stand and partial to moderate assistance for chair and bed transfers. The resident was partial to moderate assistance for walking. Record review of Resident #1's care plan dated 9/20/22 indicated a Resident #1 was a fall risk with an onset of 9/20/22. The intervention was to observe resident when ambulating for unsteady gait, dizziness, decreased balance, weakness and provide assistance as needed. Resident #1 had a diagnosis of chronic kidney disease. The intervention was to follow up with nephrologist (kidney doctor) as ordered and indicated. Resident #1 had end stage kidney disease and received dialysis. The intervention was to encourage resident to attend scheduled dialysis appointments. Resident #1 had an ADL self-care deficit. The interventions with transfers were supervision to limited assistance with transfers, encourage and remind to ask for assistance and provide assistance as needed. Record review of Resident #1' s incident report dated 2/19/24 at 11:38 a.m. indicated the incident location: out of facility during transport. The description of the incident reflected: Received call from facility van driver that while enroute back to the facility another vehicle pulled out in front of the facility van causing the van driver to hit brakes hard which lead to resident sliding out of wheelchair. Van driver pulled into near by parking lot and called EMS to come and assist and assess the resident. Prior to EMS arriving the resident had gotten herself up and sat in the passenger seat of facility van when EMS arrived the resident denied hitting her head, denied EMS the ability to assess resident also refused vital signs and to go to the ER for further evaluation from EMS. The mental status of Resident #1 was oriented to person, place and time. She had impaired memory, gait balance and was confused. The incident report was electronically signed by LVN C on 2/19/24 at 11:38 a.m. Record review of Resident #1's nursing note dated 2/19/24 indicated it was electronically signed by LVN C on 2/19/24 at 11:38 a.m. The note indicated the nurse was informed by Van Driver D that while enroute back to the facility another vehicle pulled out in front of the facility van causing Van Driver D to hit the brakes hard which led to Resident #1 sliding out of her wheelchair. Van Driver D pulled into a nearby parking lot and called EMS to come assist and assess the resident. Prior to EMS arriving the resident had gotten herself up and sat in the passenger seat of facility van. When EMS arrived the resident denied hitting her head, denied EMS the ability to assess her, refused vital signs and refused to go to the ER for further evaluation from EMS, NP notified and called RP no answer left message to return call to facility. Record review of Resident #1's nursing note dated 2/21/24 at 4:10 p.m. indicated Resident #1 had delayed bruising to her forehead. Record review of Resident #1's medication administration record dated February 2024 indicated Resident #1 had a pain level of 6 (which indicated moderately strong pain) on 2/19/24 and received Tramadol 50mg at 10:54 p.m. Record review of Van Driver D's employee file indicated a hire date of 2/24/23. The file reflected a a competency check-off Orientation Checklist Community Driver-Van-Bus for driving the van, dated 12/4/23 and 2/19/24, and signed by the Administrator and Maintenance Director F as the trainer. The [State name] Depart of Public Safety driver eligibility check revealed Van Driver A was eligible. Record review of Van Driver A's employee file indicated a hire date of 4/29/19. The [State name] Depart of Public Safety driver eligibility check revealed Van Driver A was eligible. The Orientation Checklist Community Driver-Van-Bus dated 8/23/24 indicated a check mark under the trainer's initials with no date listed and signed by the Administrator and Van Driver A. The personnel file did not indicate a job description. Record review of Van Driver B's employee file indicated a hire date of 12/29/21. The [State name] Depart of Public Safety driver eligibility check revealed Van Driver A was eligible. The Orientation Checklist Community Driver-Van-Bus dated 8/23/24 indicated Van Driver A's initials under trainer's initials with no date listed and signed by the Administrator and Van Driver B. The personnel file did not indicate a job description. During an interview on 9/23/24 at 10:56 a.m. Resident #1 said she was facing forward in the van and Van Driver D forgot to strap down her chair in the van and had to break hard causing her to fall out of her chair. She said Van Driver D did put her seat belt on but just didn't strap down her chair so when she hit the brakes her chair moved forward causing her to fall out of the wheelchair. She said she was not hurt, got up and sat on the seat. She said Van Driver D pulled over and was scared she was going to get in trouble and wanted to take her to the hospital, but she was not hurt and didn't want to go. She said she didn't think Van Driver D worked at the facility any longer and said she had not been on any other transports with her . During an attempted a phone interview with Van Driver D on 9/23/24 at 2:49 p.m. a voicemail was left with no return call by the time of surveyor exit. During an observation and interview on 9/24/24 at 10:08 a.m. Van Driver A said he had been the primary van driver for 4 months but had worked at the facility for 6 years. He said he had been trained by the previous van driver before Van Driver D. He said he had not been trained by a maintenance director or anyone from corporate. He said he had only taken papers to the rental van company to be signed and was not trained on the van. Observed a demonstration of loading a resident wheelchair into the van and securing the wheelchair with four straps, one at each corner of the wheelchair. Van Driver A did strap the four corners of the wheelchair appropriately, so the wheelchair was secure and did not move. Van Driver A then latched a seatbelt over the wheelchair and it did not appear to have been done correctly. Surveyor asked Van Driver D to sit down in the wheelchair that was facing forward towards the windshield and attach the seatbelt as if he was a resident. Van Driver A placed the shoulder strap across the chest area and latched it to the lap belt that was attached to the front track of the van. The surveyor was able to reach over and slide the belt off the driver's lap and the driver was not secured in the wheelchair. Van Driver D said he had always strapped the seatbelt that way and did see how it would not hold a resident in the wheelchair if an incident were to occur. During an observation and interview on 9/24/24 at 11:25 a.m. Maintenance Director G said he had worked at the facility for about 1 and 1/2 months. He said since he had worked at the facility he had not been trained on the van and therefore did not drive the van or do any training with the van drivers. He said he knew there was a vehicle check system in their computer program, but he had not been put in the computer system therefore the vehicle checks had not been done. He said he had a notebook that he kept notes on of anything that he did with the van but did not have any notes of any problems regarding the resident securement system. He said he had worked for the company in the past at a different facility and had knowledge of how a resident should have been properly secured in the van. Observation of a demonstration of how he would secure a resident in the van revealed he moved the lap belt from the front floor track to the back floor track. He said by having the lap belt attached to the front floor track it would not stop a resident's front forward motion. During a telephone interview on 9/24/24 at 11:40 a.m. Maintenance Director H said if a new maintenance director was hired at one of the facility's, then a maintenance director from another facility would come to the facility and train the new maintenance director; then going forward that maintenance director would be responsible for training the van drivers. He said to his knowledge no one had trained Maintenance Director G and he would make sure that Maintenance Director G got trained on the weekly maintenance logs, passenger securement and the transportation policy. During a telephone interview on 9/24/24 at 12:05 p.m. the Rental Van Owner said that he received a call from the facility sometime in February of 2024 asking for him to train the van drivers at the facility. He said the 1st time he scheduled the training no one ever showed up for the training and the 2nd time he walked around the van with an unknown female driver and oriented her to the van. He said to properly secure a resident in the van that was facing forward toward the windshield the lap belt should be secured to the back floor track of the van. He said if the lap belt was secured in the front floor track of the van it would not secure the resident in the chair and the resident would slide out of the chair. During an interview on 9/24/24 at 2:10 p.m. Van Driver B said she had worked as the facility's human resources manager for about 4 months. She said she only transported residents in the van when Van Driver D was not available. She said in the last year she had maybe done 12 transports of an average of about 1 per month. She said she had been trained on the van by Maintenance Director F. She said when she had transported residents in the van the lap belt had usually been attached to the front floor track. She said she did not usually move the lap belt when she transported residents. She said she had not had any incidents while on transport with any residents. Van Driver B said on her Orientation Checklist Community Driver-Van-Bus dated 8/23/24 it was Van Driver A's initials that completed her checklist. During an interview on 9/25/24 at 2:27 p.m. the Administrator said she was not aware that staff were not securing residents in the van properly. She said Van Driver A had been trained by Maintenance Director F . She said if residents were not secured properly in the van and an incident occurred the resident could be significantly injured. Record review of Q'Straint QRT-1 Series user instructions undated indicated: .B. Secure Passenger: 1. A. On the aisle side, attach belt with female buckle to rear tie-down pin connector; ensuring buckle rests on passenger's hip. B. on the window-side, attach belt with male tongue to rear tie-down pin connector and insert into female buckle . 3. Ensure belts are adjusted as firmly as possible, but consistent with user comfort. Warning: 1. Lap and shoulder belt should not be held away from passenger's body by wheelchair components or parts such as the wheelchair's wheels, armrests, panels or frame . 3. Occupant belts should always bear upon the bony structure of passenger's body and be worn low across the front of the pelvis, with the junction between lap and shoulder belts located near passenger's hip . Record review of the facility' policy titled Transportation Policy and Procedure for Center-Based Vehicle dated 11/16/23 with a revision date of 6/27/24 indicated: For our Residents to maintain the highest practical physical, mental, and psychological wellbeing it is the policy of ___(nursing center) to utilize the Facility vehicle for Residents who, because of medical or special needs, require transportation. Maintain a current log notebook to include: Vehicle Maintenance Log, which will include but is not limited to, all recommended routine maintenance as per the vehicle's operating manual, weekly full interior and exterior cleaning and any required non-routine maintenance. Driver Orientation: The authorized driver of the Center's vehicle must be completely oriented as to the transportation policy and procedure as well as successful completion of competency training on all facets of van usage before being permitted by the Center's executive director to drive the Center's vehicle and before being provided with keys to the vehicle. Standard orientation will also need to occur with appropriate verification in personal record. This was determined to be an Immediate Jeopardy (IJ) on 9/24/24 at 4:00 p.m. The facility Administrator, and DON were notified. The Administrator was provided with the IJ template on 9/25/24 at 4:00 p.m. and a plan of removal was requested. The facility's plan of removal was accepted on 9/25/24/24 at 2:32 p.m. and included: 1. Immediate Action Taken A. Resident #1 remains in the facility on 9/24/24. B. The facility's van immediately stopped all van transport on 9/24/2024 at 4:00 pm. C. The Administrator or designee completed the following with the two facilities designated van drivers: In-service education on the Transportation Policy which provides direction on duties of driver, driving of the van, how to operate the wheelchair lift and the wheelchair securement system, use of seat and shoulder harness, and how to transport more than 1 wheelchair. This was completed on 9/24/2024 at 7:00 pm. In-service education on Q'Straint QRT-1 Series User Instructions which provides direction on wheelchair securement, passenger securement and passenger release. This was completed on 9/25/24 at 12:00 pm. In-service education provided to van driver by administrator/designee on weekly maintenance log which includes checking operable seatbelt straps, W/C/ tie down, shoulder strap, floor W/C tie down straps that van driver will complete and provide to administrator/designee weekly. This was completed on 9/24/2024 at 7:00 pm. Sister facility maintenance director completed a skills validation check list on van driver to acknowledge skills competence on how to operate the wheelchair lift and the wheelchair securement system, seatbelts including shoulder harness. The van driver completed a return demonstration. This will be completed on 9/25/2024 at 2:00 pm. The Maintenance Director completed training with sister facility maintenance director on wheelchair securement, passenger securement and passenger release. A skills validation check list was completed on maintenance director to acknowledge skills competence on how to operate the wheelchair lift and the wheelchair securement system, seatbelts including shoulder harness. This will be completed on 9/25/2024 at 2:00 pm. The Maintenance Director completed In-service education on Q'Straint QRT-1 Series User Instructions which provides direction on wheelchair securement, passenger securement and passenger release. This was completed on 9/25/24 at 12:00 pm. The Administrator and/or designee reviewed with van driver, a new signed job description. This was completed on 9/24/2024 at 7:00 pm. 2. Identification of Residents Affected or Likely to be Affected: A. No other residents identified, all scheduled van transports for the remainder of the week will be transported by an outside vendor. This will allow the facility time for training all van drivers, complete skills competencies and return demonstration, with all van drivers. 3.Actions to Prevent Occurrence/Recurrence: A. As of 9/24/2024, any staff member hired for van transports will be provided the following by the facility maintenance supervisor. In-service education on the Transportation Policy which provides direction on duties of driver, driving of the van, how to operate the wheelchair lift and the wheelchair securement system, use of seat and shoulder harness, and how to transport more than 1 wheelchair prior to driving the van. In-service education on Q'Straint QRT-1 Series User Instructions which provides direction on wheelchair securement, passenger securement and passenger release. In-service education on weekly maintenance log which includes checking Operable seatbelt straps, W/C/ tie down, shoulder strap, floor W/C tie down straps that van driver will complete and provides to administrator/designee weekly. Completed a skills validation check list on van driver to acknowledge skills competence on how to operate the wheelchair lift and the wheelchair securement system, seatbelts including shoulder harness, and will complete a return demonstration. Have van driver sign job description duties. B. The weekly maintenance log will be reviewed in the morning meeting by the Administrator or designee. On 9/24/2024 the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to Accidents/Hazards/Supervision and reviewed plan to sustain compliance Date Facility Asserts Likelihood for Serious Harm No Longer Exists: September 25, 2024 On 9/25/24 the Surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of in-service attendance record with topics Transportation Policy and Weekly Maintenance Vehicle Log dated 9/24/24 indicated Van Driver A, Van Driver B and Maintenance Director G had been educated on duties of driver, driving of the van, how to operate the wheelchair lift and the wheelchair securement system, use of seat and shoulder harness, and how to transport more than 1 wheelchair. Record review of in-service attendance record with topics Orientation securing wheelchair for transport Q'Straint QRT-1 Series dated 9/25/24 at 1:30 p.m. indicated Van Driver A, Van Driver B and Maintenance Director G had been educated on wheelchair securement, passenger securement and passenger release. Record review of in-service attendance record with topics Transportation Policy and Weekly Maintenance Vehicle Log dated 9/24/24 indicated Van Driver A, Van Driver B and Maintenance Director G had been educated on weekly maintenance log which included checking operable seatbelt straps, W/C/ tie down, shoulder strap, floor W/C tie down straps that van driver would complete and provide to administrator/designee weekly. Record review of the Orientation Checklist Community Driver-Van-Bus skills validation check list for Van Driver A and Van Driver B to acknowledge skills competence on how to operate the wheelchair lift and the wheelchair securement system, seatbelts including shoulder harness. Van Driver A and Van Driver B completed a return demonstration. The education was provided to Van Driver A and Van Driver B on 9/25/2024 at 2:00 pm by Maintenance Director H. Record review of in-service attendance record with topics Transportation Policy and Weekly Maintenance Vehicle Log dated 9/24/24 indicated Maintenance Director G had been educated on wheelchair securement, passenger securement and passenger release. A skills validation check list was completed with Maintenance Director G to acknowledge skills competence on how to operate the wheelchair lift and the wheelchair securement system, seatbelts including the shoulder harness. The skills validation was completed on 9/25/2024 at 2:00 pm by Maintenance Director H. Record review of in-service attendance record with topics Orientation securing wheelchair for transport Q'Straint QRT-1 Series dated 9/25/24 indicated Maintenance Director G had been educated on Q'Straint QRT-1 Series User Instructions which provided direction on wheelchair securement, passenger securement and passenger release. Record review of a job description titled: Van Driver dated 9/24/24 signed by Van Driver A, Van Driver B, and Maintenance Director G. Revealed Van Driver A, Van Driver B, and Maintenance Director G were educated on the expectations of transportation. Record review of an Ad Hoc QAPI meeting that was held on 9/24/24 at 5:30 p.m. with the facility's Medical Director, Administrator, DON, and ADON revealed discussion the facility's failed system for adequate training of the facility van drivers and reviewed a plan to sustain compliance. During an interview on 9/25/24 at 3:16 p.m. Maintenance Director G said he was educated on how to properly secure a resident on the van. He said he had received education on the Q'Straint QRT-1 series securement system. He said he had received education on the weekly maintenance log which included checking operable seatbelt straps, wheelchair tie down, shoulder straps, and floor wheelchair tie down straps. He said he had received a job description and was able to verbalize knew what the expectations were for van driving. During an interview on 9/25/24 at 3:36 p.m. Van Driver A said he was educated on how to properly secure a resident on the van. He said he had received education on the Q'Straint QRT-1 series securement system. He said he had received education on the weekly maintenance log which included checking operable seatbelt straps, wheelchair tie down, shoulder straps, and floor wheelchair tie down straps. He said he had received a job description and was able to verbalize knew what the expectations were for van driving. During an interview on 9/25/24 at 3:36 p.m. Van Driver B said she was educated on how to properly secure a resident on the van. He said she had received education on the Q'Straint QRT-1 series securement system. She said she had received education on the weekly maintenance log which included checking operable seatbelt straps, wheelchair tie down, shoulder straps, and floor wheelchair tie down straps. She said she had received a job description and was able to verbalize knew what the expectations were for van driving. During an observation on 9/25/24 at 3:48 p.m. Van Driver A, Van Driver B, and Maintenance Director G were able to demonstrate properly how to secure a resident on the facility van for transport. The Administrator was informed the Immediate Jeopardy was removed on 9/25/24 at 4:30 p.m. The facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interviews and record review the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 2 of 5 staff (CNA I and CNA J) reviewed for staff qualifications. The facility failed to ensure CNA I was appropriately certified to practice and provide CNA care in the State of Texas. The facility failed to ensure CNA J was appropriately certified to practice and provide CNA care in the State of Texas. This failure could place residents at risk of not receiving care and services from staff who were properly trained. The findings included: Record review of the computer program CNA certification verification portal TULIP (Texas unified licensure information portal) revealed CNA I's certification was initially issued on [DATE] and expired on [DATE]. Record review of the computer program CNA certification verification portal TULIP revealed CNA J's certification in initially issued on [DATE] and expired on [DATE]. During an interview on [DATE] at 12:39 PM with CNA I, he said he had last worked at the facility on [DATE]. CNA I said he worked at the facility full time for about the last 6 years. CNA I said he believed he had until [DATE] to get his certification renewed. CNA I said he had his girlfriend try to log in to the credentialing system to get his certification renewed but there was a problem with his name being wrong in the system. CNA I said he learned the license was expired when the facility staff informed him a few months ago. CNA I said he had not received any information from the state that his certification was current. CNA I said he was instructed by the facility to check the state's website to renew his certification but was not able to get logged into the system. CNA I was informed by the Administrator that per the state's certification verification website, his certification had been expired since [DATE]. CNA I said the Administrator was trying to help him get his certification renewed. He said if he could not get his certification renewed, he was planning on asking the Housekeeping Supervisor if he could go to work in housekeeping. During an attempted phone interview on [DATE] at 1:22 p.m. CNA J did not answer the phone and did not return call by the time of surveyor exit on [DATE] at 5:15 p.m. During an interview on [DATE] at 2:27 p.m. the Administrator said based on the language of the state's CNA license extension, CNA I's certification would not have been valid. The Administrator said she had tried to help CNA I get logged into the computer system but there was something wrong with the way he initially signed up for the portal and she could not get him signed in. Record review of staffing schedules dated [DATE]-[DATE] indicated CNA I worked 8 shifts as a CNA during that time period. Record review of staffing schedules dated [DATE]-[DATE] indicated CNA J worked 13 shifts as a CNA during that time period. Record Review of the facility's undated Certified Nurse Aide (C.N.A.) job description for CNA's revealed the facility's CNA's essential job duties and responsibilities: Assists residents with activities of daily living including bathing, dressing, grooming, toileting, changing of bed linens, and positioning in and out of bed, chair, etc. Assists with resident recreation programs. Prepares residents for meals and snacks, assists residents in eating where needed and records food intake . Qualifications: Must be a Certified Nursing Aide in good standing with the State or must within four (4) months of employment have completed state required training and a competency evaluation program .

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation in that: The facility failed to label and date items in the dry storage and freezer. The facility failed to ensure the dish machine reached recommended minimal water temperature of 120 degrees Fahrenheit, (F) during the final rinse cycle. This failure could place the residents at risk of foodborne illnesses. Findings included: During an observation and interview [DATE] beginning at 9:20 a.m., initial kitchen tour with the Dietary Manager the following was observed: Dry storage: -Unlabeled dry cereal in bins x 3 no opened dates (Frosted Flakes, Cheerios, and Raisin Bran). 2- plastic packages of open, unsealed, unlabeled cereal in plastic packages. Unlabeled sugar and flour stored in bins with no use by date. Freezer: - - pancakes, burritos and chicken breasts with no labels, no dates when opened or expired dates. The Dietary Manager said she had worked at the facility for [AGE] years. She said that all food items stored in the dry storage area and freezer should be secured in airtight packages and labeled with use by date or date opened. She said foods stored incorrectly could be contaminated by pests or cause illness due to spoilage. During an observation and interview on [DATE] at 9:30 a.m., the Dish aide was standing at the dish machine, he said he had worked at the facility for two weeks. He said he was trained to test the machine by the Dietary Manager. Upon request the Dish Aide tested the dish machine, and it tested at 100 parts-per-million, (PPM), of hypochlorite (chlorine), and the water temperature read 80 degrees Fahrenheit, (F). The Dish Aide ran the machine two times to try to get the water temperature up to required 120 degrees Fahrenheit, (F). On the third time the machine reached 82 degrees Fahrenheit, (F). the Dish Aide said the dish machine usually reaches 100 to 110 degrees Fahrenheit, (F). The Dish Aide said that is the temp they told him it needs to reach. Dish Aide said he had not reported the problem to maintenance. During an observation and interview on [DATE] at 9:40 a.m., the Dietary Manager said they had been having problems with the machine temping after they do morning meal and wash dishes. She ran machine again, and the water temperature read 82 degrees Fahrenheit, (F). She said disposable dishware would be used until the problem was corrected. She said the dish machine not sanitizing the dishes could make the residents sick. During an interview on [DATE] at 11:30 a.m., the Maintenance Director said the Dietary Manager notified him this morning there was an issue with the dish machine not temping after this surveyor entered the kitchen and discovered a problem. He said that there is some play in the thermostat for the hot water in the kitchen and he adjusted it. They will recheck before they wash dishes after lunch . He said not sanitizing the dishes could make the residents sick. During an observation and interview on [DATE] at 12:30 p.m., the Dish Aide ran the dish machine and hit 82. Stated they will continue to use disposable dishware as directed by the Dietary Manager until the problem is resolved . During an observation and interview on [DATE] at 8:00 a.m., the Dish Aide ran the dish machine the temperature reached 122 degrees Fahrenheit, (F). During an observation and interview on [DATE] at 10:45 a.m., the Dietary Manager and Dietary Aide A checked the dish machine while washing the Robo coupe with the low temp machine, machine only reached 114 degrees Fahrenheit, (F). during three attempts on the temperature dial. The Robo coupe was then washed in the three-compartment sink. The machine was checked with a digital thermometer and only reached 114 degrees Fahrenheit, (F). The Dietary Manager said she would contact the representative for the dish machine for service and continue to use disposable dishware. During an interview on [DATE] at 2:00 p.m., the Administrator said the Dietary Manager would be responsible for in servicing the staff, and she expected the staff to test the dish machine before use as required. She said if the dish machine was not working, disposable dishware would be used, and she needs them to call out the service technician to test the machine. She said the dishes not being sanitized could make the residents sick. Record review of Infection control surveillance logs for [DATE] and February 2024 had no indication of gastro-illness or outbreak related to sanitation in the kitchen. Requested a policy for dish machine use and none provided to survey team. Review of Food and Nutrition Services Policy and procedure Manual review date [DATE], procedures . 9. Items stored in the refrigerator must be dated upon receipt, unless they contain manufacturers use by date, sell by or a date delivered. 10. Packaged frozen items that are opened and not used in their entirety must be properly sealed, labeled for continued storage. This includes individual bags of frozen vegetables removed from the original storage box, unless they have a common name of product and dated as noted above.

Based on observation, interview, and record review, the facility failed to maintain a temperature range of 71 F to 81 F for 10 of 10 residents (Resident #'s 2, 4, 7, 8, 9, 10, 11, 12, 13, and 14) reviewed for exposure to high temperatures in the facility. The facility air conditioning system had not been working adequately for at least 4 days. The temperature of a common area (dining room) used by the residents was above 81 F. The temperature of a common area of the secured unit (dining area/TV room) used by the residents was above 81 F. The temperature of a common area (lobby/TV room) used by the residents was above 81 F. An Immediate Jeopardy (IJ) was identified on 07/24/2023. The IJ template was provided to the facility on [DATE] at 6:10 PM While the IJ was removed on 07/27/2023, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. This failure placed all residents at risk for dehydration and hyperthermia (elevated body temperature that could result in stroke or death). Findings Included: Observation on 07/24/2023 at 11:40 a.m. revealed uncomfortable temperatures while walking through the main dining room, lobby, and secured unit. Upon approaching the secured unit section of the skilled nursing facility, the temperature in the hallway was noticeably warmer. On the secured unit there was a water-cooled fan at the beginning of the hallway and a water-cooled fan at the end of the hallway. The thermostat on the wall read 83 F in the middle of the secured unit hallway. During an interview on 07/24/2023 at 11:42 a.m. LVN A said the air conditioning system on the secured unit had been broken for three to four weeks. She said she had not reported to the Maintenance Man that the air conditioning was broken. She said they were not doing anything differently in assessing residents or providing additional hydration due to the air conditioner being broken. She said she works at the facility through agency and had been coming to the facility for about a year. During an interview on 07/24/2023 at 11:44 a.m. CNA B said the air conditioning system had been broken on the secured unit for two to three weeks. She said she had not reported to the Maintenance Man that the air conditioner was broken. She said they were not doing anything differently in assessing residents or providing additional hydration due to the air conditioner being broken. She said she has worked full time at the facility for about 2 months. During an interview 07/24/2023 at 01:50 p.m., the Maintenance Man said it was reported to him that morning (07/24/2023) that the air conditioning system was not working on the secured unit. He said he was working on the air conditioning and should have it up and running again as soon as he could. In an interview 07/24/2023 at 02:00 p.m. with the DON, she said the air conditioning problem on the secured unit was reported to the Maintenance Man and Administrator on Friday 07/21/2023 at 08:33 p.m. She said no residents had been relocated to an area where the air conditioning was functioning. The DON said she would get the facility's emergency plan to the surveyor as soon as someone got it to her. The DON said she did not know how long the air conditioning system had been down in the main dining room or the lobby but that it had been a while, as in more than a month. Record review of text messages provided by the DON revealed on 07/21/2023 at 08:33 PM the Maintenance Man and Administrator were notified the air conditioning system was not working on the secured unit and the temperature was 87 degrees. Observation on 07/24/2023 at 05:00 p.m. revealed a water-cooled fan at the beginning of the secured unit hallway and at the end of the secured unit hallway. The thermostat on the wall read 85 F. The following room temperatures were taken with a Performance Tool W89721 laser infrared temperature gun: Secured unit front of hallway-76.8 F room [ROOM NUMBER]-74.2 F room [ROOM NUMBER]-78.1 F Secured unit middle of the hallway- 83 F room [ROOM NUMBER]-83.9 F room [ROOM NUMBER]-83.5 F room [ROOM NUMBER]-85 F Secured unit end of hallway- 84 F During an interview on 07/24/2023 at 05:10 p.m. the Maintenance Man said he was having a hard time finding a repair man that would come to the facility due to not having the funds to pay for the service call and previous unpaid bills. During an interview on 07/24/2023 at 06:10 p.m. the DON said she could put wander guards on all residents and put one staff member to each room and move all residents off the secured unit to the end of 100-hall. Observation on 07/24/2023 at 06:45 p.m. revealed residents were being transferred to the end of 100-hall where the air conditioning was functioning by facility direct care staff. Observation and interview on 07/25/2023 at 08:30 a.m., the Maintenance Man A revealed he had contacted a repair man and he should be at the facility at 9:30 a.m. The thermostat on the wall read 83 F. During the coolest part of the day (morning) the following temperatures were obtained by the surveyor using a Performance Tool W89721 laser infrared temperature gun: Secured unit front of hallway-74.5 F room [ROOM NUMBER]-72.3 F room [ROOM NUMBER]-74.3 F Secured unit middle of the hallway- 78.8 F room [ROOM NUMBER]-80 F room [ROOM NUMBER]-79.4 F room [ROOM NUMBER]-79.7 F Secured unit end of hallway- 81 F During an observation and interview on 07/25/2023 at 8:45 a.m. revealed additional water-cooled fans were brought to the facility by a sister facility Maintenance Man B. Maintenance Man B said he had contacted an air conditioning repair man who should be at the facility by 10:00 a.m. During an Observation on 07/25/2023 at 6:00 p.m. the following temperatures were obtained by the surveyor using a Performance Tool W89721 laser infrared temperature gun: Secured unit front of hallway-79.6 F room [ROOM NUMBER]-81.5 F room [ROOM NUMBER]-82.3 F Secured unit middle of the hallway- 82.8 F room [ROOM NUMBER]-85.2 F room [ROOM NUMBER]-86.3 F room [ROOM NUMBER]-85.8 F Secured unit end of hallway- 86.8 F Lobby- 83 F Middle of main dining room- 84.6 F During an interview 07/26/2023 at 8:05 a.m. The Maintenance Man A said the air conditioning system on the secured unit had been repaired and staff were going to move the residents back to the secured unit. During an observation on 07/26/2023 at 08:10 a.m. revealed residents were being transferred back to the secured unit by facility direct care staff from the end of 100-hall. The following temperatures were obtained by the surveyor using a Performance Tool W89721 laser infrared temperature gun: Secured unit front of hallway-71.2 F room [ROOM NUMBER]-65.7 F room [ROOM NUMBER]-69.7 F Secured unit middle of the hallway- 71.7 F room [ROOM NUMBER]-69.7 F room [ROOM NUMBER]-72.2 F room [ROOM NUMBER]-66.9 F Secured unit end of hallway- 72.1 F Lobby- 77.1 F Middle of main dining room- 78.2 F During an Observation on 07/26/2023 at 1:00 p.m. the following temperatures were obtained by the surveyor using a Performance Tool W89721 laser infrared temperature gun: Secured unit front of hallway-74.4 F room [ROOM NUMBER]-68.2 F room [ROOM NUMBER]-73.5 F Secured unit middle of the hallway- 76.6 F room [ROOM NUMBER]-73.3 F room [ROOM NUMBER]-74.3 F room [ROOM NUMBER]-71.1 F Secured unit end of hallway- 75.3 F Lobby- 80.6 F Middle of main dining room- 79.9 F During an interview 07/26/2023 at 1:15 p.m. The Maintenance Man said the air conditioning system in the lobby and in the main dining room went down within an hour that morning. He said the repair man should be back at the facility that afternoon between 2:00-3:00 p.m. He said the air should be blowing 69 F- 70 F at the air vent. During an Observation on 07/26/2023 at 2:20 p.m. the following temperatures were obtained by the surveyor at the vent using a Performance Tool W89721 laser infrared temperature gun: Lobby: Vent #1-77.7 F Vent #2-77.5 F Vent #3-75.5 F Vent #4-76.1 F Main Dining Room: Vent #1-78.6 F Vent #2-77.8 F Vent #3-74.8 F Vent #4-73.7 F Vent #5-73.3 F Vent #6-74.5 F Vent #7-74.3 F Vent #8-74.5 F During an interview on 07/26/2023 at 3:00 p.m. The BOM said the air conditioning system in the kitchen, lobby and dining room has been down since before the beginning of summer. She said she thinks it was somewhere around April 2023 when the air conditioning system went out. She said she called a friend of hers that owns a repair service on 7/25/23 and told them the situation and was able to have the air conditioning repair man come out that day. She said since the CHOW on 06/01/2023 she is no longer handling the accounts payable, so she does not know why they have not had a repair man come out at this time. She said before 06/01/2023 she did not have a problem with getting the funds to pay a repair man. She said she would have a check ready for the repair man by the time the repair man had finished the job that day. During an Observation on 07/26/2023 at 04:30 p.m. multiple residents observed being served the dinner meal in the main dining room. Residents in the main dining room do not appear to be in distress. the following temperatures were obtained by the surveyor using a Performance Tool W89721 laser infrared temperature gun: Main Dining Room- 86.3 F Lobby- 80.1 F During an interview 07/26/2023 at 05:00 p.m. The Maintenance Man said the air conditioning system in the Lobby and Main Dining room are working properly. He said the air is blowing 69 F- 70 F at the air vent and that is how the temperature was supposed to be measured. He said he did not know what he was expected to do since it is over a hundred degrees outside, and the air conditioner was functioning properly. During an observation and interview on 07/27/2023 at 09:20 a.m. the Sister Facility Maintenance Man said he was not happy with the Maintenance Man. He said he had told the Maintenance Man to clean the coils on the condenser of the outside air conditioning unit and the Maintenance Man had not done so. He said the correct temperature the air should have been blowing at the air vents was 50 F- 60 F for the room temperature to be comfortable. The Sister Facility Maintenance Man said the AC units worked better if they were serviced twice a year. He said he could not determine if the facility air conditioning units had been serviced in a while. He said those things probably contributed to the air conditioning system failure. Record review of the facility maintenance logs revealed the air conditioning being broken had not been reported using the maintenance log. Record review of the local area weather dated 07/27/2023 located at: <https://weather.com/weather/monthly/l/80702542c8a914a6b950390ce10301ca35c038784e8ba155d80cd24e459fb2f0> read in part the high temperatures from 07/24/2023 to 07/27/2023 in [NAME], Texas ranged from 98 F to 99 F, with the average high temperature being 99 F. Record Review of the Extreme Weather-Heat or Cold policy of the facilities emergency preparedness manual section 5-8 provided on 07/27/2023 revealed: The priority of this facility to minimize the stress our residents could experience from extreme temperatures related to weather events. To mitigate this risk, we rigorously maintain our systems of heating, ventilation and air conditioning and generator. In the event of a disruption to these systems during extreme weather we will initiate the following actions: 1. Activate the facility's extreme weather heat P&P and appoint a facility incident commander if warranted. 2. Assess residents for signs of distress and/or discomfort. 4. Consider re-locating residents to a cooler part of the facility. 7. Provide cool washcloths and cooling fans for air circulation. 8. Encourage residents to drink fluids to maintain hydration. 10. Notify the HHSC to report an unusual occurrence and activation of facility's EOP. The facility DON was notified that an immediate jeaopardy IJ had been identified on 07/24/2023 at 06:10 PM and the IJ template was provided. The facility's plan of removal was accepted on 07/27/2023 at 08:18 AM and included: Immediate action taken: On 7/24/2023 the 10 residents on the Secure Unit were move to other beds throughout the facility at 6:15 pm. All windows were checked by maintenance director, and all were locked. On 7/25/2023 facility will increase staff back to 7 staff members on this unit from 3:00 pm until wireless audible window alarms can be placed on windows on this unit. On 7/24/2023 there were 7 staff members (6 nurse assistants and 1 licensed nurse) assigned to the unit that housed these 10 residents. On 07/25/2023 there would be 2 staff members that would be assigned to door monitor for both doors that leave the unit. These 2 staff will sit inside the unit monitoring the closed door that exits out into the facility, and the end door that exits out of the facility 24 hours a day ensuring that no residents leave the unit, until residents can be moved back to the secure unit. These 2 monitors will have no other duties but monitor the door and ensure the safety of the residents. During break periods, these 2 monitors will be relieved by staff from other areas of the building. Each monitor will document times of duties/responsibilities for each shift covered. This went into effect 7/25/2023 at 6:30 pm. On 7/25/2023 there will be 1 licensed nurse, and 2 nurse assistants assigned to provide direct care to the 10 residents on this unit. This went into effect 7/25/2023 at 6:30 pm. On 7/24/2023 the DON/Designee completed an assessment on the 10 residents on the secure unit for signs/symptoms of dehydration, heat exhaustion and heat stroke. The physician will be notified if any resident has any symptoms of dehydration, heat exhaustion, or heat stroke. This was completed 7/24/2023. On 7/24/2023 An air conditioner company was notified of the need for air conditioning repair in the facility. On 7/25/2023 Regional Nurse consultant provided 1:1 education to the facility/maintenance director related to scheduling repairs when any system malfunctions. On 7/25/2023 the air conditioner company is in the center working on the air conditioner units that are not working. The air conditioner in the kitchen has been repaired. The air conditioner for the lobby and the secured unit will be repaired by 5:00 pm 7/25/2023. The air conditioner for the lobby and for the secure unit has been repaired, operating, and working. 2. Identification of Residents Affected or Likely to be Affected: Maintenance Director/Designee completed rounds on 7/24/2023 to validate that all other air conditioners were operational. On 7/25/2023, air conditioner in the kitchen has been repaired. The air conditioner for the lobby and the secured unit will be repaired by 5:00 pm 7/25/2023. The air conditioner for the lobby and for the secure unit has been repaired, operating, and working. On 7/26/2023 the air conditioner unit in the Dining room went down about an hour ago. The Maintenance Director will place two refrigerated window units in the Dining Room today 7/26/2023 to ensure that the temperature in the Dining Rooms remains at 80 degrees or cooler until the Air Conditioner Unit can be repaired. The lobby air conditioner is operational. On 7/26/2023 the air conditioner in the lobby is not maintaining temperatures at a comfortable level. All residents were removed from the lobby area at this time, and the center will place Evaporated units in the lobby areas to maintain the temperature at or below 80 degrees. Laundry Supervisor will be taking temperatures in the lobby and Dining area this evening and tonight to validate temperature is at 80 or below. Resident will be encouraged to not sit in these areas and will be removed from lobby and Dining Rooms if temperature is not maintained. 3. Actions to Prevent Occurrence/Recurrence: On 7/24/2023 the Regional Nurse Consultant provided education to the Director of Nurses, and the Maintenance Director on the center's Extreme Weather Policy including assessing resident for any signs/symptoms of distress or discomfort, re-locating resident to a cooler part of the facility if temperature go above 81 degrees, providing cool cloths and fan for circulation, encourage hydration and notification to the Regional Nurse Consultant or Regional Director of Operations if applicable. This was completed at 8:00 pm 7/24/2023. On 7/25/2023 hydration rounds were increased for all residents in the center to 4 times a day (not including meal times) On 7/24/2023 the Regional Director of Operations will provide education to the Administrator via Telephone on the center's Extreme Weather Policy including assessing resident for any signs/symptoms of distress or discomfort, to re-locating resident to a cooler part of the facility if temperature go above 81 degrees, providing cool cloths and fan for circulation, encourage hydration and notification to the Regional Nurse Consultant or Regional Director of Operations if applicable. The education also covered reportable events (loss of HVAC system in an emergency and need to report). This was completed at 8:00pm on 7/24/2023. On 7/24/2023 the DON/designee will provide education to all staff currently in the center on Extreme Weather Policy including assessing resident for any signs/symptoms of distress or discomfort, re-locating resident to a cooler part of the facility if temperature go above 81 degrees, providing cool cloths and fan for circulation, encourage hydration and notification to the Regional Nurse Consultant or Regional Director of Operations if applicable. This was completed at 8:00 pm 7/24/2023. No staff will be allowed to work until they have completed this education. On 7/25/2023 hydration rounds were increased for all residents in the center to 4 times a day (not including mealtimes) On 7/24/2023 the DON/designee will provide education to all staff currently in the center on Abuse and Neglect Policy as a refresher of what could constitute abuse. This was completed at 8:00 pm 7/24/2023. No staff will be allowed to work until they have completed this education. On 7/25/2023 the DON/designee will provide education to all staff currently in the center on signs and symptoms of heat exhaustion to observes for and report to include a. Heavy sweating b. Cold/tiredness c. Cool/clammy skin d. Fast weak pulse, dizziness e. Nausea/vomiting f. Headache This will be completed on 7/25/2023 by 2:00 pm, and no staff will be allowed to work until they have completed this education. 4. Monitoring: The Administrator/Designee will monitor temperatures on all hallways and common areas throughout the center and record twice daily for 30 days The DON notified the center's Medical Director of the Immediate Jeopardy on 7/24/2023 at 8:00 pm. An Ad Hoc QAPI meeting will be conducted to review the issues resulting in an Immediate Jeopardy and plan of sustaining compliance. On 07/27/2023 the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: The arrival of the air conditioning repair man at the facility was observed by the surveyors on 07/25/2023 at approximately 05:30 p.m. The system was up, and running and resident rooms were spot checked for cool air coming out of the vents and falling temperatures were verified by surveyors before exiting the building on 07/25/23 at approximately 06:15 p.m. During Observations on 07/27/2023 from 10:15 a.m. to 2:50 p.m., surveyors continued to monitor temperatures in the facility. Initially, elevated temperatures were obtained in the facility secured unit of 72.3-86.8 degrees. After the air conditioning was repaired the temperature ranged 69.7- 76.2. All resident occupied areas and rooms checked were found to be between 69-75 degrees Fahrenheit. In-service sign in sheets dated 07/24/2023 and 07/25/2023 over signs and symptoms of dehydration and signs and symptoms of heat exhaustion were reviewed. The In-service sign in sheet for the Administrator, DON and Maintenance Man in-service over Emergency preparedness was reviewed. The Maintenance rounds sheets reviewed to ensure all other air conditioning systems were operational. The Ad Hoc QAPI meeting held 07/26/2023 addressing the air conditioning system. Record review revealed the DON/Designee completed an assessment on the 10 residents on the secure unit for signs/symptoms of dehydration, heat exhaustion and heat stroke. The physician will be notified if any resident has any symptoms of dehydration, heat exhaustion, or heat stroke. During staff interviews on 07/27/2023 from 10:00 a.m. to 2:50 p.m. the following clinical staff were interviewed (MA C, CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, LVN J, CNA K, CNA L, CNA M, LVN N, and Housekeeper) During these interviews LVN's, CNAs and MAs said they had been in-serviced over signs and symptoms of dehydration (feeling thirsty, Lightheaded, tiredness, dry mouth, dark colored or strong smelling urine, decreased urination) signs and symptoms of heat exhaustion elevated body temperature, hot, red, dry or damp skin, headache, dizziness, nausea, confusion, heavy sweating, cold pale or clammy skin, elevated heart rate, muscle cramps), abuse and neglect. The nurses said if they observed, or it was reported to them that any residents had s/s of heat exhaustion or dehydration they would immediately notify the physician and DON. During an interview on 7/27/23 at 2:30 p.m., the Administrator correctly listed s/s of heat exhaustion and dehydration (elevated body temperature, hot, red, dry or damp skin, headache, dizziness, nausea, confusion, heavy sweating, cold pale or clammy skin, elevated heart rate, muscle cramps/ feeling thirsty, Lightheaded, tiredness, dry mouth, dark colored or strong-smelling urine, decreased urination). She said she will monitor temperatures on all hallways and common areas throughout the center and record twice daily for 30 days ensure temperatures are maintained. The Administrator said he had been given 1 on 1 In-service over emergency preparedness/ procedures, the center's Extreme Weather Policy and immediate reporting by the Regional Director of Operations. Record Review on 07/27/2023 reveal the facility was monitoring the temperatures on all common hallways twice daily. On 07/24/2023 at 6:10 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/27/2023 at 2:50 PM, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of Pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on observation, interview and record review, the facility failed to be adequately equipped to allow resident to call for assistance for 2 of 10 residents (Residents #5 and Resident #6) reviewed for accommodation of needs. The facility failed to be adequately equipped to allow residents to call for staff assistance when needing help due to call light malfunction. The facility failed to ensure Residents #5 and #6 had a working call light. The facility failed to ensure all residents on the secured unit had a working call light. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. This failure could place the residents at risk of injury and not being able to obtain assistance or care as needed. Findings included: 1.Record review of Resident #5's electronic Face Sheet, dated [DATE], revealed an [AGE] year-old male admitted to the facility on [DATE]. Resident #5 had diagnosis which included the following: Atherosclerotic heart disease (a buildup of fats in the artery walls), venous insufficiency (veins have problems moving blood back to the heart), Hyperlipidemia (high cholesterol). Record review of Resident #5's Quarterly MDS assessment, dated [DATE], revealed a BIMS score of 10, which indicated Resident #5's cognition was moderately impaired. The MDS revealed Resident #5 required limited assistance of one person assistance for the following ADLs: transferring, toilet use, and personal hygiene. Further review of the MDS revealed Resident #1 was occasionally incontinent of urine, and continent of bowel and needed assistance for toileting hygiene. Record review of Resident #5's care plan, last revised on [DATE], revealed Resident #5 was at risk for falling due to unsteady gait, decreased balance, medications, and poor safety awareness. The interventions included Call light in reach in room and answered promptly. Encourage and remind him to use call light to ask for assistance. Record review of incident report dated [DATE] revealed Resident #5 had a fall resulting in a laceration requiring staples to laceration while taking a shower. Record review of progress note dated [DATE] at 04:53 PM revealed Resident #5 returned from emergency room with 5 staples in the back of his head. Clear CT scan but complaints of head pain. DON notified. 2.Record review of Resident #6's electronic face sheet dated [DATE], revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #6 had diagnosis which included the following: end stage renal disease (kidney failure), metabolic encephalopathy (problem in the brain), dialysis dependent (removes extra fluid and waste from the blood), type 2 diabetes (affects the way the body processes blood sugar), legal blindness (unable to see). Record review of Resident #6's Quarterly MDS assessment, dated [DATE], revealed a BIMS score of 15, which indicated Resident #6's cognition was intact. The MDS revealed Resident #6 required limited assistance of one person assistance for the following ADLs: transferring, locomotion, bed mobility and personal hygiene. Resident #6 required extensive assistance of one person for walking, dressing and toilet use. Further review of the MDS revealed Resident #6 was occasionally incontinent of urine, and frequently incontinent of bowel and needed assistance for toileting hygiene. Record review of Resident #6's care plan, last revised on [DATE], revealed Resident #6 has the potential for falls. The interventions included place the resident's call light is within reach and encourage the resident to use it for assistance as needed. During an interview and observation on [DATE] at 09:20 AM, Resident #5 said he has not had a call light for ,d+[DATE] weeks. He said he had a call light, and it broke ,d+[DATE] weeks ago, and the facility was supposed to order him a new one. He said he had not heard why it was taking so long to get a new one. When asked how he calls for help, he said he sticks his head out of his door and yells down the hallway. Resident #5 said he had fallen in the shower and sustained a laceration to the back of his head that had required staples. Resident #5's bathroom observed with no call light in place. During an interview on [DATE] at 10:00 AM, LVN O said that not all residents have a call light. She said Resident #5 and Resident #6 do not have a call light on 100 hall. She said that it was caught on camera that staff was unplugging the call light system and putting it in a drawer so that no one's call light was working. She said they had a meeting with the administrator and was told that anyone caught unplugging the call light system would be immediately terminated. She said it has gotten a lot better ever since. She said Resident #5 did have a call light, but it had broken a few weeks ago and had not yet been replaced. She said Resident #6 had not had a call light since admission. She said the main call light box sits at the nurse's station and it could be unplugged, and no one's call light will work. She said you can turn the volume up or down on the main call light box. She said she thought the facility had ordered the call light system online. She said some residents have a button that hangs on a lanyard and each resident is assigned a number. She said when the number lights up on the main box staff has to look at the key taped at the nurses' station to determine which resident was using the call light. She said once it is determined which resident has pushed the call button then staff just has to know what room that resident is in. She said the light on the outside of the room does not light up. During an interview and observation on [DATE] at 10:15 AM, Resident #6 stated she has never had a call light since the day she admitted to the facility. She said if she needs something she asks her roommate to push her call light. She said she does not know why she does not have a call light. Observation of Resident #6's bathroom revealed there was not a call light in place. During an interview [DATE] at 02:00 PM, the DON said she had stopped working for the facility for about 6 months and had returned to working for the facility in October of 2021. She said that when she returned in 2021 the current call light system was in place. She said she was told it was approximately 30 thousand dollars to fix the call light system so as a work around the owners had ordered the current call light system online. She said that it became her duty to issue out a call light button when there was a new admission. She said Resident #5 has had about 3 call lights, but no one reported to her that he currently did not have one. She said she was not sure why Resident #6 had been missed and not issued a call light when she admitted to the facility on [DATE]. She said had she been aware that those 2 residents did not have a call button she would have issued them one because she has 5 extra call buttons in her desk drawer. She said it was the maintenance man's responsibility to mount the call lights in the bathroom when residents admitted to the facility. She said she was aware that the residents on the secured unit did not have call buttons at this time, because they had initially been issued one but that most of them had been lost or thrown away or possibly stuck in drawers due to the resident's cognition. The DON said LVN T and CNA U had been given a notice of disciplinary action on [DATE] and [DATE] due to unplugging the main call light box at the nurse's station. She said after LVN T and CNA U were disciplined for unplugging the main call light box, the facility implemented the End of Shift Round Sheet. During interviews on [DATE] between 01:30 PM to 02:30 PM the following staff members were asked about the End of Shift Round Sheet: 1. CNA V said she did not know what the end of shift round sheet was. 2. CNA B said she had never used the end of shift round sheet and does all her documentation online in their chart. 3. CNA X said she knew what an end of shift round sheet is, she said it is completed at the end of the shift and turned in to the nurse. 4. LVN A said she knew what an end of shift round sheet is but had never used one at this facility. 5. CNA Y said she did not know what the end of shift round sheet was. 6. CNA Z said she knew what an end of shift round sheet is but had never used one at this facility. 7. LVN O said yes, she knew what an end of shift round sheet was but said they had not used them in a while. During an observation on [DATE] at 05:30pm with the DON all resident bathrooms on 100 and 200 halls were observed for call lights with 4 observed and 0 working at that time. Resident #5 and Resident #6's bathroom did not have call lights. Record review of disciplinary action dated [DATE] for CNA U revealed make sure call light stays on top of desk. Record review of disciplinary action dated [DATE] for LVN T revealed this staff removed call light from desk and placed it into drawer this is unacceptable. This staff will return on [DATE] on a 90-day probationary period, any write ups during this time will result in her termination from the facility. Record review of End of Shift Round Sheets form revealed the following information should be filled out at the end of the shift: 1. Date 2. Staff name completing the sheet (off going and on coming). 3. Charge nurse signatures (off going and on coming). 4. Please make sure all-round sheets are placed at the front of the focus binders to be checked the next day in the morning focus meeting by DON/ADON. 5. DON/ADON signatures. A record review of the facility's policy titled Call light Response, dated [DATE], revealed The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. 5. With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed. 6. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied . (Examples include: replace call light, provide a bell or whistle, increase frequency of rounding, etc.). The DON was informed on [DATE] at 6:10 pm that an Immediate Jeopardy (IJ) existed on [DATE], and a copy of the IJ Template was provided. The following Plan of Removal was accepted on [DATE] at 04:59 PM: 1. Immediate Action Taken: Resident # 5 was given a new call button. Resident # 6 was given a Med. Alert call button. DON/Designee completed rounds for all residents on [DATE] at 7:00 pm and validated that there were 7 residents who did not have a call light system. These residents were given bells to use as audible alarms and instructions on their use on [DATE]. DON/Designee completed rounds for all residents on [DATE] at 7:00 pm and validated that there were 23 residents that do not have a visual call light system (16 of these do have a Med. Alert call system). Staff will check all Med. Alert devices every shift to ensure they are working, batteries are working, and that alarm can be heard with the door closed, and there is no signal interruption when doors are closed and that they are not broken or misplaced. This will be documented, and the documentation will be retained in the DON office. A staff member on each shift will be responsible to complete the rounds on each shift to check the Med. Alert devices and document on the Med. Alert monitoring tool. The DON or designee will be responsible to collect and review the Med. Alert monitoring tool daily. On [DATE] at 7:00 pm Staff will start every 1-hour visual check of the 23 residents that do not have a visual call light system with documentation. This will remain in effect until the call light system can be repaired. This documentation will be retained in the DON office. A staff member on each shift will be responsible to complete the rounds on each shift to check residents that do not have a visual call light and document on Every 1-hour monitoring tool. The DON or designee will be responsible to collect and review Every 1-hour monitoring tool daily. On [DATE] The Regional Director of Operations will contact a Call Light Systems Company to come onsite to provide a bid for repair. The center has contacted a company to come to the facility to provide a bid to repair the call light system on [DATE]. 2. Identification of Residents Affected or Likely to be Affected: DON/Designee completed rounds for all residents on [DATE] at 7:00 pm to validate that no resident needed emergency assistance. On [DATE] going forward, all new or readmit resident will have a call light system upon admission. This will be validated daily on rounds by DON or designee. 3. Actions to Prevent Occurrence/Recurrence: On [DATE] DON/Designee started education on Resident call light Policy for all staff. This education was completed on [DATE] at 10:00 pm, and no staff will be allowed to work until this education has been completed. On [DATE] DON/Designee started education on Monitoring tool that will be used every 1 hour to monitor residents without a visual call light. This education was completed on [DATE] at 10:00 pm, and no staff will be allowed to work until this education has been completed. This documentation will be retained in the DON office. Staff will check all Med. Alert devices every shift to ensure they are working, batteries are working, and that alarm can be heard with the door closed, and there is no signal interruption when doors are closed and that they are not broken or misplaced. This will be documented, and the documentation will be retained in the DON office 4. Monitoring On [DATE] at 7:00 pm the facility staff will use the Resident Monitoring tool to round on residents with no visual function call system every 1 hour until the call system can be repaired. 5. On [DATE] at 7:30 pm the DON notified the Medical Director of the Immediate Jeopardy the facility received on [DATE]. On [DATE] at 1:00 pm the facility will conduct an Ad Hoc QAPI meeting to discuss the Resident call light system and plan for sustaining compliance. On [DATE] the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During an observation on [DATE] at 11:30 AM on 100 hall and the secured unit all residents had a call button or were given bells to use as audible alarms and had been given instructions on their use. During an observation on [DATE] at 11:45 AM staff were using the med alert monitoring tool and the Q 1-hour rounds on non-visual working call lights monitoring tool. Record review of an email dated [DATE] at 01:56 PM revealed the Regional Director of Operations had contacted a call light systems company to onsite to provide a bid for repair on [DATE]. During staff interviews on [DATE] from 10:00 a.m. to 2:50 p.m. the following clinical staff were interviewed (MA C, CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, LVN J, CNA K, CNA L, CNA M, LVN N, and Housekeeper) During these interviews LVN's, CNAs and MAs said they had been in-serviced over the Q 1 hour rounds on non-visual working call lights and the med alert monitoring tool. All staff interviewed were able to verbalize procedures for any non-working call lights and notifying the Administrator immediately of any call light related issues. On [DATE] at 6:10 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE] at 2:50 PM, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on observation, interview, and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and Each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 10 (Resident #4) residents reviewed for supervision. The facility failed to respond to door alarm that resulted in Resident #4 elopement on 06/14/2023. Resident #4, who had dementia and a history of previous attempts of elopement, left the facility through an alarmed door on 06/14/2023 at 04:30 AM while wearing a wander guard. The resident wandered 0.3 miles in a wheelchair down the street and was intercepted by a passerby who returned Resident #4 to the facility. An IJ was identified on 07/25/2023. The IJ template was provided to the facility on [DATE] at 06:10 PM. While the IJ was removed on 07/27/2023 the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the need for the facility to monitor its corrective action for effectiveness. This failure could place residents at risk of not being properly supervised which could result in injury or death. Findings included: Record review of Resident #4's facilities electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis include dementia with history of psychotic disturbance (problem with thinking and delusions), epilepsy (seizures), paranoid schizophrenia (delusions and hallucinations). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score of 07, indicating he had severe cognitive impairment. He required supervision to limited assistance with one person assist for dressing, toilet use and personal hygiene, and required supervision with locomotion. Record review of Resident #4's care plan dated 02/21/2022 (day created) revealed Resident #4 is an elopement risk/wanderer as evidenced by Impaired safety awareness and leaving facility grounds with interventions that included wander guard to wrist or ankle for safety, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Record review of Resident #4's quarterly elopement risk assessment dated [DATE] revealed he was at risk to elope and should be placed on the elopement risk protocol. A care plan for elopement is indicated. Record review of nursing progress note dated 02/23/2023 at 11:38 AM revealed Resident #4 found outside in parking lot on property per staff, was redirected and educated on facility set parameters while outside. Resident #4 stated understanding and denies attempted elopement. NP aware, wander guard to right ankle. Will continue to monitor. Written by LVN R. Record review of nursing progress note dated 06/14/2023 at 06:14 AM revealed Resident #4 did exit his room moments later alarm sounded. After staff searched for resident in rooms, on the front porch, behind and the facility. Resident was spotted by a motorist who then notified staff. DON notified and received orders to place resident on secured hall. Written by LVN S. Record review of Resident #4's incident report dated 06/21/2023 revealed incident description: Summary reveals that resident left facility via front door. Wander guard alarms sounded alerting staff who immediately went to door and began facility search. Resident found outside near facility grounds. Facility confirmed that door alarm activated and alerted to potential elopement when wander guard device was near door. All other doors assessed to assure that alarm activated when wander guard device was near. Investigation is confirmed that resident left building unwitnessed. Facility immediately notified 911, the resident's family, facility personnel and MD. Due to elopement, the resident was relocated to the secured unit. Resident interviewed and reported was going to get cigarettes. Doors alarmed alerting staff to potential elopement. There are no other residents with wander guard. Facility assessed the door and it noted to sound when alarm comes in contact with it as it should. Assessments completed on all other residents to ensure of any elopement potential identified. During an observation and interview on 07/24/2023 at 09:45 AM, Resident #4 was observed lying in bed in his room inside of the secured unit. When asked about the elopement on 06/14/2023, Resident #4 said he remembered the incident then said, I did what I did and I don't want to talk about it. During an interview on 07/24/2023 at 1:38 PM, LVN A said she has worked at the facility through agency for about 1 year. She said she works all over the building and is not always assigned to the secured unit. She said she had not seen Resident #4 attempt to get out of the secured unit. During an interview on 07/24/2023 at 1:48 PM CNA B said she had worked at the facility for about 2 months and had not seen Resident #4 attempt to get out of the secured unit. During an Interview on 07/24/23 at 2:00 PM the DON said she was notified by LVN S that Resident #4 had eloped on 06/14/2023 at around 04:30 AM. She said he had a wander guard on the right ankle. She said he ran out of cigarettes that night and was going to the store to get some. She said the wander guard starts alarming and locks the door if a resident gets within 3 feet of a door, however the resident was somehow able to push through the door. She said LVN S and passerby caught him and brought him back to the facility. She said he made it to the 2nd stop sign before the highway. She said they called 911 and there were no injuries at the time and resident refused treatment. She said there was a previous 1st elopement on the day his family member took him to a family reunion then the next day he went outside on 02/23/2023. She said her administrator told her it did not have to be reported if the resident did not leave the property. She said she feels like the CNA caused the first elopement with Resident #4 because she was arguing with him and said staff was with him at the time. The DON said when Resident #4 was brought back he was assessed by LVN S and placed in the secure unit on 06/14/2023. The DON said LVN S reported no injuries were noted during his assessment. The DON said an elopement risk assessment was completed at that time. The DON said she started in-service on Head Count Guidelines and Elopement. Observation on 07/24/2023 at 5:54 PM surveyor took wander guard and pushed all hallway exit doors (100 hall, 200 hall, 300 hall, 400 hall) and 2 entrance doors, they were all locked. No concerns. Record review of the facilities Missing Residents policy dated 10/24/2022 revealed This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. 4: monitoring and managing residents at risk for elopement or unsafe wandering: A- residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. The DON was informed on 07/25/2023 at 6:10 pm that an Immediate Jeopardy (IJ) existed on 07/25/2023, and a copy of the IJ Template was provided. The following Plan of Removal was accepted on 07/26/23 at 02:56 PM: 1. Immediate Action: On 6/14/2023 resident # 4 was placed on the secure unit to prevent further attempts for elopement and to keep resident safe. Family and physician were notified. On 6/14/2023 a new elopement assessment was completed for resident # 4 by DON/designee. On 6/14/2023 an assessment of resident # 4 was completed by DON/designee with no signs of distress or injury. On 7/26/2023 all doors were checked by Maintenance Director/Designee to validate that all are secure and functional with either a wander guard system or a mag-lock system 2. Identification of Residents Affected or Likely to be Affected: On 6/14/2023 a head count was completed by DON/designee to validate that all other residents were in the facility and accounted for. On 6/16/2023 an elopement assessment was completed on all 44 other residents in the facility by DON/Designee. No other residents in the general population were identified as elopement risk per the elopement assessment. On 7/26/2023 at 9:30 am DON/Designee identified only 1 resident who had a Wander guard on in the facility. This resident was evaluated by the DON to determine Elopement risk. Based on elopement risk assessment, this resident was moved to the secure unit with notification to physician and family. No other residents in the facility are wearing a wander guard bracelet. 3. Actions to Prevent Occurrence/Recurrence: On 6/14/2023 DON/Designee educated staff on Safety Training (that included Missing resident guidelines and head count guidelines) This education provides information on: (1) missing resident guidelines what do if a resident is missing, (2) how to conduct a head count to ensure no other residents have left the facility, (3) article on Nursing home abuse, center's missing patient guideline regarding investigation and root cause analysis. On 7/26/2023 DON/Designee began education with staff on Elopement/Wandering/Missing resident Policy which entails: (1) definitions, (2) Explanation and compliance guidance, (3) Process for locating a missing resident, (4) procedure post elopement. Head Count Clinical Practice Guidelines which entail: (1) process for conducting a head count when a resident is missing, (2) explanation and compliance guidance. This will be completed at 12:00 pm on 7/26/2023, and no staff will be allowed to work after this date and time until they have completed this education. On 7/26/2023 at 2:00 pm DON/Designee will conduct a missing resident drill on the Am shift to validate staff's knowledge on response to an elopement. On 7/26/2023 DON/Designee will conduct a missing resident drill at the beginning of the evening and the night shift before staff start work, to validate staff's knowledge on response to an elopement. Beginning on 7/26/2023, any new or readmit resident will have an elopement assessment completed upon admission to determine the resident's risk for elopement. Any resident with a risk of elopement will be evaluated for placement on the secure unit with order from physician and family notification. The DON/designee will be responsible for this evaluate for placement on the secure unit based on the elopement risk assessment. As of 7/26/2023 the center will not use the Wander guard bracelets in the center. 4. On 7/25/2023 the DON/Designee notified the facility's Medical Director of the Immediate Jeopardy that facility was cited for at 7:30 pm. On 7/26/2023 the facility will conduct an Ad Hoc QAPI meeting to discuss the Immediate Jeopardy related to Accidents/Hazards and on sustaining compliance. On 07/27/2023 the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During an observation on 07/26/2023 at 10:40 AM all doors were checked by surveyor to validate that all are secure and functional with either a wander guard system or a mag-lock system. During an observation on 07/26/2023 at 10:45 AM surveyor confirmed all residents with a wander guard system were moved to the secured unit. No other residents in the facility were wearing a wander guard bracelet. During an observation on 07/26/2023 at 02:20 PM, surveyor elopement drill completed. Record Review of in-services dated 07/26/2023 titled Missing Person/Elopement Risk Policy with 31 employee signatures. Record review of Ad Hoc QAPI dated 07/26/2023, (2) provide adequate supervision to prevent Resident #4's elopement after previous attempts at elopement. During staff interviews on 07/27/2023 from 10:00 a.m. to 2:50 p.m. the following clinical staff were interviewed (MA C, CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, LVN J, CNA K, CNA L, CNA M, LVN N, and Housekeeper) During these interviews LVN's, CNAs and MAs said they had been in-serviced over the missing person, elopement risk, and head count policies. All staff interviewed were able to verbalize procedures for any missing residents and notifying the Administrator immediately of any missing residents. On 07/25/2023 at 6:10 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/27/2023 at 2:50 PM, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on interviews and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation for 1 of 10 residents (Resident #2) reviewed for develop and implement abuse policies. The facility failed to implement their policies and procedures related to reporting allegations of allegations of abuse when CNA Q failed to report abuse, she witnessed on 03/25/2023 until 03/26/2023 to the abuse coordinator. This failure could place residents at risk of abuse which could lead to further abuse and neglect of other residents. On 07/25/2023 at 6:10 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/27/2023 at 2:50 PM, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. Findings include: Record review of Resident #2's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Her diagnoses included Dementia (problem in the brain affecting memory), Psychotic disorder (loss of contact with reality), anxiety (feeling of fear, and uneasiness). Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 99, which indicated resident was unable to complete the interview. She required limited to extensive assistance of 1 staff for ADL care. Record review of Resident #2's care plan revealed she had a history of Depression and receive an anti-depressant medication. Interventions were to Approach in calm manner, introduce self and explain procedure/care to be provided, provide validation of feeling by restating concerns/feelings, encourage to focus on positive. Observation of a video taken on 03/25/2023 by the facility camera's revealed LVN P was feeding another resident in the secured unit when she walked over to the couch bent down, grabbed Resident #2's face and pushed her back on the couch. LVN P then picked up Resident #2's hand and pulled Resident #2 into a standing position and turned her and pushed Resident #2 in the back forcing her to walk away from LVN P. LVN P then walked back over to the table and resumed feeding the other resident. During an interview on 07/24/2023 at 2:00 p.m. the DON Said CNA Q went to the administrator and reported that LVN P was being mean to the secured unit residents. She said the Administrator pulled the camera, and it showed LVN P shake her finger in her face and then reach up and grab Resident #2 by the face and push her back against the couch. She said LVN P said she didn't want Resident #2 to fall and tried to scoot her back in her chair. She said it happened on Sunday and CNA Q didn't report the incident until Monday morning. During an interview on 07/26/2023 at 01:31 PM CNA Q said she was passing out lunch trays on 3/25/2023. Said she pulled Resident #2's tray off the cart and put it on the table and told Resident #2 to come to the table. Said she went back to the cart to finish delivering trays to the table and Resident #2 sat up and started laughing, then LVN P turned around and grabbed Resident #2 by the face and said something to her then grabbed Resident #2 by the arm stood her up and pushed her towards the table. CNA Q said she went and told the med aid. The med aide then told LVN P what she had said, and LVN P came up to CNA Q in an aggressive manner and said just to let you know, I don't abuse my residents and I don't appreciate you talking about me in that tone. CNA Q said she didn't report it to the administrator until the next day because she did not have phone numbers saved in her phone and due to her being from out of state, they had a different reporting system where she was from. CNA Q said at her old facility they just filled out a paper and turned it in. CNA Q said it happened on the weekend and there was not much staff to ask what she should do. She said she didn't know anyone else's name so she did not ask any other staff what she should do. She said she does not remember being trained on how she was supposed to report abuse that she can remember. CNA Q said the next day she texted the DON and asked what she should do and was advised to talk with the Administrator. She said she texted the Administrator on 03/26/2023 and asked for her to call her and after reporting what happened, the Administrator came to the facility and had her write out a statement of what happened. After that she said later the Administrator told her she had gotten it on camera so she has fired the nurse and would be contacting state. Record review of LVN P's Notice of Employee Separation dated 03/27/2023 revealed she was involuntarily terminated due to resident abuse. Record review of the facility's Inservice meeting dated 03/26/2023 revealed staff were trained on abuse and neglect, exploitation, what is abuse and neglect and who to report abuse and neglect to. The in-service was conducted by the Administrator, and DON. In an attempted interview on 07/25/2023 at 11:23 a.m. LVN P did not answer the phone call. This Surveyor left a voicemail and provided the state cell number. Record Review of 13 safe surveys conducted by the facility social worker did not reveal any additional concerns. In an interview on 07/27/23 at 11:50 a.m. the Administrator said she conducted a swift and thorough investigation immediately. She notified the police. LVN P was immediately terminated. Abuse and neglect in-services were given to staff, and they were educated on reporting abuse and neglect. She said no other residents were abused by LVN P. Record review of the facility's Abuse policy dated 02/01/20221 read in part, .Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. B. Each covered, individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. C. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made. The DON was informed on 07/25/2023 at 6:10 pm that an Immediate Jeopardy (IJ) existed on 07/25/2023, and a copy of the IJ Template was provided.

Based on interview, and record review the facility failed to ensure residents the right to be free from abuse and neglect for 1 (Resident #2) of 10 residents reviewed for abuse and neglect. On 03/25/2023 at 04:39 PM, LVN P grabbed Resident #2 by the face and shoved her back on the couch, then pulled her to a standing position by the arm and turned her around and shoved her in the back pushing her away from LVN P. On 03/25/2023 CNA Q witnessed abuse by LVN P on 03/25/20223 and did not report Abuse and Neglect to the Abuse Coordinator until the day after the incident on 03/26/2023. This failure could place all residents in the facility at risk for severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. On 07/25/2023 at 6:10 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/27/2023 at 2:50 PM, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. Findings included: Record review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Dementia (problem in the brain affecting memory), Psychotic disorder (loss of contact with reality), anxiety (feeling of fear, and uneasiness). Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 99, which indicated resident was unable to complete the interview. She required limited to extensive assistance of 1 staff for ADL care. Record review of Resident #2's electronic care plan dated 09/27/2019 revealed she had a history of Depression and received an anti-depressant medication. Interventions were to Approach in calm manner, introduce self and explain procedure/care to be provided, provide validation of feeling by restating concerns/feelings, encourage to focus on positive. Observation of a video taken on 03/25/2023 by the facility cameras revealed LVN P was feeding another resident in the secured unit when she walked over to the couch bent down, grabbed Resident #2's face and pushed her back on the couch. LVN P then picked up Resident #2's hand and pulled Resident #2 into a standing position and turned her and pushed Resident #2 in the back forcing her to walk away from LVN P. LVN P then walked back over to the table and resumed feeding the other resident. The facility DON identified the staff member observed in the video. During an interview on 07/24/2023 at 2:00 p.m. the DON Said CNA Q went to the administrator and reported that LVN P was being mean to the secured unit residents. She said the Administrator pulled the camera, and it showed LVN P shake her finger in her face and then reach up and grab Resident #2 by the face and push her back against the couch. She said LVN P said she did not want Resident #2 to fall and tried to scoot her back in her chair. She said it happened on Sunday 03/26/2023 and CNA Q didn't report the incident until Monday 03/27/2023 morning. During an interview on 07/26/2023 at 01:31 PM CNA Q said she was passing out lunch trays on 3/25/2023. Said she pulled Resident #2's tray off the cart and put it on the table and told Resident #2 to come to the table. Said she went back to the cart to finish delivering trays to the table and Resident #2 sat up and started laughing, then LVN P turned around and grabbed Resident #2 by the face and said something to her then grabbed Resident #2 by the arm stood her up and pushed her towards the table. CNA Q said she went and told the med aide. The med aide then told LVN P what she had said, and LVN P came up to CNA Q in an aggressive manner and said just to let you know, I don't abuse my residents and I don't appreciate you talking about me in that tone. CNA Q said she did not report it to the administrator until the next day because she did not have phone numbers saved in her phone and due to her being from out of state, they had a different reporting system where she was from. CNA Q said at her old facility they just filled out a paper and turned it in. CNA Q said it happened on the weekend and there was not much staff to ask what she should do. She said she did not know anyone else's name so she did not ask any other staff what she should do. She said she does not remember being trained on how she was supposed to report abuse that she can remember. CNA Q said the next day she texted the DON and asked what she should do and was advised to talk with the Administrator. She said she texted the Administrator on 03/26/2023 and asked for her to call her and after reporting what happened, the Administrator came to the facility and had her write out a statement of what happened. After that she said later the Administrator told her she had gotten it on camera so she has fired the nurse and would be contacting the state. Record review of LVN P's Notice of Employee Separation dated 03/27/2023 revealed she was involuntarily terminated due to resident abuse. Record review of the facility's Inservice meeting dated 03/26/2023 revealed staff were trained on abuse and neglect, exploitation, what is abuse and neglect and who to report abuse and neglect to. The in-service was conducted by the Administrator, and DON. In an attempted interview on 07/25/2023 at 11:23 a.m. LVN P did not answer the phone call. This Surveyor left a voicemail and provided the state cell number. Record Review of 13 safe surveys dated 07/26/2023 conducted by the facility social worker did not reveal any additional concerns. In an interview on 07/27/23 at 11:50 a.m. the Administrator said she conducted a swift and thorough investigation immediately. She notified the police. LVN P was immediately terminated. Abuse and neglect in-services were given to staff, and they were educated on reporting abuse and neglect. She said no other residents were abused by LVN P. Record review of the facility's Abuse policy dated 02/01/2021 read in part, .Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. B. Each covered, individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. C. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made. The DON was informed on 07/25/2023 at 6:10 pm that an Immediate Jeopardy (IJ) existed on 07/25/2023, and a copy of the IJ Template was provided. The following Plan of Removal was accepted on 07/26/23 at 02:56 PM: Immediate Action: On 3/27/2023 DON/Designee immediately suspended staff member pending outcome of investigation (and was subsequently terminated) On 3/26/2023 DON/Designee reported incident to the local police department. On 3/26/2023 Administrator reported Incident to Health and Human Services Department. On 3/26/2023 and 3/27/2023 DON/Designee obtained witness statements from witnesses involved in the incident. On 3/26/2023 Administrator reviewed video surveillance of incident on facility camera. On 3/27/2023 DON/Designee started education on the facilities Abuse and Neglect Compliance Policy to all staff (which included: Signage of what and when to report abuse, Reporting Abuse guidelines, Resident Rights policy) On 7/26/2023 at 1:30 pm the Regional Nurse Consultant will provide 1:1 education to the facility's CNA Q who failed to notify the Administrator/DON immediately of the witnessed abuse on 3/25/2023. On 7/26/2023 at 1:00 pm the Regional Nurse Consultant provided 1:1 education to the Administrator and DON on the facility's abuse policy which included: o Definition of Abuse/Neglect, Explanation and compliance guidelines, Components of Abuse prohibition, Prevention of abuse/neglect, Identification of abuse neglect, investigating abuse/neglect, Resident protection, reporting timely abuse and neglect and QAPI. On 7/26/2023 the Business Office Manager completed 100% audit of all employee's personal files to validate that all required staff had required backgrounds checks completed on hire. This will be completed by 6:00 pm on 7/26/2023. Identification of Residents Affected or Likely to be Affected: On 3/27/2023 Social Services/Designee completed alert resident interview to validate that all resident felt safe. On 3/27/2023 Administrator reviewed video surveillance cameras to validate that no other residents were affected by the actions of this staff member. On 7/26/2023 Social Worker/Designee completed interviews with alert resident to validate all residents feel safe. This will be completed by 6:00 pm on 7/26/2023. The DON verbalized that she did not assess residents in the secure unit on 3/26/2023 to validated that no resident had any signs or symptoms of physical or emotional distress. DON was provided 1:1 education by the Regional Nurse Consultant on 7/26/2023 on identifying like residents when an abuse incident occurs. Actions to Prevent Occurrence/Recurrence: On 3/27/2023 DON/Designee started education with all staff on the facilities Abuse and Neglect Compliance Policy (which included: Signage of what and when to report abuse, and reporting abuse to the abuse coordinator, Reporting Abuse guidelines, Resident Rights policy) On 7/26/2023 the DON/Designee started education with staff on the facility's abuse policy which included: o Definition of Abuse/Neglect, Explanation and compliance guidelines, Components of Abuse prohibition, Prevention of abuse/neglect, Identification of abuse neglect, investigating abuse/neglect, Resident protection, reporting timely abuse and neglect, and reporting abuse to the abuse coordinator, and QAPI This was completed on 7/26/2023 at 12:00 pm, and no staff will be allowed to work after this date and time until they receive this education. Monitoring: Social Services/Designee will complete weekly alert resident interviews x 4 weeks to validate that all residents feel safe and free from abuse. The DON/designee will validate with daily rounds that cognitively impaired residents are free from signs of abuse. On 7/25/2023 at 7:30 pm the DON notified the facility's medical director regarding the Immediate Jeopardy the facility received related to abuse and neglect. On 7/26/2023 at 1:30 pm the facility will conduct an Ad Hoc QAPI meeting to discuss the cite related to abuse, and on plan to sustain compliance. On 07/27/2023 the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of provider investigation report confirmed LVN P was terminated on 03/27/2023. The local police department, Texas Board of Nursing and Health and Human services was notified of the incident. Witness statements and video surveillance of incident reviewed. Record review of 1:1 education provided to CNA Q dated 07/26/2023 regarding abuse/neglect, and to notify administrator immediately of witnessed or suspected abuse. Record review of 1:1 education provided to the Administrator and DON on 07/26/2023 regarding abuse/neglect policy including: 1. Definition of abuse/neglect. 2. Explanation and compliance guidelines. 3. Components of abuse prohibition. 4. Prevention of abuse and neglect. 5. Identification of abuse and neglect. 6. Investigating abuse and neglect. 7. Resident protection. 8. Reporting timely abuse and neglect and QAPI. Record review of required staff background checks completed on 07/26/2023. Record review of 26 resident interviews to validate all residents feel safe completed by the social worker on 07/26/2023. Record review of 1:1 education provided to the DON by the Regional Consultant regarding identifying like residents when an abuse incident occurs completed on 07/26/2023. Record review of all staff in-service dated 07/26/2023, titled: Abuse and Neglect Policy with Post Test with 33 staff signatures. Record review of Ad Hoc QAPI completed on 07/26/2023 at 01:30 PM. The meeting was to discuss the cite related to abuse, and on a plan to sustain compliance. During staff interviews on 07/27/2023 from 10:00 a.m. to 2:50 p.m. the following clinical staff were interviewed (MA C, CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, LVN J, CNA K, CNA L, CNA M, LVN N, and Housekeeper) During these interviews LVN's, CNAs and MAs said they had been in-serviced over the abuse/neglect policy. All staff interviewed were able to verbalize types of abuse and notifying the Administrator immediately of witnessed of suspected abuse. On 07/25/2023 at 6:10 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/27/2023 at 2:50 PM, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on observation, interview and record review, the facility failed to ensure residents were free from abuse and neglect for 4 of 6 residents reviewed for abuse/neglect. (Resident #s 1, 2, 3 and 4) The facility failed to ensure Resident #1, who had a known history of inappropriate sexual behavior, had effective interventions in place to address the residents continued inappropriate behavior/touching toward female resident and wandering into their rooms. The facility failed to refer Resident #1 for evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to ensure Resident #2 was free from Resident #1's inappropriate behavior/touching. The facility failed to protect Resident #2 from Resident #1 blocking the bedroom door with furniture to keep staff from entering while Resident #2 was asleep in bed. The facility failed to ensure Resident #3 was free/safe from Resident #1 repeatedly entering the room of Resident #3 as she slept in bed. The facility failed to protect Resident #4 from Resident #1's physical aggression when Resident #1 pulled him from his wheelchair. An Immediate Jeopardy situation was identified on 06/17/21 at 8:26 p.m. The Immediate Jeopardy was removed on 06/18/21; however, the facility remained out of compliance at a pattern of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the facility's need to complete in-service training, revise their secure unit policy, continue to monitor the implementation and evaluate the effectiveness of the corrective systems. This failure could affect residents on the secure unit and place them at risk for injury, neglect and abuse. Findings included: 1. An Admission Record dated 06/18/21 indicated Resident #1, admitted [DATE], was [AGE] years old with diagnoses of [CONDITION(S)] without behavioral disturbance, mood affective disorder, presbyopia and frontotemporal dementia. Psychiatric hospital records for Resident #1 indicated: *02/01/21 at 1:39 p.m., resident required redirection and since being moved to the geriatric unit on 01/28/21 he had formed a relationship with a female peer. He had been seen kissing her hand and stated he did not see anything wrong with that. He was cautioned about the behavior and told not to kiss her, or anyone else's hands. The resident remained on 1:1 supervision for safety since he had a tendency to pilfer and wander. *02/02/21 at 6:09 p.m., the resident was in a peer's face throughout the day. He wanted to hold her hand and kiss on her. Redirected several times not to kiss the female peer. He took the female peer to the front day room and attempted to shut the door. The nurse placed hand on the door explaining to Resident #1 the door had to stay open and Resident #1 tried to remove the nurse's hand from the door. *02/03/21 at 7:41 p.m., resident remains clingy when it comes to female peer. Resident expressed sexual comments regarding peer to his assigned 1:1 staff, lets go to (female peer at hospital) room, take off her clothes and have sex. Doctors notified of his continued inappropriate behavior towards female peer. *02/04/21 at 12:53 p.m., resident was committed for competency restoration on charges of aggravated assault with a deadly weapon. He is awake, alert and oriented to person and place. He denied auditory and visual hallucinations. *02/04/21 at 1:04 p.m., transferred to another unit due to sexually inappropriate behavior with a female peer. He requires nearly constant redirection. Social Assessment of Mental Health from the psychiatric state hospital dated 02/05/21 at 3:18 p.m. indicated Resident #1's daughter stated some of her father's violent tendencies involved the use of a firearm and described him as having two sides, one in which he was a model father and the other where he appeared manipulative, vindictive and deceitful. Physician Discharge Order Note dated 02/05/21 indicated Resident #1 was being picked up by law enforcement this afternoon by order of the Court but the reason was unclear. The order directed if Resident #1 was going to jail or a lockup, he should be placed in a single cell and closely monitored at all times due to his dementia, he will be easily confused and prone to making irrational decisions. Physician Discharge Order Note dated 03/04/21 indicated Resident #1's condition at discharge was unimproved and was determined to be stable for discharge to a secured long term care facility. Resident #1 was placed on 1:1 observations as his pilfering and wandering were irritating his peers, many of whom were young and strong and quick to become physically aggressive. He was not prescribed any [CONDITION(S)] medications as there are no psychotic symptoms to be treated. Resident #1 was briefly placed on the San [NAME] Unit and was returned to CU-5 after becoming infatuated with a singular female peer. The most recent MDS dated [DATE] indicated Resident #1 had clear speech, understood others as well as made himself understood, was moderately cognitively impaired, demonstrated no verbal or physical abusive behavioral symptoms directed towards others and wandered one to three days of the most recent seven days. A nursing progress note written by LVN B dated 03/08/21 at 10:25 a.m. indicated Resident #1 was going into female residents' rooms, shutting the doors and trying to get into bed with them. According to this note, Resident #1 was educated that this was inappropriate behavior and if he wished to visit with other residents they could sit in the common area across the table from one another; however, redirection was ineffective and the resident continued going into the rooms of female residents. A nursing progress note written by LVN B dated 03/08/21 at 10:48 a.m. indicated Resident #1 barricaded doors when going into women's rooms to keep staff out with education and redirection ineffective. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An untimed nursing progress note written by LVN B dated 03/08/21 indicated facility staff notified Resident #1's appointed post local psychiatric care system to inform of Resident #1's inappropriate behaviors of going into female residents rooms on the secured unit and shutting/barricading the doors, attempting to hide and get into female resident's beds. This nursing note indicated the ACCESS case worker expressed this was a very specific concern (Resident #1's daughter) had with him being placed at the current facility; unfortunately, with no diagnosis, the ACCESS worker said their hands were tied. A nursing progress note written by LVN B dated 03/08/21 at 1:40 p.m. indicated Resident #1's family member was notified of his behaviors. According to this progress note, the family member reported Resident #1 had started exhibiting the same behavior at the psychiatric hospital when he was transferred from the all male unit to a male/female coed unit and his behavior escalated to the point Resident #1 was transferred back to the all male unit. This note indicated the resident's family member reported to the facility Resident #1's behaviors had been inappropriate for years and had gotten him into more trouble than the incident that resulted in psychiatric hospital placement and that Resident #1 knows exactly what he is doing and uses dementia as an excuse to try and play his behavior off. The note further indicated the family member reported even before Resident #1's legal trouble he was a master manipulator his entire life and would [NAME] on women who he thought he could take advantage of. A nursing progress note written by LVN B dated 03/09/21 at 7:15 a.m. indicated Resident #1 was caught coming out of a female resident's room while the female was asleep. This note indicated when Resident #1 was redirected and told his behavior was inappropriate, he acted like he could not walk or hear and was lost. A nursing progress note written by LVN B dated 03/09/21 at 8:34 a.m. indicated NP S was notified of Resident #1's behaviors and concerns of his daughter. Resident #1 was placed on 15 minute checks for 72 hours and a new order was given for a psychological evaluation and treatment. A nursing progress note written by LVN B dated 03/09/21 at 9:52 a.m. indicated LVN H placed a large sign of Resident #1's name on his door. LVN H educated Resident #1 to only enter the door with his name written on it and Resident #1 verbalized he understood. A nursing progress note written by LVN A dated 03/09/21 at 8:40 p.m. indicated Resident #1 continues behaviors of going in female resident's rooms and following a female resident around the hallways despite redirection from staff. A nursing progress note written by LVN F dated 03/11/21 at 4:29 p.m. indicated Resident #1 continues being monitored for attempting to enter female peer's room and attempting to get into bed with Resident #3. A Care plan dated 03/16/21 indicated Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . If resident becomes agitated, provide safety, remove from area affecting others, back away and seek help as needed. A care plan dated 03/16/21 indicated Resident #1 required placement on a secured unit. The care plan noted if the resident appeared agitated/combative, the staff were to remove other residents from the area and, if possible, redirect resident to a calmer setting and seek assistance as needed; observe for and document episodes of wandering in/out of rooms. A nursing progress note written by LVN A dated 03/18/21 at 3:00 p.m. indicated Resident #1 continued with 15 minute checks as ordered for attempting to enter a female resident's room at the beginning of this shift. A care plan dated 03/18/21 indicated Resident #1 wandered around the secure unit with purpose, in and out of other residents' rooms, including female residents, requiring frequent redirection. The care plan noted staff were to redirect Resident #1 from other residents' room, out of unauthorized area without injury to self or others, observe him when out of room for wandering in/out of other room, wandering to unauthorized area and provide redirection as needed, refer to psychological services as needed. A nursing progress note written by LVN F dated 03/20/21 at 12:02 a.m. indicated Resident #1 continued to be monitored every 15 minutes checks as ordered for attempting to go into female peers' rooms and barricading doors. The note indicated the facility was looking for another facility to transfer Resident #1. A nursing progress note written by LVN G dated 03/26/21 at 1:31 p.m., indicated Resident #1 was on day 6 of 7 day monitoring for cursing staff, slamming doors and constantly attempting to go in and out of female residents' rooms, having to be redirected the majority of the shift. A nursing progress note written by RN R dated 04/10/21 at 6:28 p.m., indicated Resident #1 continues to wander into others' rooms, does not take direction well as exhibited by behaviors. Resident #1 was walking with a steady gait and almost fell over when redirected from another resident's room. A nursing progress note written by LVN K dated 04/12/21 at 1:19 p.m., indicated Resident #1 was attempting to lure a female resident into his room. A nursing progress note written by LVN J dated 04/13/21 at 1:35 p.m., indicated day 1 of 7 day monitoring for Resident #1 targeting females. Resident #1 continued to try to lure females into his room. This note indicated the ADON spoke with Resident #1 about the behaviors and was placed on 15 minute monitoring for 72 hours. A nursing progress note written RN R dated 04/24/21 at 5:51 p.m., indicated Resident #1 required continuous observation related to taking utensils off food cart, cursing other residents under his breath, wandering into female resident rooms. The note indicated Resident #1 was impulsive and exhibited sneaky behaviors while awake. A nursing progress note written by LVN F dated 04/25/21 at 10:40 p.m., indicated day 3 of 7 day monitoring for Resident #1 pilfering, going into other's rooms, attempting to lure females into his own room. A nursing progress note written by LVN F dated 04/27/21 at 4:15 a.m., indicated Resident #1 was very difficult to redirect and remained on monitoring for pilfering from staff and peers and continuing to sneak into female's rooms. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note written by LVN F dated 05/01/21 at 5:33 a.m., indicated day 7 of 7 day monitoring for Resident #1 pilfering and sneaking into female's rooms. A nursing progress note written by LVN F dated 05/03/21 at 3:42 a.m., indicated it was day 2 of 7 behavioral monitoring for Resident #1 following females into their rooms, trying to lure female residents to his room, aggravating peers, becoming angry when redirected. A nursing progress note written by LVN F dated 05/10/21 at 4:33 a.m., indicated it was day 7 of 7 behavioral monitoring due to Resident #1 urinating in the hallway and blocking doors with furniture to keep staff out. A Behavioral Health Diagnostic assessment dated [DATE] at 9:55 a.m. indicated Resident #1 was exquisitely paranoid if anyone approached his room although he went into others' rooms due to his entitlement and being more intellectual than anyone else (peers and staff!). This note indicated Resident #1 had postured sexual acting out with female peers. The Psychological Treatment Plan dated 05/18/21 included the following recommendations and services for Resident #1: *psychological consultation is recommended to assist staff in developing and implementing behavior plans to reduce patient's affective and/or cognitive symptoms. *individual therapy to reduce patient's affective and/or cognitive symptoms. *behavior modifying therapy *Resident #1 appears to need to reduce anxieties about being in long term care and begin to further adhere to directive and external loci of control. His hoarding metal eating utensils led to plasticware being brought onto secure unit. He has no problem going into others rooms. He was sexually provocative with female peers in his first few weeks of residency. *Service Plan: estimated frequency and duration of treatment - 4 times per month for 6 months. Estimated number of sessions - 24. Review at next plan of care - 09/18/21. A social services note written by the administrator dated 06/03/21 at 10:00 a.m., indicated Resident#1 understood both verbal and non-verbal expression and had the ability to express his ideas and wants. This note indicated Resident #1 and Resident #1's family expect to remain in this facility. A nursing progress note written by LVN J dated 06/03/21 at 11:59 a.m., indicated Resident #1 was on day 1 of 3 of 15 minute checks for having a female peer in his room. A nursing progress note written by LVN A dated 06/04/21 at 6:09 p.m., indicated Resident #1 continued on 15 minute checks related to having a female resident in his room two days in a row. This note indicated Resident #1 had been informed of the inappropriate nature of having females in his room alone and Resident #1 verbalized understanding. A nursing progress note written by RN Q dated 06/05/21 at 11:14 a.m., indicated Resident #1 was on 15 minute checks for safety. A nursing progress note written by LVN J dated 06/08/21 at 11:27 a.m., indicated Resident #1 was on day 5 of 7 every 15 minute monitor checks for taking female peers into his room. This note further indicated Resident #1 was on day 1 of 10 monitoring every 15 minutes due to attempting to lure female peer into his room. A nursing progress note written by LVN A dated 06/08/21 at 5:35 p.m. read as follows: This nurse was sitting at desk documenting. Upon glancing up, this nurse noted female resident (Resident #2) was standing in window, looking outside. This nurse watched Resident #1 approach Resident #2 and begin telling her to sit in a nearby chair so he could put a sock on her left foot. Resident #2 started walking away as this nurse asked Resident#1 to please leave Resident #2 alone. Resident #1 began to follow Resident #2 and as this nurse approached, Resident #1 placed his hand on the front of Resident #2's right shoulder and tried to guide her into another chair to put a sock on her. This nurse again asked Resident #1 to leave Resident #2 alone. Resident #1 became upset and stomped his foot down on the CNA's foot. Resident #1 tried to coax Resident #2 into lying down on the couch. Documentation indicated the administrator, DON, ADON were notified and a voice message left for the nurse practitioner. According to this note, Resident #1's daughter was notified and agreed on trying to find better/safer placement for Resident #1. Resident #1 was placed on 15 minute safety checks as ordered. Incident Report dated 06/08/21 indicated Resident #2 was standing at the window when Resident #1 approached, telling Resident #2 to sit down so he could put a sock on her left foot. Resident #2 began walking away as the nurse told Resident #1 to leave Resident #2 alone but Resident #1 followed Resident #2 and tried to physically guide her into a chair against her will. A care plan dated 06/08/21 indicated this was day 1 of 10 for Resident #1 being on 15 minute checks due to attempting to lure female peer into room with the goal of having no serious injury to self or others due to his behaviors. The care plan noted staff interventions: *notify provider of any increased confusion/agitation or inappropriate behaviors; *observe for inappropriate/aggressive behaviors with peers and notify provider as indicated; *every 15 minute checks for 10 days as ordered' *refer to/follow up with psych as indicated. A nursing progress note written by LVN J dated 06/09/21 at 11:34 a.m., indicated Resident #1, while on 15 minute checks, tried to enter a female resident's room while the female was sleeping. During an interview on 06/17/21 at 3:53 p.m., the DON said in order to transfer Resident #1 the facility would have to go to the courts and, as a condition of his probation, he had to transfer to a secure unit. The DON said Resident #1 targets women who don't have a voice, which is him targeting (Resident #2). She said Resident #1 was accepted to an all male secure unit but was unable to transfer because there were no beds due to evacuees. The DON said Resident #1 was a manipulator and his family member stated he has splits personality disorder. The DON said Resident #1 was originally sent to the in house psychologist. She said Resident #1 was putting his nightstand in front of the door to keep the staff out. Staff went around and entered his room through the adjoining bedroom and found Resident #2 in Resident #1's room. The DON said they moved Resident #2 to the very front of the hall for her safety because Resident #2 lived across the hall from Resident #1. The DON said she called weekly checking with the receiving facility in efforts to get him out but they still have no beds. The DON said Resident #1's care plan meeting was today (06/17/21) and [MEDICATION(S)] will be started in an effort to prevent him from having sexual arousal but it usually takes 7 days to work. The DON denied anyone reported Resident #1 sexually touched Resident #2. She said Resident #1 knows exactly what he is doing and never demonstrates those behaviors in her presence. The DON said the facility did not have a policy for admission or criteria for the secured unit. During an interview on 06/17/21 at 4:25 p.m., administrator/social worker said they were waiting for an opening on the male secure unit where he was accepted, hopefully in July Resident #1 will be able to go there. She said they tried to get Resident #1 more mental health help from the psychologist and was told his behaviors were all dementia related. She said the family wants Resident #1 to stay close and will not be agreeable to him going outside of the East Texas area. The administrator/social worker said, We're doing the best we can in the situation. We're trying to manage it in house the best we can. There's nothing else we can do. She said referrals had not been made to any other facilities outside of the East Texas area. During an interview on 06/17/21 at 4:30 p.m., the NP said we have had Resident #1 on one-on-one supervision and 15 minute checks in the past for his behaviors. She said it was decided today (06/17/21) to put Resident #1 on [MEDICATION(S)]. The NP said, If I had [MEDICATION(S)], he (Resident #1) would be one-on-one all of the time. I am aware of him touching females' (unknown) breasts and bottoms, yes ma'am, they have informed me of that. The plan is to get him (Resident #1) to a male unit. I am very concerned about the inappropriate behavior and the vulnerability of the secured unit. During an interview on 06/17/21 at 5:40 p.m., the DON said Resident #1 had been put on one on one supervision per orders of the NP, due to safety precaution and danger to self and others. During an observation and interview on 06/17/21 at 5:50 p.m., Resident #1 was observed on the secured unit seated at a table with his one-on-one assigned staff having a snack. Resident #1 said, I felt like they were watching me before but they're really watching me now. A nursing progress note written by the DON dated 06/17/21 at 6:21 p.m., indicated 15 minute checks were discontinued and Resident #1 was started on one-on-one observation immediately due to state surveyor stating resident was a potential threat in causing sexually harm to female resident (Resident #2). This note indicated Resident #1 would remain one-on-one until discharge. A care plan dated 06/17/21 indicated Resident #1 has a history of sexually inappropriate and aggressive behaviors with peer. This care plan noted Resident #1 was placed on one-on-one supervision for his protection and the protection of others. The care plan noted staff interventions: *encourage and assist with keeping resident and target separate in common areas; *notify physician, family of inappropriate behaviors; *observe resident in hallways, provide redirection away from target's room; *observe resident when out of room for seeking out female target resident and provide redirection as needed; *refer to psychological services as indicated *remind/explain why behavior is inappropriate. During an interview on 6/18/21 at 1:58 p.m., the DON said Resident #1 had been admitted to the facility from a behavioral hospital. The DON said she had evaluated Resident #1 for placement at the facility and had reviewed his record at the hospital before he came to the facility, but there was only three days of records available. The DON said she had not reviewed the additional records that were received when he was admitted , and that she was not aware that Resident #1 had sexually inappropriate behavior before he was admitted to the facility. During an interview on 6/18/21 at 2:20 p.m., the administrator said Resident #1 had been evaluated for admission to the facility by the DON. The administrator said when Resident #1 was admitted to the facility, additional records from the state hospital were received and placed in his chart. The administrator said she was not aware of the behaviors described in Resident #1's additional records received from the hospital. The administrator said after the first incident Resident #2 was moved to another room located so that anyone going to her room would have to pass by the nurses' station. The administrator said Resident #1 had been seen by a psychologist who determined he had dementia and no other problems, and that there was nothing further to be done for him. The administrator said anytime an inappropriate behavior had been identified, Resident #1 had been placed on 15 minute checks. The administrator said she understood that some people might say that a lot can happen in 15 minutes, and that was true. The administrator said she could not say whether or not the facility would have accepted Resident #1 if they had been aware of the behavior described in his records, but that the facility might have intervened sooner. The administrator said she was aware that Resident #1 followed Resident #2 around and required redirection, that Resident #1 had been found in Resident 2's room, and that Resident #1 tried to go to bed with Resident #2. The administrator said she was not aware that Resident #1 had touched Resident #2 inappropriately, nor was there any documentation of those behaviors. During an interview on 06/18/21 at 3:24 p.m., Psychologist X said he met once with Resident #1 at the request of the facility to ensure he carried a dementia diagnosis. The psychiatric hospital did not actually give the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Psychologist X said Resident #1 postured sexual acting out with female peers such as leering at them, being invasive by lingering in their personal space. Psychologist X said Resident #1 knew boundaries but felt boundaries did not apply to him; therefore, had to be watched closely because he followed the female residents. Psychologist X said if Resident #1 was corrected by staff he would stop the inappropriate behavior, and then go back and do it again when no one was looking. Psychologist X said Resident #1 was narcissistic enough to see any woman and believe, in his mind, oh she wants me. Psychologist X said had he known Resident #1 was placed on an all male unit due to behaviors with female residents at the behavioral hospital, he would have recommended 1:1 observation on the secured unit as a precaution. Psychologist X said he did not officially see or treat Resident #1 because as it turns out, the facility only wanted him (Resident #1) assessed for the diagnosis, so I did not add him on for services, although I did recommend treatment. Psychologist X said the facility did not implement the recommended Treatment Plan. Medication Administration Review Report dated 06/18/21 indicated Resident #1 was to remain one on one supervision every shift for safety precaution starting 06/17/21, following surveyor intervention. Resident #1 was started and received the first dose of [MEDICATION(S)] tablet delayed release 125 mg on 06/17/21. The [MEDICATION(S)] was ordered by mouth twice daily related to unspecified mood (affective) disorder until 06/23/21, give times 7 days. 2. An Admission Record dated 06/18/21 indicated Resident #2, admitted [DATE], was [AGE] years old with diagnoses of unspecified [CONDITION(S)], asthma, dysphagia, [CONDITION(S)] disorder, disorganized [CONDITION(S)], dementia, cognitive communication deficit, pseudobulbar affect (PBA) and gastrostomy status. The most recent MDS dated [DATE] indicated Resident #2 had unclear speech, rarely/never made herself understood and sometimes understood others. Resident #2 was severely cognitively impaired for daily decision making skills. A care plan dated 12/16/20 indicated Resident #2 had impaired cognition/thought processes as evidenced by poor short term and long term memory and impaired decision making ability requiring placement on a secured unit due to risk of elopement and potential to wander in unsafe areas. The care plan noted staff were to keep Resident #2's routine consistent and when she is attempting to communicate allow her time to complete thoughts, provide wording as able, encourage to point or use gestures. A nursing progress note written by LVN B dated 03/09/21 at 7:20 a.m. indicated the nurse was trying to get into female resident #988's (Resident #2's) room, the door was blocked by a bedside table; after, pushing through, Resident #1 was hovering over #988's (Resident #2's) bed while she was asleep, with the sheets in his hand, pulling them back. The note indicated when Resident #1 heard the door open, he sprinted to the bathroom. The nurse redirected Resident #1, who started to hold his head and repeat, I'm lost. I'm confused. When the nurse reminded Resident #1 of the inappropriate behavior and he could possibly go back to jail, Resident #1 went to his room and slammed the door. A nursing progress note written by RN R dated 03/20/21 at 7:27 p.m. indicated Resident #2 continued to pace, walk, wander consistently since the early morning and was redirected from other rooms. This note indicated Resident #2 pulled off her clothing, socks, shoes and removed the dressing from site. A nursing progress note written by LVN F dated 04/07/21 at 1:21 a.m. indicated Resident #2 continued being monitored for removing clothing, hitting and pilfering with no behaviors noted this shift. A nursing progress note written by RN R dated 04/10/21 at 9:43 p.m. indicated Resident #2 continued to undress, wander with no episodes of hitting at staff. A nursing progress note written by RN R dated 04/17/21 at 3:04 p.m. indicated Resident #2 received a new order for [MEDICATION(S)]. A care plan dated 05/19/21 indicated Resident #2 had a moderate risk of wandering and wandered throughout the secured unit. The care plan noted staff to observe her when out of room for wandering in/out of other rooms, wandering to unauthorized area and provide redirection as needed. During an interview on 06/17/21 at 11:42 a.m., LVN A said Resident #1 was sexually inappropriate. LVN A said Resident #1 had gone into females' rooms and taken females into his room. LVN A said Resident #1 has had Resident #2 in his room twice and touched her breasts and touches the women's legs. She said she witnessed Resident #1 putting his arm around Resident #2's waist and rubbing her lower back while on 15 minute monitoring checks. LVN A said Resident #2 was in her room, in bed when Resident #1 entered Resident #2's bedroom and was rubbing her breasts while she was in bed. She said Resident #1 was placed on every 15 minute monitoring checks. She said both the administrator and DON were aware of Resident #1's sexually inappropriate behavior and instructed the staff to watch Resident #1 every minute. This LVN said Resident #1 was currently on 15 minute monitoring checks again for the most recent incident when Resident #1 tried to force Resident #2 to put on sock. During an interview on 06/17/21 at 1:15 p.m., CNA C said she was assigned to the secured unit but did not know Resident #1 was currently on every 15 minute checks. She said she heard he had previously been on every 15 minute monitoring checks because a nurse entering the doors of the secured unit saw Resident #2 leaving Resident #1's room with Resident #1 very close behind Resident #2 but nobody knows how long, or what happened when, Resident #1 had Resident #2 in his room unsupervised. CNA C said the CNA was charting at the computer and, when at the computer, staff cannot see up/down the hall because the computer was set up in a nook so [NAME] knows when Resident #1 and Resident #2 went into Resident #1's room. She said Resident #1 and Resident #2 were witnessed exiting Resident #1's room on a weekend by RN R and Resident #1 was placed on 15 minute checks. She said she intervened when Resident #1 had Resident #2 hemmed up in a corner. CNA C said Resident #1 comprehends and knows right from wrong but Resident #2 was advanced dementia, which was the reason Resident #1 was educated on the inappropriate behavior. CNA C said Resident #2 was the only person Resident #1 put his hands on or tried to assist. CNA C said Resident #1 never touched or assisted male residents. C [TRUNCATED]

Based on interview and record review the facility failed to promptly consult the nurse practitioner of critical lab results for 1 of 4 residents reviewed for laboratory services. (Resident #1) The facility failed to promptly consult the nurse practitioner of Resident #1's critical lab results received on [DATE] at 7:51 p.m. until [DATE] at 9:01 a.m. Resident #1 was sent to the hospital and expired. An Immediate Jeopardy (IJ) situation was identified [DATE]. While the IJ was removed on [DATE] at 12:15 p.m. the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for delay in medical evaluation, treatment, or death. Findings included: Physician orders [REDACTED].#1 was a [AGE] year-old male, re-admitted [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1's cognition was severely impaired, he required supervision/set help only with eating, and needed two persons to assist with hygiene/dressing. The MDS indicated Resident #1 was incontinent for bowel and frequently incontinent of urine. A Potential for Fluid Deficit related to disease process care plan revised [DATE] for Resident #1 noted, .Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated . A nursing note for Resident #1 dated [DATE] indicated, .The resident was noted having behaviors out of their norm by undressing and picking at feces and whipping it on their lower body and peri area .The resident was assessed .having dysuria and diminished lung sounds to upper lobes . The nursing notes indicated LVN B notified the nurse practitioner who gave an order for [REDACTED]. A Laboratory Service Report for Resident #1 dated [DATE] indicated bloodwork was collected [DATE] at 4:15 p.m. and received [DATE] at 7:51 p.m. The following labs were critical: BUN (blood urea nitrogen which is a waste product formed by the kidney when protein is broken down by the body) was 111 (,[DATE] normal reference), Creatinine (a waste product produced by muscle) was 4.52 (0XXX,[DATE].40 normal reference) and GFR (glomerular filtration rate which is the rate in which waste is filtered out of the blood by the kidney) was 15 (>=60 normal reference range). During an interview on [DATE] at 12:40 p.m., LVN B said LVN A reported Resident #1's chest x-ray and labs were abnormal during the morning shift change on [DATE]. During an interview on [DATE] at 4:39 p.m., LVN A said she received Resident #1's lab results on [DATE] at midnight and only glanced at the white count. LVN A said she did notice his chest x-ray was abnormal and called the nurse practitioner who she was unable to reach by phone or pager. When asked if she called the physician or DON about the critical lab values, LVN A stated, No. LVN A said she did not see the BUN, Creatinine, or GFR were elevated. During an interview on [DATE] at 5:30 p.m., the nurse practitioner said she was not notified of Resident #1's critical lab values until [DATE] after speaking with LVN B. She then gave the order for Resident #1 to be sent to the emergency room . A Nursing Note dated [DATE] at 9:01 a.m. indicated LVN B spoke with the nurse practitioner and Resident #1 was sent to the emergency room for critical lab values at 9:41 a.m. The emergency room Notes dated [DATE] for Resident #1 noted .Presents with acute kidney injury with elevated BUN and creatinine secondary to volume depletion . The Hospital Discharge Summary dated [DATE] indicated Resident #1 expired on [DATE] at 8:00 p.m. The Hospital Discharge Summary noted, .Final [DIAGNOSES REDACTED].#2 acute hypoxemia [MEDICAL CONDITION] #3 volume depletion . During an interview on [DATE] at 11:05 a.m., the DON said LVN A should have notified the nurse practitioner when she received the lab results. If LVN A was unable to reach the nurse practitioner, she should have notified the physician or myself. The DON then said LVN A did not notify her of the abnormal lab values. Lab Tests online.org notes .An increased BUN and creatinine level may mean that your kidneys are not working as they should . A GFR of 15 indicates severe loss of kidney function. An undated Notification Policy noted, The facility will inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative and document in the resident's medical record, where applicable, when there is: .Any laboratory diagnostic results that fall outside of clinical reference ranges . The Administrator was notified on [DATE] at 4:31 p.m. an immediate jeopardy (IJ) situation was identified due to the above failures. The IJ template was provided to the administrator and a plan of removal was requested. The facility's plan of removal was accepted on [DATE] at 6:00 p.m. and indicated the following: Immediate in-service began on [DATE] as of [DATE] all nurses 6 am - 2 pm, 2 pm -10 pm nurses have been in-serviced. 10 pm - 6 am will be in-serviced by LVN C before shift. All weekend Nurse's will be in-serviced prior to their shift by RN D [DATE] on who will be in-serviced prior to the start of their next shift on the notification of physician of critical labs and process when physician cannot be reached. This in-service will be given to all Nurse's. Before any new nurse's start or return this in-service will be given before they start their shift. Steps when receiving a critical lab: 1st Lab will call and notify charge nurse of the critical lab before it is faxed. 2nd We call NP (phone number removed) of the critical labs and wait on new orders to be received. 3rd If NP do not answer the phone you your next step is to call MD (phone number removed). 4th Always notify RN DON (phone number removed) of all critical lab values and with and update of new orders received. 5th If you cannot get ahold of NP, MD, or DON then you will call the Administrator (phone number removed). 6th Make sure all critical labs have been faxed to Physician Fax Number (phone number removed). Make sure you attach a copy of the fax confirmation to the critical lab value. 7th Make sure everything has been documented in PointClickCare once all steps have been completed. Immediate audit of 30 days past critical labs to ensure timely compliance by DON or designee. 43 residents have the potential to be a risk due to this alleged deficient practice. Facility DON or designee will audit all critical labs daily x 4 weeks, then weekly times 4 weeks, then monthly for x 2 months and review compliance in QAPI until Administrator determines compliance. On [DATE] the surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: 1. Review of a list of all nurses employed by the facility who were in-serviced on receiving critical lab values and notification of physician, nurse practitioner, and administrative personnel. 2. Interviewed 8 LVNs and 2 RNs that worked various shifts who were able to verbalize the correct steps to implement when critical lab value is received. 3. Interviewed the DON to ensure the audit of critical labs for the past 30 days had been initiated. There were no critical lab values that had not been addressed. On [DATE] at 12:15 p.m. the Administrator was informed the immediate jeopardy was removed; however, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 2 of 4 residents reviewed for accidents (Resident #s 1 and 2). The facility did not provide for safe footing in the resident shower rooms on the secured unit, Hall 100/200, and Hall 300. Resident #1 slipped on the wet floor in the shower room on the secured unit resulting in the resident's fractured wrist. Resident #2 slipped on the wet floor in the shower room on Hall 100/200 shower room. The facility did not evaluate the hazards and risks of the shower room floors and implement interventions to prevent repeat falls from occurring. This failure could place 58 residents who used the showers at risk of serious injury. Findings included: 1. Current physician orders [REDACTED].#1 was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. A Care Plan initiated on 05/17/16 indicated Resident #1 was at risk for falls due to unsteady gait, decreased balance, medications, and poor safety awareness. Interventions included staff to provide assistance to keep the floor free from clutter, and trip and spill hazards. The care plan indicated Resident #1 had an ADL self-care performance deficit with interventions including the resident must have hands on assistance when ambulating/transferring to the shower chair. The current MDS dated [DATE] indicated Resident #1 had moderately impaired cognition for daily decision making. He required supervision of 1 staff member for ambulation, used a cane, and he required physical help limited to transfer only of 1 staff member for bathing. The resident had no falls since admission/last assessment. A weekly nursing summary dated 8/18/17 indicated Resident #1 required supervision with set-up help only with bed mobility and transfers. Nursing Progress Notes for Resident #1 indicated the following entries on 08/30/17: * At 9:45 a.m., the nurse was called to the shower room by CNA A, Resident #1 was lying on his back in the shower room nude, awake, and alert. The resident denied hitting his head and had no lumps, bruises, or redness to his head. A small dark purple bruise was noted to the inner side of his right hand. The resident complained of tenderness to touch on his left wrist but, there was no swelling, bruising, or increased warmth to touch noted. CNA A said she turned to get a towel, heard a loud noise, and noted the resident on his back on the floor. * At 9:55 a.m., the NP was notified and an order was received for a stat x-ray of Resident #1's left wrist/forearm; * At 3:00 p.m., x-ray results received. Resident #1 had an acute fracture of Resident #1's wrist. The NP was notified and an order received to send the resident to the emergency room (ER) for evaluation and treatment; and * At 6:30 p.m., Resident #1 returned from the ER with a cast on his left wrist. An undated ER Patient Information sheet indicated Resident #1 had a Colles' fracture with description of a type of broken wrist with the radius bone (long bone of forearm under the thumb) being fractured. A facility Provider Investigation Report dated 08/31/17 indicated CNA A assisted Resident #1 to the shower room. CNA A turned around to grab a towel, wash cloth, and soap as the resident was walking into the shower room. As CNA A was turned around, Resident #1 fell while walking to the shower chair. The resident denied hitting his head, but complained of hurting his left hand. Orders were received for an x-ray and the x-ray results indicated the resident had broken his wrist. The resident was sent to the hospital for treatment of [REDACTED]. A weekly nursing summary dated 9/1/17 indicated Resident #1 now required limited assistance with one person to physically assist with bed mobility and transfers. During an observation on 09/07/17 at 10:00 a.m., Resident #1 was asleep in his bed. He had a cast on his left forearm and his arm was in a sling. During an interview on 09/07/17 at 11:15 a.m., CNA A said on 8/30/17, she assisted Resident #1 while he walked to the secured unit shower room. She said the resident was the first shower of the day so she did not notice any wetness on the floor. She said as Resident #1 walked to the shower chair, she stopped and turned around to the table to grab a wash cloth and soap. She said she heard a loud noise and turned to find the resident on the floor. CNA A said she noticed the floor was damp at that time. She said she usually placed a blanket or towel on the floor of the shower after she helped bathe residents because the floor would be very slippery. She said they did not have mats to put on the floor of the showers to prevent falls. During an observation on 09/07/17 at 10:05 a.m., the shower room on the secured unit door was locked. The shower room had a center area with a locked cabinet and a table with linen supplies on it. There was a shower stall to the left and a shower stall to the right of the center area. The shower room floor was damp and very slippery. There was no anti-slip mat or other anti-fall things in place on the shower floor. During an observation and interview on 09/07/17 at 10:08 a.m., the secured unit shower room floor was damp and very slippery. There was no anti-slip mat or material on the shower floor. LVN C said the shower room floor can be slippery when wet. She said there were not anti-slip mats or strips on the floor to prevent falls/slipping. During an observation and interview on 09/07/17 at 10:20 a.m., the secured unit shower room floor was damp and very slippery. There was no anti-slip mat or material on the shower floor. The maintenance director said he did not realize the shower room floors were slippery when wet. He indicated the facility had no anti-slip mats or strips for the showers. During an interview on 09/07/17 at 11:00 a.m., CNA D said she had to place a blanket on the floor in the shower room when bathing residents because the floor was very slippery when wet. She said they did not have anti-slip mats to put on the floor of the showers to prevent falls. 2. A face sheet printed 07/05/17 indicated Resident #2 was a [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. A Care Plan initiated on 06/30/16 indicated Resident #2 was at risk for falls due to unsteady gait, decreased balance, medications, and poor safety awareness. Interventions included staff to provide assistance to keep the floor free from clutter and trip and spill hazards. The care plan indicated Resident #2 had an ADL self-care performance deficit with interventions including providing extensive to limited assistance from staff to assist the resident while she transferred herself. The MDS dated [DATE] indicated Resident #2 had severely impaired cognition. She required extensive assistance of 1 staff member for transfers and required limited physical help of 1 staff member for bathing. The resident required limited to extensive assistance of 1 staff member for ambulation and she used a wheelchair for mobility. Resident #2 had 1 fall with no injury since the last assessment. An Incident/Accident Report dated 06/05/17 indicated Resident #2 was in the Hall 100/200 shower room and attempted to stand without assistance. She slipped on the wet floor causing her to fall. There was no indication anything was on the floor to help prevent slipping or falls. A written statement by CNA B dated 06/05/17 indicated she assisted Resident #2 in the shower when the resident slipped while transferring from the shower chair to the wheelchair on the wet shower room floor. CNA B was not available for interview. During an interview on 09/07/17 at 2:25 p.m., the DON said she was aware Resident #2 had a fall in the shower in June 2017. She said she did not realize the issue with the slippery floors in the shower room. During an observation on 09/08/17 at 9:30 a.m., the Hall 100/200 shower room did not have anti-slip mats, strips, or material on the tile floor. The floor was very slippery when wet. 3. During an observation on 09/08/17 at 9:45 a.m., the Hall 300 shower room had no anti-slip mat or material on the tile floor. The floor was very slippery when wet. An undated Fall and Post-Fall Management policy and procedure indicated .Goals: .3. Provide appropriate strategies and interventions directed to resident, environmental factors, and staff A Shower/Tub Bath policy and procedure revised October 2010 indicated .Steps in the Procedure: .12. Place a non-skid bath mat on the floor where the resident will step in/out of the tub/shower The CMS 672 form dated 09/07/17 indicated a census of 64 residents with 6 bedfast residents.

Based interview, and record review, the facility failed to implement interventions based on the comprehensive assessment to prevent development and worsening of pressure injuries for 1 of 6 residents reviewed for pressure injuries. (Resident #60) The facility did not perform weekly skin assessments, implement dietary interventions, repositioning or pressure relief for Resident #60. Resident #60 was admitted with a stage 2 pressure injury to her right buttock that healed. The area reopened as a stage 2 on her right buttock and she developed a facility acquired stage 2 pressure injury on her left buttock. Both areas increased in size and worsened from two stage 2 pressure injuries to one larger unstageable pressure injury that covered across each buttock. These failures contributed to the development of new pressure injuries and the worsening of pressure injuries for Resident #60. This failure could place 3 residents with pressure injuries at risk for the development of new pressure injuries or worsening of existing pressure injuries. Findings included: Physician orders [REDACTED].#60, admitted [DATE], was an [AGE] year old female with [DIAGNOSES REDACTED]. An admission wound care sheet dated 09/27/16 indicated Resident #60 was admitted with a stage 2 pressure injury on her right buttock. An initial MDS dated [DATE] indicated Resident #60 admitted with a stage 2 pressure injury and required extensive assistance with transfers, dressing, and personal hygiene. A Braden scale dated 10/04/16 indicated Resident #60 was high risk for developing pressure injuries. A care plan initiated 10/18/16 indicated Resident #60 was at risk for skin break down due to decreased mobility, with the following interventions specified: .Monitor for skin break down, (Weekly head to toe skin assessment) .Provide pressure relieving and positioning devices as needed . A wound care sheet dated 10/30/16 indicated Resident #60's stage 2 pressure injury on her right buttock healed. A nursing note dated 10/31/16 for Resident #60 indicated the dietitian recommended Vitamin C (supplement) twice a day and protein twice a day for 30 days to promote wound healing. The recommendation was not initiated. The MARs dated November 1 - 30, 2016 indicated Resident #60 did not receive the Vitamin C or protein. The most recent MDS dated [DATE] indicated Resident #60 required extensive assistance with transfers, dressing, and personal hygiene. The resident exhibited no behaviors and had no pressure injuries. The nursing notes dated 10/30/16 - 12/20/16 for Resident #60 indicated approximately seven entries of refusing to be repositioned by staff. The care plans updated 11/09/16 did not address Resident #60 having behaviors such as refusing to be repositioned by staff. The hospital records dated 01/04/17 indicated she was transferred to inpatient hospice. During an interview on 01/25/17 at 9:45 a.m., LVN M said Resident #60 refused to be repositioned at times. During an interview on 01/25/17 at 4:12 p.m., CNA O said Resident #60 refused to be repositioned. During an interview on 01/25/17 at 10:00 a.m., the owner/interim DON said Resident #60 refused to be repositioned. A wound care sheet dated 11/30/16 indicated Resident #60 pressure injuries: Pressure injury 1- Stage 2 that re-opened on her right buttock measuring 1 centimeters (cm) x 0.6 cm x 0.1 cm. Pressure injury 2- A new facility acquired stage 2 on her left buttock measuring 2.4 cm x 1.6 cm x 0.1 cm. The wound care assessments for Resident #60 did not include an assessment for the week of 12/05/16. During an interview on 01/24/17 at 4:00 p.m., the ADON said they did not have a care plan for Resident #60's pressure injuries. The ADON said she could not recall any pressure relieving devices used for Resident #60. The next wound care sheet assessment dated [DATE] indicated Resident # 60's pressure injuries had increased in size. The stage 2 pressure injury now spanned to the right and left buttock and measured 7 cm x 7 cm x 0.1 cm. A wound care sheet dated 12/20/16 indicated Resident # 60's pressure injury on her right and left buttock worsened to unstageable and increased in size to 9 cm x 7.5 cm x 1 cm. A physician telephone order dated 12/21/16 indicated the following: low air loss mattress, gel cushion to wheel chair, Glucerna (supplement) 4 ounces with medication pass, Vitamin C 500 milligrams, Zinc, ProMod (protein supplement) 30 cubic centimeters, and [MEDICATION NAME] (supplement) at bedtime to promote wound healing. An undated Prevention of Pressure Ulcer policy noted .Purpose .To prevent skin breakdown and development of pressure sores .Develop care plan to eliminate or minimize risk factors .If a pressure ulcer is present, the licensed nurse is responsible to record condition of the skin, including stage, size . The National Pressure Ulcer Advisory Panel at http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ accessed 01/19/17, noted the following pressure ulcer definitions: .The updated staging system includes the following definitions: Pressure Injury: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue . .Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermisPartial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. .Unstageable Pressure Injury: Obscured full-thickness skin and tissue lossFull-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. The CMS 672 dated 01/23/17 indicated 3 residents had pressure injuries.

Based on interview, and record review the facility failed to provide adequate supervision to prevent accidents for 1 of 7 residents reviewed for accidents. (Resident #60) Resident #60 who required extensive assistance of two persons, was transferred by only 1 staff. During the transfer attempt, Resident #60 slid off the bed and sustained a compression fracture to her back. This failure contributed to Resident #60 sustaining a compression fracture to her back. This failure could place 8 residents who were totally dependent on staff at risk of injuries during transfer. Findings included: Physician orders [REDACTED].#60, admitted [DATE], was [AGE] years with [DIAGNOSES REDACTED]. Her orders indicated, .All transfers require two person assist every shift for unsteady balance, weakness . A fall care plan initated 10/12/16 indicated Resident #60 was at risk for falls and had a .fear of falling . The most recent MDS dated [DATE] indicated Resident #60 required extensive assistance of two persons with transfers. An Incident/Accident Report dated 10/21/16 indicated CNA J assisted Resident #60 to her bed and while sitting on the side of the bed, she slid to the floor. The report indicated CNA J caught the resident and helped her sit on the floor. A computed tomography (CT) scan dated 11/01/16 indicated Resident #60 sustained a compression fracture to L2 (second lumbar vertebra.) The reason for the exam noted back and right hip pain status [REDACTED]. During an interview on 01/24/17 at 3:15 p.m., CNA J said she transferred Resident #60 by herself using a stand up lift. She said Resident #60 slid from the side of the bed and she assisted her to the floor. CNA J said Resident #60 required two persons for transfers, but could be transferred with one when using the stand up lift. During an interview on 01/24/17 at 4:00 p.m., the ADON said CNA J transferred Resident #60 without assistance. She said Resident #60 required 2 people to transfer even when using the lift. The ADON said Resident #60 was physically unable to stand. The ADON said an in-service was conducted after the incident and she thought CNA J had been written up. During an interview on 01/24/17 at 5:25 p.m., the ADON said she had no evidence CNA J was written up for the incident. She said CNA J was still employed. A Negligence In-Service document dated 11/09/16 did not include CNA J's signature to indicate she attended. During an interview on 01/26/17 at 12:25 p.m., CNA J said she did not recall recently attending an in-service related to the incident. An employee file for CNA J indicated her hire date was 08/25/16. The file did not include evidence of written disciplinary action. A Safe Lifting and Movement of Residents policy revised December 2013 noted, .In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents . The CMS 672 dated 01/23/17 indicated 8 residents were totally dependent on staff for transfers.

Based on observation, interview, and record review, the facility failed to provide services in accordance with each resident's written plan of care. (Resident #1) The facility did not follow Resident #1's care plan, and LVN A gave a peanut butter sandwich to Resident #1, who had orders for a pureed diet. Resident #1 choked on the sandwich, resulting in his death. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 22 residents receiving mechanically altered diets, including pureed, at risk for harm or death. Findings included: A face sheet and physician orders [REDACTED].#1, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. A nursing care plan dated [DATE] indicated Resident #1 was on a pureed diet with nectar thick liquids. He had a history of [REDACTED]. Staff were to serve the resident a pureed diet as ordered, monitor and record meals, and help divert attention from food by offering activities and choices. Resident #1 and his family requested he be on full code status. A CNA ADL Tracking Form dated ,[DATE] indicated staff recorded Resident #1's appetite and meal consumption to be good with supervision or limited assistance during all meals. A Medication Review Report dated [DATE] indicated Resident #1 had physician orders [REDACTED]. The MDS dated [DATE] indicated Resident #1 was severely cognitively impaired and required total assistance with eating and all other activities of daily living. The facility's security video, date stamped [DATE] at 1820 (6:20 p.m.), indicated LVN A retrieved an unidentified food object from an ice chest at the nursing station. LVN A unwrapped the food object and handed it to Resident #1, who was sitting in the hallway. Full view of Resident #1 was obstructed by a cart. At 1824 (6:24 p.m.), LVN A walked over to Resident #1, took the item from Resident #1 and threw the item into the trash. Full view of Resident #1 continued to be blocked by the cart. At 1825 (6:25 p.m.), CNA C and MA A were walking down the hall and CNA C stopped to look at Resident #1. CNA C turned toward the nursing station and LVN A went to Resident # 1. LVN A returned to the nursing station and appeared to be looking for Resident #1's medical chart. CNA C waved her hands and LVN B appeared into view. LVN B placed Resident #1 on the floor, with assistance from LVN A. At 1827 (6:27 p.m.), LVN B started chest compressions on Resident #1 and LVN A retrieved a mask from a crash cart and started assistance with breathing. CNA C was on the telephone. No [MEDICATION NAME] maneuver was observed. During an interview on [DATE] at 11:15 a.m., MA A said she was working on [DATE] during the evening shift. She was walking down the Hall 300 with CNA C. MA A said CNA C noticed something was wrong with Resident #1. She said LVN A checked Resident #1, then went back to the nursing station and was looking for Resident #1's medical chart. She said CNA C called for LVN B. LVN B asked for Resident #1's code status, and then instructed her to call 911. LVN B and LVN A placed Resident #1 on the floor and LVN B started chest compressions. LVN A retrieved the crash cart and started using the bag on Resident #1. CNA C called 911 and CPR was continued until EMS arrived. She said she did not see any food on Resident #1. During an interview on [DATE] at 2:24 p.m., LVN B said he was working on [DATE] during the evening shift. He said CNA C yelled for him to come down Hall 300. He said CNA C said Resident #1 was not breathing. He said when he arrived, he asked Resident #1's code status. He said LVN A opened the chart and he saw the green colored sheet on the front of the chart which indicated full code. LVN B instructed staff to call 911. With the assistance of LVN A, LVN B placed Resident #1 on the floor and started chest compressions. LVN A retrieved the crash cart and started using the bag on Resident #1. LVN B continued CPR until EMS arrived. He said he did not see any food on Resident #1. He said he saw Resident #1's chest rise when LVN A pushed in air. LVN B said there was no indication of food blocking Resident #1's airway. LVN B said he felt Resident #1 had a [MEDICAL CONDITION] or some other incident to cause him to stop breathing, and did not see any evidence of choking at the time. He said he would never give a sandwich to a resident with orders for a pureed diet. Hospital records dated [DATE] indicated Resident #1 was admitted on [DATE] at 8:30 p.m. from the nursing home. The record indicated Resident #1 was eating when he started to choke and went into respiratory arrest. CPR was started. Resident #1 was pronounced dead on [DATE] at 8:56 p.m. During an interview on [DATE] at 10:15 a.m., the administrator said she was the abuse coordinator. She said Resident #1 died at the hospital on [DATE] from choking on a peanut butter sandwich. She said Resident #1 was on a pureed diet. She said she reviewed the security footage at the time of the incident and observed LVN A unwrapping a sandwich and giving it to Resident #1. She said later, Resident #1 was found unresponsive and died . She said LVN A was terminated and a new policy/procedure was developed to ensure staff were aware of all residents with orders for pureed diets, and their code status. She said red and green name tags were placed on the faceplate of each resident's room to alert staff of each resident's code status. She said stars on the name plate indicated special precautions for pureed and thickened liquid diets. She said all staff received in-service training on the new policy/procedure. The policy dated [DATE] provided by the administrator on [DATE] required . All residents will have identification cards posted outside their respective rooms. The identification cards will be green for full code status and red for do not resuscitate. Those residents with physician ordered pureed diets will have a star beside their picture. All direct care staff will be educated on this facility policy No staff may work on the floor until they have signed this in-service. During an interview on [DATE] at 12:50 p.m., CNA A said this was her first day to work at the facility. She said she did not know what the colors or stars on the door indicated. She said she had not received training concerning the colors or the meaning of the stars. During an interview on [DATE] at 12:53 p.m., MA B said she had worked at the facility for one year. She said she did not know what the colors red and green indicated about the resident. During an interview on [DATE] at 12:57 p.m., CNA B said she worked at the facility for two weeks. She said she did not know what the colors red and green or the stars on the nameplates of the residents' doors indicated about the resident. She said she had not received training concerning the colors or the meaning of the stars. The Abuse/Neglect Prohibition Policy dated ,[DATE] revised defined neglect as .failure to provide goods and services necessary to avoid physical harm . The policy required The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The administrator and DON were notified on [DATE] at 2:17 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 3:51 p.m. and included: All new hires will be in-serviced, prior to working the floor, on the facility's procedure to: .STARS are placed on the resident's name tags to identify those requiring pureed food items and/or thickened liquids. All staff, currently working in the facility, have been re-in-serviced on the above policy/procedure. Oncoming staff (,[DATE]) will be re-in-serviced prior to clocking in. Staff Scheduled for ,[DATE] on [DATE], will be re-in-serviced on the above policy/procedure prior to clocking in. Ongoing, all staff will be re-in-serviced prior to clocking in for their next scheduled shift . New Hire Checklist/General Orientation Outline has been updated to include the above in-service .Ongoing monitoring for compliance will be reviewed in the quarterly QA meetings. On [DATE] the surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Two CNAs were interviewed and said they received training on the policy/procedure before they started their shift on [DATE] at 6:00 a.m. They said they understood the stars on the resident's doors indicated the resident was to only receive pureed foods and/or thickened liquids. They were able to identify residents requiring pureed diets. Two nurses were interviewed and said they received training on the policy/procedure before they started their shift on [DATE] at 6:00 a.m. They said they understood the stars on the resident's doors indicated the resident was to only receive pureed foods and/or thickened liquids. They were able to identify residents requiring pureed diets. Stars were observed on the name plates of five residents who required pureed foods and/or thickened liquids. The new policy updated on [DATE] required .All residents will have identification cards posted outside their respective rooms. The identification cards will be green for full code status and red for do not resuscitate. Those residents with physician ordered pureed diets will have a star beside their picture. All direct care staff will be educated on this facility policy No staff may work on the floor until they have signed this in-service. Review of time punch records and in-service completion records from [DATE] at 2:00 p.m. until [DATE] at 6:00 a.m., indicated all nursing and dietary staff had received in-service on the new policy before working the floor. Review of the undated New Hire Checklist/General Orientation Outline form indicated .30. Code Status and Diet Coding for Residents . had been added to the basic orientation for new hires. On [DATE] at 1:56 p.m., the DON was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated [DATE] indicated 22 residents had orders for a mechanically altered diet.

Based on observation, interview, and record review, the facility implement policies and procedures to prohibit neglect for 1 of 5 residents reviewed for neglect. (Resident #1) The facility did not ensure Resident #1 received the physician ordered diet. LVN A gave a peanut butter sandwich to Resident #1, who had orders for a pureed diet. Resident #1 choked on the sandwich, resulting in his death. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 22 residents receiving mechanically altered diets, including pureed, at risk for harm or death. Findings included: A face sheet and physician orders [REDACTED].#1, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. A Medication Review Report dated [DATE] indicated Resident #1 had physician orders [REDACTED]. A nursing care plan dated [DATE] indicated Resident #1 was on a pureed diet with nectar thick liquids. He had a history of [REDACTED]. Staff were to serve the resident a pureed diet as ordered, monitor and record meals, and help divert attention from food by offering activities and choices. Resident #1 and his family requested he be on full code status. The MDS dated [DATE] indicated Resident #1 was severely cognitively impaired and required total assistance with eating and all other activities of daily living. The facility's security video, date stamped [DATE] at 1820 (6:20 p.m.), indicated LVN A retrieved an unidentified food object from an ice chest at the nursing station. LVN A unwrapped the food object and handed it to Resident #1, who was sitting in the hallway. Full view of Resident #1 was obstructed by a cart. At 1824 (6:24 p.m.), LVN A walked over to Resident #1, took the item from Resident #1 and threw the item into the trash. Full view of Resident #1 continued to be blocked by the cart. At 1825 (6:25 p.m.), CNA C and MA A were walking down the hall and CNA C stopped to look at Resident #1. CNA C turned toward the nursing station and LVN A went to Resident # 1. LVN A returned to the nursing station and appeared to be looking for Resident #1's medical chart. CNA C waved her hands and LVN B appeared into view. LVN B placed Resident #1 on the floor, with assistance from LVN A. At 1827 (6:27 p.m.), LVN B started chest compressions on Resident #1 and LVN A retrieved a mask from a crash cart and started assistance with breathing. CNA C was on the telephone. No [MEDICATION NAME] maneuver was observed. During an interview on [DATE] at 11:15 a.m., MA A said she was working on [DATE] during the evening shift. She was walking down the 300 hall with CNA C. MA A said CNA C noticed something was wrong with Resident #1. She said LVN A checked Resident #1, then went back to the nursing station to look for Resident #1's medical chart. She said CNA C called for LVN B. LVN B asked for Resident #1's code status, and then instructed her to call 911. LVN B and LVN A placed Resident #1 on the floor and LVN B started chest compressions. LVN A retrieved the crash cart and started using the bag on Resident #1. CNA C called 911 and CPR continued until EMS arrived. She said she did not see any food on Resident #1. During an interview on [DATE] at 2:24 p.m., LVN B said he was working on [DATE] during the evening shift. He said CNA C yelled for him to come down Hall 300. He said CNA C said Resident #1 was not breathing. He said when he arrived, he asked Resident #1's code status. He said LVN A opened the chart and he saw the green colored sheet on the front of the chart which indicated full code. LVN B instructed staff to call 911. With the assistance of LVN A, LVN B placed Resident #1 on the floor and started chest compressions. LVN A retrieved the crash cart and started using the bag on Resident #1. LVN B continued CPR until EMS arrived. He said he did not see any food on Resident #1. He said he saw Resident #1's chest rise when LVN A pushed in air. LVN B said there was no indication of food blocking Resident #1's airway. LVN B said he felt Resident #1 had a [MEDICAL CONDITION] or some other incident to cause him to stop breathing, and did not see any evidence of choking at the time. He said he would never give a sandwich to a resident with orders for a pureed diet. Hospital records dated [DATE] indicated Resident #1 was admitted on [DATE] at 8:30 p.m. from the nursing home. The record indicated Resident #1 was eating when he started to choke and went into respiratory arrest. CPR was started. Resident #1 was pronounced dead on [DATE] at 8:56 p.m. During an interview on [DATE] at 10:15 a.m., the administrator said she was the abuse coordinator. She said Resident #1 died at the hospital on [DATE] from choking on a peanut butter sandwich. She said Resident #1 was on a pureed diet. She said she reviewed the security footage at the time of the incident and observed LVN A unwrapping a sandwich and giving it to Resident #1. She said later, Resident #1 was found unresponsive and died . She said LVN A was terminated and a new policy/procedure was developed to ensure staff were aware of all residents with orders for pureed diets, and their code status. She said red and green name tags were placed on the faceplate of each resident's room to alert staff of each resident's code status. She said stars on the name plate indicated special precautions for pureed and thickened liquid diets. She said all staff received in-service training on the new policy/procedure. The policy dated [DATE] provided by the administrator on [DATE] required . All residents will have identification cards posted outside their respective rooms. The identification cards will be green for full code status and red for Do not resuscitate. Those residents with physician ordered pureed diets will have a star beside their picture. All direct care staff will be educated on this facility policy No staff may work on the floor until they have signed this in-service. During an interview on [DATE] at 12:50 p.m., CNA A said this was her first day to work at the facility. She said she did not know what the colors or stars on the door indicated. She said she had not received training concerning the colors or the meaning of the stars. During an interview on [DATE] at 12:53 p.m. MA B said she had worked at the facility for one year. She said she did not know what the colors red and green indicated about the resident. During an interview on [DATE] at 12:57 p.m. CNA B said she worked at the facility for two weeks. She said she did not know what the colors red and green or the stars on the nameplates of the residents' doors indicated about the residents. She said she had not received training concerning the colors or the meaning of the stars. The Abuse/Neglect Prohibition Policy dated ,[DATE] revised defined neglect as .failure to provide goods and services necessary to avoid physical harm . The policy required The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The administrator and DON were notified on [DATE] at 2:17 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 3:51 p.m. and included: All new hires will be in-serviced, prior to working the floor, on the facility's procedure to: .STARS are placed on the resident's name tags to identify those requiring pureed food items and/or thickened liquids. All staff, currently working in the facility, have been re-in-serviced on the above policy/procedure. Oncoming staff (,[DATE]) will be re-in-serviced prior to clocking in. Staff Scheduled for ,[DATE] on [DATE], will be re-in-serviced on the above policy/procedure prior to clocking in. Ongoing, all staff will be re-in-serviced prior to clocking in for their next scheduled shift . New Hire Checklist/General Orientation Outline has been updated to include the above in-service .Ongoing monitoring for compliance will be reviewed in the quarterly QA meetings. On [DATE] the surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Two CNAs were interviewed and said they received training on the policy/procedure before they started their shift on [DATE] at 6:00 a.m. They said they understood the stars on the resident's doors indicated the resident was to only receive pureed foods and/or thickened liquids. They were able to identify residents requiring pureed diets. Two nurses were interviewed and said they received training on the policy/procedure before they started their shift on [DATE] at 6:00 a.m. They said they understood the stars on the resident's doors indicated the resident was to only receive pureed foods and/or thickened liquids. They were able to identify residents requiring pureed diets. Stars were observed on the name plates of five residents who required pureed foods and/or thickened liquids. The new policy, updated on [DATE] required .All residents will have identification cards posted outside their respective rooms. The identification cards will be green for full code status and red for do not resuscitate. Those residents with physician ordered pureed diets will have a star beside their picture. All direct care staff will be educated on this facility policy No staff may work on the floor until they have signed this in-service. Review of time punch records and in-service completion records from [DATE] at 2:00 p.m. until [DATE] at 6:00 a.m., indicated all nursing and dietary staff had received in-service on the new policy before working the floor. Review of the undated New Hire Checklist/General Orientation Outline form indicated .30. Code Status and Diet Coding for Residents . had been added to the basic orientation for new hires. On [DATE] at 1:56 p.m., the DON was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated [DATE] indicated 22 residents had orders for a mechanically altered diet.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures to prohibit neglect for 1 of 5 residents reviewed for neglect. (Resident #1) The facility did not follow physician orders, and LVN A gave a peanut butter sandwich to Resident #1, who had orders for a pureed diet. Resident #1 choked on the sandwich, resulting in his death. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 22 residents receiving mechanically altered diets including pureed at risk for harm or death. Findings included: The Abuse/Neglect Prohibition Policy dated ,[DATE] revised defined neglect as .failure to provide goods and services necessary to avoid physical harm . The policy required The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. A face sheet and physician orders [REDACTED].#1, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. A Medication Review Report dated [DATE] indicated Resident #1 had physician orders [REDACTED]. A nursing care plan dated [DATE] indicated Resident #1 was on a pureed diet with nectar thick liquids. He had a history of [REDACTED]. Staff were to serve the resident a pureed diet as ordered, monitor and record meals, and help divert attention from food by offering activities and choices. Resident #1 and his family requested he be on full code status. The MDS dated [DATE] indicated Resident #1 was severely cognitively impaired and required total assistance with eating and all other activities of daily living. The facility's security video, date stamped [DATE] at 1820 (6:20 p.m.), LVN A retrieved an unidentified food object from an ice chest at the nursing station. LVN A unwrapped the food object and handed it to Resident #1, who was sitting in the hallway. Full view of Resident #1 was obstructed by a cart. At 1824 (6:24 p.m.), LVN A walked over to Resident #1, took the item from Resident #1 and threw the item into the trash. Full view of Resident #1 continued to be blocked by the cart. At 1825 (6:25 p.m.), CNA C and MA A were walking down the hall and CNA C stopped to look at Resident #1. CNA C turned toward the nursing station and LVN A went to Resident # 1. LVN A returned to the nursing station and appeared to be looking for Resident #1's medical chart. CNA C waved her hands and LVN B appeared into view. LVN B placed Resident #1 on the floor, with assistance from LVN A. At 1827 (6:27 p.m.), LVN B started chest compressions on Resident #1 and LVN A retrieved a mask from a crash cart and started assistance with breathing. CNA C was on the telephone. No [MEDICATION NAME] maneuver was observed. During an interview on [DATE] at 11:15 a.m., MA A said she was working on [DATE] during the evening shift. She was walking down the 300 hall with CNA C. MA A said CNA C noticed something was wrong with Resident #1. She said LVN A checked Resident #1, then went back to the nursing station and was looking for Resident #1's medical chart. She said CNA C called for LVN B. LVN B asked for Resident #1's code status, and then instructed her to call 911. LVN B and LVN A placed Resident #1 on the floor and LVN B started chest compressions. LVN A retrieved the crash cart and started using the bag on Resident #1. CNA C called 911 and CPR was continued until EMS arrived. She said she did not see any food on Resident #1. During an interview on [DATE] at 2:24 p.m., LVN B said he was working on [DATE] during the evening shift. He said CNA C yelled for him to come down Hall 300. He said CNA C said Resident #1 was not breathing. He said when he arrived, he asked Resident #1's code status. He said LVN A opened the chart and he saw the green colored sheet on the front of the chart which indicated full code. LVN B instructed staff to call 911. With the assistance of LVN A, LVN B placed Resident #1 on the floor and started chest compressions. LVN A retrieved the crash cart and started using the bag on Resident #1. LVN B continued CPR until EMS arrived. He said he did not see any food on Resident #1. He said he saw Resident #1's chest rise when LVN A pushed in air. LVN B said there was no indication of food blocking Resident #1's airway. LVN B said he felt Resident #1 had a [MEDICAL CONDITION] or some other incident to cause him to stop breathing, and did not see any evidence of choking at the time. He said he would never give a sandwich to a resident with orders for a pureed diet. Hospital records dated [DATE] indicated Resident #1 was admitted on [DATE] at 8:30 p.m. from the nursing home. The record indicated Resident #1 was eating when he started to choke and went into respiratory arrest. CPR was started. Resident #1 was pronounced dead on [DATE] at 8:56 p.m. During an interview on [DATE] at 10:15 a.m., the administrator said she was the abuse coordinator. She said Resident #1 died at the hospital on [DATE] from choking on a peanut butter sandwich. She said Resident #1 was on a pureed diet. She said she reviewed the security footage at the time of the incident and observed LVN A unwrapping a sandwich and giving it to Resident #1. She said later, Resident #1 was found unresponsive and died . She said LVN A was terminated and a new policy/procedure was developed to ensure staff were aware of all residents with orders for pureed diets, and their code status. She said red and green name tags were placed on the faceplate of each resident's room to alert staff of each resident's code status. She said stars on the name plate indicated special precautions for pureed and thickened liquid diets. She said all staff received in-service training on the new policy/procedure. The policy dated [DATE] provided by the administrator on [DATE] required . All residents will have identification cards posted outside their respective rooms. The identification cards will be green for full code status and red for do not resuscitate. Those residents with physician ordered pureed diets will have a star beside their picture. All direct care staff will be educated on this facility policy No staff may work on the floor until they have signed this in-service. During an interview on [DATE] at 12:50 p.m., CNA A said this was her first day to work at the facility. She said she did not know what the colors or stars on the door indicated. She said she had not received training concerning the colors or the meaning of the stars. During an interview on [DATE] at 12:53 p.m., MA B said she had worked at the facility for one year. She said she did not know what the colors red and green indicated about the resident. During an interview on [DATE] at 12:57 p.m., CNA B said she worked at the facility for two weeks. She said she did not know what the colors red and green or the stars on the nameplates of the residents' doors indicated about the resident. She said she had not received training concerning the colors or the meaning of the stars. The administrator and DON were notified on [DATE] at 2:17 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 3:51 p.m. and included: All new hires will be in-serviced, prior to working the floor, on the facility's procedure to: .STARS are placed on the resident's name tags to identify those requiring pureed food items and/or thickened liquids. All staff, currently working in the facility, have been re-in-serviced on the above policy/procedure. Oncoming staff (,[DATE]) will be re-in-serviced prior to clocking in. Staff Scheduled for ,[DATE] on [DATE], will be re-in-serviced on the above policy/procedure prior to clocking in. Ongoing, all staff will be re-in-serviced prior to clocking in for their next scheduled shift . New Hire Checklist/General Orientation Outline has been updated to include the above in-service .Ongoing monitoring for compliance will be reviewed in the quarterly QA meetings. On [DATE] the surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Two CNAs were interviewed and said they received training on the policy/procedure before they started their shift on [DATE] at 6:00 a.m. They said they understood the stars on the resident's doors indicated the resident was to only receive pureed foods and/or thickened liquids. They were able to identify residents requiring pureed diets. Two nurses were interviewed and said they received training on the policy/procedure before they started their shift on [DATE] at 6:00 a.m. They said they understood the stars on the resident's doors indicated the resident was to only receive pureed foods and/or thickened liquids. They were able to identify residents requiring pureed diets. Stars were observed on the name plates of five residents who required pureed foods and/or thickened liquids. The new policy updated on [DATE] required .All residents will have identification cards posted outside their respective rooms. The identification cards will be green for full code status and red for do not resuscitate. Those residents with physician ordered pureed diets will have a star beside their picture. All direct care staff will be educated on this facility policy No staff may work on the floor until they have signed this in-service. Review of time punch records and in-service completion records from [DATE] at 2:00 p.m. until [DATE] at 6:00 a.m., indicated all nursing and dietary staff had received in-service on the new policy before working the floor. Review of the undated New Hire Checklist/General Orientation Outline form indicated .30. Code Status and Diet Coding for Residents . had been added to the basic orientation for new hires. On [DATE] at 1:56 p.m., the DON was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated [DATE] indicated 22 residents had orders for a mechanically altered diet.