Every finding on record at Colonial Manor Advanced Rehab & Healthcare

Based on interview and record review, the facility failed to ensure each resident had the right to access personal and medical records pertaining to himself or herself within 24 hours and allow the resident to obtain a copy of the records or any portions thereof upon request for 1of 4 residents (Resident #1) reviewed for resident rights.The facility failed to provide a copy of Resident #1's medical records to Resident #1's RP after requesting the records on 05/13/26.This failure could place residents at risk of not having access to records when requested.Findings included:Record review of Resident #1's face sheet, dated 08/12/26, reflected a [AGE] year-old female, admitted on [DATE], diagnoses included: nontraumatic intracerebral hemorrhage (stroke characterized by sudden bleeding into the brain tissue which can lead to serious neurological deficits), spastic quadriplegic cerebral palsy (condition that affects muscles and movement), anoxic brain damage (brain is completely deprived of oxygen), contractures (shortening of muscles, tendons, skin, and nearby soft tissues) of hands and knees, and major depressive disorder (mental health condition with persistent feelings of sadness, loss of interest, various emotional/physical problems). The RP was listed as the RP for Resident #1. Record review of Resident #1's quarterly MDS assessment, dated 07/10/26, reflected a BIMS was not conducted as Resident #1 was never/rarely understood. Record review of Resident #1's care plan, dated 08/12/26, reflected [Resident #1] had impaired cognition and was at risk for a further decline in cognitive and functional abilities due to anoxic brain damage and stroke. Date initiated: 09/03/19. Record review of Resident #1's authorization to disclose health information form completed and signed by Resident #1's RP reflected it was signed on 05/13/26. Records requested: medication records and entire records for January 2026-May 2026. There were visible markings on the 6s of the dates. Record review of Resident #1's guardianship, dated 10/09/19, reflected the RP was appointed as the guardian of Resident #1. The guardianship record was notarized and filed with the county. During an interview, on 08/12/26 at 1:40 PM, the RP stated she requested records on 05/13/26. The RP stated the facility kept giving her the runaround and she did not understand why they took so long. During an interview, on 08/12/26 at 2:35 PM, the HID stated Resident #1 was unable to decide or give consent for the release of information, but Resident #1's RP had POA or guardianship for Resident #1. The HID stated on 05/13/26, Resident #1's RP requested records from January-May 2025. The HID stated about a week later she asked the RP if she was sure about the dates and the RP stated she meant to request January-May 2026. The HID stated the RP changed the dates, but she did not fill out a new request form and the request remained with the date of 05/13/26. The HID stated they had to verify the RP had the appropriate paperwork to show that she had a valid POA or guardianship, which she did. The HID stated the facility then switched companies which caused a further delay. The HID stated the ADM communicated with the RP about this process. The HID stated the facility had 15 business days to provide records from the date the resident or RP submitted the request. During an interview, on 08/12/26 at 3:40 PM, the ADM stated Resident #1's RP requested records on 05/13/26, but initially the RP had requested records from 2025. The ADM stated the facility transitioned to a new company on 05/29/26. The ADM stated sometime in June 2026, the HID informed her that the RP said the dates were wrong as she meant to request records from 2026. The ADM stated she told the HID to obtain a new request form with the correct dates, but she did not, and they only updated the dates on the same form dated 05/13/26. The ADM stated since they transitioned to a different company, she was unsure of who to send the request to. The ADM stated she figured out the correct person to send the request to around the second week of June. The ADM stated the only records request form they had for Resident #1 was dated 05/13/26. The ADM stated the records were ready on around 07/29/26. The ADM stated it was maybe a month or more to get the records ready as it was a lot of back and forth with the RP and with the company transition. The ADM stated it took about 30 business days from the time they got the request to the correct person to when the records were ready. The ADM stated the records release of information policy indicated they had 15 business days to provide the records. The ADM stated she kept in communication with the RP and explained the delays, but she had no tracking log to show the updates or follow ups for the request. Record review of the facility's Medical Records - Release of Information (ROI) policy, dated November 2023, reflected - Overview: . The information released should be complete and timely.Policy: b. Deadline for ROI - should be produced within 15 business days after the date of receipt of the request.Procedures: 1. Confirm authorization to disclose information is on file.5. Record the date/time request was received.7. Monitor request, follow up where needed, maintain tracking log until request is finalized. Record review of the facility's Resident Rights policy, dated February 2016, revised February 2021, reflected - 6. a. The resident has the right to access personal and medical records pertaining to him or herself.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for 4 Residents (Residents #122, #106, #92 and #12) of 11 residents reviewed for infection control practices during personal care:1. The facility staff were not following Isolation Precautions on wearing Personal Protective Equipment (PPE) when entering Resident #122's room.2. Resident #106 was not on EBP and/or isolation precautions for known contagious diseases. 3. Resident #92 was not on EBP and/or isolation precautions for known contagious diseases. These failures could place residents that require assistance with personal care as well as employees and visitors, at risk of communicable diseases and healthcare-associated cross-contamination and infections. The findings included: he findings included: 1.Record review of Resident #122's admission Record dated 06/23/2026 revealed she was a [AGE] year-old female admitted [DATE] with diagnoses which included dementia (general term for loss of memory, language, problem-solving and other thinking abilities) and unspecified psychosis (when a person has trouble telling the difference between what's real and what's not), ESBL in urine (indicates an urinary tract infection caused by bacteria that produce an enzyme rendering many common antibiotic ineffective). Record review of Resident #122's entry MDS assessment dated [DATE] revealed a BIMS score of 5 indicating severe cognitive impairment. Record review of Resident #122's Baseline Care Plan initiated 06/21/2026 revealed contact precautions were not addressed. Record review of Resident #122's Medication Administration Record for June 2026 revealed an order for Resident requires transmission-based precautions of (contact, droplet, airborne) due to ESBL to urine. During an observation on 06/23/2026 11:20 a.m., Resident #122 was on contact isolation precautions. Outside Resident #122's room was on contact isolation, personal protective equipment on the door that had masks, gloves and gowns available. CNA H entered Resident #122 (contact isolation precautions) room without any personal protective equipment. During an interview on 06/23/2026 at 11:20 a.m., CNA H stated when there was isolation precautions in place, the staff needed to put on gloves, and gown before entering room. CNA H stated she went into the room really quick because she was going to put a yellow bag in the isolation bin. She stated she did not know it was not allowed to enter the room without personal protective precautions just to put the yellow bag. 2. Record review of Resident #106's face sheet indicated an [AGE] year-old female with an admission date on 03/11/26 and an original admission date on 10/28/19. Diagnoses included malnutrition, Diabetes, dementia, depression, lung disease, Parkinson's, Alzheimer's, MRSA (Methicillin Resistant Staphylococcus Aureus, a contagious super bug bacteria resistant to most common antibiotics and much harder to treat), ESBL (Extended Spectrum Beta Lactamase resistance, certain types of bacteria that have become highly resistant to many common antibiotics. They spread through direct contact with unwashed hands or by touching contaminated surfaces), and feeding tube placement dated 03/11/26. Record review of Resident #106's MDS assessment dated [DATE] revealed a BIMS score of 00 indicating severe cognitive impairment. She was dependent on staff for all ADL's. She was incontinent of bladder and bowel. She did not have a urinary catheter. She required a feeding tube. Record review of Resident #106's physician orders dated 06/16/26 and 06/23/26 revealed the same order: Resident #106 required transmission-based precautions of contact isolation due to ESBL to Urine. Resident #106 was in private room by herself because of active infection and all meals, activities, rehab and other services being done in room. Active 06/23/26. Nitrofurantoin Macro crystal Capsule 100 MG Give 1 capsule by mouth every 12 hours for UTI (ESBL) for 10 Days Active 6/17/2026. Erythromycin Ophthalmic Ointment 5 MG/GM Instill 1 application in both eyes four times a day for conjunctivitis (a very contagious eye infection spread through direct or indirect contact). for 7 Days. Clean eyes with warm water prior to each ointment application 06/05/26. Record review of Resident #106's care plan dated 04/20/26 was not updated to include contact isolation precautions or EBP (enhanced barrier precautions) for contagious infections and feeding tube until 06/24/26. Record review of Resident #106's progress note dated 05/26/26 revealed Resident #106 is incontinent of bladder. Pads/briefs are used. Acute E. coli UTI (05/15/2026). Progress note dated 05/26/26 .is incontinent of bladder. Pads/briefs are used. Progress note change of condition dated 6/3/26 at 6:25 am revealed Resident #106 had the following change in condition: redness to both eyes 6/7/26 at 2:58 pm: Resident #106 continues with erythromycin ophthalmic ointment 5 mg/gm four times a day for 7 days diagnosis: conjunctivitis. No notes indicated Resident #106 was on isolation precautions until 6/17/26 at 2:32 pm: The resident has an active infection. The resident has a UTI infection. The resident has other symptoms as follows: The resident is receiving medication for the infection. No side effects were noted. Isolation precautions are in place. The resident is on contact precautions. The resident resides in a private room. Record review of Resident #106's reported lab results dated 06/15/26 at 11:36 am revealed: E. Coli (ESBL) Extended-Spectrum Beta Lactamase-producing this organism is uniformly resistant to all penicillin, cephalosporins, and aztreonam. Observation and interview with Resident #106's Care Giver on 06/23/26 at 9:51 am revealed she was observed to have no PPE on while touching Resident #106 and standing so close to her bed that her clothing was rubbing against the side rails and bed covers. She said the resident did not go out of her room because of the isolation. She said the therapy people came to the room for Resident #106's exercises. She said they put gowns and gloves on. She said no one told her what the infection meant-that she only knew Resident #106 had an infection in her urine. She said Resident #106 did not have a urinary catheter. She said sometimes she helped staff turn the resident and change her brief. She said no one trained her on PPE. She said she did not know how to put it on or if there was a sequence to take it off. She said she did not think about why the therapy people put on gloves and a gown, but maybe she should, too. She said all therapy was done in the room, but she was not sure why. Signage in the room indicated Contact precautions. 3. Record review of Resident #92's face sheet indicated a [AGE] year-old female with an admission and original admission date on 04/07/26. Diagnoses included Alzheimer's, malnutrition, anxiety, dementia, high blood pressure, abdominal distention, and depression. Record review of Resident #92's quarterly MDS assessment dated [DATE] revealed a BIMS score of 14, indicating no cognitive impairment. She was dependent on staff for toileting, bathing, lower-body dressing, and footwear. She required maximal assistance with oral hygiene, upper body dressing, personal hygiene, positioning in bed, and transfers. She was always incontinent of bladder and bowel. Record review of Resident #92's physician orders dated 06/20/26 reflected C. Diff precautions (Clostridium Difficile is a severe bacterial infection of the intestine that causes extreme watery diarrhea, stomach pain, and inflammation). Active 06/20/26. Resident requires transmission-based precautions of contact isolation due to ESBL in the urine. The resident is in a private room by himself/herself because of active infection, and all meals, activities, rehab, and other services being done in the room every shift for UTI ESBL for 10 days. Active 06/24/26. Record review of Resident #92 's care plan dated 04/07/26 indicated she had ESBL in her urine. Date Initiated: 06/24/2026 The resident's urinary tract infection will resolve without complications by the review date. Date Initiated: 06/24/2026 Target Date: 07/30/2026 Contact Precautions per doctor orders Date Initiated: 06/24/2026 Revision on: 06/24/2026. Interventions included Resident/family/caregiver teaching should include: Good hygiene practices: Females to wipe and cleanse from front to back, Clean peri area well after bowel movement in order to help prevent bacteria in urinary tract, cranberry juice or prune juice to help keep urine acidic, void at first urge. Do not hold urine for an extended period of time. Wear clean underwear daily. Take the full course of antibiotic therapy even if much improved after a few days of therapy. Date Initiated: 06/24/2026 Record review of Resident #92 's progress note dated 06/21/26 revealed: Acute Diarrhea. Multiple episodes reported by nursing. C. difficile testing and stool culture ordered. Initiate contact precautions pending diagnostic results. Monitor stool frequency, consistency, and signs of infection. 06/20/26: change in condition: Resident #92 was having multiple episodes of diarrhea, new order for C. Diff stool culture and contact precautions. Observation of Resident #92's room on 06/23/26 at 10:54 am revealed no signage for C-Diff isolation precautions. There was no signage for contact precautions on Resident #92's door nor in the room. She had a feeding tube. 4. Record review of Resident #12's face sheet indicated an [AGE] year-old female with an admission date on 11/29/25, and an original admission date on 07/02/21. Diagnoses included dementia, depression, (ESBL) resistance 03/23/26, malnutrition, and kidney disease. Record review of Resident #12's quarterly MDS assessment dated [DATE] revealed a BIMS score of 03, indicating severe cognitive impairment. She was dependent on staff for ADL's. She required moderate assistance with oral hygiene and eating. She required maximal assistance with upper-body dressing. She was always incontinent of bladder and bowel. Her active diagnoses included MDRO. Record review of Resident #12's physician orders dated 02/16/26; Enteral Feed (use of the digestive tract to take in food or medicine) Order every night shift, Enteral Tube site care with mild soap and water. May leave open to air. Apply dressing only if drainage is present and change daily. Observe the site for redness, drainage, swelling, or purulent (full of pus or containing pus) discharge, and notify the physician if present. Verbal Active 02/16/26. Provide catheter care every shift for Urinary catheter use. Active 12/02/25. Record review of Resident #12's care plan dated 03/21/26 revealed, Focus of Feeding Tube: requires the use of a feeding tube and is at risk . Date Initiated: 02/16/26. Interventions did not include EBP at this time. Focus: Resident #12 requires Enhanced Barrier Precautions due to a stage 4 pressure ulcer to the sacrum (lower back), a Foley catheter, and a Feeding Tube. Date Initiated: 01/23/25 and revised on 06/04/26. Interventions included: Educate the resident and family on the reason and procedure for enhanced barrier precautions. Wear a gown and gloves during high-contact resident care activities. Date Initiated: 09/17/25. Ensure EBP signage is posted outside the resident's room and above the head of the resident's bed. Date Initiated: 09/17/2025. Record review of Resident #12 's progress note dated 06/24/26 revealed: the resident is not exhibiting diarrhea at this time, the resident did have a stool collected this morning with results pending. Resident on contact isolation for precaution until results are back. Resident is noted with a Foley leaking .06/15/26: Recurrent wound infection secondary to ESBL. 06/20/26: Resident was having multiple episodes of diarrhea, NP was notified, new order for blood work, C.diff/stool culture, and contact precautions. During an interview on 06/23/2026 at 11:20 a.m., CNA H stated when there was isolation precautions in place, the staff needed to put gloves, and gown before entering room. CNA H stated she went into the room really quick because she was going to put a yellow bag in the isolation bin. She stated she did not know it was not allowed to enter the room without personal protective precautions just to put the yellow bag. In an interview with CNA G on 06/24/26 at 12:10 pm, she said staff were trained frequently on infection control and PPE. She said she was last trained 2 weeks ago. She said the difference between isolation precautions and EBP was that EBP was only for tubes (feeding tubes, catheters, IV lines, and some dressings). She said, isolation was the whole room every time-gowns, gloves for sure, and masks if there was a chance of getting splashed. In an interview with CNA B on 06/24/26 at 12:13 pm, she said she had training on PPE 2 weeks ago. She said, EBP was 'lighter, ' and staff only needed to wear PPE when they might get something on them, like peri care, and the nurses did for tube feedings and meds. She said depending on the isolation, it required basics such as gowns and gloves. A mask and/or an N95 mask could also be worn. In an interview with the DON on 06/24/26 at 12:19 pm, she said, The caregivers were educated on PPE when any resident was diagnosed with a condition requiring PPE. She said she and the ADON's monitored and did surveillance on infection control and PPE. She said the ADON or charge nurses educated the caregivers. She said the charge nurses were supposed to redirect private caregivers about PPE in isolation rooms. She said PPE and infection control were important to protect the residents and prevent the spread of infection. She said Residents #12 and #92 did not have C-diff but should have been placed on isolation contact precautions immediately, until testing was done, which came back negative for both. She said isolation precautions should be in care plans. She said if the new cultures came back positive, it would be cross-contamination, and more education would be needed for staff because the two residents were in the same hallway. She said the process of receiving orders was to make certain they were followed. She said care plans and orders went hand in hand, meaning if there was an order written that would impact all staff, it would need to be in the care plan. She said all staff were responsible for knowing which residents needed EBP and/or isolation precautions and she did not know the caregiver for Resident #106 was not wearing PPE. During an interview on 06/24/2026 at 02:26 p.m., LVN F stated the isolation cart should contain gowns, gloves, and masks outside of the room and be available to staff and family who enter the room when a resident was diagnosed with contact isolation precautions for ESBL in the urine. LVN F stated that all staff and visitors should wear personal protective equipment before entering the room to prevent the spread of infection to other residents. During an interview on 06/25/2026 at 11:35 a.m., DON stated that contact Isolation precautions should be followed by all staff because of the potential for spreading infections to other residents. DON stated that in-service training on infection control were the key to preventing this from happening again. Record review of in-services revealed 03/10/26-Isolation precautions. All nurses must monitor and ensure all isolation precautions are being followed. 03/27/26- Staff to maintain infection control per protocol at all times. ADON instructed CNA staff on the importance of ensuring each resident's plan of care is available and accessible at all times. Staff were instructed to check for the plan of care at the start of their shift and to immediately notify the ADON or DON if the POC was missing, incomplete, or unavailable. 05/22/26-All nursing staff to follow all EBP precautions by wearing appropriate PPE for all incontinent care, showers, wound care with attached Isolation Precautions. Review of facility's policy titled Infection Prevention and Control Program with an origination date 09/22/2015 revealed; (Transmission-Based Precautions) It is the policy use precautions to reduce the risk and prevent transmission of infectious agents. Transmission-Based Precautions are for residents known or suspected to be infected with infectious agents, including certain epidemiologically important pathogens, which require additional control measures to effectively prevent and reduce the risk of transmission. These precautions are to be used in adjunct with standard precautions. Under Fundamental Information: In addition to consistent use of Standard Precautions, additional precautions may be warranted in certain situations as described below: 1. Contact Precautions-a. Intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment. Under Procedure: Contact Precautions c. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination ( e.g.C. difficile, .) Under Type and Duration of Transmission- Based Precautions Recommended for Selected Infections and Conditions: Multidrug-resistant organisms (MDROs), infection or colonization (i.e. MRSA.ESBLs.) Contact Isolation for the duration of illness or until colonized. Review of CDC (Centers for Disease Control) guidelines revealed: https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning Personal protective equipment upon room entry and properly discarding it before exiting the patient room is done to contain pathogens.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for two of two nourishment rooms. 1. The facility failed to ensure refrigerator temperature logs were filled out correctly for nourishment room [ROOM NUMBER]. 2. The facility failed to ensure food items in nourishment room [ROOM NUMBER] were labeled and dated appropriately. 3. The facility failed to ensure that there were no personal items stored in the refrigerator in nourishment room [ROOM NUMBER]. 4. The facility failed to ensure that leftovers were discarded within 72 hours in nourishment room [ROOM NUMBER] refrigerator. These failures could place residents who consumed food from the kitchen at risk for food borne illness. Record review of temperature log for nourishment room [ROOM NUMBER] indicated two places for documentation of temperatures. The option 1 was indicated for use of storage vaccines with a minimum and maximum temperature range using a digital thermometer. Option 2 was indicated for use when the temperature device does not have a minimum and maximum indicator. The temperature log dated June 1 through June 23, 2026, revealed staff were logging temperatures on the option 1 area which is indicated for vaccine monitoring. Option 2 of the temperature log was blank. Observation on 6/24/26 at 3:20pm revealed an analog (something that represents data, information, or physical quantities as variable and measurable values) thermometer, indicating the temperature log area for use is option 2. Observation on 6/24/26 at 3:25pm of the facility's nourishment 1 refrigerator revealed the following: 2 clear sandwich sized bags of green substance were not labeled or dated. 1 blue bowl with a clear lid was labeled with a name and room number but no date. 2 clear 32 ounce plastic cups containing a light brown substance in the door of the refrigerator were not dated or labeled. 9 small water bottles wrapped in plastic were not labeled or dated. A zippered pouch lunch box was stored in the refrigerator labeled with a staff member name (according to an interview with ADON J). A black bowl wrapped in a clear plastic bag was labeled and dated 6/16/2026 indicating the food had been stored for longer than 72 hours after opening. During an interview with ADON J 6/24/26 at 3:30 pm, she stated the refrigerator in nourishment room [ROOM NUMBER] was for to be used for residents only, all items were to be labeled and dated, staff personal items were to be stored in the staff refrigerator, and open food items should be discarded after 3 days. ADON J stated that if food is not stored properly, it can cause cross contamination. ADON J stated it is expected that all staff will follow the rules for storing resident nutritional items in the refrigerator. ADON J stated the refrigerator is her responsibility to maintain as it has enteral feeding supplies and other items necessary for all residents' nutritional needs. During an interview with ADON K on 6/24/26 at 3:45pm, ADON K stated she was not aware they were using the temperature log inappropriately. ADON K stated she had not been trained on how to use the logs. ADON K stated that monitoring the temperatures and logging the temperatures were her responsibility. ADON K stated the refrigerators should be used for resident food items only, each item should be dated and labeled appropriately, and opened items should be discarded within 3 days. During an interview with the DON on 6/25/2026 at 11:45am, the DON stated the expectations are for staff to follow the proper food storage process including labeling and dating all food, keeping personal items out of the resident refrigerator, and throwing items away within a timely manner. The DON stated it is the responsibility of the ADON(s) or Unit Manager(s) to ensure items are stored and maintained properly in the resident refrigerators. The DON stated ADON's are responsible for cleaning the fridges and storing and updating supplies in the nourishment room, and that housekeeping cleans the room. During an interview with the Administrator on 6/25/26 at 12:00pm, he stated it is the responsibility of and expected that the ADON will follow the policy and standards set in labeling and storing food items in resident refrigerator. The Administrator stated both nourishment room refrigerators are to be monitored, cleaned, and to notify maintenance for repairs. The ADON's are to keep a written daily log of temperatures and arrange food in a manner that prevents cross contamination. The Administrator stated that due to the change of ownership, the only policy about cold food storage was for dining services. References: FDA Food Code 2022 Ch. 2-102.20 Food Protection Manager Certification 2-103 Duties 2-103.11 Person in Charge. The PERSON IN CHARGE shall ensure that: (E) EMPLOYEES are visibly observing FOODS as they are received to determine that they are from APPROVED sources, delivered at the required temperatures, protected from contamination, UNADULTERED, and accurately presented, by routinely monitoring the EMPLOYEES' observations and periodically evaluating FOODS upon their receipt 2-4 Hygienic Practices 2-401 Food Contamination Prevention 2-401.11 Eating, Drinking, or Using TOBACCO PRODUCTS

Based on interview and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 2 (03/01/2026 and 03/15/2026) of 90 days reviewed for RN hours, for the months January 1, 2026 through March 31, 2026.The facility failed to have RN coverage for 2 days on Sunday, 03/01/2026 and 03/15/2026.This failure could place residents at risk of harm by denying residents the advanced critical thinking skills a registered nurse could provide.Findings included:Record review of the facility's March 2026, nursing schedule reflected that on 03/01/2026 and 03/15/2026, there were no RNs scheduled. During an interview on 06/24/2026 at 9:00 a.m., the Administrator said it was the responsibility of the facility's DON to ensure the facility had 8 consecutive hours of RN coverage 7 days a week. The Administrator said the facility had recently changed their software. She said the software company that was responsible for reporting staffing statistics to CMS/PBJ (mandatory quarterly reporting system) up to end of May 2026 was their previous software company. She said she no longer had access to staff's timesheets prior to 05/30/2026. She said she was going to contact the previous software's representative to see if they could provide RN's timesheets for 03/01/2026 and 03/15/2026. During an interview on 06/25/2026 at 1:48 p.m., the DON said it was her responsibility to ensure the facility had 8 consecutive hours of RN coverage. She said the facility had recently undergone a change their software system and was not sure if they still had access to the timesheets in the previous software. She said a negative outcome for not having 8 consecutive hours of RN coverage 7 days a week would be making sure staff had RN support. During an interview on 06/25/2026 at 1:55 p.m., the Administrator said she was not able to provide proof of 8 consecutive RN hours for 03/01/2026 and 03/15/2026. She said, looking back on resident assessments done on those days by an RN it showed on paper an RN worked 2.44 hours on 03/01/2026 and .20 minutes on 03/15/2026. The Administrator said she was not sure why the schedule for 03/01/2026 and 03/15/2026 did not show an RN scheduled. She said, I know I had RN coverage on those days. The Administrator said there were no negative outcomes because it was an oversight and she was certain the facility had 8 consecutive hours of RN coverage on 03/01/2026 and 03/15/2026 but was not able to obtain their timesheets. Record review of the facility's Staffing, Sufficient and Competent Nursing policy, revised in August 2022, reflected:Policy Statement: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Sufficient Staff.3. A registered nurse provides services at least eight (8) hours every 24 hours, seven (7) days a week.

Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 of 4 residents (Resident #40) reviewed for respiratory care. The facility failed to ensure proper storage of Resident #40's nebulizer mask tubing when it was not kept in a plastic bag when not in use. This failure could place residents requiring oxygen at risk for respiratory infections due to the potential for microorganisms infiltrating their oxygen, nebulizer equipment and supplies causing a decline in physical health. The findings included: Record review of Resident #40's face sheet, dated 06/23/2026, revealed resident was a [AGE] year-old male, admitted to the facility on [DATE]. Diagnosis included acute respiratory failure with hypoxia (lungs cannot provide enough oxygen to the blood and the organs). Record review of Resident #40's admission MDS, dated [DATE] revealed was still in progress. Record review of Resident #40's Care Plan, dated 06/16/2026 revealed the following: Problem - The resident has impaired respiratory status and is at risk for shortness of breath, respiratory distress, increased anxiety, and hypoxia. Intervention - provide nebulizer therapy as ordered. During an observation on 06/23/2026 at 10:55 a.m., during initial rounds, revealed Resident #40 was in his bed. His nebulizer mask tubing was lying out on his nightstand and the tubing was touching the floor. During an interview on 06/23/2026 at 10:55 a.m., CNA G stated that the nurse was responsible to put the nebulizer mask with tubing away in a zip top bag. CNA G stated that the tubing was not supposed to be touching the floor because it could cause contamination and infection. During an interview on 06/24/2026 at 02:20 p.m., LVN A stated that she was the nurse for Resident #40. LVN A stated that when nebulizer mask and tubing were not in use they should be inside the zip top bag. LVN A stated that the negative outcome would be the mask and tubing could get contaminated and possible infection concerns. During an interview on 06/25/2026 at 11:35 a.m., the DON said nebulizer masks and oxygen tubing should be stored in a zip top bag at bedside when not in use. The DON stated the potential negative outcomes would be the mask and tubing could get dirty and possible infection control concerns. Record Review of the facility's policy Respiratory: Nebulizer Mist Therapy, with a revision date 11/04/2025, revealed the following [in part]:To deliver prescribed pulmonary medications in a fine mist of suspended particles directly in peripheral areas of the lung. Plastic bag for nebulizer and mouthpiece or mask storage. Store nebulizer, mouthpiece in separate, labeled plastic bag (change all disposable parts once a week and label with date and initials.

Based on observation, interview, and record review the facility failed to ensure the resident had a right to personal privacy including personal care for 1 staff (LVN A) providing care to 1 of 3 residents (Resident #19) reviewed for personal privacy, in that: LVN A did not closed Resident #19's privacy blinds during medication administration via feeding tube, leaving the resident in plain view of the outside parking lot area. The deficient practice could affect residents in the facility who received medication via mic-key-tube and could result in the resident being unnecessarily exposed and cause embarrassment. The findings were: Record review of Resident #19's face sheet dated 06/25/2026 revealed she was admitted to the facility on [DATE] with diagnoses which included unspecified nontraumatic intracerebral hemorrhage (bleeding in the brain not caused by injury) and spastic quadriplegic cerebral palsy (causing severe muscle stiffness in all four limbs, body, and face). Record review of Resident #19's care plan revealed: Resident #19 was on feeding tube and at nutritional & dehydration risk related to tube feeding due to dysphagia (difficulty swallowing), cerebrovascular accident (when blood flow to an area of the brain is cut off, depriving brain tissue of oxygen and causing brain cells to die), anoxic (without oxygen), brain damage and was NPO. Interventions: administer medications as ordered. Record review of Resident #19's MDS dated [DATE] revealed resident had a feeding tube while a resident. Record review of Resident#19's physicians orders for 6/25/2026 revealed orders for medications to be administered via mic-key-tube (a type of medical feeding tube that sits almost flat against the skin) that included, Aspirin Tablet 81 MG QD, Levetiracetam Solution 100 MG/ML, 15ml q 12 hrs, and Acetaminophen-Codeine Suspension 120-12 MG/5ML, 10ml q 8 hrs. During observation on 06/24/2026 at 10:45am, LVN A was observed performing a medication pass for Resident #19 in her room. During the administration of medications via mic key tube, the window blinds facing the parking lot were completely open. Resident #19 was visible from the outside while receiving medications. During an interview on 6/24/2026 at 2:20p.m., LVN A stated, I forgot to close them and that it was important to close blinds to make sure resident get privacy during personal treatments and if not followed would leave the exposed. During an interview on 6/25/2026 at 11:40a.m., DON confirmed that staff were trained to secure full visual privacy-including closing doors, privacy curtains, and window blinds prior to initiating any medication administration or physical treatment. DON stated this protected their privacy during feeding or medication administration. Record review of the facility's policy titled Activities of Daily Living with a revised date 1/1/2024 revealed Screen and drape resident for maximum privacy

Based on observations, interviews, and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one resident (Resident #8) of 24 residents reviewed for quality of care. The facility failed to follow or revise the physician's orders for Resident #8's soft helmet to be on at all times, may remove for bathing. Resident #8 was not wearing his helmet, and it could not be found anywhere in his room.This deficient practice could affect residents who require care and monitoring, placing them at risk of not receiving the care and services they need.Findings were:Record review of Resident #8's face sheet revealed a [AGE] year-old male with an admission date of 05/14/26 and an original admission date of 01/27/25. Diagnoses included stroke with left non-dominant paralysis, diabetes, mood disorder, major depressive disorder, recurrent/moderate anxiety disorder, cancer, high blood pressure, obstructive uropathy (blockage of the urinary tract usually requiring an in-dwelling catheter), and dementia.Record review of Resident #8's quarterly MDS dated [DATE] revealed a BIMS score of 00, indicating severe cognitive impairment. His active diagnosis was stroke; he developed psychosis, and he was unable to speak. He required a feeding tube for malnutrition and was pleasure feeding on a no-restrictions diet, pureed texture, and thin liquid consistency as of 06/14/26. He was dependent on staff for all ADL's and required mechanical lifting for transfers. Record review of Resident #8's care plan dated 01/27/25 revealed: Focus: behavioral problem as evidenced by attempts to self-transfer, yells while in bed, has hallucinations, hits, punches, and scratches himself while in bed. Date initiated 04/14/26 and revised on 06/03/26. The goal was for his behavior not to interfere with the delivery of care or services or result in harm to self or others through the next review date. Date Initiated: 04/14/25 and revised on 11/26/25. Interventions included: Soft helmet on at all times, may remove for bathing (in all caps). Focus: psychotropic medications. Date Initiated: 04/17/25 and revised on 06/03/26. Interventions included: Target behavior is yelling, screaming, disruptive behaviors, attempting to get out of bed, pulling on feeding tube, hitting and scratching self at times, restlessness. Date Initiated: 04/17/25 and revised on 06/03/26. Record review of Resident #8's physician's orders dated 06/11/26 revealed: Soft helmet on at all times, may remove for bathing (in all caps). Record review of Resident #8's change in condition dated 6/23/26 at 3:34 pm revealed: self-inflicted scratches to his forehead. This condition, symptom, or sign has occurred before. Additional Information: Resident provided with another soft helmet to help prevent self-inflicted scratches to his head/forehead. The physician's assistant was made aware and ordered to monitor him closely and assure soft helmet is on at all times. Observation of Resident #8 and his room, and interview with the PTA on 06/23/26 at 2:52 pm revealed Resident #8 was lying in bed on his back looking around, moving and bending his arms and legs, scratching his head, and intermittently yelling. He did not make eye contact or indicate any understanding of the questions asked by this surveyor. He did not have a soft helmet on, nor was one in sight. The PTA said Resident #8 only had to wear his soft helmet when he was out of bed. She said he was not wearing it at this time, and he was in bed. She said she would look for it. She said she had not actually looked at the order. In an interview with the PTA on 06/23/26 at 2:58 pm, she said she could not locate Resident #8's helmet in his room or in the therapy department. She said she took a new one to him and put it on him. She said she thought maybe his family member had taken it to wash his clothes because she washed all of Resident #8's laundry. She said nursing was responsible for following orders.In a phone interview with Resident #8's family member on 06/25/26 at 9:45 am, she said he did not wear the helmet all the time. She said he had it because he scratched his head a lot and could make it bleed, or when he was anxious, he would hit himself, and that was why the facility got the soft helmet for him. She said he just got it and started using it last week. She said she visited him every evening. She said she washed all of his clothing, but never took the helmet home to wash it. She said she had not seen anything on the in-room camera to give her alarm. In an interview with the DON on 06/25/26 at 12:19 pm, she said all patient care staff were responsible for following orders and clarifying them if need be. She said the process of receiving orders was to make certain they were followed. She said not following orders for the helmet was noncompliance.In an interview with the DOR on 06/25/26 at 12:30 pm, she said the therapy department made the recommendation for Resident #8 to have the soft helmet because he would scratch his head until it bled and hit himself when he became agitated, which was often. She said she was unaware the physician's orders indicated Resident #8 should have been wearing the helmet at all times because she had not looked at them. She said the orders should have been changed if Resident #8 was not going to be wearing the helmet at all times. She said everyone was responsible for patient safety and should have been following the orders or have the order changed. Record review of the facility policy updated 02/2025 titled, Physician Orders under purpose: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of physician orders to ensure the resident receives the necessary care and services.

Based on observations, interviews, and record reviews, the facility failed to ensure that the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, for 3 residents (Resident #106, #92, and #12) of 8 residents whose care plans were reviewed for timing and revision.1. Resident #106's care plan did not indicate isolation precautions for known contagious diseases.2. Resident #92's care plan did not indicate isolation precautions for known contagious diseases until 06/24/26. 3. Resident #12's care plan did not indicate isolation precautions for known contagious diseases. These failures could affect residents in the facility by placing them at risk of not being provided with necessary care or services and not having personalized plans developed to address their specific needs.The findings were:1. Record review of Resident #106's face sheet indicated an [AGE] year-old female with an admission date on 03/11/26 and an original admission date on 10/28/19. Diagnoses included malnutrition, Diabetes, dementia, depression, lung disease, Parkinson's, Alzheimer's, MRSA (Methicillin Resistant Staphylococcus Aureus, a contagious super bug bacteria resistant to most common antibiotics and much harder to treat), ESBL (Extended Spectrum Beta Lactamase resistance, certain types of bacteria that have become highly resistant to many common antibiotics. They spread through direct contact with unwashed hands or by touching contaminated surfaces), and feeding tube placement dated 03/11/26.Record review of Resident #106's MDS assessment dated [DATE] revealed a BIMS score of 00, indicating severe cognitive impairment. She was dependent on staff for all ADL's. She was incontinent of bladder and bowel. She did not have a urinary catheter. She required a feeding tube. Record review of Resident #106's physician orders dated 06/16/26 and 06/23/26 revealed the same order: Resident #106 required transmission-based precautions of contact isolation due to ESBL in the urine. Resident #106 was in a private room by herself because of an active infection, and all meals, activities, rehab, and other services were being done in the room. Verbal Active 06/23/26. Verbal Active 06/16/2026. Nitrofurantoin Macro crystal Capsule 100 MG Give 1 capsule by mouth every 12 hours for UTI (ESBL) for 10 Days. Active 6/17/2026. Erythromycin Ophthalmic Ointment 5 MG/GM Instill 1 application in both eyes four times a day for conjunctivitis (a very contagious eye infection spread through direct or indirect contact) for 7 Days. Clean eyes with warm water prior to each ointment application 06/05/26.Record review of Resident #106's care plan dated 04/20/26 reflected it was not updated to include contact isolation precautions or EBP for contagious infections and a feeding tube until 06/24/26. Record review of Resident #106 's progress note dated 05/26/26 reflected .is incontinent of bladder. Pads/briefs are used. Acute E. coli UTI (05/15/2026). Progress note dated 05/26/26 .is incontinent of bladder. Pads/briefs are used. Progress note change of condition dated 6/3/26 at 6:25 am revealed Resident #106 had the following change in condition: redness to both eyes 6/7/26 at 2:58 pm: Resident #106 continues with erythromycin ophthalmic ointment 5 mg/gm QID x 7 days dx: conjunctivitis.No notes indicated Resident #106 was on isolation precautions until 6/17/26 at 2:32 pm: The resident has an active infection. The resident has a UTI infection. The resident has other symptoms as follows: The resident is receiving medication for the infection. No side effects were noted. Isolation precautions are in place. The resident is on contact precautions. The resident resides in a private room.Record review of Resident #106's reported lab results dated 06/15/26 at 11:36 am revealed E.SCHERICHIA COLI (ESBL) EXTENDED-SPECTRUM BETA-LACTAMASE-PRODUCINGTHIS ORGANISM IS UNIFORMLY RESISTANT TO ALL PENICILLINS, CEPHALOSPORINS, AND AZTREONAM.Observation and interview with Resident #106's Care Giver on 06/23/26 at 9:51 am revealed she was observed to have no PPE on while touching Resident #106 and standing so close to her bed that her clothing was rubbing against the side rails and bed covers. She said the resident did not go out of her room because of the isolation. She said the therapy people came to the room for Resident #106's exercises. She said they put gowns and gloves on. She said no one told her what the infection meant, and she only knew Resident #106 had an infection in her urine. She said Resident #106 did not have a urinary catheter. She said no one trained her on PPE. She said she did not know how to put it on or if there was a sequence to take it off. She said she did not think about why the therapy people put on gloves and a gown, but maybe she should, too.2. Record review of Resident #92's face sheet indicated a [AGE] year-old female with an admission and original admission date on 04/07/26. Diagnoses included Alzheimer's, malnutrition, anxiety, dementia, high blood pressure, abdominal distention, and depression.Record review of Resident #92's quarterly MDS assessment dated [DATE] revealed a BIMS score of 14, indicating no cognitive impairment. She was dependent on staff for toileting, bathing, lower-body dressing, and footwear. She required maximal assistance with oral hygiene, upper body dressing, personal hygiene, positioning in bed, and transfers. She was always incontinent of bladder and bowel.Record review of Resident #92's physician orders dated 06/20/26; reflected C. Diff precautions (Clostridium Difficile is a severe bacterial infection of the intestine that causes extreme watery diarrhea, stomach pain, and inflammation). Active 06/20/26. Resident requires transmission-based precautions of contact isolation due to ESBL in the urine. Resident is in a private room by himself/herself because of active infection, and all meals, activities, rehab, and other services being done in the room every shift for UTI ESBL for 10 Days Active 06/24/26. Record review of Resident #92's care plan dated 04/07/26 revealed a focus of Resident #92 has ESBL in the urine. Date Initiated: 06/24/26. Interventions included: Contact Precautions per MD orders. Date Initiated: 06/24/26. Resident/family/caregiver teaching should include good hygiene practices: Females to wipe and cleanse from front to back, clean peri area well after bowel movement in order to help prevent bacteria in urinary tract, cranberry juice or prune juice to help keep urine acidic, Void at first urge. Do not hold urine for an extended period of time. Wear clean underwear daily. Take the full course of antibiotic therapy even if much improved after a few days of therapy. Date Initiated: 06/24/26. Record review of Resident #92 's progress note dated 06/21/26 revealed: Acute Diarrhea. Multiple episodes reported by nursing. Blood work, C. difficile testing, and stool culture ordered. Initiate contact precautions pending diagnostic results. Monitor stool frequency, consistency, and signs of infection. 06/20/26: change in condition: Resident #92 was having multiple episodes of diarrhea, new order for blood work, C. Diff stool culture, and contact precautions. Observation of Resident #92's room on 06/23/26 at 10:54 am revealed no signage for C-Diff isolation precautions. There was no signage for contact precautions on Resident #92's door nor in the room. She had a feeding tube. 3. Record review of Resident #12's face sheet indicated an [AGE] year-old female with an admission date on 11/29/25 and an original admission date on 07/02/21. Diagnoses included dementia, depression, (ESBL) resistance 03/23/26, malnutrition, and kidney disease. Record review of Resident #12's quarterly MDS assessment dated [DATE] revealed a BIMS score of 03, indicating severe cognitive impairment. She was dependent on staff for ADL's. She required moderate assistance with oral hygiene and eating. She required maximal assistance with upper-body dressing. She was always incontinent of bladder and bowel. Her active diagnoses included MDRO. Record review of Resident #12's physician orders dated 02/16/26; reflected Enteral Feed (use of the digestive tract to take in food or medicine) Order every night shift Enteral Tube site care with mild soap and water. May leave open to air. Apply dressing only if drainage is present and change daily. Observe site for redness, drainage, swelling, or purulent (full of pus or containing pus) discharge, and notify physician if present. Active 02/16/26. Provide catheter care every shift for Urinary catheter use. Active 12/02/25. Record review of Resident #12's care plan dated 03/21/26 revealed a Focus of Feeding Tube: requires the use of a feeding tube and is at risk . Date Initiated: 02/16/26. Interventions did not include EBP at this time. Focus: Resident #12 requires Enhanced Barrier Precautions due to stage 4 to sacrum (lower back), a Foley catheter, Feeding Tube. Date Initiated: 01/23/25 and revised on 06/04/26. Interventions included: Educate the resident and family on the reason and procedure for enhanced barrier precautions. Wear gown and gloves during high-contact resident care activities. Date Initiated: 09/17/25. Ensure EBP signage is posted outside the resident's room and above the head of the resident's bed. Date Initiated: 09/17/2025. Record review of Resident #12 's progress note dated 06/24/26 revealed: the resident is not exhibiting diarrhea at this time, the resident did have a stool collected this AM with results pending. Resident on contact isolation for precaution until results are back. Resident is noted with a Foley leaking .06/15/26: Recurrent wound infection secondary to ESBL. 06/20/26: Resident was having multiple episodes of diarrhea, NP was notified, new order for blood work, C. diff/stool culture, and contact precautions.In an interview with CNA A on 06/24/26 at 12:10 pm, she said staff were trained frequently on infection control and PPE. She said she was last trained 2 weeks ago. She said the difference between isolation precautions and extra barrier precautions (EBP) was EBP was only for tubes (feeding tubes, catheters, IV lines, and some dressings). She said isolation was the whole room every time-gowns, gloves for sure, and masks if there was a chance of getting splashed. She said all residents should have a sign indicating EBP and/or Isolation and what kind of isolation, for example, Contact Isolation. In an interview with CNA B on 06/24/26 at 12:13 pm, she said she had training on PPE 2 weeks ago. She said EBP was lighter and just when you might get something on you, like peri care, and the nurses did for tube feedings and meds. She said that depending on the isolation, it required basics such as gowns and gloves. A mask and/or an N95 mask could also be worn. She said all residents should have a sign indicating EBP and/or Isolation and what kind of isolation, for example, Contact Isolation.In an interview with the DON on 06/24/26 at 12:19 pm, she said the caregivers were educated on PPE when the resident was diagnosed with a condition requiring PPE. She said she and the ADON's monitored and did surveillance on infection control and PPE. She said the ADON or charge nurses educated the caregivers. She said the charge nurses were supposed to redirect private caregivers about PPE in isolation rooms. She said PPE and infection control were important to protect the residents and prevent the spread of infection. She said Residents' #12 and #92 did not have c-diff but should have been placed on isolation contact precautions immediately, until testing was done, which came back negative for both. She said isolation precautions should be in care plans. She said if the new cultures came back positive, it would be cross-contamination and more education because the two residents were in the same hallway. She said the process of receiving orders was to make certain they were followed. She said care plans and orders went hand in hand, meaning if there was an order written that would impact all staff, it would need to be in the care plan. Record review of the facility policy dated 02/10/21, titled Comprehensive Care Plans, Policy: reflected It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma-informed. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #122) of 8 residents reviewed for baseline care plans. The facility failed to include Resident #122's use of contact precautions in her baseline care plan. This failure could result in residents not receiving needed care and treatment.Findings Included: Record review of Resident #122's admission Record dated 06/23/2026 revealed she was a [AGE] year-old female admitted [DATE] with diagnoses which included dementia (general term for loss of memory, language, problem-solving and other thinking abilities) and unspecified psychosis (when a person has trouble telling the difference between what's real and what's not), ESBL in urine (indicates an urinary tract infection caused by bacteria that produce an enzyme rendering many common antibiotic ineffective). Record review of Resident #122's entry MDS assessment dated [DATE] revealed a BIMS score of 5 indicating severe cognitive impairment. Record review of Resident #122's Baseline Care Plan initiated 06/21/2026 revealed contact precautions were not addressed. Record review of Resident #122's Order Summary for June 2026 revealed an order for Resident requires transmission-based precautions of (contact, droplet, airborne) due to ESBL to urine. During an observation on 06/23/2026 at 11:20 a.m., Resident #122 was on contact isolation precautions. Outside Resident #122's room was an isolation , personal protective equipment on the door that had masks, gloves and gowns available. CNA H entered Resident #122's (contact isolation precautions) room without any personal protective equipment. During an interview on 06/23/2026 at 11:20 a.m., CNA H stated when there was isolation precautions in place, the staff needed to put on gloves, and gown before entering room. CNA H stated she went into the room really quickly because she was going to put a yellow bag in the isolation bin. She stated she did not know it was not allowed to enter the room without personal protective precautions just to put the yellow bag. During an interview on 06/25/2026 at 10:15 a.m., RN D stated Resident #122 had an order for Contact Precautions due to ESBL to urine. RN D stated that this order was effective since the date of admission on [DATE]. RN D stated it was important to have this information in the Baseline Care Plan to provide staff with all the information needed to meet Resident #122's needs after her admission. RN D stated that the admitting nurse was responsible for completing baseline care plans. During an interview on 06/25/2026 at 11:35 a.m., the DON revealed that the admitting Nurse was responsible for completing Baseline Care Plans, and that Resident #122's Baseline Care Plan should have included her use of contact precautions. The DON stated that the facility was using personal protective equipment and providing good care, but through oversight, it just did not make it onto the Baseline Care Plan within the 48 hours, but had been added later. Record review of the facility policy titled Baseline Care Plans with a revision date 04/02/2024 revealed Resident person-centered baseline care plans are developed and implemented for new admission residents. Baseline care plans are developed and implemented within 48 hours of a resident new admission. The baseline care plans include measurable objectives to address the resident's immediate medical, clinical, functional, mental, and psychosocial person-centered needs.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 of 6 residents (Resident #121) reviewed for accidents and hazards: The facility failed to ensure a (diabetic) lancet was not left sitting on top of Resident #121's bedside table unattended. This failure could place residents at risk of access to or injury from a lancet.Findings were: Record review of Resident #121's admission Record dated 06/23/2026 revealed she was a [AGE] year-old female admitted [DATE] with diagnoses which included diabetes mellitus due to underlying condition with hyper glycemia (a chronic metabolic condition where the body either resists the effects of insulin or does not produce enough to maintain normal glucose levels). Record review of Resident #121's entry MDS assessment dated [DATE] revealed a BIMS score of 14 indicating intact cognitive status. Record review of Resident #121's Baseline Care Plan initiated 06/21/2026 revealed: Resident has a diagnosis of diabetes and is at risk for unstable blood sugars and abnormal results. Interventions: monitor blood sugar as ordered by physician. Record review of Resident #121's Medication Administration Record for June 2026 revealed an order for Humulin Regular injection solution. Inject as per sliding scale before meals and at bed time related to diabetes mellitus. During an observation on 06/23/2026, at 11:08 a.m., revealed on top of Resident #121's bedside table, there was a diabetic lancet. During an interview on 06/23/2026 at 11:10 a.m., LVN E stated the (diabetic) lancet was supposed to be secured in the medication cart or thrown away in the disposable sharps container. LVN E stated the negative outcome could be someone could come by and grab it off the bedside table. During an interview on 06/25/2026 at 11:35 a.m., the DON stated the lancet should be kept in the medication cart until use and if used should be thrown away in the sharps container. The DON said it would be a safety issue if it were left unattended and anyone could grab it. Record review of the facility's policy titled Obtaining a fingerstick glucose level with revision date 10/2011, revealed: Procedure:6.discard lancet into the sharp's container.

Based on observation, interview, and record review, the facility failed to establish a system of records of disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, for four Resident (Resident #25) of 14 residents reviewed for controlled medication use, in that: Resident #25's Individual Resident's Controlled Substance Record did not accurately reflect Resident#25's Tramadol medication amount on hand. This failure could place all residents on the 500 hall at risk for medication overdose, medication under-dose, and ineffective therapeutic outcomes. The findings included: Record review of Resident #25's admission Record dated 06/23/2026 reflected she was an [AGE] year old female admitted on [DATE] with diagnoses Type 2 Diabetes Mellitus without complications (a chronic metabolic condition where the body wither resists the effects of insulin or does not produce enough to maintain normal glucose levels), contracture to right hand (the permanent tightening or shortening of muscles, tendons, skin, or soft tissues that causes joints to become stiff). Record review of Resident#25's Quarterly MDS (Minimum Data Set) assessment, dated 04/24/2026, revealed Resident #25 had a BIMS score of 00 which meant severe cognitive impairment. Record review of Resident#25's June/2026 Physician's Orders revealed:Order date: 06/26/2025Orders: Tramadol [Schedule V controlled pain medication] 50 mg [milligram] give 1 tablet by mouth every 6 hours as needed DX pain. During an observation on 06/23/2026 at 2:30 p.m. of Resident#25's Tramadol 50 mg medication blister pack revealed 13 tablets remaining. Record review of Resident#25's Individual Resident's Controlled Substance Record for Tramadol revealed 14 tablets on hand. During an interview on 06/24/2026 at 02:30 p.m., LVN E said when she gave Tramadol 50 milligrams 1 tab for pain she forgot to sign Resident #25's Controlled Substance Record for Tramadol. LVN E said that she was pulled away and forgot to sign. LVN E said that the controlled substance record was a secondary chart to make sure the medication count was correct and that they had to be matching. LVN E said that the Control Substance Record had to be signed right after the resident took the medication. During an interview on 06/25/26 at 11:35 a.m., the DON said the nurses should sign the controlled substance sheet when they popped the medication out from the blister pack. The DON said the nurses should sign off on the MAR after administering the medication to the resident. Record review of facility's policy titled Controlled Substances with a revision date 11/2022 reflected: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Controlled substances are counted upon delivery.

Based on observation, interview and record reviews the facility failed to ensure a resident receives treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, and maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or the resident preferences indicate otherwise, for 2 (Resident #1 and Resident #2) of 7 residents, reviewed for nutritional status.The facility failed to ensure Resident #1 and Resident #2 were weighed weekly per physician's orders. This failure could place residents at risk for nutritional deficit, weight loss, skin breakdown, and overall decline in quality of life.Findings included:1. Record review of Resident #1's face sheet, dated 05/28/26, reflected an [AGE] year-old female, admitted on [DATE] diagnoses included: other fracture of left patella (kneecap) encounter for routine healing, muscle wasting and atrophy (reduction in muscle mass and strength), dysphagia (trouble swallowing), cognitive communication deficit (communication is impaired due to underlying cognitive dysfunction rather than a primary language or speech problem), rheumatoid arthritis (chronic autoimmune system that primarily affects the joints, causing pain, swelling, and stiffness), dementia (decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), malignant neoplasm of unspecified site of left breast (breast cancer), and malignant neoplasm of unspecified lung (lung cancer). Resident #1 was discharged on 04/14/26. Record review of Resident #1's MDS assessment, dated 04/13/26, reflected a BIMS was not conducted as Resident #1 was never/rarely understood, indicating severe cognitive impairment. The MDS assessment reflected Resident #1 had a weight of 151 lbs., noted with weight loss and not on a weight-loss regimen. The MDS assessment reflected Resident #1 was dependent (helper does all of the effort) for eating (ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident). Record review of Resident #1's care plan, dated 05/28/26, reflected [Resident #1] was on a mechanical soft diet with thin liquids and at risk for malnutrition. Date initiated: 06/06/25. Interventions included: administer medications as ordered, monitor intake, supplements as ordered, and report signs and symptoms of malnutrition such as emaciation (unusually thin or weak), cachexia (loss of muscle mass), temporal (temple region of the head) wasting or any significant weight loss to the physician as detected. [Resident #1] had unplanned weight loss related to decreased oral intake and cancer. Date initiated: 10/21/25. Interventions included: labs as ordered, monitor and evaluate any weight loss, and offer substitutes. Record review of Resident #1's order summary, dated 05/28/26, reflected the following physician orders: Weekly weights with start date of 02/18/26. Record review of Resident #1's weight summary, dated 05/28/26, reflected weekly weights from 02/18/26 until 03/26/26. The weight summary reflected a weight of 162 lbs. on 03/26/26, and a weight of 151 lbs. on 04/07/26. There was no weight noted for the week of 03/30/26. 2. Record review of Resident #2's face sheet, dated 05/28/26, reflected a [AGE] year-old male, admitted on [DATE], diagnoses included: cerebral palsy (neurological disorders that affect movement, posture, and coordination), unspecified dementia (decline in cognitive function severe enough to interfere with daily life affecting memory loss, language, problem solving, and other cognitive abilities), cognitive communication deficit (communication is impaired due to underlying cognitive dysfunction rather than a primary language or speech problem), dysphagia (trouble swallowing), and unspecified protein-calorie malnutrition (undernutrition caused by insufficient intake of both protein and calories). Record review of Resident #2's MDS assessment, dated 05/01/26, reflected a BIMS was not conducted as Resident #2 was never/rarely understood, indicating severe cognitive impairment. The MDS assessment reflected Resident #2 had a weight of 105 lbs., noted with weight loss and not on a weight-loss regimen. The MDS assessment reflected Resident #2 required substantial/maximal assistance (helper does more than half the effort) for eating (ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident). Record review of Resident #2's care plan, dated 05/20/26, reflected [Resident #2] was on a mechanical soft diet with thin liquids and at risk for malnutrition. Date initiated: 10/11/23. Interventions included: administer medications as ordered, monitor bowel movements, supplements as ordered, and report signs and symptoms of dysphagia (trouble swallowing) to the physician. [Resident #2] had unplanned weight loss related to poor oral intake. Date initiated: 07/28/25. Interventions included: labs as ordered, monitor and evaluated any weight loss, monitor intake, and offer substitutes. Record review of Resident #2's order summary, dated 05/28/26, reflected the following physician orders: Weekly weights with start date of 04/28/26. Record review of Resident #2's weight summary, dated 05/28/26, reflected a weight of 105 lbs. on 05/01/26, a weight of 105 lbs. on 05/12/26, and a weight of 103 lbs. on 05/27/26. There was no weight noted for the week of 05/04/26 or 05/18/26. During an interview and observation, on 05/28/26 at 3:10 PM, Resident #2 was asked basic questions and he did not respond. Resident #2 was not interviewable. Resident #2 had no visible bruises or skin tears. During an interview, on 05/29/26 at 10:45 AM, ADON A stated RA C weighed the residents and gave the weights to the DON to input in PCC. ADON A stated the residents were weighed either weekly or monthly, depending on the physician's order. ADON A stated residents were weighed weekly if they had weight loss and it was important to follow the order to monitor the weights and see if the interventions worked. ADON A stated Resident #1 had weight loss and weekly weights was ordered as one of the interventions. ADON A stated as far as she knew, Resident #1 was weighed weekly as ordered, but she did not know the weights. During an attempted interview, on 05/29/26 at 12:10 PM, RA C was not working. A phone call was attempted, but RA C did not answer and a voicemail was left requesting a callback. During an interview, on 05/29/26 at 1:15 PM, ADON B stated RA C weighed the residents, weekly or monthly, depending on the physician's order. ADON B stated RA C gave the weights to the DON and the DON input the weights in PCC. ADON B stated she assisted the DON to input the weights, if the DON was unable to. ADON B stated Resident #2 had weight loss and one of the interventions implemented was to do weekly weights. ADON B stated the weights had been taken weekly for Resident #2 and she was unsure if the DON had the weights noted on paper, but the weights should have been documented in PCC. ADON B stated it was important to follow the order for the weekly weights to monitor the weight and to ensure the interventions were effective. During an attempted interview, on 05/29/26 at 1:30 PM, RA C did not answer and a voicemail was left requesting a callback. During an interview, on 05/29/26 at 1:45 PM, the DON stated she made a list of residents and RA C used that list to take the weights that were needed weekly. The DON stated all residents were weighed monthly and certain residents were weighed weekly usually due to weight loss. The DON stated the nursing team ensured the weights were done and then RA C gave her the list of weights which she entered in PCC. The DON stated Resident #1 and Resident #2 were noted with weight loss and one of the interventions implemented was to do weekly weights, which were started on 02/18/26 for Resident #1 and on 04/28/26 for Resident #2. The DON stated she reviewed the records she had in a binder and did not find other weights that were not in PCC for the week of 03/30/26 for Resident #1, and for the week of 05/04/26 or 05/18/26 for Resident #2. The DON stated as far as she knew, the weights for Resident #1 and Resident #2 were done weekly as ordered, but she did not find the weights missing. The DON stated the facility's policy indicated the weights should have been entered in PCC. The DON stated there were no negative outcomes for Resident #1 or Resident #2 as the staff still implemented the interventions for weight loss. The DON stated the purpose of weekly weights was to assess if the interventions were effective. The DON stated Resident #2's weight had been stable and he was doing better with his oral intake. The DON stated Resident #1 was discharged on 04/14/26, but Resident #1 had been terminally ill, on hospice, the family declined a feeding tube, and she continued to refuse to eat. The DON stated the facility was not able to accurately calculate percentages of weight loss without having the weekly weights done or documented appropriately. Record review of the facility's Weight Management policy, dated 10/02/23, reflected - The facility management/clinical team will know the weight status of their residents, including the number of residents who have had a significant and insidious weight loss (gradual, unintended, progressive weight loss over time). Resident weights will be recorded in each resident's medical record monthly, unless specifically ordered otherwise.It is important that weights are accurate for them to be of value as an assessment tool. It is also important that all resident weights are accurately recorded in the individual resident's clinical record in a timely manner.1. All weights (admission, readmission, weekly and monthly) are to be entered into the Point Click Care (PCC) weight system.

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 2 medication carts (400 hallway cart) reviewed for medication storage. The facility failed to ensure a medication named Normal Saline flush was not sitting on top the unattended 400 hall medication cart on 3/12/26 at 3:45 p.m. This failure could place all residents at risk of misuse of medication and decreased quality of life. Findings included: During an observation on 05/12/2026 at 3:45 p.m., revealed on top of the unattended 400 hall medication cart, there was a saline flush. During an interview on 05/12/2026 at 3:50 p.m., with LVN A she said normal saline flush should have been inside the medication cart and locked. She said a resident could take the normal saline, other residents or visitors. She said residents could have an allergic reaction or the normal saline flush could get contaminated. During an interview 05/14/2026 at 4:45 pm with DON she said no medication or saline flush should have been left on top of the medication cart. She said another resident could go and take the medication. She said any resident or visitor could get an adverse reaction. Record Review of facility policy titled Medication Storage with an implemented date 1/21/2021, revealed: it is the policy of this facility to ensure all medications housed on our premises will be stored, dated and labeled according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #1) reviewed for infection control. 1. The facility failed to ensure CNA B and CNA C used the required personal protective equipment for Resident #1, who was on enhanced barrier precautions due to feeding tube during incontinent care on 05/13/26. 2. The facility failed to ensure CNA B performed hand hygiene while providing incontinent care to Resident #1 on 05/13/26 and failed to ensure CNA B and CNA C performed hand hygiene for at least 20 seconds. These failures could place the residents at risk of cross-contamination and development of infection.Findings included: Record review of Resident #1's face sheet dated 05/13/26 reflected a [AGE] year-old female with and admission date 08/16/19. Diagnoses included dysphagia (difficulty swallowing) and cerebral infraction (more commonly known as an ischemic stroke, a brain tissue death caused by a prolonged lack of blood flow). Review of Resident #1's Care Plan dated 08/26/19 revealed: Revised on 04/03/24 Focus: The resident required Enhanced barrier precautions due to g-tube. Goal: The resident will remain free from active infection with MDROs through the review date. Interventions included: Wear gown and gloves during high-contact resident care activities. Review of Resident #1's quarterly MDS Assessment, dated 04/12/26 revealed her BIMS score was 00 meaning she was severely cognitive impaired. Further review revealed she had a feeding tube while a resident. Record review of Resident #1's 05/13/2026 Order summary report reflected, Enteral Feed Order every night shift g-tube site care with mild soap and water. May leave open to air. Apply dressing only if drainage is present and change daily. Observe site for redness, drainage, induration or purulent discharge and notify physician if present An observation on 05/13/26 at 03:30 p.m. of incontinent care revealed CNA B and CNA C performed hand hygiene for 15 seconds and did not have personal protective equipment on. During an interview with CNA B on 05/13/26 at 03:45 p.m. CNA B stated any resident with a tube was required to be on enhanced barrier precautions. She stated she should have worn a gown and just overlooked it when she entered the room. She stated the risk of not following Enhanced Barrier Precautions was the spread of infection. CNA B said she was aware handwashing was for at least 20 seconds for the lathering and she said the negative outcome could be the spread of contamination. During an interview with CNA C on 05/13/26 at 03:50 p.m. CNA C stated any resident with a tube was required to be on enhanced barrier precautions. She stated she should have worn a gown and just forgot it when she entered the room. She stated the risk of not following Enhanced Barrier Precautions was the spread of infection. CNA B said that she was aware handwashing was for at least 20 seconds for the lathering. During an interview on 05/14/25 at 04:45 p.m. the DON stated any resident who had a feeding tube was placed on Enhanced Barrier precautions to help reduce the spread of Multiple Drug-Resistant Organism's. She stated any contact with a resident with a wound required the use of gown and gloves. She stated the staff had received numerous trainings on the use of Enhanced Barrier Precautions. She stated staff were always required to perform hand hygiene before care and after care. She stated they do train on infection control during their skills checks and anytime they had any issues with infections in the building. She stated the risk of not adhering to the protocol was increased risk of infections. Record review of the Facility's policy titled, Infection Prevention and Control Program, with implemented date 10/24/22, reflected, 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 guidelines. Record review of the facility's policy titled, Hand Hygiene with implemented date 2/20/2020, reflected, 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 fingersd. Rinse with water.e. Dry thoroughly with a single-use towel.f. Use clean towel to turn off the faucet.

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #1) of 3 residents reviewed for respiratory care.The facility failed to ensure Resident #1's oxygen was administered at the prescribed setting of 3 liters per minute on 3/19/2026 as ordered by the physician.This deficient practice could place residents at risk of developing respiratory complications and a decreased quality of care. Findings included:Record review of Resident #1's admission record, dated 3/19/26, indicated a [AGE] year-old female with an admission date of 3/12/2026. Resident #1's diagnoses included chronic pulmonary edema (a long-term condition where fluid slowly builds up in the lung's air sacs, making it hard to breathe), acute respiratory failure with hypoxia (a condition defined by the respiratory system's failure to maintain adequate blood oxygen levels), and pleural effusion (an abnormal buildup if excess fluid between the thin membranes [pleura] that surround the lungs and line the chest cavity).Record review of Resident #1's Quarterly MDS assessment, dated 3/16/2026, indicated Resident #1's BIMS score was 11, indicating moderate cognitive impairment. Further review indicated Section O, -Special Treatments, Procedures, and Programs, respiratory treatments indicated oxygen therapy was marked as a treatment performed on admission and while a resident.Record review of Resident #1's active physician orders, as of 3/17/2026, indicated continuous oxygen three liters per N/C every shift. Order Date:3/17/2026.Record review of Resident #1's care plan, dated 02/23/2026, indicated Focus: Behavioral Problem: Resident #1 has a behavior problem as evidenced by: . removes O2 nasal cannula, chewing on O2 tubing. Interventions: Administer medications as ordered.During an observation of Resident #1 on 3/19/2026 at 10:56 a.m., the setting on the oxygen concentrator was at 2.5 liters per minute via nasal canula. The oxygen setting was checked by LVN A who was observed adjusting the setting to three Liters as physician ordered. During this observation, Resident #1 was lying in her bed with no signs of respiratory distress noted. Resident #1 was confused and unable to answer questions about the oxygen setting.During an interview on 3/19/2026 at 10:45 a.m., LVN A, said she checked Resident #1's oxygen setting during morning rounds and it was at three liters. She said oxygen saturation level was 98% at 9:30 a.m. LVN A said the order was for three liters. She said a negative outcome was SOB and respiratory distress. She said the last training on oxygen therapy was received this month (March).During an interview on 3/19/2026 at 11: 37 a.m., ADON B, she said she made rounds every morning to check oxygen settings for the residents. ADON B said managers made Quality of Life rounds every morning, to address problems, such as oxygen settings. She said a negative outcome to not administering the oxygen as prescribed setting was a lowered oxygen saturation (blood is not carrying enough oxygen to the tissues) for a resident. ADON B said oxygen therapy in-service was done last month (February).During an interview on 3/19/2026 at 12:15 p.m., ADON C, said she rounded every morning which included checking oxygen settings. She said Resident #1's oxygen setting earlier in the morning was set at three liters. ADON C said she performed rounds three times a day. She said the negative outcomes of not having the oxygen setting as prescribed were respiratory distress and SOB. She said the last in-service on oxygen therapy was two weeks ago.Record review of the facility's policy titled, Medication-Treatment Administration and Documentation Guidelines, dated 4/6/2023, indicated .4. Administer the medication according to the physician order.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 of 4 residents reviewed for quality of care (Resident #1).The facility failed to respond to Resident #1's call light to provide care for 1 hour and 45 minutes on 12/25/2025.This failure could place residents at risk for a delay in care and services. Findings included:Record review of Resident #1's face sheet dated 1/15/2025 indicated a [AGE] year-old female with an admission date of 7/17/2024. Resident #1's diagnoses included: Hemiplegia and Hemiparesis (paralysis or weakness to one side of the body) affecting left non-dominant side, Contracture of Muscle (muscle in a tight position, making it hard to move) Left Hand, Lack of Coordination, Schizoaffective Disorder (intense mood swings and reality-bending psychotic episodes), Epilepsy (brain disorder causing recurring seizures).Record review of Resident #1's Quarterly MDS assessment dated [DATE] indicated a BIMS score of 04 (severe cognitive impairment). Section GG-Functional Abilities GG0130- Self Care indicated she was Dependent on staff for Eating, Oral hygiene, Shower/bathe self, lower body dressing, putting on/taking off footwear, Personal hygiene. She required Substantial/maximal assistance for Toileting hygiene and Upper body dressing. She required substantial/maximal assistance for roll left and rignt, She was dependent sit to lying, lying to sitting on the side of the bed, and chair/bed-to-chair transfer. Toilet transfer, tub/shower transfer, and walk 10 feet were coded as Not Applicable. Record review of Resident #1's care plan with a revision date of 3/19/2025 revealed Resident #1 has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Interventions listed include.Bolsters in bed to aid with positioning, encourage resident to use call light to call for assistance before attempting any activities of daily living that resident cannot do independently, ensure/provide a safe environment: call light in reach, adequate low glare light, bed in lowest position and wheels locked.Record review of Resident #1' care plan with a revision date of 11/19/2025 revealed Resident #1 has the potential for falls related to reduced mobility, hemiplegia-left sided weakness, repeated falls. Had an actual fall. Interventions listed included.floor mat next to bed to aid in fall precaution, Neuro checks, s/p fall, keep bed in the lowest position when not providing care, place the resident's call light is within trach and encourage the resident to use it for CNA assistance.Record review of Resident #1's care plan with a revision date of 1/06/2026 revealed Resident # 1 has a behavior problem as evidenced by.throws herself on the floor, slides down to the mat. Interventions listed include: Monitor behaviors and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Give a clear explanation of daily activities prior to and as they occur during each contact. Encourage as much participation and interaction by the resident as possible,In an observation and interview on 1/14/2026 at 8:53 AM with Resident # 1, she was lying in bed, awake. The resident's bed was at the lowest position, and her call light was in her hand. Noted a floor mat at the side of her bed and wedges positioned on both her sides. Resident #1 said, everything is fine. She said the staff take long at times to answer her call light. She said she had fallen a while back because she tried getting up and got dizzy. She said, I slid off my bed and was sitting on the mat they have there. She said it took about one hour for the staff to come into her room and help her back to her bed. She said she had no injuries and was helped back to bed.In an interview on 1/14/2026 at 12:28 PM with a Family member, she said no one came into Resident #1's room to check on her after she pressed the call light. Observed a video shown by Resident #1's family member revealing Resident # 1 slipping to the floor landing on a floor mat on her buttocks and then pressed the call light at 4:43 AM. The next video showed the staff in the room assisting the resident back to bed at 6:36 AM. Resident #1's Family Member said there were no recordings because the camera only records if there was movement. She said she was thankful Resident #1 had no injuries, but no one entered her room until 2 hours later. She said she met with the DON and the social worker and brought forth her concern and showed them the video. During an observation of a surveillance video on 1/14/26 at 12:28 PM from Resident #1's room with a timestamp dated 12/25/25 at 4:37 AM , the resident is observed lying in bed with her feet dangling to the side of the bed. At 4:43 AM, Resident #1 was observed sliding down from the left side of the bed in a sitting position. Resident #1 was observed pressing the call light within eight seconds of her being in a sitting position on the floor mat, against her bed. The call light against the wall was seen turned on and blinking. At 4:44 AM the resident was seen waving the call light up in the air and placing it on top of the bed and at 4:45 AM the resident positioned herself lying on the floor. A second surveillance video from Resident #1's room with a timestamp dated 12/25/2025 at 6:36 AM, revealed CNA A was observed entering the resident room and removing a blanket off Resident #1's legs as Resident #1 was still on the floor, and within 10 seconds, LVN B entered the room and began to check Resident #1. No video footage was provided between 4:45 AM and 6:36 AM.In an interview with LVN B at 11:48 AM on 1/14/2026, LVN B said Resident #1 had a fall during the shift change at 6:30 AM. He said that while he was getting report from the night nurse, the morning CNA reported the resident was on the floor. He said he and the night nurse went into the resident's room to check her and to help her back onto her bed. LVN B said he notified the provider and the RP, and neuro-checks were started and completed according to facility guidelines. He said the resident did not complain of pain and he did not remember if the call light was on upon entering the room.In an interview with CNA C at 12:03 PM on 1/14/2026, CNA C said she received report from the outgoing shift and they had informed her that they were still making rounds, but that Resident #1 was still pending to be seen. She said that while she went for linens, her co-worker, CNA A entered Resident #1's room and quickly notified the nurses that the resident was on the floor. She said she could not remember if the call light was on.In an interview with the ADON at 2:32 PM on 1/14/2026, the ADON said when residents turn on the call lights, the staff is made aware by the light turning on outside of the resident's door and by the monitors located at the nurse's station. She said the monitors indicate the room number and for how long the call light has been on. She said the call light cannot be turned off from the monitors at the nurse's station but instead, the staff would have to physically go into the resident's room to turn it off.In an interview with the Maintenance Director at 8:20 AM on 1/15/2026, the Maintenance Director said that due to the safety of residents, there is no option to turn off the call light from the monitors at the nurse's station. He said that once a resident turns on the call light, it will remain on until the staff physically turn it off from inside the resident's room. He said there used to be a system in place that recorded how long the call lights were on for, but with the new call light system in place, there is no recorded log on how long the call lights stay on.In an interview with LVN D at 12:30 PM on 1/15/2026, LVN D said she had peeked her head in to check in on Resident #1 around 4 AM and saw the resident's legs moving and that she was okay. She said that she and another nurse began to make rounds around 5:15 AM until 6:10 AM but did not go into Resident # 1's room. LVN D said did not think the call light was on but she was not sure.In an interview with CNA A at 11:00 AM on 1/15/2026, CNA A said she saw the call light on for Resident # 1 when she came on shift, at 6 AM, and told her co-worker that they were going to begin their round with resident #1 because she was told by the outgoing staff that they had not been able to go into Resident #1's room yet. She said she had opened the door and saw the resident on the floor and immediately notified the nurses. CNA A said the staff immediately went into the room and the nurses checked the resident and assisted Resident #1 back to bed.In an interview with CNA F at 2:19 AM on 1/15/2026, CNA F said that on 12/24/2025 one CNA was scheduled work a double shift (2pm-10pm and 10pm-6am) but called in to work. She said a second CNA was scheduled 10pm-6 am but was a no-call no-show. CNA F said she had informed the night CNAs to assist in Hall 700 due to the shortage. In an interview with CNA E at 3:26 PM on 1/15/2026, CNA E said she worked 12/24/2025 night shift (10pm-6am in Hall 600 (assigned hall) and assisted making rounds in Hall 700. She said she could not remember what time she had done her round in the hall where Resident #1 resided and that around 4:30 AM stood outside Resident #1's door but did not go in. She said that around 6:12 AM, she saw the call light on and figured the other staff were going to go in because they were standing in the area. She said she was in a rush because she had to leave.In an interview with the DON at 3:46 PM on 1/15/2026, the DON said Resident #1's family member showed her a video of Resident #1 scooting herself in bed until she slides off the bed, landing in a sitting position on a floor mat at 4:45 AM and a second video showing the CNA walking into the room at 6:15 AM. The DON said she started the investigative process on 12/25/25 which included skin assessments for all the residents in Station 2 and no negative outcomes, due to the time frame of the call light not answered, were concluded. The DON said she re-instructed the staff on checking in on the residents every 30 minutes. She said Resident #1's family member was upset because of the length of time it took for the staff to respond to the call light. Record review of Staff In-Service on Resident Rights, Abuse/Neglect, and Fall Management indicated a Date Presented 12/25/25for all shiftsRecord review of Staff In-Service on TOPIC: ADON instructed on the importance of maintaining skin integrity, comfort, dignity, and infection prevention by ensuring residents are checked every 2 hours and PRN. Date Presented 12/25/2026 Record review of Staff in-service on Customer Service and Call lights indicated Date presented 12/31/2025 and 1/5/26 for all shifts. Record review of Staff In-Service on Resident Rights, Abuse/Neglect, Fall Management, and Customer Service indicated Date Presented 12/26/25, 12/29/25, and 12/31/2025 for all shifts Record review of Staff In-Service on TOPIC: DON re-educated nursing staff to assure all call lights are being answered on a timely manner- Staff to round every 2 hours and PRN and assure all call lights are within patient reach. Date presented 1/07/26Record review of Staff In-service on Staff in-service TOPIC: Abuse/Neglect- To ensure all staff recognize, report, and prevent abuse and neglect to protect resident safety and dignity. Abuse- Willful infliction of injury, unreasonable confinement, intimidation, or punishment that causes physical harm, pain, or mental anguish. Neglect- failure to provide goods or services necessary to avoid physical harm, pain, mental anguish or emotional stress. Date Presented: 12/31/25 Record review of the facility policy titled Call Light/Bell Response dated 8/11/13 revealed the following: .emphasize that all staff stop and respond to call lights as able. If responding staff is unable to assist the patient, the appropriate licensed nurse or nursing assistant is contacted.

Based on observation, interview, and record review the facility failed to ensure each resident the right to be free from abuse for two residents (Resident #2 and Resident #3 ) of 6 residents reviewed for abuse. The facility failed to protect R #2 and R #3 from being hitting each other on 10/15/25 as they passed each other in the hallway. These failures have the potential to place residents at risk of serious injury and continued abuse.The Findings Include: Resident #2 Record review of R #2 face sheet revealed an [AGE] year-old male initially admitted on [DATE] and then readmitted on [DATE] with diagnosis of physiological condition(the internal physical and chemical states of a living organism that affect its bodily functions, ranging from maintaining homeostasis to experiencing illness or stress, Dementia (A group of thinking an social symptoms that interferes with daily functioning), and Insomnia (a common sleep disorder characterized by difficulty falling asleep, staying asleep, or both, leading to insufficient or poor-quality sleep) Non-Alzheimer's Dementia(Lewy body dementia, vascular or multi-infarct dementia; mixed dementia; frontotemporal dementia such as Pick's disease; and dementia related to stroke, Parkinson's or Creutzfeldt-[NAME] disease), and Psychotic Disorder (other than schizophrenia a serious mental illness characterized by a loss of contact with reality, known as psychosis). Record review of R #2's Care Plan date 08/22/25 revealed R#2 has an activity of daily life self-care performance deficit and is at risk for not having their needs met in a timely manner. Performance deficit is related to dementia, debility, history of falls, right knee effusion surgery, muscle weakness, lack of coordination, abnormalities of gait and mobility, a need for assistance with personal care, is independent for meeting emotional, intellectual, and social needs. R#2 has a behavior problem as evidenced by pulling IV out, aggression with staff. R#2 is resistant to care and is at risk for injury, a decline in functional abilities, and not having their needs met in a timely manner. R#2 requires cueing for activity attendance and social interaction related to cognitive impairment and is at risk for isolation. Record review of R #2' s progress notes dated to 10/15/2025 revealed R #2 social worker was informed resident was involved in a physical altercation with a female resident. R #2 explained when he was wheeling himself towards the nurse's station from the dining room the fR#3 grabbed him by the shirt on his left side and would not let him go. When R#2 verbalized to R#3 to release him R#3 refused. R #2 explained how he attempted to remove R#3's hand and that was when R#3 struck his left shoulder. R#2 voiced how he attempted to stop R#3 from hitting him but was unsuccessful. Upon reviewing video surveillance, it was shown that R#3 was the aggressor and struck at R#2 several times on the left shoulder. R#2 was assessed by charge nurse and did not see any signs of discoloration or redness. R#2 did not voice having any pain. R#2 voiced that he felt fine. The local police department came into the facility to take report resident voiced would not like to press any charges R#2's family member however voiced she would like to press charges against R#3. The family was to follow up with local police department with the case number given from the report taken by officer. R#2 would continue to be monitored for any pain or change in condition. Staff would continue to monitor and meet residents' needs. Record review of R #2's MDS Quarterly dated 10/29/25 revealed R#2 had a BIMS Score of 06 which indicated that a resident's cognition was severely impaired dad significant difficulty with cognitive tasks and may require increased staff support for daily living activities. The MDS revealed no change in cognitive, or behaviors. R#2's Mood indicated to rarely feel isolated. not indicated to be present at time of assessment. The MDS indicated Resident #2 used a wheelchair and is dependent on staff to help in some daily activities. Resident #3 Record review of R #3 face sheet revealed a [AGE] year-old female initially admitted on [DATE], with diagnosis of Cerebral Infarction due to Embolism of Right Middle Cerebral Artery( a condition were a blood clot travels through the blood to the brain and blocks oxygen and blood flow to blood vessels in the brain, causing tissue damage.), Dementia (a group of thinking an social symptoms that interferes with daily functioning), Unspecified Psychosis (a diagnostic category for a patient experiencing psychotic symptoms like delusions or hallucinations, but where there is not enough information to make a specific diagnosis, or the symptoms don't meet the criteria for another disorder), Delusional disorders ( a serious mental illness characterized by one or more non-bizarre, false beliefs that persist for at least one month, despite evidence to the contrary) and Alzheimer's Disease with late on set (a progressive disease that destroys memory and other important mental functions). Record review of Resident #3's MDS Quarterly dated 09/23/25 revealed Resident #3 had a BIMS Score of 09-moderate cognitive impairment a notable change for normal cognitive abilities and could signal a need for further assessment, as it suggests problems with thinking and memory. The MDS revealed no cognitive patterns present. The resident mood assessment reveals rare feelings of loneliness. The MDS revealed R#3 had no behaviors present indicating psychosis, rejection of care or wandering. Functional abilities revealed she had upper and lower extremity limitation on one side and used a wheelchair. R #3's functional abilities revealed she needed partial to substantial help with hygiene and toileting but minimal help in repositioning in bed and feeding herself. Record review of Resident #3's progress notes dated 10/15/2025 the CNA reported R #3 hit another resident while they passed each other in the hallway, staff member immediately separated and reported the incident to LVN F. LVN F assessed both residents, and no complaints of pain was voiced at that time. R #3 was able to move all extremities without difficulty and no redness or bruising was noted at the time. The incident was reported to the nurse practitioner for further instructions. On 10/15/25 the social worker was informed R#3 was involved in a physical altercation with a R#2. R#3 explained when she was wheeling herself down the hall going towards her room R#3 made a flirty sexual comment towards her. R#3 explained how she asked for R#2 to stop, and he wouldn't. R#3 voiced she felt as if R#2 was going to hit her because of how he looked at her, so she struck R#2 and R#2 struck at her back on her chest and collar bone area. Video surveillance was reviewed, and it was noted that R#3 was out in the hall wheeling herself towards the nurses' station and R#2 was also heading towards the nurses' station when R#2 pulled up next to R#3 and R#3 was seen striking R#2 in the left shoulder area multiple times. R#2 struck R#3 and the pair were separated by a staff member immediately. R#3 was assessed by the charge nurse and had no signs of discoloration and did not voice any pain at that time. R#3 has been placed on a 1 to 1 for the safety of herself and others. The social worker was instructed to have resident moved due to resident's history of physical aggression and physically hitting a male resident several times. A referral had been sent to a local behavioral hospital and acceptance was pending due to pending medical clearance. The social worker was instructed to send R#3 to ER to be medically cleared and assessed for inpatient behavioral services. On 10/20/25 R#3 was cleared and released by local hospital to return to the facility. Record review of R #3's care plan dated 10/20/24 revealed R #3 used psychotropic medications (antidepressants) related to dx of labile moods, delusional disorder, depression, mood disorder, insomnia, and psychosis behavior was to be monitored, documented, and reported for adverse reactions to antidepressant therapy. R#3 is to have been monitored, record and report to physician side effects and adverse reactions of psychoactive medication such as unsteady gait, tardive dyskinesia(a disorder of involuntary, repetitive movements ,often affecting the face, limbs and trunk caused by long-term use of certain medications, particular antipsychotics), Extra Pyramidal Symptoms (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. R#3 has impaired cognition and is at risk for a further decline in cognitive and functional abilities related to dementia and CVA (cerebrovascular accident), memory deficit related to CVA, symptoms and signs involving cognitive function following CVA related to Alzheimer's diagnosis. R#3 has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Performance deficits are related to severe weakness, hemiplegia left side from CVA, history of left radius fracture, Osteoarthritis, right shoulder rotator cuff tear, lack of coordination, pain, muscle weakness, abnormalities of gait and mobility, contracture left hand, contracture, history of falls. R#3 was dependent on staff for meeting emotional, intellectual, physical, and social needs due to physical limitations. R#3 had an ADL self-care performance deficit related to weakness, poor mobility related to hemiplegia affecting the left side. R #3 has a behavior problem as evidenced of fluctuating thoughts of suicidal ideations, refuses care, meds, makes false accusations of staff members, she consistently changes her stories. R#3 was seen for counseling. Prefers female staff, two staff members at all times. Attempts to self-transfer without assistance. Attempting to strike other residents, aggressive towards other residents and staff, hit another resident. In an observation and interview on 11/18/2025 at 5:03 PM of R #3 reveal she was in her wheelchair sitting out in the hall. R #3 stated R#2 like to tell her he loved her and flirted with her. R#3 told to R#2 to leave her alone because she was married and her husband was very jealous. R#3 stated she did not remember very well how the incident occurred. R#3 stated she was not fearful of any staff or other resident in the facility. R #3 stated she had not seen or had another altercation with R#2. In an observation and interview on 11/18/25 at 5:17 P.M. with Resident #2 he was in bed watching television waiting for his dinner tray to be brought to him. R#2's deminer was anxious and he stated he was looking for his shoes. R#2 recalled the incident and stated he was in the dining room and R#3 told him a bad word, so he pulled her hair and then R#3 hit him. R #2 stated he was sore afterward but not too painful. R#2 stated he had never had an issue with R #3 this was the first time he had an altercation with R #3. R#2 stated he was not fearful of any staff or other residents. R#2 stated he stays away from R#3 and had not had any contact with R#3. In an interview on 11/18/25 5:25 P.M. with CNA A she stated resident # 2 can be aggressive sometimes with staff but the incident with R #2 was the first time she was aggressive with a resident. CNA A stated R # 2 has not been aggressive with her the resident is always pleasant when she provides care. She was not present when the incident occurred but was told to keep the two residents apart from each other. In an interview on 11/18/25 at 5:42 PM the Social Worker (SW) stated what was seen on the camera was both were going to their rooms when R#2 pulled up next to R#3 then R#3 started to hit R #2 and then R #2 began hit R #3 back. The SW Could not tell if R #2 made contact with R #3. The SW stated when she spoke with R #3 she stated R #2 made flirty comments to R #3 and she got upset and swung at R #2. The incident occurred in the hallway as they were going to their rooms in two different halls. R #3 was sent to be evaluated for the aggressive behavior and placed on a 1 to 1 monitor. R #2 had followed up visits and monitored for his injury. They did three days of evaluations for each resident to monitor any aggressive behaviors the following 3 days. R#3 had another incident with another resident where she was the victim and R #2 had no other incidents. The SW stated the abuse coordinator is the Administrator and was able to verbalize the different types of abuse. When an abuse incident was reported to her and she would call the Administrator so the investigation could begin, and responsible party was notified along with doctor and the Administrator/Abuse the coordinator. The SW stated the in-services are to be conducted and interventions are put into place to prevent abuse incidents. The Abuse Coordinator is responsible for making sure the policy and procedure for abuse is done correctly, because if the proper preventions are not implemented correctly the incidents can recur. In an interview on 11/18/25 at 5:57 PM CNA D stated a few days after R #3 was moved from 700 to 200 she was feeling angry and said if she ever saw R #2 again she would want to smack him. CNA D said R#3 had no aggressive behavior with residents or staff members in the new hall she was placed in. CNA D stated R #3 would become confused and would tell the staff to help her look for her car but she does not own a car. CNA D stated R #2 did show signs of aggression as one day R #2 became aggressive because he could not get to his bed and the CNA could not help him right away and he had to wait till the CNA could help him. CNA D stated R #3 was aggressive the day of the incident and was yelling so she was sent to the hospital for an evaluation. CNA D said the administrator was the abuse coordinator and was able to distinguish different types of abuse. CNA D said last week was the last training for abuse. In an interview on 11/19/25 at 9:27 AM CNA E stated she was an as needed nursing staff member and worked on 10/15/25 when the incident occurred. CNA E stated she was picking up the breakfast trays in the 100 hall when she saw both residents striking each other. CNA E stated she immediately separated the residents, called for help, and wheeled R #3 to nurses' station #2. CNA E stated the charge nurse did the head-to-toe assessment on R#2 but could not say if the charge nurse did the assessment on R#3. CNA E stated she did not see any marks or discolorations on R #2. CNA E stated she did not know of any other altercations between R #2 and R #3. CNA E stated she did not know of any altercations with other residents or staff. CNA E stated the last training she received was 2 months ago because she only worker as needed at night. CNA E stated the administrator was the abuse coordinator and was able to verbalize the different types of abuse. In an interview on 11/19/25 at 5:23 PM LVN C stated R #2 has never been aggressive with her or seen him be aggressive with other residents or staff. LVN C said she began working in September and has not had too much contact with either resident. LVN C had no problems with R #3 being aggressive or refusing care from her. LVN C said the abuse coordinator was the administrator and could verbalize different types of abuse. LVN C said last month was the last training she received on abuse. In an interview on 11/19/25 at 10:41 AM with LVN B she said R#2 does good in the halls never show aggression towards other residents and never bothers anyone. Resident #2 is quiet, keeps to himself, and mainly stays in his room. LVN B said she could not really say much about R #3 because she did not have too much contact with her. LVN B stated she did not know of any altercations with R #2 other than the one With R #3. LVN B was able to describe what a willful act was but felt the mental condition of the residents made a difference in the determination of the act being willful or not. LVN B was able to state several types of abuse, and the administrator was the abuse coordinator. LVN B stated the there was enough staff for the facility to monitor residents with behavior problems to prevent other incidents from happening. The last abuse in-service was two weeks ago. In an interview on 11/19/25 at 11:01 AM with LVN F stated she did the assessment for R #3 and R #3 told her she hit R #2 because of what he told her. LVN F stated the residents had a previous relationship with R #2. LVN F stated R #2 tended to be a little spicy with the female residents. LVN F stated R #2 did not like to be told to what to do by females in general. LVN F stated there were no visible marks on the left arm area of R#2 and both residents were separated from each other right away. LVN F said the head-to-toe assessments revealed no injuries or marks on either resident. LVN F stated R#3 can be outspoken as well as her family and the family did not want meds for R#3's behaviors. LVN F stated R#2 did not have any behavior medication at the time the incident occurred. LVN F stated R#3 was sent out for a psychiatric evaluation at the local hospital. LVN F stated R #3 had a urinary tract infection, but the resident denied treatment for it. LVN F stated R #2 and his family refused medication to help with his aggressive behaviors. LVN F stated the incident between R#2 and R#3 was a willful act of abuse by R#3. LVN F stated R#2's right to be free from abuse was violated by R#3. LVN F stated the abuse coordinator was the administrator and was able to verbalize the different forms of abuse. In an interview on 11/20/25 at 1:05 PM with DON she stated both residents were friends before and maybe had a relationship on the day of the incident R #2 told R #3 something to provoked her and R #3 hit him. The DON said this was the first time they had a physical altercation but could not say if they exchanged words in the past. The family of R #2 was wanting to press charges but changed their mind, but a police report was done. R #3 was moved to another hall away from R#2 when they stopped being friends so that no altercations could occur. After the altercation R #3 was moves farther away to the other side of the facility so that no other incidents could occur. R #3 was placed on a 1 to 1 monitor until she was sent to ER for a psych eval for aggressive behavior and a medication change if needed. The DON stated personally she did not see this as a willful act because she was defending herself from R #2 advances. The right of R #2 was not violated because of the cognitive impairment of R #3. In an interview on 11/20/25 at 2:06 PM with the Administrator (admin)/ Abuse Coordinator stated there was a video of the incident but could not say if the facility still had the video available. The admin recalled in the video R #3 had reached out and touched R #2. The admin stated a CNA was helping a resident and heard loud voices and went out to the hallway and saw R #2 and R #3 in an altercation and called for help as she separated R #2 and R #3. The admin stated when the nurse and the CNA separated R#2 and R #3, and a head-to-toe assessment was done on both residents and R#3 was placed on a 1 to 1 monitor and was sent to a hospital so a psych eval could be done. The admin stated R#3 was released to return to the facility. The admin stated interventions for both residents are still in place with the residents moved far apart from each other and no interaction between them can occur. The admin stated R#2 and R#3 were still being monitored for interaction with each other. The admin stated the facilities policies and procedures are monitored for the effectiveness by the DON and ADON. The admin stated the SW also does follow up visits with residents and the facility doctor or psychiatric clinic ensure medication does not need to be adjusted or changed. The admin stated she has nurses do follow up visits then random spot checks on resident to monitor behaviors. The admin stated the DON meets with resident see how they are doing and the admin and SW also do spot checks after the resident returns from an admission to the hospital for an evaluation by the psychiatric unit. The administrator and DON are responsible for ensuring the policy and procedures are implemented correctly. The DON stated the abuse and neglect trainings and in-services are to be monitored monthly to ensure all policy and procedure are done correctly. The admin stated in services are consistently monitored by the DON and ADONS to ensure the facility is in compliance with the state. In Record review of the facilities Abuse Policy and Procedures dated 09/06/24 it states the policy of this facility is to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through eh use of technology

Based on observations, interviews, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 4 residents (Resident #1) reviewed for supervision.CNA A did not follow 2-person assist as stated on Resident #1's care plan when providing incontinent care and repositioning on two separate occasions on [DATE] at around 12:00am and 1:00am. On [DATE] at 3:30am CNA A found Resident #1 on the floor. Resident #1 was sent to the hospital and later expired on [DATE].An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 3:51pm. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These deficient practices could affect residents who require 2-person assist by placing them at risk of injuries and not receiving the appropriate level of assistance and care. The findings included: Record review of Resident #1's face sheet, dated [DATE], revealed the resident was an [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: cerebral infarction (blocked blood flow to brain causing brain tissues damage), hemiplegia (paralysis or severe weakness to one side of body) and hemiparesis (weakness to one side of body) following unspecified cerebrovascular disease (conditions that affect blood flow to brain) affecting left non-dominant side. Cognitive communication deficit (difficulties in communication could be from cognitive impairment), vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to brain), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Record review of Resident #1's quarterly MDS assessment, dated [DATE], revealed Resident #1 was rarely/never understood and indicated a BIMS should not be conducted. Resident #1 was coded as dependent for rolling left and right and toileting/hygiene. Record review of Resident #1's care plan with a closed date of [DATE] reflected Resident #1 was bed bound and required total x2 assist (2-person assistance) for bed mobility and toileting. Record review of Resident #1's task care record reflected CNA A turned and repositioned Resident #1 at 1:13 am on [DATE]. Record review of Resident #1's task care record reflected CNA A checked off that Resident #1 had a small bowel movement at 1:13 am on [DATE]. Observation of facility surveillance footage of Resident #1's hallway on [DATE] revealed CNA A had entered or exited Resident #1's room approximately 4 times between 12:00am and 3:26am for no more than roughly one minute at a time on video footage that was able to be reviewed without any instances of skipped footage. The video surveillance would at times skip forward and miss seconds to a minute of footage, 1 of the 4 times identified did not show CNA A entering Resident #1's room when the footage skipped roughly 45 seconds from 3:23am to 3:24am where CNA A was then seen exiting Resident #1's room. LVN B was noted to have entered Resident #1's room at 1:19am and exited by 1:20am. At 3:27am CNA A was seen on video footage taking an item from a linen cart into Resident #1's room, CNA A remained in Resident #1's room until approximately 3:39am a total of about 12 minutes when he then exited the room and proceed down the hall to the nurse's station and briefly spoke with LVN B and C before he was noted returning down Resident #1's hall. At time of CNA A seen walking back down the hall video surveillance then skipped forward about a minute to 3:41am where CNA A was seen entering Resident #1's room for about 10 seconds and then exited and proceeded down hall way to nurses station to call LVN B and C when all 3 staff members went to Resident #1's room, prior to this time, CNA A was not seen entering Resident #1's room with any other staff member.During an interview with Administrator on [DATE] at around 6:00pm stated the time stamp on the video surveillance footage was 10 minutes ahead or 10 minutes behind. During an interview on [DATE] at 6:18pm with LVN B who stated she called EMS at 3:32am as per the time stamp of the call on her phone, when compared to the video footage time stamp LVN B is seen running back to the nurse's station to make call at 3:42am indicating the time stamp on the video surveillance was 10 minutes ahead. Record review of Resident #1's nursing notes dated [DATE] at 3:45am written by LVN B stated an aide had reported they found Resident #1 on the floor and saw blood, LVN B and other charge nurse (LVN C) went to assess and identified a laceration to scalp and active bleeding, pressure was applied to stop bleeding until the paramedics arrived, vitals were taken, 3rd party on call service was called, hospice and responsible party for Resident #1 were made aware. Resident #1 received order to be sent out to emergency room. Record review of Resident #1's physician orders reflected an order dated [DATE] at 3:45am for her to be transferred to the emergency department. Record review of Resident #1 hospital records date [DATE] at 5:34am stated Resident #1 had a 12 cm scalp laceration to the right head extending from the forehead to the parietal region. Record review of Resident #1 hospital records reflected Resident #1 expired at the hospital on [DATE] at 10:34am. Record review of CNA A's undated statement about Resident #1 reflected he found Resident #1 on the floor while rounding between rooms and stated the last time he had changed her was around 12:00am when he changed her by himself. During an interview with CNA A on [DATE] at 2:58pm stated he worked on [DATE] and entered his shift about 10 minutes till 12:00am and worked until 6:00am. CNA A stated on [DATE] he worked with Resident #1. CNA A stated he entered Resident #1's room after 12:00am at some time close to 1:00am and stated at that time he checked if resident was wet or dry. CNA A stated she was dry and he repositioned her from supine (laying on back facing up) to her side and facing towards the door, CNA A stated he placed a wedge on Resident #1's back, used a blanket as a posey in the front of her body that had been placed under the fitted sheet, and placed a pillow between her legs. CNA A stated the air mattress Resident #1 had in place was working appropriately on [DATE]. CNA A stated he only moved her that one time when he repositioned her. CNA A stated he repositioned Resident #1 by himself and stated she should have been a 2 person assist and stated he did not use 2 people because he was not sure and stated he had done it on his own previously. CNA A stated he then went to check on Resident #1 at 3:30am and found her on the floor. CNA A stated he remembered entering Resident #1's room around 3:27am but stated he did not recall being in there for 13 minutes when checking her. CNA A stated he did have a linen cart with sheets and stated he may have taken some linen into Residents #1's room but he did not recall what time that was at. CNA A stated he did not recall going into Resident #1's room for 13 minutes or taking in linen to her room prior to finding her on the floor. CNA A denied Resident #1 falling while changing, repositioning or moving Resident #1. During a follow up interview with CNA A on [DATE] at 5:21pm stated Resident #1 was non verbal and mostly moaned or groaned and was unable to move herself. CNA A clarified that he had worked with Resident #1 on his own before with only 1 person assistance an stated nurses who he was unable to recall had seen him do so and had not told him anything. CNA A stated on [DATE] there were 2 other nurses and 2 other aides available to assist but he did not ask anyone for help. CNA A stated he had previously been trained and knew where to find a residents assistance level in their POC and Kardex and stated he did not know Resident #1 was a 2 person assist until later and thought she was a 1 person assist because he had provided 1 person assist in the past and no one had said much. CNA A stated he should have asked and checked the Resident #1's assistance levels. CNA A stated he had previously been trained prior to Resident #1's fall on Resident #1 being a 2 person assist. CNA A stated then stated that he had worked Resident #1 twice on [DATE], the first time around 12:00am when he repositioned her and checked if she was dry and then later around 1:00am he stated he thought that he had changed her. CNA A stated he took roughly 20 seconds to a minute to change Resident #1. CNA A stated he went to go see how Resident #1 was at around 3:00am or 3:30am when he found Resident #1 on the floor and went to call the nurses. CNA A stated Resident #1 was bleeding from her head and appeared in pain because she was grimacing. CNA A stated the facility policy was to use 2 people if a resident required 2 person assist, CNA A stated he did not follow the facility policy In this situation. CNA A stated using 1 person assist when a resident required 2 could negatively impact a resident because it would put a resident at risk for fall. During an interview with LVN B on [DATE] at 12:54pm LVN B stated she worked on [DATE] from 6:00pm till 6:00am and was the nurse for Resident #1 and worked with CNA A. LVN B stated CNA A did not ask her for any help and stated she did not assist CNA A with any care for Resident #1 on [DATE]. LVN B stated she went into Resident #1's room around 1:00am and to turn off her TV. LVN B stated at that time Resident #1 was positioned in the middle of the bed facing the door with a low bed. LVN B stated she did not see Resident #1 again until CNA A notified her that Resident #1 was on the floor at around 3:30am. LVN B stated CNA A told her he had just exited from resident room from across the hall when he entered Resident #1's room and saw her on the floor. LVN B stated Resident #1 was not verbal and only groaned. LVN B stated when she entered Resident #1's room she was on the floor flat on her back with the bed in a low position and the air mattress functioning and set appropriately. LVN B stated Resident #1 had a puddle of blood around her head and a cut. LVN B stated LVN C stayed to render help and LVN B ran to call 911 and get the paperwork ready. LVN B stated CNA A had stated he changed Resident #1 at around midnight by himself. LVN B stated Resident #1 required 2-person assistance and was unable to move on her own and would not have been able to roll herself off the bed. During a follow up interview with LVN B on [DATE] at 6:18pm stated she notified the administrator of Resident #1 fall and laceration at 3:50am after emergency medical services had taken her. LVN B stated she notified the Administrator that CNA A found Resident #1 On the floor during a round, and she had a laceration and was bleeding and was being sent to the hospital. LVN B clarified that the cut she saw on Resident #1 was on her forehead. LVN B stated the facility policy stated they had to provide 2-person assist If the residents required it. LVN B stated CNA A did not follow the facility policy in this situation. LVN B stated using 1 person assist for residents who required 2 could negatively impact residents due to residents potentially falling if there was no staff on the other side of the bed to catch them. During an interview with LVN C on [DATE] at 11:45am stated Resident #1 was not her resident on [DATE] during her shift from 6:00pm - 6:00am. LVN C stated CNA A had said he changed Resident #1 at least once prior to the fall but stated he did not say at what time. LVN B stated CNA A stated he had changed Resident #1 by himself. LVN B stated he did not help CNA A with Resident #1 on [DATE]. LVN B stated CNA A notified her and another nurse that he had seen Resident #1's feet on the floor and realized she was not on the bed and then went to notify them. During a follow up interview with LVN C on [DATE] at 7:02pm stated when she was notified of Resident #1 was found on the floor she was in supine position (on her back) and there was a pool of blood and she saw an injury to her head on the right side and looked like her skin pulled back and placed pressure on her head while LVN B called 911 and the notifications. LVN C stated Resident #1 was awake and conscious. During an interview with the Administrator on [DATE] at around 8:07pm stated the DON was on leave and out of the country and did not currently have cell phone service to receive calls. The Administrator said that on [DATE] at around 3:30am CNA A found Resident#1 on the floor while completing his round and notified LVN B and C. The Administrator stated through the facility investigation which included an interview and statement from CNA A, the facility identified that CNA A did not have any assistance from other staff when he provided care to Resident #1. The Administrator stated Resident #1 required 2 person assistance for all ADLs, bed mobility, repositioning and when being changed and was not able to move herself. As per Administrator CNA A stated he knew Resident #1 was a 2 person assist and stated he had been trained on the POC (plan of care) but still decided to provide care by himself and said he could do it himself. The Administrator stated there were 2 other aides and 2 other nurses that were available to assist CNA A during that shift at that station and in total 10 other staff in the facility that could have helped. The Administrator stated CNA A stated at around 1:00AM or 1:15am on [DATE] he went into resident #1's room to provide incontinent care and reposition Resident #1 and left her in the center of the bed facing the door. The Administrator stated CNA A had been previously trained over the POC and Kardex and where to find residents levels of assistance. The Administrator stated CNA A did not mentioned anything about dropping Resident #1 or working with her when she fell. The Administrator all staff including CNA A had been trained previously to Resident #1 requiring 2 person assistance. The Administrator stated she was thinking Resident #1's fall occurred due to body alignment and stated she was thinking Resident #1 was possibly not centered in the bed. The Administrator stated the facilities policy regarding following a resident's plan of care when they required 2 person assist and stated therapy evaluation will determine if a residents were 1 or 2 person and in return the plan of care will show the level of care needed and if staff did not follow the plan of care for safety then it was an immediate termination for the staff member. The Administrator stated CNA A did not follow this policy in this situation. The Administrator providing residents who required 2 person assistance with only 1 person assistance could impact residents safety and cause injury. During an interview on [DATE] at 5:50pm the Administrator stated she was the abuse coordinator and responsible for reporting any incident or allegation of abuse, neglect or exploitation to state agencies. The Administrator stated she completed annual training over reporting requirements along with going over provider letters or trainings from an online training program the facility used and stated staff was trained over abuse and neglect frequently and stated that training was provided to her by the Regional Director of Operations and to the staff by the DON or one of the ADONs. The Administrator confirmed that Resident #1 was found on the floor with a laceration to her head on [DATE] and was unable to explain what happened and was not witnessed and required to be sent out to the hospital for treatment. The Administrator stated she received a text from LVN B on [DATE] at around 3:40am or 3:50am that stated Resident #1 had an unwitnessed fall, laceration with active bleeding with first aide rendered, notifications made to a 3rd party on call service used by facility, 911 activated, doctor and responsible part of Resident #1 were notified. The Administrator stated she did see the message about 5am. The Administrator stated around 12:00pm on [DATE] she was notified by family of Resident #1 that she had expired. The Administrator stated incidents like this was to be reported with 2 hours to HHSC and she stated she reported when she found out that Resident #2 had expired and stated she did not report with into two hours of her unwitnessed fall because the severity of the laceration was not said and the incident report was not alarming or suspicious. The Administrator stated to ensure staff provided her with sufficient information and assessment of resident's incidents to allow her to determine reporting timeline she would ask questions, review the incident report and reach out for any updates on residents at the hospital. The Administrator stated the facility policy for reporting allegations and incidents abuse, neglect and exploitation referred to a provider letter but was unable to state which provider letter aside from stating it was the most recent one. The Administrator stated she did follow the facility policy in this situation and stated not appropriately reporting allegation or incidents of abuse, neglect and exploitation could negatively impact residents because their safety can be impacted and their residents safety was their priority. Record Review of a document titled, Termination Form and dated [DATE] reflected CNA A's termination date as [DATE].Record review of facility Inservice training report dated [DATE] that stated staff must review all assigned plans of care to assure appropriate staff was in place prior to rendering care and staff had to be able to demonstrate how to access the plan of care, how to reach and what it meant and the importance of being complaint. Review of sign in attendance documentation reflected CNA A had completed this Inservice. Record review of facility ADL care policy provided and with an origination date of [DATE] did not mention any verbiage related to following resident care plan when 2-person assistance is required. During an interview on [DATE] at 4:18pm the Administrator stated she reached out to cooperate and was told that their ADL policy was the care plan policy. Record review of facility Inservice training report dated [DATE] that covered allegations of abuse, neglect and exploitation to be reported immediately and no later than 2 hours and other incidents that are reportable to be reported immediately but not later than 24 hours to HHSC. Review of sign in attendance sheet for Inservice reflected the Administrator had completed this Inservice. Record review of facility policy titled, Policy and Procedure: Abuse, Neglect and Exploitation with an revised date of [DATE] stated under section, IV. Identification of Abuse, Neglect, and Exploitation.B. Possible indicators of abuse include, but are not limited to.3. Physical injury of a resident, of unknown source.8. Failure to provide care needs such as comfort, safety, feeding, bathing, dressing turning & repositioning VII. Reporting/Response A. The facility reports abuse and abuse allegations that include:1. Reporting allegations involving staff to-resident abuse, resident-to resident altercations involving allegations of abuse, injuries of unknown source, misappropriation of resident property exploitation, and mistreatment.2. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involves Abuse (with or without bodily injury)b. An Incident that results in serious bodily injury and that involves any of the following: Neglect Exploitation Mistreatment Injuries of unknown source Misappropriation of resident propertyC. Not later than 24 hours after the incident occurs or is suspected. An incident that does not result in serious bodily injury but that involves any of the following: Neglect Exploitation A missing resident Misappropriation of resident property Drug thief Fire Emergency situation that pose a threat to resident health and safety A death under unusual circumstances Communicable disease situation that pose a threat to resident health and safety. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 3:51pm. The administrator was notified. The Administrator was provided with the IJ template on [DATE] at 5:46pm The following Plan of Removal (POR) submitted by the facility was accepted on [DATE] at 1:25 pm: Tag Cited: F-689Issue Cited: Free of Accidents/Hazards/Supervision#5 1. Immediate Action Taken On [DATE] Resident #1 had an unwitnessed fall sustained a laceration @ 0330am, first aid rendered was sent to the hospital Facility initiated investigation Reported to Texas Health and Human Services Intake#1021508, physician and RP, [local police department] CNA A suspended on 7/7 and terminated [DATE]. 2. Identification of Residents Affected or Likely to be Affected: On [DATE] the DON/Designee completed an audit on all residents identified as two person-assist; 64 resident were identified in the facility. On [DATE] the DON/Designee completed an audit on all residents identified with air mattress, 46 residents were identified in the facility 3. Actions to Prevent Occurrence/Recurrence: DON reviewed staffing levels on [DATE] to ensure adequate staffing; no changes required DON/designee conducted audit on [DATE] @6:00pm reviewed all residents requiring two-person assist; point of care and care plan reviewed for accuracy DON/designee conducted audit on [DATE] @6:00pm identified all residents on air mattress, and review orders against setting for accuracy. On [DATE] DON/designee in-service all staff on Abuse/Neglect Policy completed on [DATE] by 5:00pm, Any new hires by the facility will receive education upon hire. On [DATE] DON/designee in-service all staff on Fall Management completed on [DATE] by 5:00pm, Any new hires by the facility will receive education upon hire. On [DATE] DON/designee in-service all direct care staff on resident Point of Care completed on [DATE]. Any new hires by the facility will receive education upon hire. On [DATE] DON/designee Performed two-person skill validation with return demonstration on all direct care staff, completed on [DATE]. Any new hires by the facility will receive skill validation training Charge nurses with monitoring tool will monitor the point of care for ADL assistance and ensure the CNAs are adhering to the residents' point of care every shift to ensure the designated level of care for each resident is accurate per point of care. Any discrepancies will be corrected immediately, reported to the DON/designee and re-education as needed. S Charge nurse will print out Kardex daily and review with CNAS Charge nurse will conduct walking rounds with CNA and acknowledge S Documented on monitoring sheet, any discrepancies will be reported immediately to DON/ADON DON/designee will review charge nurse monitoring form daily 5 times a week. All findings will be reviewed in morning meeting with IDT and revisions to plan may be made as necessary. DON/designee will do monitoring in random shifts for 3 residents 5x week to ensure the designated level of care for each resident is accurate per point of care. Ad Hoc QAPI conducted on [DATE] @ 2:00pm with Medical Director to review and discuss plan to sustain compliance. 0n [DATE] at 7:30 pm the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy's the facility received related to resident free of accident/hazards/supervision and review plan to sustain compliance. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: ______[DATE]__________ The state surveyor confirmed the facility's Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy that included: Record Review on [DATE] of facilities immediate actions taken in response to Resident #1's fall reflected LVN B documented Resident #1's fall on a nursing note dated [DATE] which included her being notified of fall, how Resident #1 presented when observed by nurse, vitals, notifications made and orders received. Note dated [DATE] from an on call provider reflected Resident #1's fall and their orders to send Resident #1 out to the emergency department. A post fall evaluation was completed in response to Resident #1's fall with an effective date of [DATE]. Facility initiated neuro checks on [DATE] at 3:30am. Facility generated incident report dated [DATE] that included summary of Resident #1's incident, immediate actions taken, pain scale which reflected a pain level of 7, and the notifications made. Facility initiated investigation into incident that included staff statements, resident skin assessments, and report made to HHSC, police department was contacted however report for incident was not yet completed. Documentation of termination of CNA A's employment reviewed and reflected he was terminated on [DATE]. Record review of staffing list for [DATE] was signed as reviewed by ADON D and identified a total of 2 nurses and 3 aides working on station 1 where Resident #1 was located and 3 nurses and 3 aides working in station 2 for a total of 11 staff that were scheduled and worked on [DATE] at time of Resident #1's fall. Record review of facility audit that identified a total of 64 residents who required 2 person assistance was signed as verified on [DATE]. Record review of facility audit of residents with air mattress included review of order listing report document with list of residents with mattress orders in place with a date of [DATE]. A total of 46 resident were noted to be identified with air mattress orders in place. Record review of staff training dated from [DATE] to [DATE] reflected staff had been trained over abuse and neglect, fall management, POC, with nursing staff completing a 2 person skills validation with return demonstration. On [DATE] and [DATE] a total of 10 aides, 8 LVNs, from all shifts 1 ADON and Administrator were interviewed with all staff stating they had recently received training with in the past few day that covered the abuse and neglect policy that included what to report and who to report, the kinds of abuse and the timeline for reporting and fall management that included how to prevent falls, what to do when they occur, who to notify and incident reports, use of wedges, bolsters, mats and low beds and using 2 persons. Staff had been trained over the plan of care and where to find it and how to where to find resident assistant levels and identify how many staff are required for assistance. Nursing staff had also completed a 2 person skill validation that required them to reposition and move a resident in bed with use of 2 people and be checked off by leadership staff. Staff were aware of new procedure of charg e nurses reviewing resident Kardex with aides at start of all shifts and complete walking rounds with the aides to ensure they understand the level of assistance required for residents care. Nursing staff was aware of aides signing on the Kardex to indicate they understood and charge nurses filling out the monitoring sheet that also included if aides required more education and notifying the DON or an ADON if a any discrepancies were noted. to All staff interviewed were able to recall training and procedures they were educated on. ADON E along with charge nurses were aware of review of monitoring sheets daily during the morning meetings, with ADON E stating her and ADON D were to separately monitoring 3 residents 5 times a week on a random shift to ensure residents level of care is accurate. Record review and observation completed by survey reflected 6 sampled residents, Residents #2, #3, #4, #5, #6 and #7 had information on their care plan and Kardex indicating their level of care (2 person assistance) and had orders in place for air mattress which were observed to be on appropriate setting when compared to orders that were in place. The Administrator was informed the Immediate Jeopardy (IJ) was removed on [DATE] at 7:59pm. The facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately, but not later than 2 hours after the allegation was made, if the alleged violation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for 1 of 4 residents (Resident #1) reviewed for reporting injuries of unknown origin. The facility failed to report within 2 hours to Health and Human Services Commission when Resident #1 was found on the floor on [DATE] at 3:30am with a laceration to forehead that the resident was unable to explain and was not witnessed and required her to be sent to the hospital. This failure could place residents at risk for undetected abuse, neglect and/or decline in feelings of safety and well-being. The findings included: Record review of Resident #1's face sheet, dated [DATE], revealed the resident was an [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: cerebral infarction (blocked blood flow to brain causing brain tissues damage), hemiplegia (paralysis or severe weakness to one side of body) and hemiparesis (weakness to one side of body) following unspecified cerebrovascular disease (conditions that affect blood flow to brain) affecting left non-dominant side. Cognitive communication deficit (difficulties in communication could be from cognitive impairment), vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to brain), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Record review of Resident #1's quarterly MDS assessment, dated [DATE], revealed Resident #1 was rarely/never understood and indicated a BIMS should not be conducted. Resident #1 was coded as dependent for rolling left and right and toileting/hygiene. Record review of Resident #1's care plan with a closed date of [DATE] reflected Resident #1 was bed bound and required total x2 assist (2-person assistance) for bed mobility and toileting. Record review of Resident #1's task care record reflected CNA A turned and repositioned Resident #1 at 1:13 am on [DATE]. Record review of Resident #1's task care record reflected CNA A checked off that Resident #1 had a small bowel movement at 1:13 am on [DATE]. Observation of facility surveillance footage of Resident #1's hallway on [DATE] revealed CNA A had entered or exited Resident #1's room approximately 4 times between 12:00am and 3:26am for no more than roughly one minute at a time on video footage that was able to be reviewed without any instances of skipped footage. The video surveillance would at times skip forward and miss seconds to a minute of footage, 1 of the 4 times identified did not show CNA A entering Resident #1's room when the footage skipped roughly 45 seconds from 3:23am to 3:24am where CNA A was then seen exiting Resident #1's room. LVN B was noted to have entered Resident #1's room at 1:19am and exited by 1:20am. At 3:27am CNA A was seen on video footage taking an item from a linen cart into Resident #1's room, CNA A remained in Resident #1's room until approximately 3:39am a total of about 12 minutes when he then exited the room and proceed down the hall to the nurse's station and briefly spoke with LVN B and C before he was noted returning down Resident #1's hall. At time of CNA A seen walking back down the hall video surveillance then skipped forward about a minute to 3:41am where CNA A was seen entering Resident #1's room for about 10 seconds and then exited and proceeded down hall way to nurses station to call LVN B and C when all 3 staff members went to Resident #1's room, prior to this time, CNA A was not seen entering Resident #1's room with any other staff member. During an interview with Administrator on [DATE] at around 6:00pm stated the time stamp on the video surveillance footage was 10 minutes ahead or 10 minutes behind. During an interview on [DATE] at 6:18pm with LVN B who stated she called EMS at 3:32am as per the time stamp of the call on her phone, when compared to the video footage time stamp LVN B is seen running back to the nurse's station to make call at 3:42am indicating the time stamp on the video surveillance was 10 minutes ahead. Record review of Resident #1's nursing notes dated [DATE] at 3:45am written by LVN B stated an aide had reported they found Resident #1 on the floor and saw blood, LVN B and other charge nurse (LVN C) went to assess and identified a laceration to scalp and active bleeding, pressure was applied to stop bleeding until the paramedics arrived, vitals were taken, 3rd party on call service was called, hospice and responsible party for Resident #1 were made aware. Resident #1 received order to be sent out to emergency room. Record review of Resident #1's physician orders reflected an order dated [DATE] at 3:45AM for her to be transferred to the emergency department. Record review of Resident #1 hospital records date [DATE] at 5:34M stated Resident #1 had a 12 cm scalp laceration to the right head extending from the forehead to the parietal region. Record review of Resident #1 hospital records reflected Resident #1 expired at the hospital on [DATE] at 10:34am. Record Review of TULIP (HHSC online incident reporting application) on [DATE] at 9:00am revealed the facility made a self-reported related to Resident #1's fall on [DATE] at 2:58pm, more than 2 hours after the fall had occurred on [DATE] at 3:30am. Record review of CNA A's undated statement about Resident #1 reflected he found Resident #1 on the floor while rounding between rooms and stated the last time he had changed her was around 12:00AM when he changed her (Resident #1) by himself. During an interview with CNA A on [DATE] at 2:58pm stated he worked on [DATE] and entered his shift about 10 minutes till 12:00am and worked until 6:00am. CNA A stated on [DATE] he worked with Resident #1. CNA A stated he entered Resident #1's room after 12:00am at some time close to 1:00am and stated at that time he checked if resident was wet or dry. CNA A stated she was dry and he repositioned her from supine (laying on back facing up) to her side and facing towards the door, CNA A stated he placed a wedge on Resident #1's back, used a blanket as a posey in the front of her body that had been placed under the fitted sheet, and placed a pillow between her legs. CNA A stated the air mattress Resident #1 had in place was working appropriately on [DATE]. CNA A stated he only moved her that one time when he repositioned her. CNA A stated he repositioned Resident #1 by himself and stated she should have been a 2 person assist and stated he did not use 2 people because he was not sure and stated he had done it on his own previously. CNA A stated he then went to check on Resident #1 at 3:30am and found her on the floor. CNA A stated he remembered entering Resident #1's room around 3:27am but stated he did not recall being in there for 13 minutes when checking her. CNA A stated he did have a linen cart with sheets and stated he may have taken some linen into Residents #1's room but he did not recall what time that was at. CNA A stated he did not recall going into Resident #1's room for 13 minutes or taking in linen to her room prior to finding her on the floor. CNA A denied Resident #1 falling while changing, repositioning or moving Resident #1. During a follow up interview with CNA A on [DATE] at 5:21pm stated Resident #1 was non verbal and mostly moaned or groaned and was unable to move herself. CNA A clarified that he had worked with Resident #1 on his own before with only 1 person assistance an stated nurses who he was unable to recall had seen him do so and had not told him anything. CNA A stated on [DATE] there were 2 other nurses and 2 other aides available to assist but he did not ask anyone for help. CNA A stated he had previously been trained and knew where to find a residents assistance level in their POC and Kardex and stated he did not know Resident #1 was a 2 person assist until later and thought she was a 1 person assist because he had provided 1 person assist in the past and no one had said much. CNA A stated he should have asked and checked the Resident #1's assistance levels. CNA A stated he had previously been trained prior to Resident #1's fall on Resident #1 being a 2 person assist. CNA A stated then stated that he had worked Resident #1 twice on [DATE], the first time around 12:00am when he repositioned her and checked if she was dry and then later around 1:00am he stated he thought that he had changed her. CNA A stated he took roughly 20 seconds to a minute to change Resident #1. CNA A stated he went to go see how Resident #1 was at around 3:00am or 3:30am when he found Resident #1 on the floor and went to call the nurses. CNA A stated Resident #1 was bleeding from her head and appeared in pain because she was grimacing. CNA A stated the facility policy was to use 2 people if a resident required 2 person assist, CNA A stated he did not follow the facility policy In this situation. CNA A stated using 1 person assist when a resident required 2 could negatively impact a resident because it would put a resident at risk for fall. During an interview with LVN B on [DATE] at 12:54pm LVN B stated she worked on [DATE] from 6:00pm till 6:00am and was the nurse for Resident #1 and worked with CNA A. LVN B stated CNA A did not ask her for any help and stated she did not assist CNA A with any care for Resident #1 on [DATE]. LVN B stated she went into Resident #1's room around 1:00am and to turn off her TV. LVN B stated at that time Resident #1 was positioned in the middle of the bed facing the door with a low bed. LVN B stated she did not see Resident #1 again until CNA A notified her that Resident #1 was on the floor at around 3:30am. LVN B stated CNA A told her he had just exited from resident room from across the hall when he entered Resident #1's room and saw her on the floor. LVN B stated Resident #1 was not verbal and only groaned. LVN B stated when she entered Resident #1's room she was on the floor flat on her back with the bed in a low position and the air mattress functioning and set appropriately. LVN B stated Resident #1 had a puddle of blood around her head and a cut. LVN B stated LVN C stayed to render help and LVN B ran to call 911 and get the paperwork ready. LVN B stated CNA A had stated he changed Resident #1 at around midnight by himself. LVN B stated Resident #1 required 2-person assistance and was unable to move on her own and would not have been able to roll herself off the bed. During a follow up interview with LVN B on [DATE] at 6:18pm stated she notified the administrator of Resident #1 fall and laceration at 3:50am after emergency medical services had taken her. LVN B stated she notified the Administrator that CNA A found Resident #1 On the floor during a round, and she had a laceration and was bleeding and was being sent to the hospital. LVN B stated the Administrator responded to her text at 3:51am. LVN B clarified that the cut she saw on Resident #1 was on her forehead. LVN B stated the facility policy stated they had to provide 2-person assist If the residents required it. LVN B stated CNA A did not follow the facility policy in this situation. LVN B stated using 1 person assist for residents who required 2 could negatively impact residents due to residents potentially falling if there was no staff on the other side of the bed to catch them. During an interview with LVN C on [DATE] at 11:45am she stated Resident #1 was not her resident on [DATE] during her shift from 6:00pm - 6:00am. LVN C stated CNA A had said he changed Resident #1 at least once prior to the fall but stated he did not say at what time. LVN B stated CNA A stated he had changed Resident #1 by himself. LVN B stated he did not help CNA A with Resident #1 on [DATE]. LVN B stated CNA A notified her and another nurse that he had seen Resident #1's feet on the floor and realized she was not on the bed and then went to notify them. During a follow up interview with LVN C on [DATE] at 7:02pm she stated when she was notified of Resident #1 was found on the floor she was in supine position (on her back) and there was a pool of blood and she saw an injury to her head on the right side and looked like her skin pulled back and placed pressure on her head while LVN B called 911 and the notifications. LVN C stated Resident #1 was awake and conscious. During an interview with the Administrator on [DATE] at around 8:07pm she stated the DON was on leave and out of the country and did not currently have cell phone service to receive calls. During an interview with the Administrator on [DATE] at around 8:07pm she stated on [DATE] at around 3:30am CNA A found Resident#1 on the floor while completing his round and notified LVN B and C. The Administrator stated through their investigation, interview and statement from CNA A they identified that CNA A did not have any assistance from other staff when he provided care to Resident #1. The Administrator stated Resident #1 required 2 person assistance for all ADLs, bed mobility, repositioning and when being changed and was not able to move herself. As per Administrator CNA A stated he knew Resident #1 was a 2 person assist and stated he had been trained on the POC (plan of care) but still decided to provide care by himself and said he could do it himself. The Administrator stated there were 2 other aides and 2 other nurses that were available to assist CNA A during that shift at that station and in total 10 other staff in the facility that could have helped. The Administrator stated CNA A stated at around 1:00AM or 1:15am on [DATE] he went into resident #1's room to provide incontinent care and reposition Resident #1 and left her in the center of the bed facing the door. The Administrator stated CNA A had been previously trained over the POC and Kardex and where to find residents levels of assistance. The Administrator stated CNA A did not mentioned anything about dropping Resident #1 or working with her when she fell. The Administrator all staff including CNA A had been trained previously to Resident #1's on Resident #1 requiring 2 person assistance. The Administrator stated she was thinking Resident #1's fall occurred due to body alignment and stated she was thinking Resident #1 was possibly not centered in the bed. The Administrator stated the facilities policy regarding following a residents plan of care when they required 2 person assisted stated therapy evaluation will determine if a resident is 1 or 2 person and in return the plan of care will show the level of care needed and if staff did not follow the plan of care for safety then it was an immediate termination for the staff member. The Administrator stated CNA A did not follow this policy in this situation. The Administrator providing residents who required 2 person assistance with only 1 person assistance could impact residents safety and cause injury. During an interview on [DATE] at 5:50pm with the Administrator she stated she was the abuse coordinator and responsible for reporting any incident or allegation of abuse, neglect or exploitation to state agencies. The Administrator stated she completed annual training over reporting requirements along with going over provider letters a trainings from an online training program the facility used and stated staff was trained over abuse and neglect frequently and stated that training was provided to her by the Regional Director of Operations and to the staff by the DON or one of the ADONs. The Administrator confirmed that Resident #1 was found on the floor with a laceration to her head on [DATE] and was unable to explain what happened and was not witnessed and required to be sent out to the hospital for treatment. The Administrator stated she received a text from LVN B on [DATE] at around 3:40am or 3:50am that stated Resident #1 had an unwitnessed fall, laceration with active bleeding with first aide rendered, notifications made to a 3rd party on call service used by facility, 911 activated, doctor and responsible part of Resident #1 were notified. The Administrator stated she did see the message until about 5am. The Administrator stated around 12:00pm on [DATE] she was notified by family of Resident #1 that she had expired. The Administrator stated incidents like this was to be reported with 2-hours to HHSC and she stated she reported when she found out that Resident #2 had expired and stated she did not report with into two hours of her unwitnessed fall because the severity of the laceration was not said, and the incident report was not alarming or suspicious. The Administrator stated to ensure staff provided her with sufficient information and assessment of resident's incidents to allow her to determine reporting timeline she would ask questions, review the incident report and reach out for any updates on residents at the hospital. The Administrator stated the facility policy for reporting allegations and incidents abuse, neglect and exploitation referred to a provider letter but was unable to state which provider letter aside from stating it was the most recent one. The Administrator stated she did follow the facility policy in this situation and stated not appropriately reporting allegation or incidents of abuse, neglect and exploitation could negatively impact residents because their safety can be impacted, and their resident's safety was their priority. Record review of facility Inservice training report dated [DATE] that covered allegations of abuse, neglect and exploitation to be reported immediately and no later than 2 hours and other incidents that are reportable to be reported immediately but not later than 24 hours to HHSC. Review of sign in attendance sheet for Inservice reflected the Administrator had completed this Inservice. Record review of facility policy titled, Policy and Procedure: Abuse, Neglect and Exploitation with an revised date of [DATE] stated under section, IV. Identification of Abuse, Neglect, and Exploitation.B. Possible indicators of abuse include, but are not limited to.3. Physical injury of a resident, of unknown source.8. Failure to provide care needs such as comfort, safety, feeding, bathing, dressing turning & repositioning VII. Reporting/Response A. The facility reports abuse and abuse allegations that include:1. Reporting allegations involving staff to-resident abuse, resident-to resident altercations involving allegations of abuse, injuries of unknown source, misappropriation of resident property exploitation, and mistreatment.2. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involves Abuse (with or without bodily injury)b. An Incident that results in serious bodily injury and that involves any of the following: Neglect Exploitation Mistreatment Injuries of unknown source Misappropriation of resident propertyC. Not later than 24 hours after the incident occurs or is suspected. An incident that does not result in serious bodily injury but that involves any of the following: Neglect Exploitation A missing resident Misappropriation of resident property Drug thief Fire Emergency situation that pose a threat to resident health and safety A death under unusual circumstances Communicable disease situation that pose a threat to resident health and safety

Based on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of each resident's needs, for one Resident (Resident #71), of twenty-four residents reviewed for call light access. Resident #71's call light was placed out of reach of Resident #71 while in bed. This failure could place residents on at risk for not being able to call for assistance from staff. The findings were: Record review of Resident #71's Admission Record, dated 04/22/25, revealed Resident #71 was [AGE] year-old hospice resident and was admitted to the facility on [DATE]. Resident #71's diagnoses included encephalopathy (any disease or disorder of the brain, specifically one that causes dysfunction), dementia (a group of thinking and social symptoms that interferes with daily functioning), cerebral infarction (stroke), type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood), and congestive heart failure (a condition where the heart cannot pump enough blood to meet the body's needs). Record review of Resident #71's Quarterly MDS assessment, dated 02/25/25, revealed Resident #71: -was understood by others, -was able to understand others, -BIMS was 03 which means he had severe cognitive impairment, -Bed mobility was partial/moderate assistance with 1 person assist -Eating was partial/moderate assistance with 1 person assist -Shower/bath dependent with 2 person assist -Toileting was partial/moderate assistance with 1 person assist -Toilet transfer was not attempted due to medical issue or safety concerns -Transfers were total assistance with 2 person with Hoyer Lift, and -was frequently incontinent of bowel and bladder. Record review of Resident #71's care plan, dated 04/15/25 and revised 04/22/25, revealed: FOCUS: o Behavioral Problem: Resident #71 has a behavior problem as evidenced by: exiting his room, and sitting in wheelchair with no clothing on. Resident crawling on floor, yelling and screaming, arguing with room mate and using foul language. Throws call light on floor Date Initiated: 09/13/2023 Revision on: 04/22/2025 GOALS: o The resident's behavior will not interfere with the delivery of care or services, or result in harm to self or others through the next review date. Date Initiated: 09/13/2023 Revision on: 01/17/2025 INTERVENTIONS/TASKS: o Administer medications as ordered. Monitor and document for effectiveness and potential adverse side effects. Date Initiated: 09/13/2023 CN SW o Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and interventions in behavior log. Date Initiated: 09/13/2023 CN o Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. Date Initiated: 09/13/2023 CN C.N.A. o Give a clear explanation of daily care activities prior to and as they occur during each contact. Encourage as much participation and interaction by the resident as possible. Date Initiated: 09/13/2023 CN C.N.A. o When resident becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmly in conversation, or attempting to other interventions. If response is aggressive then approach at a later time after ensuring the safety of the resident and nearby residents. Date Initiated: 09/13/2023 CN C.N.A. o Intervene as necessary to protect the rights and safety of others. Remove resident to an alternate location when needed to protect the rights and safety of others. Date Initiated: 09/13/2023 CN C.N.A. In an observation and interview on 04/22/25 at 09:37 AM Resident #71's call light was seen on the floor at the left side of his bed. Resident stated they had not given him a call light yet. He said he has not had one. In an interview on 04/22/25 at 09:46 AM CNA A stated the call lights were supposed to be within the resident's reach. CNA A stated if the resident did not have the call light within reach, the resident would not be able to call for help if they needed it. In an interview on 04/24/25 at 10:35 AM CNA E stated the resident's call light needs to be within the resident's reach in case they need something. CNA E stated if the call light were not within reach, the resident could fall, or something could happen, and the CNAs would not know. CNA E stated anything could happen. 04/24/0 2:31 PM The DON stated the call light needed to be within the resident's reach while in bed otherwise the resident would not be able to get help when they needed it, and their needs may not be met in a timely manner. The DON stated the CNAs rounded every two hours or as needed. The DON stated the charge nurse, LVNs, Quality of Life (department heads), and she were the ones who monitor the CNAs. In an interview on 04/24/25 at 03:16 PM The administrator stated the resident's call light was to be within reach of the resident while they were in bed or if the resident had a preference for it to be somewhere else, it would be care planned. She said if the call light were not in reach, the resident's needs may not be met. Record review of the facility's policy on, Call Light/Bell Response, dated 08/11/13 revealed: Purpose: To provide an audio and, or visual system to alert staff when patient assistance is needed. Guideline: -Place call light/bell within patient's reach regardless of patient location such as: *in bed *on commode *unaccompanied in sitting area

Based on interview, record review, and observation, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 6 resident (Resident #51) reviewed for accidents. The facility did not provide supervision to prevent Resident #51's from sustaining multiple falls in the facility. This failure could place residents with a history of falls at risk for additional falls and injuries. The findings included: Record review of Resident #51's admission record dated, 8/15/2023, revealed he was an [AGE] year old male, with an initial date of 6/17/2019, and had the following diagnosis: multiple fractures of ribs to the right side with routine healing a laceration without foreign body of left forearm, unspecified fracture of first lumbar vertebra (the five bones in your lower back) with routine healing, a wedge compression fracture of second lumbar vertebra with routine healing, an abnormality of gait and mobility, a lack of coordination, age-related physical debility, unsteadiness on his feet, muscle wasting and atrophy, and a cognitive communication deficit. Record review of Resident #51's significant change MDS assessment dated [DATE], revealed Resident #51 had a BIMS score of 00 which indicated his cognition was not intact and he had unclear speech. He was sometimes understood and he could sometimes understand others. He required 1 person assistance for all ADLs, with extensive assistance for dressing, toilet use and personal hygiene. He required limited assistance with bed mobility and supervision for transfers, walking in room, walking in corridor, locomotion on the unit, locomotion off the unit, and for eating. Record review of Resident #51's Comprehensive Care Plan initiated 5/4/2020 and revised 12/13/2023 revealed: Focus: Resident #51 had a high risk for falls related to cognitive impairment, He had gait/balance problems. He was non-redirectable at times and insisted on not sitting down or using a wheelchair. Resident was non-compliant with the use of call light. He had a history of a fall with multiple rib fractures & compression fracture to the spine. He had impulsive behaviors. Date initiated: 5/4/2020. Interventions included: Anticipated and met the resident's needs. Placed items frequently used by the resident within easy reach when in the room. Educated the resident/family/caregivers about safety reminders and what to do if a fall occurs. Completed a fall risk screening upon admission and quarterly to identify risk factors. Placed the resident's call light within reach and encouraged the resident to use it for assistance as needed. Goal revised 8/14/2023 s/p fall: risk for falls and injury will be minimized through the next review date of 1/11/2024. Dates revised with interventions: 9/7/2023 - Helmet to aid with injuries prevention. 9/28/2023 - Redirected to compliance with medical equipment for safety precaution. 10/25/2023 - Educated and redirected resident to use assistive devices. 11/1/2023 - Assisted with toileting q 2h and prn. 11/28/2023 - Therapy evaluated and treated, educated and reoriented to call for assistance. 12/12/2023 - Fall precautions wer placed at all times. 12/13/2023 - MD ordered Neuro checks and resident was redirected as needed. 2/13/2024 - Helmet was on at all times to aid with injuries prevention. Safety checks completed q 1 hrs. to monitor whereabouts due to fall risks. 2/15/2024 - Floor mats were placed next to bed Record review of Resident #51's orders dated 8/24/2023 revealed the resident was placed on Hospice care for DX: Other Specified Degenerative Disease of Nervous System. Record Reviewed of Incident/accident log: Falls on the following dates: 9/1/23, 9/3/23, 9/12/23, 9/19/23, 9/25/23, 10/16/23, 10/25/23, 11/11/23, 11/26/23, 12/7/23, 12/12/23, 12/18/23, 12/21/23, 12/25/23 x 3, and 12/27/23. Record review of Resident #51's fall incident dated 09/01/2023 at 05:49 - location: 202-A. Description: A loud noise heard from the nurse's station. Resident #51 found on bathroom floor in room. Resident able to stand up with assistance. Resident able to answer questions clearly and follow commands. Resident had redness to the forehead and abrasion to right forearm. Resident able to move all four extremities. Resident alert and oriented at the time of fall and during head-to-toe assessment. Resident stated that he fell but unable to explain how or if he hit any extremities during the incident. Reported no pain or discomfort throughout body. Vitals taken. RP was made aware of resident incident. Hospice nurse notified. Hospice PCP notified. 911 contacted. Transportation arranged. DHR ER contacted to give report. DON notified of fall. Resident refused treatment/transportation multiple times when EMS arrived at facility. Hospice nurse/PCP aware of refusal and pending eval. RP attempted to be contacted regarding refusal but no response - pending callback. Neuro checks were started. Post fall assessment recommendations: 9/1/23 - refer to rehab to screen and follow up with recommendations. Fall precautions at all times. All items within reach. Handle care gently and unhurried. Non-skid shoes or socks to aid with ambulation. CNA x 1 to assist with ADLs. Helmet to aid with safety. Keep close to nurse's station. Record review of Resident #51's fall incident dated 09/5/2023 at 21:39 - location: 202-A. Description: CNA reported that resident fell while walking to bed. CNA stated resident tripped over his own feet and fell . Resident found on floor laying on left side in front of bed near dresser. Resident able to move all four extremities. Reports no pain or discomfort at the time. Resident had abrasion to the back of the scalp - no active bleeding to the areas. Resident alert and oriented. Resident able to follow commands. Pupils equal, round and reactive to light and accomodation present. Resident stated that he fell and unable to explain why or how incident occurred. No pain to head or other extremities reported. Complete head to toe assessment done. Vital signs taken. 911 contacted. Hospice nurse notified. RP aware. DON aware. ER contacted for report. Resident refused transfer to hospital when EMS arrived. Post Fall assessment recommendations: 9/5/23-Monitor closely. Refer to rehab to screen and follow up with recommendations. Call light within his reach. Handle care gently and unhurried. Keep close to nurses' station when out of bed. Non-skid shoes or socks to aid with ambulation. Record review of Resident #51's fall incident dated 09/12/2023 at 19:20 - location: 202-A. Description: Resident found on floor in room in front of closet near ac unit. Resident alert and oriented. Resident reopened previous scalp abrasion. No active bleeding. Wound cleaned. Resident was grabbing something from the closet and fell back. No pain or discomfort during shift. Complete head to toe done. Vitals obtained. Hospice nurse, hospice PCP notified of incident. Resident refused transfer to hospital for treatment/eval. No pain or discomfort notified. RP notified of incident/refusal of hospital transfer. Orders implemented and neuro checks started. Safety precautions implemented. Call light left within reach. Resident educated on use of helmet when ambulating. Post Fall assessment recommendations: 9/12/23 - Refer to rehab to screen and follow up with recommendations. Monitor closely. Call light within his reach. Non-skid shoes or socks to aid with ambulation. Keep close to nurse's station when out of bed. Fall precautions at all times. Record review of Resident #51's fall incident dated 09/19/2023 at 13:30 - location: 202-A. Description: A bang was heard at the nurse station from the resident's room. Resident was lying on the floor to the left side next to the doorway. Appeared resident pushed his bedside table outside of his door and when heading back he lost his balance. Red mark noted to the top of the head, left side. Hospice made aware and nurse will come to assess. RP was notified. Soft helmet that was placed earlier was removed by resident. Resident unable to give description. Denied pain. Neuro checks initiated. ROM to all extremities. Post Fall assessment recommendations: 9/13/23 - Refer to rehab to screen and follow up with recommendations. Monitor closely. Call light withing his reach. Handle care gently and unhurried. [NAME] withing his reach. Keep close to nurses' station when out of bed. Encourage resident to wear helmet. Non-skid shoes or socks to aid with ambulation. Record review of Resident #51's fall incident dated 09/25/2023 at 04:58 - location: 202-A. Description: Resident seen walking with unsteady gait via walker. Resident found in restroom on knees next to toilet holding the bathroom rails. Resident with skin tear to left forearm and two small line impressions on forehead where head was against wall. Resident able to move all four extremities. Resident stated that he was using the bathroom and fell over. Did not hit head and does not report pain or discomfort. Vital signs taken. Complete head to toe done, hospice notified, orders implemented. TAO applied to skin tear as ordered, neuro checks started. RP attempted to be notified multiple times and pending call back. Resident seen walking around facility post fall with walker. No complaints with helmet and continues to remove. Post Fall assessment recommendations: 9/25/23-Refer to rehab to screen and follow up with recommendations. Monitor closely. [NAME] within his reach. Non-skid shoes or socks to aid with ambulation. Encourage resident to use call light for assist and change position slowly. Encourage resident to wear helmet. Record review of Resident #51's fall incident dated 10/16/2023 at 14:43 - location: 202-A. Description: A noise was heard from the nurse station. Resident was found lying on the floor in front of the closet. Resident was noted with unsteady balance and gait, uses a walker, and has a helmet for safety but does not always leave in place. ROM to all extremities. Resident unable to give description of incident. Neuro checks initiated. RP, hospice, and NP made aware of the incident. Post Fall assessment recommendations: 10/16/23 - Refer to rehab to screen and follow up with recommendations. Monitor closely. Handle care gently and unhurried. Call light within his reach. Non-skid shoes or socks to aid with ambulation. Helmet at all times. Fall precautions at all times. Record review of Resident #51's fall incident dated 10/25/2023 at 05:48 - location: 202-A. Description: Resident was seen standing near his bed without walker, near the window. I was walking pass his room and saw him lose balance and fall to the floor landing on his butt and right elbow. Resident did not hit his head during the fall. Resident able to move all four extremities with no abnormalities noted. No bruising skin tears, or other abnormalities noted during head-to-toe assessment. Resident able to come to standing position. Resident stated that he fell back. Resident denies pain with movement. Resident denies hitting head. Stated he only hit his butt and right elbow. Completed head to toe done. Vitals taken. Hospice Nurse notified. RP attempted to be called, voicemail left, pending call back. DON notified. Post fall assessment recommendations: Assess and follow up recommendations. Monitor closely. Call light within reach. Helmet on at all times. Fall precautions at all times. Encourage resident to use non-skid shoes or socks to aid with ambulation. Keep close to nurse's station when out of bed. Record review of Resident #51's fall incident dated 11/11/2023 at 20:40 - location: 202-A. Description: Resident found on the floor in room near his bed with walker on his back side. Resident was sitting up with pants semi down. Resident alert and oriented x 2, able to follow simple commands. Resident moves upper and lower extremities with no abnormalities determined. Small skin tear to left thumb noted. Call light left within reach and safety precautions implemented. Neuro checks implemented. Resident continues to use walker around facility/room. Non-compliant with use of helmet. Resident stated that he fell back and hit the floor. Complete head to toe done, vitals taken. Hospice nurse notified and pending assessment to be done in the morning. RP attempted to be contacted but no response - pending call back. Voice mail left. Post fall assessment recommendations: 11/11/23-Refer to rehab to screen and follow up with recommendations. Monitor closely. Handle care safely and unhurried. Call light within reach. Non-skid socks or shoes to aid ambulation. Fall precautions at all times. Record review of Resident #51's fall incident dated 11/26//2023 at 07:09 - location: 202-A. Description: Resident sitting on his buttocks beside the bed. Noted resident with skin tear to back of head. Has ROM to all 4 extremities. Assisted up and back to bed. Wound care nurse informed along with nurse at hospice and stated that she will send a nurse to assess him today. Left message for RP. DON made aware along with PCP. Resident unable to give description. Denies pain. Neuro checks initiated. Post fall assessment recommendations: 11/26/23-Refer to rehab to screen and follow up with recommendations. Monitor closely. Call light within his reach. Handle care gently and unhurried. Non-skid shoes or socks to aid with ambulation. Fall precautions at all times. Record review of Resident #51's fall incident dated 12/7/2023 at 11:05 - location: 202-A. Description: Resident was up ambulating and standing in his doorway without his walker and the soft helmet the aides had just placed on him. [NAME] given to resident and reminded to use, then aide notified resident had a fall with a laceration to back of head. Pressure was applied until the bleeding stopped. Resident on floor turning himself back and forth. Resident unable to give description. 911 initiated and hospice made aware. Resident complaining of pain to head. ROM to all extremities with no pain verbalized. DON and RP made aware of incident and that resident being sent to ER. Report called in and transported out of building at 11:20. Post fall assessment recommendations: 12/7/23-Refer to rehab to screen and follow up with recommendations. Monitor closely. Call light within his reach. Handle care gently and unhurried. Non-skid shoes or socks to aid with ambulation. Fall precautions at all ties. Keep close to nurses' station when out of bed. Record review of Resident #51's fall incident dated 12/12/2023 at 20:16 - location: 202-A. Description: Resident had an un-witnessed fall and was found by the fish tanks. Resident had a small head abrasion to the back of the head. Resident found lying on his back side with walker next to him. Resident able to move upper and lower extremities with no pain or discomfort. No abnormalities noted. Head to toe completed. Pupils equal, round and reactive to light and accomodation present. Minor bleeding from abrasion noted. Hospice nurse notified and came to evaluate resident. No new orders given at this tie. Resident offered pain medication but refused. Resident able to voice needs. Alert to person and place with some confusion. Resident placed back into bed. Neuro checks implemented. Pending call back from RP. DON notified via phone. Post fall assessment recommendations: 12/12/23-Refer to rehab to screen and follow up with recommendation. Monitor closely. Call light within his reach. Handle care gently and unhurried. [NAME] within his reach. Non-skid shoes or socks to aid with ambulation. Keep close to nurse's station when out of bed. Record review of Resident #51's fall incident dated 12/18/2023 at 18:56 - location: 202-A. Description: Loud nose heard from nurse's station. SN went to resident room and resident was found on restroom floor near toilet with walker next to resident. Resident was alert and oriented to person and place. Resident table to stand up and sit on wheelchair. Resident able to move upper and lower extremities with full ROM. Redness noted to the left backside of resident's head. No skin tear, abrasion, pain or discomfort reported to the area by resident. Resident refused to be placed in bed. Resident's helmet placed again but resident removed helmet as soon as SN walked away. Completed head to toe. Vitals taken. Full ROM in upper and lower extremities. RP made aware. Hospice nurse RN aware and will come to evaluate resident later today. Neuro checks implemented. Post fall assessment recommendations: 12/18/23 - Referred to rehab to screen and follow u with recommendations. Non-skid shoes or socks to aid with ambulation. Keep close to nurse's station when out of bed. Fall precautions at all times. Helmet on at all times. Record review of Resident #51's fall incident dated 12/21/2023 at 18:50 - location: 202-A. Description: Resident was found on the floor on his back in the hallway. Resident was wearing soft helmet and was using his walker while ambulating. Small pool of blood was noted on the floor behind back of his head. Resident had sutures intact to the back of his head due to previous unwitnessed fall. No new injuries noted. ROM to all extremities without difficulty or pain. Resident was unable to give description. Head to toe assessment completed. VS were within parameters. There was a small amount of bleeding to the back of his head. Resident transferred to his wheelchair used 3 persons for safety. Resident then placed in bed. No new injuries noted. Resident was instructed to use his call light for assistance if he was going to get out of bed. Resident nodded his head yes. Hospice was notified. Spoke to RN/DON and stated she will come by to see him. PR notified. ADON/DON notified. Neuro checks started for 72 hr. Low bed for safety. Call light placed withing reach and continued monitoring. Post fall assessment recommendations: 12/21/23-Referred to rehab to screen and followed up with recommendations. Monitored closely. Fall precautions placed at all times. Call light withing his reach. Non-skid or socks to aid with ambulation. Helmet used while out of bed. Kept close to nurses' station when out of bed. Record review of Resident #51's fall incident dated 12/25/2023 at 08:45 - location: 202-A. Description: Heard patient yell and something hit the wall. Walked into patient room and saw that patient was laying on the floor. Shoulder noted up against the wall and body laying sideways. Stated that his right wrist was hurting and denied hitting head. Resident unable to give description. Called for assistance. CNA was able to assist with getting patient off the floor. Resident placed in wheelchair and assessed. Hospice was called and a message was left of patient falling and requested a call back. Family member called and advised of incident. Resident with intact staples to back of right head. No bleeding/cuts or swelling noted at the time. Post fall assessment recommendations: 12/25/23- Medication changes: Added Temazepam. Refer to rehab to screen and follow up with recommendations. Handle care gently and unhurried. Helmet while out of bed. Non-skid shoes or socks to aid with ambulation. Record review of Resident #51's fall incident dated 12/27/2023 at 05:00 - location: 202-A. Description: SN heard loud noise from room. SN proceeded quickly. Pt found sitting on floor in between chair, walker, and bed. Resident unable to give description. SN assess - with pupils equal, round and reactive to light and accomodating. No changes in level of consciousness, no s/s of pain or discomfort. No injury or redness/swelling noted. Patient assisted back into bed with two people. Post fall assessment recommendations: 12/27/23-Refered to rehab to screen and follow up with recommendations Monitored closely. Call light placed within his reach. Handled care gently and unhurried. Non-skid shoes or socks to aid with ambulation. Encouraged resident to use call light for assistance. Helmet on while out of bed. Observation on 02/13/24 at 03:00 PM. Resident # 51 in bed awake with head of bed elevated, bed in low position and floor mats to both side of bed. Call light in reach to left side of bed. Room and restroom free of clutter. Resident did not respond to any of my questions. No side rails. No injuries noted. Resident would not respond to any questions. In an interview on 2/14/24 at 10:00 AM with LVN/ADON G, she said she could not recall specific falls, but interventions were done with hospice. Staff had called family to see if they could come spend more time with resident. Resident was checked on every 2 hours. He did not like to be out of his room. Fall precautions included bed low position and floor mats since resident did not get up and walk as much on his own anymore. LVN/ADON G said they would get him up to the wheelchair when resident allowed. In an interview on 02/16/24 at 02:30 PM with DON, she said resident #51 had a history of stroke. He was very impulsive. He walked with a walker. Resident #51 was on hospice and they communicated with them regarding resident interventions and non-compliance. Since changing medication from Temazepam to Trazadone HCl Oral Tablet 100 MG at bedtime for insomnia, he was not as impulsive anymore. They did q 1 hr. checks to monitor and see if Resident #51 was wearing his helmet, because Resident #51 was not compliant. Last fall was on 12/27. The DON said they have completed the following interventions: Hospice, Med intervention, rehab, helmet, toileting because he was always going to closet/bathroom looking for items. They were constantly reassessing to see if Resident #51's needed any changes to his interventions. She said that they do monthly trainings, quarterly trainings and post-incident retrainings for falls. She stated that is ongoing. To monitor she stated that she did rounding at least 4-5 times a day, monitored staff interaction with residents, asked for feedback from ADONs in morning meetings and obtained resident feedback for any concerns. She also obtained information during IDT meetings. To prevent from falls from happening again, the DON stated that when nurses called her to inform her of a fall, she looked at the resident's POC to see what may have caused the fall. Based on that information, it may determine if she looked at other interventions. She opened up POC at the morning meetings, to see if they maxed out all interventions, looked for alternatives like getting the family involved, or move closer to the nurses. The DON stated that the Nurse Practitioner completed rounds Monday through Friday and made sure to assess residents if the Primary Care physician was not at the facility that day. She stated they also have an on call 3rd eye MD that will assess the residents if needed. In an interview on 2/17/24 at 9:31 AM, CNA E said he did rounds for resident #51 every 2 hrs. The first round was completed when CNA E arrived at facility. Resident was given extensive care. Resident was incontinent, and he became agitated easily. Resident #51 used to get up and be in the hallway a lot. Resident was a fall risk. Resident #51 stayed near him and walks with resident to the room. Resident has not had a fall while under his care. In an interview on 02/17/24 at 10:00 AM, the DON said if a fall happened, the protocol for fall management would be completed. Nursing would do their assessments and protocols of neuro checks. The immediate need would have been met. In an interview on 2/17/24 at 10:22 AM, CNA F said resident #51 required 2-person care. Resident had a helmet due to falls. CNA F said she checked on Resident #51 frequently, like every 20 minutes just to ensure he was ok. The staff had been doing hourly checks on Resident #51 for a couple months. CNA F said Resident #51's previous falls were not hard falls - there were no injuries, but staff always made sure not to move resident until the nurse checked him. Record Review of the facility's Fall Management System Policy dated 2/19/2021 reflected: It is the policy of this facility that each resident will be assessed to determine his/her risk for falls, and a plan of care implemented based on the resident's assessed needs. Procedure includes: D. Documentation requirements for residents sustaining a fall 1. A licensed nurse will complete an Incident/Accident Report after each fall . 2. The licensed nurse will document the fall . 3. The licensed nurse will assess and document the condition of the resident at least once pre shift for at least 72 hrs post fall. 4. Documention in the nurs'es notes and/or care plan will reflect interventions attempted. 5. Un-witnessed falls are considered potential head injury and required completion of neurochecks. 6. The Resident Fall Tracking log is to reflect each fall individually of each resident . E. Investigation and follow-up of accidents involving falls. 1. The licensed nurse will initiate the Incident/Accident investigation immediately after each fall utiziing the Investigation Follow-up guideline. 2. Interventions will be implemented in an attempt to prevent the resident from sustaining further falls. Based on the investigation results, the licensed nurse will initiate intervention measures as soon as practicable (e.g., placing a chair alarm, removing obstacles out of path to B/R, placing resident on a low bed, ect.). 6. Falls are reported per Federal and State guidelines. Record review of of incident reports dated 9/1/2023 to 12/27/2023 showed documentation required under procedures and investigation and follow-up were completed.

Based on interviews and record review the facility failed to ensure residents were free of significant medication errors for 1 (Resident #7) of 3 residents reviewed for medication errors in that: The facility did not follow physician's orders for Resident #7 when Resident #7 was administered 1 ml of Morphine Sulfate (concentrate) Oral Solution 100 MG/5ML (Morphine Sulfate) instead physician's order of 0.1ml morphine sulfate. An Immediate Jeopardy was identified on 08/11/2023. The Immediate Jeopardy template was provided to the facility on [DATE] at 7:23 PM. While the Immediate Jeopardy was removed on 08/13/2023 at 6:54 p.m., the facility remained out of compliance at a scope of isolated and severity level of actual harm because all staff had not been trained on residents free of significant medication error. The failure could place residents at risk for complications and possible death from receiving the wrong or excessive dosage of medication. The findings included: Record review of Resident #7's Admission Record dated 12/12/2022 indicated Resident #7 was an [AGE] year-old female and was admitted to facility on 09/28/2022 with the following diagnoses: of encephalopathy (a broad term for any brain disease that alters brain function or structure), COVID-19, lobar pneumonia (acute exudative inflammation of the entire lobe), generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), gastro-esophageal reflux disease without esophagitis (a type of Gerd that does not involve inflammation of the esophagus), spinal stenosis, cervical region (narrowing of the spinal canal), dependence on supplemental oxygen, depression, acute respiratory failure with hypercapnia, type 2 diabetes mellitus without complications, hyperlipidemia (elevated levels of lipids like cholesterol and triglycerides in the blood), chronic pain syndrome, hypertension, chronic ischemic heart disease ( heart problems caused by narrowed heart arteries), peripheral vascular disease, constipation, secondary kyphosis (fracture in one or more vertebral bodies) spondylosis (age related wear and tear of the spinal disks), adult failure to thrive, and history of falls. Record review of Resident #7's MDS assessment, dated 12/15/2022 indicated: -BIMS score was 15 (cognitively status independent, decisions consistent/reasonable) -coded as being under hospice -required limited assistance with one person assist with bed mobility, transfer, walk-in corridor, walk-in-room, and toilet use -required supervised with one person assist for locomotion on unit, locomotion off unit, dressing and personal hygiene -was independent with setup help only for feeding -history of falls prior to admission/entry or re-entry Record review of Resident #7's comprehensive care plan dated 09/29/2022 revealed: Resident #7 was under hospice Focus: Resident #7 has a terminal illness and is receiving hospice or palliative care. During the end-of-life process weight loss, skin breakdown, dehydration, fecal impaction, and the gradual o or rapid loss of the ability to move may be unavoidable. Date initiated: 01/08/2023 Goal: Dignity will be maintained, and the resident will be kept comfortable and pain free within one hour of interventions through the next review. Date initiated: 01/08/2023 Interventions: Coordinate with hospice to ensure the resident's spiritual, emotional, intellectual, physical, and social needs are met. Date initiated 01/08/2023; Assist with ADL's and provide comfort measures as needed. Date initiated 01/08/2023; Monitor for abnormal weight loss, poor appetite, and skin breakdown. Report abnormals to the physician as noted. Date initiated 01/08/2023; Monitor for signs and symptoms of increased pain, discomfort-give medications and treatments as ordered and monitor for relief. Date initiated 01/08/2023. Record review of Resident #7's comprehensive plan dated 09/29/2022 revealed Morphine Sulphate (concentrate) Oral Solution 100 mg/5 ml (morphine sulfate) was not care planned. Record review of Resident #7's eMAR for January 2023 revealed: Morphine Sulfate (concentrate) Oral Solution 100 mg/5ML (morphine Sulphate) Give 0.1 ml by mouth every 1 hours as needed for severe pain 7-10. Start date-01/09/2023 16:01 (04:01 p.m.) and discontinue date-01/11/2023 08:22. Further review of eMAR indicated Resident #7 did not receive Morphine Sulfate (concentrate) Oral Solution 100 mg/5ML (morphine sulfate) from January 09, 2023, through January 11, 2023. Physician's order was under orders on PCC. Record review of Resident #7's progress note dated 01/09/2023 at 16:04 (04:04 p.m.) revealed Note This order is outside of the recommended dose or frequency. Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML Give 0.1 ml by mouth every 1 hours as needed for Severe Pain 7-10 Pain. Record review of Resident #7's progress note dated 01/10/2023 at 14:00 (04:00 p.m.) revealed eMAR Medication Administration Note: Duplicate Order - Note Text: Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML Give 0.1 ml by mouth every 1 hours as needed for Severe Pain 7-10 Pain Record review of Resident #7's progress note date 01/10/2023 at 18:47 (06:47 p.m.) revealed eMAR Medication Administration Note: Duplicate Order - Note Text: Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML Give 0.1 ml by mouth every 1 hours as needed for Severe Pain 7-10 Pain Both progress notes dated 01/10/2023 at 14:00 (02:00 p.m.) and 18:47 (06:47 p.m.) had been stuck off. Record review of the hospital records dated 01/10/2023 at 18:23 (06:47 p.m.) revealed the following: Patient is an 87 y/o (year old) F (female) with PMH (past medical history) of DM (diabetes mellitus), CVD (cardiovascular disease) with no residual effect per son who presents as trauma admission s/p (status post) unwitnessed GLF (ground level fall) at 17:00 on 01/10/2023. Per family member, patient lives in a nursing facility and had a fall from her wheelchair as she was trying to get up. No LOC (loss of consciousness). Patient at baseline is non ambulatory; uses a wheelchair. On presentation, patient difficult to awaken, sternal rub elicits limited response. History limited due to patient's status; patient's family member present at bedside is also unclear of history. Physical Examination: General: minimally responsive; open eyes minimally after sternal rub. Eye: unable to examine HENT: V shaped laceration on the left side of forehead Respiratory: Lungs are clear to auscultation, respirations are non-labored Cardiovascular: Normal rate, regular rhythm, good pulse equal in all extremities Gastrointestinal: soft, non-tender, non-distended Musculoskeletal: unable to examine Integumentary: decubitus ulcer in sacral area and heal, present on admission Neurologic: minimally responsive to sternal rub Cognition and Speech: unable to examine Psychiatric: unable to examine. Impression and Plan Patient non arousable initially on exam. Head CT on arrival shows 0.4 subdural hematoma, repeat CT head recommended in the AM. Hospital Cause: Heat CT (cat scan) on arrival shows 0.4 mm subdural hematoma. Dr. consulted recommended repeat CT (cat scan) head the following morning which was stable with 4 mm subdural hematoma. No intervention per neurosurgery. Patient is complaining of neck pain with history of cervical stenosis, previous workup negative for acute cardiac pathology. Patient's family requested application to new SNF (skilled nursing facility), during her stay patient had no acute events. Patient is ready for discharge. Operative Report: Consent: signed by patient Location: forehead Preparation and technique: 3 sutures placed Interview on 08/10/2023 at 5:55 p.m. via telephone with LVN A revealed on 01/10/2023 at about 4:00 p.m. RN A came to the nurse's station where she was and advised her Resident #7 was requesting pain medication due to having neck pain. LVN A said she told RN A Resident #7 had recently been prescribed Morphine for pain. LVN A said she and RN A walked over to Resident #7's room because she wanted to make sure Resident #7 was alert and I just wanted to observe her to make sure she was in pain. LVN A said she had been in Resident #7's room a short time before and she did not complain of any pain. Upon entering Resident #7's room, Resident #7 was observed sitting in her wheelchair next to her bed. LVN A said Resident #7 did complain of neck pain and requested pain medication. At that time LVN A said she and RN A went outside to the hall and unlocked the med cart and pulled the Morphine box out and compared the label on the box with the order which indicated to give 0.1 ml as needed for pain every 1 hour. LVN A said after she and RN A verified the name, dosage, and route she went back to Resident #7's room to transfer her to bed while RN A stayed in the hall preparing the medication. LVN A said she transferred Resident #7 back to bed and advised her not to get up and if she needed anything to make sure to press the call light. Soon after that RN A came into Resident #7's room and administered Morphine. LVN A said RN A held up the syringe, showed it to her, and asked if it was ok to administer the Morphine, LVN A said, I didn't physically look at the syringe, but I said yes, and RN A administered the Morphine orally. LVN A said we both left back to the nurse's station and immediately RN A said she thought she had given Resident #7 the wrong dose of Morphine. At that point, LVN A replied, what do you mean RN A repeated I gave Resident #7 the wrong dose. LVN A said she immediately walked over to the med cart unlocked it and pulled the Morphine box out of the narc box to check the syringe. LVN A said after Morphine was given to a resident, the syringe was placed in a red plastic bag and placed back in the manufacture's box along with the Morphine. LVN A said when she checked the manufacture's box the syringe was not there. LVN A asked RN A where she had left the syringe and her response was I think I left it in Resident #7's room. LVN A said she went to Resident #7's room and found the syringe in a plastic bag on top of the dresser. At that point, RN A picked up the syringe and pointed to the 1.0 ml and told LVN A that's how much I gave her. LNV A said the facility has no protocol on how to manage medication errors, she said what she did after learning of the medication error what she learned in nursing school. LVN A said she immediately went to check on Resident #7 and found her to be alert, not in respiratory distress and still lying-in bed. LVN A said, I don't remember if RN A or I notified hospice nurse, DON, and family member but they were notified immediately of the medication error. LVN A said I went to check on Resident #7 a couple more times, she checked her breathing and was not in distress and was alert. LVN A said she does not remember the exact times she checked on Resident #7's saying, it's been a while. LVN A said between 5:30 p.m. and 5:45 p.m., a CNA was walking by Resident #7's room and noticed her laying on her left side on the floor. CNA called for help and LVN A ran to assist her. LVN A said Resident #7 was right by the door laying on her left side, bleeding from her forehead and had a bump on top of her scalp. LVN A said Resident #7 told her she managed to get out of bed, sit herself on her wheelchair when she tried reaching for something and fell . LVN A said she asked Resident #7 why she had gotten out of bed, and she replied, you know I'm stubborn. LVN A said she called Resident #7's doctor to inform of fall and was given instruction to send Resident #7 to the hospital to be evaluated. LVN A was asked if she notified Resident #7's doctor of the morphine dose error and she said yes adding I also notified the hospital when I called to let them know we were sending Resident #7 to the ER due to the fall. LVN A said Resident #7 was sent to the hospital due to the fall and not to the Morphine medication error. LVN A said Resident #7 had a history of falling and had received stiches on her head before due to the falls she had sustained since being admitted . LVN A said she made an incident report related to the medication error and the fall Resident #7 sustained on 01/10/2023. Surveyor asked LVN A how a medication error of Morphine negatively affect Resident #7 she replied to the most serious side effect could be respiratory distress. LVN A said the next day (01/11/2023) the DON and Administrator provided both she and RN A an in-service training on medication errors, were counseled individually and suspended for 3 days pending an investigation. Surveyor asked LVN A if RN A had given an explanation as to why she gave the wrong dose and she said RN A told her that in her previous job it was customary to give 1.0 of morphine so she figured it was the same at this facility. Interview via telephone on 08/11/2023 at 9:40 a.m., the PCP said he was not informed of Resident #7's morphine medication error. He said he wanted to make sure we understood this was the first time he was informed. The PCP said if he had been informed of the morphine medication error that would have unleashed a whole new protocol. Surveyor asked what he would have instructed the nurse to do, he replied, there would have been two possible responses. If resident was not experiencing respiratory distress, pulse was within range, she was cognitively aware, and heart rate was not abnormal, I would have instructed the nurse to observe the resident continuously (he did not say how long because everyone is different), resident did not need to be sent to the hospital because at that point because resident was stable. If the resident were experiencing respiratory distress, pulse was not within range, was not cognitively aware, and heart rate was abnormal, he would have instructed the nurse to administer Narcan and sent to hospital immediately. The PCP said Resident #7 received 10 times her prescribed order of morphine. The PCP said 1.0 is the max dose of morphine and not deadly for a hospice resident because eventually they will require a higher dose. The PCP said Resident #7 still needed to be monitored for any adverse effect. Interview via telephone on 08/11/2023 at 10:30 a.m., The Hospice DON said Resident #7 was placed on hospice due to respiratory failure. The Hospice DON said facility called hospice at 09:32 p.m. on 01/10/2023 to inform them Resident#7 suffered a fall and sent to the hospital due to sustaining a hematoma to her forehead. The Hospice DON said on 01/11/2023 at 11:15 a.m. Facility's DON called them and advised of the morphine medication error. The Hospice DON said facility's DON said the syringes that came in the manufacture's box of the morphine medication did not have numbers only lines and that could have caused the RN A to administer the wrong dosage of morphine to Resident #7. The Hospice DON said the medication/syringe was delivered by the pharmacy and it was considered a multi-use syringe. The Hospice DON said as a correction plan the hospice company delivered 10 to 15 syringes with numbers to avoid another medication error. The Hospice DON was asked if facility had called immediately, she would have sent their hospice RN to go to facility and assess Resident #7 at facility. The Hospice DON if the facility had notified them as soon as the medication error said she would have also instructed hospice RN to check her level of consciousness more frequent, her vitals for hypertension and fall precautions for at least 2 hours after medication error. The Hospice DON said Narcan would have been ordered depending how Resident #7 looked. Interview via telephone on 08/11/2023 at 11:00 a.m. The Hospice DON called back to say she had spoken to previous acting hospice DON (at time of incident) who had clarified the first-time facility's DON had reported morphine medication error was on 01/11/2023. The Hospice DON also verified they had notified Resident #7's primary physician of her fall on 01/10/2023 at 9:30 p.m. Interview on 08/11/2023 at 11:15 a.m., LVN A said she had struck out Morphine entry on progress notes at 18:47 on PCC because she was not the one who had administered the morphine to Resident #7. Interview via telephone on 08/11/2023 at 12:50 p.m., RN A said on January 10, 2023, at approximately 4:00 p.m. while working under the supervision of LVN A (as it was her first day on the floor since being hired) She walked into Resident #7's room to check on her. RN A said Resident #7 complained of neck pain and requested pain medication. She immediately went looking for LVN A and found her in the nurse's station. She informed LVN A Resident #7 was requesting pain medication due to neck pain. Staff F said she was told by LVNA Resident #7 was under hospice care and had a PRN (as needed) order of Morphine. RN A said she proceeded to the medication cart to prepare the syringe with the morphine solution. RN A said after she prepared the syringe with the morphine solution, she went looking for LVN A. RN A said she found LVN A in the medication storage room and appeared to be talking to someone on the phone because she had an ear pod in one ear. RN A said she signaled LVN A though the glass window to come out. RN A said LVN A opened the door without coming out and at that time they both checked the Morphine order with the label, name, dose, route, and I showed her the syringe with the morphine solution, and she nodded yes, she gave me a thumbs up. RN A said she then proceeded to Resident #7's room to administer the morphine. RN A said she first educated Resident #7 on the medication she was going to receive and transferred her back to her bed and administered the Morphine oral solution. RN A said she went to check on Resident #7 after 30 minutes or 1 hour (was not sure on the time) and Resident #7 was good being her normal self. RN A said, we did our thing throughout our shift and around 5 or 6 p.m. LVN A calls out for help because Resident #7 had fallen and had a wound on her forehead. RN A said she stayed with Resident #7 while LVN A went to call 911. LVN A said Resident was found between her bed and bathroom. RN A said she discovered the morphine medication error at about 6:30 p.m. when she was looking back at the eMAR and discovered I had given more than I should RN A said she immediately informed LVN A but does not remember what her response was. RN A said, I texted DON at 6:31 p.m. telling her LVN A and I wanted to meet with her tomorrow to review possible med error. RN A said she texted DON because it was after working hours for DON. As per RN A, DON responded back via text at 7:00 p.m. telling her Yes, please do so. RN A said Resident #7 had already been discharged to the hospital by the time she discovered the morphine medication error. RN A said sometime before the end of her shift LVN A told her We could have fixed it RN A reply to LVN A was there's no fixing, I gave what I gave. Surveyor asked RN A if she knew what RN A meant by that and she said, to put 0.1 ml in the narc sheet even though I had given 1.0 ml of morphine. RN A said the next morning, DON met with both and them together and individually. She said they also had a general training with all nurses to make sure all nurses were doing their job. RN A said she received training on how to read eMAR and was not sure on the topics of other trainings received after med error incident. She said she and LVN A were suspended pending the outcome of the investigation. Surveyor asked RN A how Resident #7 could have been negatively impacted by receiving 1.0 ml of morphine sulfate instead of the ordered 0.1 ml, she said her breathing distress and high blood pressure. Staff F said 1.0 ml of morphine sulfate is appropriate for hospice patients but there must have been a reason Resident # 7's doctor had prescribed 0.1 ml of morphine sulfate. RN A said she decided to voluntarily quit her job as a registered nurse at the facility because she was told by someone RN A had written a statement saying she had never shown her the syringe. RN A said she believed they would take LVN's statement over her since she had just been hired. RN A also said it was not a healthy environment and did not feel comfortable working at the facility. RN A said she took a picture of the syringe used to administer the morphine sulphate to Resident #7. Interview via telephone on 08/11/2023 at 11:20 a.m. The Medical Director said he was informed of Resident #7's medication error by the facility's nurse on duty (did not have nurse's name) on 01/11/2023 and was not sure of the time either. The Medical Director said he and the rest of the QAPI team discussed medication error on 02/23/2023. The Medical Director said during the meeting they checked narcotic orders for all residents. The Medical Director was asked how Morphine medication error could negatively impacted Resident #7 and his response was she could have suffered neurological sedation, respiratory depression or excessive sedation but added Resident #7 did not have any negative effects. The Medical Director said if Resident #7 had suffered any side effects he would have ordered Narcan and sent to the hospital immediately. The Medical Director emphasized he was available to the facility 24/7 and facility did not notify him immediately. Interview on 08/11/2023 at 3:00 p.m., The DON said she expects all her nurses to inform her immediately in case of a medication error. She said if she is not at facility (after working hours) she expects a call from them immediately. The DON said she would ask the nurse what medication was given, the dosage and the correct dosage and depending on what they would tell her, she would instruct them to either monitor or send to hospital. The DON said she immediately notifies resident's primary physician, family representative, medical director, and administrator of the medication error. The DON said after resident is cared for, she will complete the medication error report, start an investigation, re-educate staff and report to HHSC. The DON said the medication error was discovered after Resident #7 was discharged to the hospital due to sustaining an unwitnessed fall. The DON said Resident #7 had a history of falls and was non-compliant. The DON said she notified Resident # 7's primary doctor and hospice immediately of the fall but was not sure if she informed them of the medication error on the same day. The DON said the fall or medication error was not care planned because Resident #7 did not go back to facility after being discharged from hospital. Interview on 08/11/2023 at 3:30 p.m., The Administrator said facility's policy regarding medication error was for the nurses to let the DON know immediately after discovering a medication error was occurred. The Administrator said depending on how the resident was feeling, DON will instruct of appropriate action. The Administrator said it was the DON's responsibility to inform her of any medication errors immediately after being notified of one. The Administrator was asked how a morphine medication error could negatively affect Resident #7; her response was I don't know how to answer that question. Observation on 08/11/2023 at 1:41 p.m., RN A texted picture to surveyor and it showed a thin syringe with 4 lines (0.25 ml, 0.50 ml, 0.75 ml, and 1 ml). Record review of the facility policy titled Prevention of Medication Errors dated 05/30/2018 indicated: Anticipated Outcome Residents will be free of incidents related to medication Fundamental Information Medication error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specification or accepted professional standard and principals. Significant medication error: means one which caused the resident discomfort or jeopardizes his or her health and safety. Review MAR to identify medication to be administered Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. Administer medication as ordered with the appropriate amount of fluid or food. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR at the time of medication administration. If medication is a controlled substance, sign narcotic book and complete other standard of practice documentation Nurse /Medication Aide will be able to identify or have quick reference of action and common side effects of medication. Correct any medication discrepancies and report to director of nursing Staff education regarding risk of medication errors The Administrator was informed the Immediate Jeopardy was removed on 08/13/2023 at 6:54 p.m. The facility remained out of compliance at a severity level of 4 and a scope of J due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 1. Immediate Action Taken On 1/10/2023 resident # 7 was sent to the hospital and never returned to the facility. On 8/11/2023 DON/Designee completed an audit of all residents receiving Morphine in the center to verify that correct dose of Morphine was entered into the computer. This will be completed at 10:00 pm on 8/11/2023. On 8/11/2023 DON/Designee completed rounds on all residents to verify that a physician's notification was completed if a resident was identified with a change of condition. No residents were identified On 8/11/2023 DON/Designee started education with all licensed nurses on: o Policy on Medication Administration Guidelines that provide directions on the process of verifying labels for accuracy, verifying administration accuracy, verifying a focused assessment, administering the medication according to the physician's orders. This will be completed by 10:00 pm on 8/11/2023, and no licensed nurse will be allowed to work until they have received this education. o Policy on Preventing/Detecting adverse consequences and Medications errors that provides directions to license nurses on immediate actions to take for a signification medication related error or adverse consequence: License nurse will notify the attending physician promptly of any significant error or adverse consequence License Nurse will Immplement (that is how it was written on POR) orders as directed by physician, and the resident is monitored closely for 24 to 72 hours or as directed. License Nurse will Communicate with other across shifts as indicated to alert staff of the need to monitor resident License Nurse will Complete an Incident report or Medication error form License Nurse to Report significant error to the DON DON will report significant error to Consultant Pharmacist This will be completed by 3:00 pm on 8/12/2023, and no licensed nurse will be allowed to work until they have received this education. The DON/Designee will be responsible for ensuring all license nurses understand and follow the guidelines for a significant error or adverse consequence. o Policy on Notification Change of Condition that provides directions on notifying family and physician when a change in a resident's conditions occurs. This will be completed by 10:00 pm on 8/11/2023, and no licensed nurse will be allowed to work until they have received this education. o A skills competency on Medication Administration will be completed for all license nurses, validating proficiency in Medication Administration to validate medication administration competency and action to take if a significant error occurs. The DON/Designee will be responsible to ensure all license nurses are proficient in Medication Administration. This will be completed by 10:00 pm on 8/11/2023, and no licensed nurse will be allowed to work until they have received this education. 2. Identification of Residents Affected or Likely to be Affected: On 8/11/2023 DON/Designee started an audit review of all residents with new orders for the past 7 days to verify that correct dose of medications was entered into the computer correctly and no significant error occurred. This will be completed by 10:00 am on 8/12/203. 3. Actions to Prevent Occurrence/Recurrence: The DON/Designee daily will review all new medication orders during the morning meeting to verify all orders were entered correctly x 30 days. The DON/Designee daily will review the 24-hour report daily x 30 days to verify that any resident with a change of condition has physician and family notification. The DON/Designee will do random skills validation reviews with licensed nurses to verify medication administration competency and knowledge on what steps to take if a significant error occurs. The DON/Designee will be responsible to ensure all licenses nurses are proficient in Medication administration. On 8/11/2023 at 8:15pm the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy's the facility received related to residents free from significant medication error and Notification in change of condition and reviewed plan to sustain compliance. Verification: Started on 08/15/2023 at 2:35 and included: The following observations, record reviews and interviews were conducted by the survey team to ensure licensed staff's understanding of in-service trainings received between 08/11/2023 and 08/13/2023: Observation on 08/16/2023, LVN C was observed during med pass by survey team, no discrepancies were observed. Observation on 08/16/2023, LVN D was observed during med pass by survey team, no discrepancies were observed. Observation on 08/16/2023, LVN D was observed during med pass by survey team, no discrepancies were observed. Observation on 08/16/2023, RN B was observed during med pass by survey team, no discrepancies were observed. Record review of the licensed nurses In-Service Program Attendance Record for the following topic Medication Administration Guidelines conducted by DON. 23 LVN's and 7 RN's were in-serviced between 08/11/2023 and 08/14/2023. Record review of the licensed nurses In-Service Program Attendance Record for the following topic Preventing and detecting adverse consequences and medication errors conducted by DON. 23 LVN's and 7 RNs were in-serviced between 08/11/2023 and 08/13/2023. Record review of the licensed nurses In-Service Program Attendance Record for the following topic Notification Change of Condition conducted by DON 23 LVN's and 7 RN's were in-serviced between 08/11/2023 and 08/14/2023. Interviews on 08/15/2023 between 8:00 am and 5:00 pm, the survey team interviewed 28 licensed staff (23 LVN's and 5 RN's), all 28 licensed staff verbalized understanding of what they learned during in-services they received between 08/11/2023 and 08/13/2023. Interview on 08/15/2023 at 9:30 a.m., LVN D was able to verbalize understanding of the following in-services received: Medication Administration Guidelines, Preventing and detecting adverse consequences and medication errors, and Notification Change of Condition. Interview on 08/15/2023 at 9:45 a.m., RN B was able to verbalize understanding of the following in-services received: Medication Administration Guidelines, Preventing and detecting adverse consequences and medication errors, and Notification Change of Condition. Interview on 08/15/2023 at 10:00 a.m., RN F was able to verbalize understanding of the following in-services received: Medication Administration Guidelines, Preventing and detecting adverse consequences and medication errors, and Notification Change of Condition. Interview via telephone on 08/15/2023 at 11:55 a.m., LVN M was able to verbalize understanding of the following in-services received: Medication Administration Guidelines, Preventing and detecting adverse consequences and medication errors, and Notification Change of Condition. Interview on 08/15/2023 at 3:15 p.m., LVN C was able to verbalize understanding of the following in-services received: Medication Adminis [TRUNCATED]

Based on interview and record review the facility failed to ensure drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 3 of 3 residents (Resident #8, Resident #9, and Resident # 10) being reviewed for pharmacy services. Facility did not ensure that narcotics were reconciled as being given from the resident's eMAR to the resident's narcotic reconciliation form on medication cart. This failure could place residents at risk of not receiving their narcotic medications and drug diversion. An Immediate Jeopardy was identified on 08/13/2023. The Immediate Jeopardy template was provided to the facility on [DATE] at 6:54 p.m. While the Immediate Jeopardy was removed on 08/17/2023 at 2:30 p.m., the facility remained out of compliance at no actual harm but potential for more than minimal harm due to no evidence of actual harm to any resident, because of the facility's need to complete in-servicing and auditing interventions. The findings included: Record review of Resident #8's Admission Record indicated Resident #8 was an [AGE] year-old male admitted on [DATE] with the following diagnosis: Dementia with no behavioral disturbance, sequelae of cerebral infarction (residual effects or conditions produced after acute phase of an illness or injury has ended), other instability left wrist, chronic venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes), presence of aortocoronary bypass graft (a surgical procedure used to treat coronary heart disease), dysphagia (difficulty swallowing), oropharyngeal phase (malignant cells form in the tissues of the oropharynx) nondisplaced fracture of the lateral epicondyle of left humerus, contracture left hand, vascular dementia (brain damaged caused by multiple strokes), psychotic disturbance, mood disturbance and anxiety, dysphasia following cerebral infarction, presence of automatic cardiac defibrillator, Unspecified atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), bipolar disorder, presence of cardiac pacemaker, epilepsy, and epileptic syndrome. Record review of Resident #8's MDS assessment, dated May 09, 2023, revealed: BIMS-left blank (severe impairment) requires extensive assistance with a two person assist with bed mobility requires limited assistance with a two person assist with transfer, dressing, eating and personal hygiene Record review of Resident #8's comprehensive care plan dated 03/08/2023 revealed: Focus: Resident #8 has a terminal illness and is receiving hospice or palliative care. Goal: Dignity will be maintained, and the resident will be kept comfortable and pain free within one hour of interventions through next review. Date initiated: 03/08/2023/Target date: 05/21/2023. Interventions: Monitor signs and symptoms of increased pain, discomfort-give medications and treat as ordered and monitor for relief. Record review of Resident #9's Admission Record indicated Resident #9 is a [AGE] year old female, admitted on [DATE] with the following diagnosis: fracture of unspecified part of neck of right femur, osteoarthritis, scoliosis in thoracic region, acute kidney failure, history of falls, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, diverticulosis of large intestine, age-related physical debility, need for assistance with personal care, muscle wasting and atrophy, lack of coordination, personal history of covid-19, dysphagia (difficulty swallowing), alternating exotropia (outward turning eyes), edema, constipation, seasonal allergic rhinitis, major depressive disorder, hypertension, hypokalemia (low potassium), hyperlipidemia (elevated levels of lipids), anemia, hypothyroidism, gastro-esophageal reflux disease without esophagitis, presence of intraocular lens, vitreous membranes and strands, right eye. Record review of Resident #9's MDS record dated 07/18/2023 revealed: BIMS: 12 (cognitively intact) Requires extensive assistance with a two person assist for bed mobility Requires extensive assistance with a one person assist for dressing, toilet use, personal hygiene Record review of Resident #8's eMAR schedule for February 2023 revealed: Morphine Sulfate Oral Solution 20 MG/5ML (Morphine Sulfate), give 0.25 ml via G-tube every hour of sob (shortness of breath) and or severe pain. Start date: 02/03/2023 at 0945 D/C 08/12/2023 Record review of Resident #8's eMAR schedule for March-August 2023 revealed: Morphine Sulfate (concentrate) Oral Solution 20 MG/ML (morphine sulfate) give 0.25 ml sublingually every 1 hours as needed for SOB (shortness of breath)/Severe Pain 7-10. Record review of Resident #8's orders for Lorazepam Oral Concentrate 2 MG/ML, give 2 MG/ML every 4 hours as needed for anxiety (sublingual). Record review of Resident #8's eMAR schedule for March 24,2023-June 12, 2023, revealed: Lorazepam Oral Concentrate 2 MG/ML. Give 1m by mouth every 4 hours as needed for anxiety, give sublingual. Record review of Resident #8's Controlled Substance Record of Administration (NARC sheet) and eMAR (electronic medication administration record) revealed: Record review of Resident #8's eMAR schedule for March 24,2023-June 12, 2023, revealed: Lorazepam Oral Concentrate 2 MG/ML. Give 1m by mouth every 4 hours as needed for anxiety, give sublingual. Record review of Resident #8's Controlled Substance Record of Administration (NARC sheet) and EMAR revealed: April 2023, 8 doses of Lorazepam 2 mg/ml were signed off on the Controlled Substance Record of Administration (NARC Sheet) and 15 were signed off on eMAR. May 2023, 4 doses of Lorazepam 2 mg/ml were signed off on the Controlled Substance Record of Administration (NARC Sheet) and 4 were signed off on eMAR. June 2023, 6 doses of Lorazepam 2 mg/ml were signed off on the Controlled Substance Record of Administration (NARC Sheet) and 3 were signed off on eMAR. From February 3, 2023, to August 12, 2023, 38 doses Morphine Sulfate (concentrate) Oral Solution 20 MG/ML (morphine sulfate) were signed off on the Controlled Substance Record of Administration (NARC sheet) while only 16 doses of Morphine Sulfate (concentrate) Oral Solution 20 MG/ML (morphine sulfate) were signed off on the Electronic Medication Administration Record (eMAR). From June 2023 to July 12, 2023, 8 doses of Morphine Sulfate (concentrate) Oral Solution 20 MG/ML (morphine sulfate) were signed off on Resident #9's Controlled Substance Record of Administration (NARC Sheet) while only 2 doses were signed off her Electronic Medication Administration Record (eMAR). Interview on 08/12/2023 at 10:30 p.m., DON and ADON were asked to reconcile Resident #8's order of Morphine Sulfate (concentrate) Oral Solution 20 MG/ML (morphine sulfate) with his Controlled Substance Record of Administration with his record of Electronic Medication Administration Record (eMAR) in front of surveyor. Both DON and ADON confirmed 38 doses of Morphine Sulfate (concentrate) Oral Solution 20 MG/ML (morphine sulfate) were signed off on his Controlled Substance Record of Administration and only 16 doses were signed off on his Electronic Medication Administration Record (eMAR). Surveyor asked why the discrepancies and DON replied, I need to check with my nurses. Record review of Resident #9's eMAR schedule for June-July 2023 revealed: Morphine Sulfate (concentrate) Solution 20 MG/ML-give 0.25 ml sublingually every 4 hours as needed for Pain/SOB (shortness of breath). Start date-04/12/2023-Discontinue date-07/21/2023. Interview on 08/12/2023 at 10:40 p.m., DON and ADON were asked to reconcile Resident #9's order of Morphine Sulfate (concentrate) Oral Solution 20 MG/ML (morphine sulfate) with her Controlled Substance Record of Administration with her record of Electronic Medication Administration Record (eMAR) in front of surveyor. Both DON and ADON confirmed 8 doses of Morphine Sulfate (concentrate) Oral Solution 20 MG/ML (morphine sulfate) while only 2 doses were signed off her Electronic Medication Administration Record (eMAR). Surveyor asked why the discrepancies and DON replied, I need to check with my nurses. Record review of Resident #10's Admission Record dated 8/13/23 reflected [AGE] year-old male with an admitted [DATE] and with diagnoses of Malignant Neoplasm of Vertebral Column (cancerous tumor of Spinal column), Malignant Neoplasm of Liver (cancerous tumor of liver) Not specified as Primary or Secondary, Malignant Neoplasm (cancerous tumor) Unspecified Part of Unspecified Bronchus or Lung, Malignant Neoplasm(cancerous tumor) of Pelvic Bones, Sacrum (triangular bone between hipbones of the pelvis in lower back) & Coccyx (small triangular bone at bottom of spinal column), Malignant Neoplasm(cancerous tumor) of Bone & Articular Cartilage (living tissue that lines the bony surface of joints) Unspecified, and Unspecified Cirrhosis (damage where healthy cells are replaced by scar tissue) of Liver. Record review of Resident #10's Clinical Physician Orders dated 8/11/23 reflected he had orders for -Oxycodone HCI Oral Tablet 10 MG 0.5 by mouth every 1 hour as needed start date: 7/7/23, d/c (discontinue) date: 7/12/23 -Oxycodone HCI Oral Tablet 10 MG 0.5 by mouth every 1 hour as needed start date: 7/15/23, d/c (discontinue) date: 7/21/23 -Oxycodone HCI Oral Tablet 10 MG .05 by mouth every 1 hour as needed start date: 7/10/23, d/c (discontinue) date: 7/14/23 -Oxycodone HCI Oral Tablet 10 MG give 10 MG by mouth every 1 hour as needed start date: 7/22/23, d/c (discontinue) date: 7/24/23 -Oxycodone HCI Oral Tablet 10 MG give 10 MG by mouth every 1 hour as needed start date: 7/21/23, d/c (discontinue) date: 7/21/23 -Record review of Resident #10's EMAR reflected on 7/10/23 at 0529 dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth. Record review of Resident #10's Controlled Substance Record of Administration reflected on 7/10/23 at 0530 and again at 2315 dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth. -Record review of Resident #10's EMAR reflected on 7/11/23 at 2342 dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth. Record review of Resident #10's Controlled Substance Record of Administration reflected on 7/11/23 at 0530 and again at 2342 dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth. -Record review of Resident #10's EMAR reflected on 7/12/23 at 2359 dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth. Record review of Resident #10's Controlled Substance Record of Administration reflected on 7/12/23 at 0109, 0402, and 2359 dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth. -Record review of Resident #10's EMAR reflected on 7/15/23 no dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth Record review of Resident #10's Controlled Substance Record of Administration reflected on 7/15/23 at 2320 dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth. -Record review of Resident #10's EMAR reflected on 7/17/23 10:31, 12:09 dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth. Record review of Resident #10's Controlled Substance Record of Administration reflected on 7/17/23 at 11:00, 12:00, 1400 dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth. -Record review of Resident #10's EMAR reflected on 7/19/23 1149 dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth. Record review of Resident #10's Controlled Substance Record of Administration reflected on 7/19/23 at 1149, 1430 dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth. -Record review of Resident #10's EMAR reflected on 7/22/23 0845 dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth. Record review of Resident #10's Controlled Substance Record of Administration reflected on 7/22/23 at 8:45 and 9:45 dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth. In an interview on 8/14/23 at 11:43 a.m. LVN M stated she does not recall it was human error and she did not have an excuse for not documenting on the EMAR of Resident #10's narcotic dosage. She said she knew she is supposed to document on both the EMAR and the narcotic sheet. In an interview on 8/14/23 at 1:21 p.m. LVN W stated she corrected her error and let the hospice nurse know. She said she filled out medication error paperwork when she failed to document on EMAR the dosage of narcotic given to Resident #10. She said she knew the procedure but was maybe in a rush that day. She could not remember. Record review of facility's policy on Drug Diversion Guideline dated 02/23/2017 revealed: The following recommendations are designed to reduce and limit drug diversions: Signing the narcotic shift count sheet means you are accepting responsibility for the controlled substances. Therefore, do not sign unless you are certain that all the controlled substances are present and have not been alternated/tempered with or altered in any way. Document usage both on MAR and narcotic count sheet as soon as possible after administration of medication Document administration of PRN's controlled substances on the MAR's including dose, date, time, route and effectiveness of medication Notify the DON and/or pharmacy consultant immediately in the event of suspected drug tampering or diversion Reporting Drug diversions or potential drug diversions are reported immediately to Administrator, DON, Pharmacy, State Agency, and Police for investigation. Record review of facility's policy on Clinical Document Guidelines dated 03/25/2014 revealed: Policy The patients clinical record provides a record of the health status, including observations, measurements, history and prognosis and serves as a primary document describing health care services provided to the patient Fundamental Information The clinical record is used by healthcare team to record, preserve and communicate the patient's progress and current treatment Procedure Clinical document entries should be objective, factual information and communication that pertain to the care of the patient for i.e., patient centered Clinical document entry should contain the month, day, year and the time the narrative is written Entries are signed by the person writing the narrative and include the first initial, last name and the title or credentials of the author Each healthcare team member must document his or her own clinical record entries An Immediate Jeopardy was identified on 08/13/2023. The Immediate Jeopardy template was provided to the facility on [DATE] at 6:54 p.m. A plan of removal was accepted on 08/13/2023 at 6:54 p.m. and indicated the following: 1. Immediate Action Taken A. DON/Designee completed a resident Pain assessment on resident #8, and #9, verified that these 2 residents did not have a negative outcome due to license nurse failure to either initial the E-MAR after the medication administration, or failure to sign out for the medication on the Narcotic controlled count sheet. Resident # 10 was discharged from the facility on 7/22/2023. This was completed on 8/13/2023 at 7:45 pm. B. On 8/13/2023 DON/Designee began education with all licensed nurses On Clinical Practice Guidelines Medication and Documentation with emphasis on: Administer the medication according to the physician order. Document initials and/or signature for medications and treatments administered on the E- MAR immediately following administration. When a controlled medication is administered the licensed nurse obtains the medication from the locked area. The licensed nurse administering the medication immediately enters the following information on the accountability record when removing the dose from controlled storage; date and time of administration, amount administered, signature of the nurse administering the dose. (Also document controlled medication dose administrated on the E-MAR) Strike out initials for those medication or treatment that were not administered and document reason for the non -administration in the clinical record. When a dose of a controlled medication is removed from the container for administration but refused or not given, the medication must be destroyed with two nurse witness. Both nurses sign the accountability record on the line representing the dose. Document PRN medication and treatment administration on the E-MAR along with the reason immediately following administration. Document effectiveness of the intervention on the E-MAR as indicated Review each E-MAR after each medication administration is completed and prior to the end of the shift to validate documentation is completed and supports services provided according to physician orders. Document omission or held medication on the 24- Hour Report Complete a Medication Error Report for medication administration discrepancies Provide a summary of medication administration issues to on-coming charge nurse during shift-to-shift report This education will be completed on 8/14/2023 by 10:00am and no licensed nurse will be able to work until this education has been completed. The DON/Designee will be responsible to ensure this education is completed and all licensed nurses understands bullet points above related to providing accurate administration and documentation of medication. 2. Identification of Residents Affected or Likely to be Affected: A. On 8/13/2023 DON/Designee identified all resident who receive a controlled medication and completed an audit to ensure that if a resident received a controlled medication, it was signed out on the Narcotic controlled count sheet, and that it was initialed on the E-MAR as given and that both the match. B. For discrepancies identified from the audit; the DON/Designee will complete a Medication Error Report for each identified issue, with immediate notification to Physician and Hospice provider if applicable. This will be completed on 8/14/2023 by 10:00 am. 3.Actions to Prevent Occurrence/Recurrence: A. DON/Designee will use The QAPI Narcotic Monitoring form daily x 30 day to ensure that all Controlled substances are reconciled with the E-MAR: It is signed out for on the Controlled Narcotic Count sheet, that it is initialed on the E-MAR at the time of administration There is documenting for omission or held medication on the 24- Hour Report There is a completed Medication Error Report for medication administration discrepancies If a dose of a controlled medication is removed from the container for administration but refused or not given, the medication was destroyed with two nurse witness. Both nurses sign the accountability record on the line representing the dose. On 8/13/2023 the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to Pharmacy Services and reviewed plan to sustain compliance. Verification: Started on 08/15/2023 at 2:35 and included: The following observations, record reviews and interviews were conducted by the survey team to ensure licensed staff's understanding of in-service trainings received between 08/11/2023 and 08/13/2023: Observation on 08/16/2023, LVN C was observed during med pass by survey team, no discrepancies were observed. Observation on 08/16/2023, LVN D was observed during med pass by survey team, no discrepancies were observed. Observation on 08/16/2023, LVN D was observed during med pass by survey team, no discrepancies were observed. Observation on 08/16/2023, RN B was observed during med pass by survey team, no discrepancies were observed. Record review of the licensed nurses In-Service Program Attendance Record for the following topic Medication Administration Guidelines conducted by DON. 23 LVN's and 7 RN's were in-serviced between 08/11/2023 and 08/14/2023. Record review of the licensed nurses In-Service Program Attendance Record for the following topic Preventing and detecting adverse consequences and medication errors conducted by DON. 23 LVN's and 7 RNs were in-serviced between 08/11/2023 and 08/13/2023. Record review of the licensed nurses In-Service Program Attendance Record for the following topic Notification Change of Condition conducted by DON 23 LVN's and 7 RN's were in-serviced between 08/11/2023 and 08/14/2023. Interviews on 08/15/2023 between 8:00 am and 5:00 pm, the survey team interviewed 28 licensed staff (23 LVN's and 5 RN's), all 28 licensed staff verbalized understanding of what they learned during in-services they received between 08/11/2023 and 08/13/2023. Interview on 08/15/2023 at 9:30 a.m., LVN D was able to verbalize understanding of the following in-services received: Medication Administration Guidelines, Preventing and detecting adverse consequences and medication errors, and Notification Change of Condition. Interview on 08/15/2023 at 9:45 a.m., RN B was able to verbalize understanding of the following in-services received: Medication Administration Guidelines, Preventing and detecting adverse consequences and medication errors, and Notification Change of Condition. Interview on 08/15/2023 at 10:00 a.m., RN F was able to verbalize understanding of the following in-services received: Medication Administration Guidelines, Preventing and detecting adverse consequences and medication errors, and Notification Change of Condition. Interview via telephone on 08/15/2023 at 11:55 a.m., LVN M was able to verbalize understanding of the following in-services received: Medication Administration Guidelines, Preventing and detecting adverse consequences and medication errors, and Notification Change of Condition. Interview on 08/15/2023 at 3:15 p.m., LVN C was able to verbalize understanding of the following in-services received: Medication Administration Guidelines, Preventing and detecting adverse consequences and medication errors, and Notification Change of Condition. Record review of facility audits of eMAR's and Narcotic sheets of all residents receiving controlled substance medications were provided to Survey Team. Discrepancies discovered during the audit were reported to resident, resident's PCP, HHSC, police and noted on their progress notes. Record review of progress notes dated 08/15/2023 at 5:28 for Resident #8 revealed: Nurse informed primary care physician regarding Morphine eMAR missed documentation error which occurred on 2/4/23, 4/15/23, 4/24/23, 4/30/23, 5/16/23, 6/7/23, 6/11/23, 6/12/23, 6/24/23, 7/29/23, 8/5/23, 8/6/23, 8/7/23, 8/8/23, 8/9/23, 8/10/23, 8/12/23, 8/13/23. Resident sustained no negative outcome related to error. MD gave no new order r/t medication error. Nurse also informed RP of same. All due care rendered. No distress noted. Call light w/in reach. Created by ADON 1 Record review of progress notes dated 08/15/2023 at 5:41 p.m. for Resident #8 revealed: Nurse informed primary care physician regarding Lorazepam eMAR missed documentation error which occurred on 4/27/23, 5/2/23, 05/03/23, 6/11/23, 6/12/23. Resident sustained no negative outcome related to error. MD gave no new order r/t medication error. Nurse informed RP of same. All due care rendered. No distress noted. Call light w/I reach. Created by ADON 1 Record review of progress notes dated 08/15/2023 at 5:14 for Resident #9 revealed: Nurse informed primary care physician regarding Morphine eMAR missed documentation error which occurred on 6/10/23. Resident sustained no negative outcome related to error. MD gave no new order r/t medication error. Nurse also informed RP of same. All due care rendered. No distress noted. Call light w/in reach. Created by ADON 1 Record review of progress notes dated 08/15/2023 at 5:46 for Resident #2 revealed: Nurse informed doctor regarding Ativan eMAR missed documentation error which occurred on 10/27/2022, 01/17/2023, 06/06/2023. Resident sustained no negative outcome related to error. MD gave no new order r/t medication error. Nurse informed RP of same. All due care rendered. No distress noted. Call light w/I reach. Created by DON. Record review of progress notes dated 08/15/2023 at 05:46 for Resident #3 revealed: Nurse informed doctor regarding Tramadol eMAR documentation error which occurred on 05/18/23, 05/19/2023, 05/20/23. Resident sustained no negative outcome related to error. MD gave no new order r/t medication error. Nurse informed RP of same. All due care rendered. No distress noted. Call light w/in reach. Created by DON. Record review of progress notes dated 08/15/2023 at 05:22 for Resident #5 revealed: Nurse informed doctor regarding Tylenol # 3 eMAR missed documentation error which occurred on 04/19/23, 04/15/23, 04/16/23, 04/17/23, 05/2/23, 05/2/23, 05/4/23,06/05/23. Resident sustained no negative outcome related to error. MD gave no new orders r/t medication error. All due care rendered. No distress noted. Call light w/in reach. Record review of progress notes dated 08/15/2023 at 05:20 for Resident #6 revealed: Nurse informed doctor regarding Lyrica eMAR missed documentation error which occurred on 08/13/23 which time on narcotic sheet and eMAR did not completely match. Resident sustained no negative outcome related to error. MD gave no new order r/t medication error. Nurse informed resident of same. All due care rendered. No distress noted. Call light w/in reach. Created by DON Record review of progress notes dated 08/15/23 at 5:24 for Resident #11 revealed: Nurse informed doctor regarding Tramadol medication error, RX ordered was completed but Resident continues to receive Tramadol without MD ordered on the following dates: 12/24/22, 12/25/22, 12/26/22, 12/27/22, 12/28/22, 12/29/22, 12/30/22, 12/31/22, 01/01/23, 01/02/23, 01/03/23, 01/04/23, 01/05/23, 01/06/23, 01/07/23, 01/08/23, 01/09/23, 01/10/23, 01/11/23, 01/12/23, 01/13/,23, 01/14/23, 01/15/23, 01/16/23, 01/17/23, 01/21/23, 01/23/23, 01/25/23, 01/26/23. Resident sustained no negative outcome related to error. MD gave no new order r/t medication error. Nurse informed RP of same. All due care rendered. No distress noted. Call light w/in reach. Created by DON. Record review of progress notes dated 08/15/2023 at 5:35 for Resident # 13 revealed: Nurse informed doctor regarding Tramadol eMAR missed documentation error which occurred on 07/17/23, 07/23/23, 08/07/23. Resident sustained no negative outcome related to error. MD gave no new order r/t medication error. Nurse informed RP of same. All due care rendered. No distress noted. Call light w/in reach. Created by DON Interview on 08/17/2023 at 10:56 a.m., DON said facility does have a policy in place regarding medication administration. DON was asked how often she would conduct audits to make sure the Controlled Substance Record of Administration and eMAR coincided with each other, her response was daily. She said she would conduct random daily audits whenever she passed by a medication cart, whenever she would see a nurse administering medication or during care plan meetings. She said she would go over the eMAR and the Controlled Substance Record of Administration to make sure all doses were documented. DON said eMAR system was implemented one year ago and all staff were trained on how to use it. Surveyor asked DON if she conducted daily random audits of the eMAR and the Controlled Substance Record of Administration how could she have missed so many entries for Resident #8 and Resident #9, her response was she would have to check with the nurses to see what happened. Administrator was also present during the interview but did not participate in the interview. DON said she would have to get with her Regional Nurse to see if a new policy needed to be drafted related to documentation of medication. Interview on 08/17/2023 at 11:45 a.m., DON said regarding drug diversion/missed documentation, I cannot personally answer but make sure we are complying. She said she does random (daily) audits on eMAR and Narc sheets to make sure they coincide. If there is an issue with the nurses not documenting on eMAR then that is on them because they have been trained 100 % by the facility and are board certified by the state of Texas. She said she cannot answer for those nurses that are not following policy. DON said her safety net is she conducts daily random audits and before 08/17/2023 she had not found any discrepancies during those daily random audits. DON said it was not until the Immediate Jeopardy was identified when she and ADON conducted 100% audits on all resident's eMAR, and Controlled Substance Record of Administration and discrepancies were identified. DON said facility has nurses that are not complying with their policy of documenting on eMAR, and it has been reported to the state as non-compliance. DON said police has also been notified. Administrator was present but did not participate in the interview. The DON said she had trained all licensed staff in the above trainings. She said she will be conducting daily reviews of all new medication orders during the morning meetings to verify all orders were entered correctly for 30 days. She/designee will review the 24-hour report daily for 30 days to verify that any resident with a change of condition has physician and family notification. The DON/designee will do random skill validation review with licensed nurses to verify medication administration competency and knowledge on what steps to take if a significant error occurs. The DON said she or designee will be responsible to ensure all licensed nurses were proficient in Medication Administration. Interview on 08/17/2023 at 12:40 p.m., Administrator said she has reported all discrepancies found in the above audits to the state and police. She said she will make sure DON/designee follow up on the conditions listed above for the next 30 days. Administrator said DON/designee will use the QAPI Narcotic form for 30 days to ensure all controlled substance are reconciled with the eMAR. The Immediate Jeopardy was removed on 08/17/2023 at 2:30 p.m.

Based on observation, interview and record review the facility failed to ensure adequate supervision and assistive devices to prevent accidents for 1 resident (R#4) of 7 residents reviewed for accidents, in that: Registered Nurse (RN E) and Certified Nurse Assistant (CNA D) failed to use a mechanical lift to transfer R#4 resulting in R#4 sustaining a left femoral fracture. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 03/03/2023 and ended on 03/09/2023. The facility corrected the non-compliance before the investigation began. Past Non-Compliance form sent to Administrator on 8/11/2023 at 7:23 PM. This failure could lead to the injury of residents that are transferred with a mechanical lift. The findings included: Record review of R #4's file reflected an [AGE] year-old female, with an original admitted [DATE]. Diagnoses included: Osteoporosis (bones become weak and brittle), fracture of lower end of left femur (upper leg), Myalgia (muscle pain), fracture of left tibia (one of the two bones that connects the knee with the ankle bones), fracture of upper end of left humerus (upper arm), history of falling, Major Depressive Disorder, Epilepsy (disturbed nerve cell activity in the brain), Hemiplegia (paralysis of one side of the body), muscle wasting and atrophy, and muscle weakness. Record review of R #4's MDS assessment dated [DATE] reflected R#4 had a BIMS score of 15 (cognitively intact), required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, dressing, toilet use, and personal hygiene. The MDS also reflected R #4 required total dependence (full staff performance every time during entire 7-day period) with transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position). R #4 required a two-person physical assist for bed mobility, transfer, dressing, toilet use, and personal hygiene. Record review of R #4's Care Plan dated 06/26/2023 reflected R #4 sustained alteration in musculoskeletal status related to left hand contracture-hemiplegia, left humerus fracture, left tibia fracture, and left femur fracture. R #4's care plan also reflected R #4 required total assistance x 2 with mechanical lift for transfers. Record Review reflected a progress note documented by RN E indicated on 03/03/2023 RN E and CNA D transferred R #4 from her wheelchair to the bed at approximately 5:54 PM. RN E and CNA D transferred R #4 without a mechanical lift. At the time of the transfer R #4 complained of pain to her left leg. An order for an x-ray was obtained. Further review of R #4 nurse's notes documented by RN F on 03/03/2023 at 8:30 PM reflected R #4 complained of pain and was sent out to the hospital for an x-ray approximately 2 hours later. The hospital x-ray revealed a distal fracture (break in the bone just above the knee) of the left femur. Record review of a progress note documented by RN F dated 03/04/2023 at 3:44 AM indicated R #4 stated she did not fall at any time. She stated that during the day shift, when she was being transferred from the bed, the mechanical lift was not working and that an attempt was made to transfer her. That was when she felt pain to her left lower extremity and immediately the attempt to transfer her was stopped. Nurse Practitioner was informed. Record review of the facility investigation dated 03/11/2023 revealed CNA D and RN E conducted a manual transfer due to the mechanical lift not operating. CNA D informed RN E of the mechanical lift not working, and RN E decided to do a manual transfer with CNA D. R #4 complained of pain to her left lag. RN F notified the doctor. X-ray results showed no fracture. R #4 continued to complain of pain. RN F notified the doctor. New order to send R #4 to the emergency room for evaluation and treatment. R #4 returned to the facility with no fracture and no hospital paperwork. RN F contacted the hospital and RN F was told R #4 had a left femoral fracture. New orders for pain medication. The Administrator interviewed R #4. R #4 stated she did not fall. R #4 stated she did not feel the incident was intentional and she gets good care at the facility. Investigation findings: Unfounded. Provider action taken post-investigation: RN E and CNA D were terminated. In-serviced all staff on abuse, neglect, fall management, Hoyer transfer, and plan of care. Transfer skill review. Interview with R #4 on 08/08/2023 at 11:45 AM revealed RN E and CNA D transferred her without using the mechanical lift, resulting in pain to her left leg when her left leg got stuck under her right leg during the transfer. She was checked by the nurse, sent to the hospital, and was diagnosed with a fracture. Interview with RN F (incoming shift nurse on 03/03/2023) on 08/10/2023 at 10:30 AM revealed R #4 was transferred by RN E and CNA D without a mechanical lift. RN F said he was not working when the transfer was done as he came into his shift after. RN F said he was working when R #4 was complaining of pain and R #4 was sent out the hospital due to pain to her left leg. It was determined R #4 obtained a fracture to her left leg. RN F said he recalled RN E being in a hurry to leave the facility during their shift change. RN F said the facility did trainings after this incident on how to properly use the mechanical lift. RN F said whenever there is an incident, the facility also does trainings on abuse/neglect, resident rights, and fall prevention, which the facility also did in this case. Interview with the Maintenance Supervisor on 08/10/2023 at 1:15 PM revealed the facility had a total of four mechanical lifts used for transfers. He added that the lifts were serviced every 3 months by the medical equipment provider. Maintenance Supervisor said there had not been any inoperable lifts or issues reported during the month of March 2023. Interview with the DON on 08/10/2023 at 3:40 PM revealed RN E and CNA D transferred R #4 without a mechanical lift, resulting in a femoral fracture to her left leg. The DON indicated that both staff were feeling pressured because at the time of transfer, R #4 was crying and wanting to get into bed, although the sling for the lift was not positioned well. The DON said CNA D and RN E did not use the lift because of the sling, not because the lift was not working, or the battery was not charged. The DON added that if there was any issue with the mechanical lift, whether it was the battery, lift, or sling, staff should get another mechanical lift, and not transfer the resident manually. The DON said staff should have followed R #4's care plan which indicated that she required a two-person transfer with the mechanical lift. The DON said R #4 had Osteopenia and brittle bones. The DON said failing to use the mechanical lift, placed R #4 at risk of obtaining injuries such as fractures, which was what ended up happening. The DON said all staff had been re-educated on the proper usage of mechanical lifts and transfers, on abuse/neglect, fall management, and resident rights. Interview with the Administrator on 08/11/2023 at 11:45 AM revealed RN E and CNA D transferred R #4 without a mechanical lift, resulting in a left femoral fracture. The Administrator said staff were trained on how to properly transfer residents. The Administrator said staff are trained when they are hired, annually, quarterly, and as needed. The Administrator said all staff were trained again after this incident with R #4. The Administrator added that there were several mechanical lifts, batteries, and extra slings that can be used at any time throughout the facility. The Administrator said the staff should have taken steps to follow R #4's care plan. The Administrator said RN E and CNA D were both terminated due to poor performance during the incident. The Administrator said to prevent an incident like that from reoccurring, they re-trained and re-educated all staff. The Administrator said staff have been in-serviced on mechanical lifts, transfers, resident rights, abuse/neglect, and fall management. The Administrator said they completed the in-services with all staff to ensure they knew where the batteries were located, how to properly use the sling, and the lift. The Administrator said the skills review for all staff were completed where staff demonstrated how to complete the skills. The Administrator said there have not been any similar situations or issues happen since then. Record Review of the Transfer of Residents Policy dated, 05/2012 revealed: -Transfers are defined as the act of moving a resident from one surface to another. The goal is to ensure the safety of the resident when moving from one place to another, to prevent injuries to the resident. Record Review of the Mechanical Lift Policy dated, 04/24/2014 revealed: -To move immobile residents from whom manual transfer poses potential for a resident injury. The following observations, interviews and record reviews were conducted by the survey team to ensure the Past Non-Compliance was corrected by 03/09/2023: -The following interviews were conducted by the Survey Team on 08/09/2023 and 08/10/2023: 2 CNA's, 2 LVN's, and 1 RN. -Staff acknowledged understanding of the topics they were in-serviced regarding the mechanical lift. -In-services reflect 57 staff were trained on the mechanical lift from 03/04/2023-03/09/2023. -Interviews with the DON, Administrator, and record review of the employee files reflected that CNA D and RN E were terminated due to poor performance during the incident with R #4. -On 08/17/2023, CNA N and CNA O were observed during a transfer with a mechanical lift. No discrepancies were noted. Interview with R #5 on 08/08/23 at 2:00 PM revealed she was doing fine. When asked if she had any issues with her care, R #5 shook her head no. When asked if she had any complaints or concerns, R #5 shook her head no. Other baseline questions were asked. However, R #5 would mumble or was clearly not understood. Interview with CNA A on 08/09/2023 at 1:55 PM revealed CNA A worked and transferred R #4 on the morning of 03/03/2023. CNA A said the mechanical lift was working on the morning of 03/03/2023 without issue. CNA A said if the mechanical lift was not working properly due to the battery or other reason, the staff should not do the transfer without the lift. CNA A said they should look for another battery or another lift. CNA A said R #4 required a two-person transfer with the mechanical lift. CNA A said the facility did trainings on how to use the lift properly, abuse/neglect, fall management, and rights. CNA A said the trainings are completed constantly, but the trainings were also completed after R #4 was injured. Interview with LVN C on 08/09/2023 at 3:00 PM revealed LVN C worked on 03/04/2023 when R #4 was requesting a police report be made for her injury. LVN C said she had informed the nurse and the nurse indicated to go ahead and call the police. LVN C said an officer came out to the facility and spoke to R #4 regarding her fracture. LVN C said she was not working on 03/03/2023 when R #4 got injured. LVN C said R #4 has always been a two person transfer with the mechanical lift. LVN C said the battery for the lift is charged in the supply room. LVN C said it is up to everyone to ensure the battery is charged. LVN C said there are extra lifts in the facility. LVN C said the facility did do trainings for abuse/neglect, rights, fall management, and how to use the lift properly. LVN C said the DON also did a skills review. LVN C said the trainings are done constantly but they were also done after R #4 was injured. Interview with LVN G on 08/10/2023 at 2:05 PM revealed LVN G said the extra battery for the lift is charging in the supply room next to the nurse's station. LVN G said when staff are hired, they are shown where the battery is kept. LVN G said if the lift is not working or if the battery is not charged, then the staff should tell the resident to wait a moment. LVN G said the staff can either look for another lift, change the battery, or charge the current battery a bit to use the lift. LVN G said the staff should not do the transfer without the lift if the resident requires it as they need to follow the care plan. LVN G said the facility constantly do trainings, but they were also done after R #4 was injured on 03/03/2023. LVN G said the trainings were on abuse/neglect, rights, fall management, and how to use the lift properly. LVN G said they were told about the extra batteries, extra slings, and how to ensure the lift is working before trying to use it. Interview with CNA H on 08/10/2023 at 2:35 PM revealed CNA H said R #4 requires the two-person transfer with the mechanical lift. CNA H said whenever she is going to use the mechanical lift, she ensures is has battery and that it is in good condition to use. CNA H said there is an extra battery in the supply room by the nurse's station. CNA H said if the mechanical lift is not working, the staff should look for another one. CNA H said the facility constantly does trainings with them to ensure they know how to do transfers or about abuse/neglect. CNA H said the DON did a training to review their skills after R #4 got hurt on 03/03/2023. CNA H said the DON also did trainings on abuse/neglect, rights, fall management, and how to use the lift properly. In an observation with R #17 on 08/10/23 at 5:35 PM. CNA N and CNA O knocked on the door, closed the door and washed their hands. CNA N closed the blinds. The CNAs explained to R #17 what they were going to do. CNA O turned him to place sling under his right side. CNA N turned him to place the sling under his left side. The CNAs kept asking R #17 if he is okay throughout process. CNA N moved the Hoyer lift into position and put on the brakes. CNA N lowered the mechanical lift. The CNAs connected the clips into place. CNA N lifted the mechanical lift using the remote. The CNAs comforted R #17 throughout, ensuring him he was okay. The CNAs moved the mechanical lift over with R #17 in the sling. The CNAs positioned the lift in front of the wheelchair and put the brakes on the lift. CNA N lowered the sling. The CNAs ensured R #17's feet, body, and wheelchair were in good position as the sling was lowered to the wheelchair. The CNAs unhooked the sling. CNA N moved the lift away. CNA O moved R #17 in the wheelchair and positioned him in front of the television. CNA O informed R #17 that it would be time for dinner soon. In an interview with R #17 on 08/10/23 at 5:46 PM, R #17 was asked what his name was and how was he doing. R #17 did not respond. R #17 was asked other baseline questions, but he did not respond. Record review reflected that from 03/04/2023-03/09/2023 all staff were in-serviced and re-educated on the proper usage of the mechanical lift, mechanical transfers-staff to use 2-person assist for mechanical transfers, staff to audit the mechanical lift prior to moving the machine, assure battery was charged, slings were matching, intact, and not torn. If the battery was not charged, staff were to find a new charged battery promptly. Plan of care-staff to follow the resident's plan of care at all times. The facility also in-serviced and re-educated all staff on resident rights, abuse/neglect, and fall management. A skills review was also completed for transfers including performance criteria of: properly cleaned hands prior to procedure, explained procedure to resident and encouraged resident to participate, provided for privacy as appropriate, used transfer device specified by care plan (Hoyer, slid board, etc.), used gait belt and obtained assistance as indicated by care plan, locked brakes or stabilized chair if not equipped with brakes, safely transferred resident using proper body mechanics, and type of transfer observed (chair to bed, bed to chair, chair to commode). Record review on 08/11/23 reflected there were 34 residents in the facility that use a mechanical lift, including R#4, R #5, and R #17. Record Review of Employee files reflected: RN E - Acknowledgement of abuse neglect and exploitation on 05/21/2021 Date of hire for RN E - 05/27/2021 CNA D - Acknowledgement of abuse neglect and exploitation 01/11/2023 Facility trainings done on 01/11/2023 for CNA D included: Reporting abuse, neglect and misappropriation of belongings, and Residents rights and responsibilities. Date of hire for CNA D - 01/13/2023

Based on interviews and record review, the facility failed to immediately consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status due to medication error for one (Resident #7) of three residents reviewed for resident rights. The facility failed to notify Resident #7's physician in a timely manner when Resident #7 was administered 1 ml of Morphine Sulfate (concentrate) Oral Solution 100 MG/5ML (Morphine Sulfate) instead physician's order of 0.1ml morphine sulfate on 01/10/2023. An Immediate Jeopardy was identified on 08/11/2023. The Immediate Jeopardy template was provided to the facility Administrator on 08/11/2023 at 7:23 PM. While the Immediate Jeopardy was removed on 08/13/2023 at 6:54 p.m., the facility remained out of compliance at a scope of isolated and severity level of actual harm because of the facility's need to complete in-servicing and monitoring interventions. This failure could place residents at risk of not receiving appropriate care and interventions and/or death. The finding included: Record review of Resident #7's Admission Record dated 12/12/2022 indicated Resident #7 was an [AGE] year-old female and was admitted to facility on 09/28/2022 with the following diagnosis: of encephalopathy (a broad term for any brain disease that alters brain function or structure), COVID-19, lobar pneumonia (acute exudative inflammation of the entire lobe), generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), gastro-esophageal reflux disease without esophagitis (a type of Gerd that does not involve inflammation of the esophagus), spinal stenosis, cervical region (narrowing of the spinal canal), dependence on supplemental oxygen, depression, acute respiratory failure with hypercapnia, type 2 diabetes mellitus without complications, hyperlipidemia (elevated levels of lipids like cholesterol and triglycerides in the blood), chronic pain syndrome, hypertension, chronic ischemic heart disease ( heart problems caused by narrowed heart arteries), peripheral vascular disease, constipation, secondary kyphosis (fracture in one or more vertebral bodies) spondylosis (age related wear and tear of the spinal disks), adult failure to thrive, and history of falls. Record review of Resident #7's MDS assessment, dated 12/15/2022 indicated: -BIMS score was 15 (cognitively status independent, decisions consistent/reasonable) -Coded as being under hospice care -required limited assistance with one person assist with bed mobility, transfer, walk-in corridor, walk-in-room, and toilet use -required supervised with one person assist for locomotion on unit, locomotion off unit, dressing and personal hygiene -was independent with setup help only for feeding -history of falls prior to admission/entry or re-entry Record review of Resident #7's comprehensive care plan dated 09/29/2022 revealed: Resident #7 was under hospice Focus: Resident #7 has a terminal illness and is receiving hospice or palliative care. During the end-of-life process weight loss, skin breakdown, dehydration, fecal impaction, and the gradual o or rapid loss of the ability to move may be unavoidable. Date initiated: 01/08/2023 Goal: Dignity will be maintained, and the resident will be kept comfortable and pain free within one hour of interventions through the next review. Date initiated: 01/08/2023 Interventions: Coordinate with hospice to ensure the resident's spiritual, emotional, intellectual, physical, and social needs are met. Date initiated 01/08/2023; Assist with ADL's and provide comfort measures as needed. Date initiated 01/08/2023; Monitor for abnormal weight loss, poor appetite, and skin breakdown. Report abnormals to the physician as noted. Date initiated 01/08/2023; Monitor for signs and symptoms of increased pain, discomfort-give medications and treatments as ordered and monitor for relief. Date initiated 01/08/2023. Record review of Resident #7's comprehensive care plan dated 09/29/2022 revealed Morphine Sulphate (concentrate) Oral Solution 100 mg/5 ml (morphine sulfate) was not care planned. Record review of Resident #7's eMAR for January 2023 revealed: Morphine Sulfate (concentrate) Oral Solution 100 mg/5ML (morphine Sulphate) Give 0.1 ml by mouth every 1 hours as needed for severe pain 7-10. Start date-01/09/2023 16:01 and discontinue date-01/11/2023 08:22. Further review of eMAR indicated Resident #7 did not receive Morphine Sulfate (concentrate) Oral Solution 100 mg/5ML (morphine sulfate) from January 09, 2023, through January 11, 2023. Physician order viewed under orders. Record review of Resident #7's progress note dated 01/09/2023 at 16:04 (04:04 p.m.) revealed Note: This order is outside of the recommended dose or frequency. Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML Give 0.1 ml by mouth every 1 hours as needed for Severe Pain 7-10 Pain. Record review of Resident #7's progress note dated 01/10/2023 at 14:00 (04:00 p.m.) revealed eMAR Medication Administration Note: Duplicate Order - Note Text: Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML Give 0.1 ml by mouth every 1 hours as needed for Severe Pain 7-10 Pain Record review of Resident #7's progress note date 01/10/2023 at 18:47 revealed eMAR Medication Administration Note: Duplicate Order - Note Text: Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML Give 0.1 ml by mouth every 1 hours as needed for Severe Pain 7-10 Pain Both progress notes dated 01/10/2023 at 14:00 and 18:47 had been struck off. Record review of Resident #7's comprehensive care plan and progress notes indicated no notes from facility why Resident #7 was sent to the hospital. Record review of the hospital records for Resident #7, dated 01/10/2023 at 18:23 (06:23 p.m.) revealed the following: Patient is an 87 y/o (year old) F (female) with PMH (past medical history) of DM (diabetes mellitus), CVD (cardiovascular disease) with no residual effect per son who presents as trauma admission s/p (status post) unwitnessed GLF (ground level fall) at 17:00 on 01/10/2023. Per family member patient lives in a nursing facility and had a fall from her wheelchair as she was trying to get up. No LOC (loss of consciousness). Patient at baseline is non ambulatory; uses a wheelchair. On presentation, patient difficult to awaken, sternal rub elicits limited response. History limited due to patient's status; patient family member present at bedside is also unclear of history. Physical Examination: General: minimally responsive; open eyes minimally after sternal rub. Eye: unable to examine HENT: V shaped laceration on the left side of forehead Respiratory: Lungs are clear to auscultation, respirations are non-labored Cardiovascular: Normal rate, regular rhythm, good pulse equal in all extremities Gastrointestinal: soft, non-tender, non-distended Musculoskeletal: unable to examine Integumentary: decubitus ulcer in sacral area and heal, present on admission Neurologic: minimally responsive to sternal rub Cognition and Speech: unable to examine Psychiatric: unable to examine. Impression and Plan Patient non arousable initially on exam. Head CT on arrival shows 0.4 subdural hematoma, repeat CT head recommended in the AM. Hospital [NAME]: Heat CT (cat scan) on arrival shows 0.4 mm subdural hematoma. Dr. consulted recommended repeat CT (cat scan) head the following morning which was stable with 4 mm subdural hematoma. No intervention per neurosurgery. Patient is complaining of neck pain with history of cervical stenosis, previous workup negative for acute cardiac pathology. Patient's family requested application to new SNF (skilled nursing facility), during her stay patient had no acute events. Patient is ready for discharge. Operative Report: Consent: signed by patient Location: forehead Preparation and technique: 3 sutures placed Interview on 08/10/2023 at 5:55 p.m. via telephone with LVN A, revealed on 01/10/2023 at about 4:00 p.m. Staff F came to the nurse's station where she was and advised her Resident #7 was requesting pain medication due to having neck pain. Staff E said she told Staff F Resident #7 had recently been prescribed Morphine for pain. LVN A said she and RN A walked over to Resident #7's room because she wanted to make sure Resident #7 was alert and I just wanted to observe her to make sure she was in pain. LVN A said she had been in Resident #7's room a short time before and she did not complain of any pain. Upon entering Resident #7's room, Resident #7 was observed sitting in her wheelchair next to her bed. LVN A said Resident #7 did complain of neck pain and requested pain medication. At that time LVN A said she and RN A went outside to the hall and unlocked the med cart and pulled the Morphine box out and compared the label on the box with the order which indicated to give 0.1 ml as needed for pain every 1 hour. LVN A said after she and RN A verified the name, dosage, and route she went back to Resident #7's room to transfer her to bed while RN A stayed in the hall preparing the medication. LVN A said she transferred Resident #7 back to bed and advised her not to get up and if she needed anything to make sure to press the call light. Soon after that RN A came into Resident #7's room and administered Morphine. LVN A said RN A held up the syringe, showed it to her, and asked if it was ok to administer the Morphine, LVN A said, I didn't physically look at the syringe, but I said yes, and RN A administered the Morphine orally. LVN A said we both left back to the nurse's station and immediately RN A said she thought she had given Resident #7 the wrong dose of Morphine. At that point, LVN A replied, what do you mean RN A repeated I gave Resident #7 the wrong dose. LVN A said she immediately walked over to the med cart unlocked it and pulled the Morphine box out of the narc box to check the syringe. LVN A said after Morphine was given to a resident #7, the syringe was placed in a red plastic bag and placed back in the manufacture's box along with the Morphine. LVN A said when she checked the manufacture's box the syringe was not there. LVN A asked RN A where she had left the syringe and her response was I think I left it in Resident #7's room. LVN A said she went to Resident #7's room and found the syringe in a plastic bag on top of the dresser. At that point, RN A picked up the syringe and pointed to the 1.0 ml and told LVN A that's how much I gave her. LVN A said the facility has no protocol on how to manage medication errors, she said what she did after learning of the medication error was what she learned in nursing school. LVN A said she had been working at this facility for about 5 years and was trained on medication pass when hired. LVN A said she immediately went to check on Resident #7 and found her to be alert, not in respiratory distress and still lying-in bed. LVN A said, I don't remember if RN F or I notified hospice nurse, DON, and family member but they were notified immediately of the medication error. LVN A said I went to check on Resident #7 couple more times, I checked her breathing and was not in distress and was alert. LVN A said she does not remember the exact times she checked on Resident #7's saying, it's been a while. LVN A said between 5:30 p.m. and 5:45 p.m., a CNA was walking by Resident #7's room and noticed her laying on her left side on the floor. CNA called for help and LVN A ran to assist her. LVN A said Resident #7 was right by the door laying on her left side, bleeding from her forehead and had a bump on top of her scalp. LVN A said Resident #7 told her she managed to get out of bed, sit herself on her wheelchair when she tried reaching for something and fell . LVN A said she asked Resident #7 why she had gotten out of bed, and she replied, you know I'm stubborn. LVN A said she called Resident #7's doctor to inform of fall and was given instruction to send Resident #7 to the hospital to be evaluated. LVN A was asked if she notified Resident #7's doctor of the morphine dose error and she said yes adding I also notified the hospital when I called to let them know we were sending Resident #7 to the ER due to the fall. LVN A said Resident #7 was sent to the hospital due to the fall and not to the Morphine medication error. LVN A said Resident #7 had a history of falling and had received stiches on her head before due to the falls she had sustained since being admitted . LVN A said she made an incident report related to the medication error and the fall Resident #7 sustained on 01/10/2023. Surveyor asked LVN A how a medication error of Morphine negatively affect Resident #7 she replied to the most serious side effect could be respiratory distress. LVN A said the next day (01/11/2023) the DON and Administrator provided both she and RN A an in-service training on medication errors, were counseled individually and suspended for 3 days pending an investigation. Surveyor asked LVN A if RN A had given an explanation as to why she gave the wrong dose and she said RN A told her that in her previous job it was customary to give 1.0 of morphine so she figured it was the same at this facility. Interview via telephone on 08/11/2023 at 9:40 a.m., Primary Care physician (PCP) said he was not informed of Resident #7's morphine medication error. He said he wanted to make sure we understood this was the first time he was informed. The PCP said if he had been informed of the morphine medication error that would have unleashed a whole new protocol. Surveyor asked what he would have instructed the nurse to do, he replied, there would have been two possible responses. If resident was not experiencing respiratory distress, pulse was within range, she was cognitively aware, and heart rate was not abnormal, I would have instructed the nurse to observe the resident continuously (he did not say how long because everyone is different), resident did not need to be sent to the hospital because at that point because resident was stable. If the resident were experiencing respiratory distress, pulse was not within range, was not cognitively aware, and heart rate was abnormal, he would have instructed the nurse to administer Narcan and sent to hospital immediately. The PCP said Resident #7 received 10 times her prescribed order of morphine. PCP said 1.0 is the max dose of morphine and not deadly for a hospice resident because eventually they will require a higher dose. The PCP said Resident #7 still needed to be monitored for any adverse effect. Interview via telephone on 08/11/2023 at 10:30 a.m., The Hospice DON said Resident #7 was placed on hospice due to respiratory failure. The Hospice DON said facility called hospice at 09:32 p.m. on 01/10/2023. to inform them Resident#7 suffered a fall and sent to the hospital due to sustaining a hematoma to her forehead. The Hospice DON said on 01/11/2023 at 11:15 a.m. Facility's DON called them and advised of the morphine medication error. The Hospice DON said facility's DON said the syringes that came in the manufacture's box of the morphine medication did not have numbers only lines and that could have caused RN A to administer the wrong dosage of morphine to Resident #7. The Hospice DON said the medication/syringe was delivered by the pharmacy and it was considered a multi-use syringe. The Hospice DON said as a correction plan the hospice company delivered 10 to 15 syringes with numbers to avoid another medication error. The Hospice DON said if the facility had called immediately after the morphine medication error, she would have sent the hospice RN to the facility to assess Resident #7. The Hospice DON said she would have also instructed hospice RN to check her level of consciousness more frequent, her vitals for hypertension and fall precautions for at least 2 hours after medication error. The Hospice DON said Narcan would have been ordered depending how Resident #7 looked. Interview via telephone on 08/11/2023 at 11:00 a.m. The Hospice DON called back to say she had spoken to the previous acting hospice DON (at time of incident) who had clarified the first-time facility's DON had reported morphine medication error was on 01/11/2023. The Hospice DON also verified they had notified Resident #7's primary physician of her fall on 01/10/2023 at 9:30 p.m. Interview on 08/11/2023 at 11:15 a.m., LVN A said she had struck out Morphine entry on progress notes at 18:47 on PCC because she was not the one who had administered the morphine to Resident #7. Interview via telephone on 08/11/2023 at 12:50 p.m., RN A said on January 10, 2023, at approximately 4:00 p.m. while working under the supervision of Staff E (as it was her first day on the floor since being hired) she walked into Resident #7's room to check on her. RN A said Resident #7 complained of neck pain and requested pain medication. She immediately went looking for LVN A and found her in the nurse's station. She informed LVN A Resident #7 was requesting pain medication due to neck pain. RN A said she was told by LVN A Resident #7 was under hospice care and had a PRN (as needed) order of Morphine. RN A said she proceeded to the medication cart to prepare the syringe with the morphine solution. RN A said after she prepared the syringe with the morphine solution, she went looking for LVN A. RN A said she found LVN A in the medication storage room and appeared to be talking to someone on the phone because she had an ear pod in one ear. RN A said she signaled LVN A though the glass window to come out. RN A said LVN A opened the door without coming out and at that time they both checked the Morphine order with the label, name, dose, route, and I showed her the syringe with the morphine solution, and she nodded yes, she gave me a thumbs up. RN A said she then proceeded to Resident #7's room to administer the morphine. RN A said she first educated Resident #7 on the medication she was going to receive and transferred her back to her bed and administered the Morphine oral solution. RN A said she went to check on Resident #7 after 30 minutes or 1 hour (was not sure on the time) and Resident #7 was good, being her normal self. RN A said, we did our thing throughout our shift and around 5 or 6 p.m. LVN A calls out for help because Resident #7 had fallen and had a wound on her forehead. RN A said she stayed with Resident #7 while LVN A went to call 911. RN A said Resident was found between her bed and bathroom. RN A said she discovered the morphine medication error at about 6:30 p.m. when she was looking back at the eMAR and discovered I have given more than I should. RN A said she immediately informed LVN A but does not remember what her response was. RN A said, I texted DON at 6:31 p.m. telling her LVN A and I wanted to meet with her tomorrow to review possible med error. RN A said she texted DON because it was after working hours and DON was no longer at facility. As per RN A, DON responded back via text at 7:00 p.m. telling her Yes, please do so. RN A said Resident #7 had already been discharged to the hospital by the time she discovered the morphine medication error. RN A said sometime before the end of her shift LVN A told her We could have fixed it RN A reply to LVN A was there's no fixing, I gave what I gave. Surveyor asked RN A if she knew what LVN A meant by that and she said, to put 0.1 ml in the narc sheet even though I had given 1.0 ml of morphine. RN A said the next morning, DON met with both and them together and individually. She said they also had a general training with all nurses to make sure all nurses were doing their job. RN A said she received training on how to read eMAR and was not sure on the topics of other trainings received after med error incident. She said she and LVN A were suspended pending the outcome of the investigation. Surveyor asked RN A how Resident #7 could have been negatively impacted by receiving 1.0 ml of morphine sulfate instead of the ordered 0.1 ml, she said her breathing distress and high blood pressure. Staff F said 1.0 ml of morphine sulfate was appropriate for hospice patients but there must have been a reason Resident # 7's doctor had prescribed 0.1 ml of morphine sulfate. RN A said she decided to voluntarily quit her job as a registered nurse at the facility because she was told by someone LVN A had written a statement saying she had never shown her the syringe. RN A said she believed they would take LVN's statement over her since she had just been hired. RN A also said it was not a healthy environment and did not feel comfortable working at the facility. LVN A said she took a picture of the syringe used to administer the morphine sulphate to Resident #7 Interview via telephone on 08/11/2023 at 11:20 a.m. The Medical Director said he was informed of Resident #7's medication error by the facility's nurse on duty (did not have nurse's name) on 01/11/2023 and was not sure of the time either. The Medical Director said he and the rest of the QAPI team discussed medication error on 02/23/2023. The Medical Director said during the meeting they checked narcotic orders for all residents. The Medical Director was asked how Morphine medication error could negatively impacted Resident #7 and his response was she could have suffered neurological sedation, respiratory depression or excessive sedation but added Resident #7 did not have any negative effects. The Medical Director said if Resident #7 had suffered any side effects he would have ordered Narcan and sent to the hospital immediately. The Medical Director emphasized he was available to the facility 24/7 and facility did not notify him immediately. Interview on 08/11/2023 at 3:00 p.m., The DON said she expects all her nurses to inform her immediately in case of a medication error. She said if she was not at facility (after working hours) she expects a call from them immediately. The DON said she will ask the nurse what medication was given, the dosage and the correct dosage and depending on what they tell her, she would instruct them to either monitor or send to hospital. The DON said she immediately notifies resident's primary physician, family representative, medical director, and administrator of the medication error. The DON said after resident was cared for, she would complete the medication error report, start an investigation, re-educate staff and report to HHSC. The DON said the medication error was discovered after Resident #7 was discharged to the hospital due to sustaining an unwitnessed fall. The DON said Resident #7 had a history of falls and was non-compliant. The DON said she notified Resident # 7's primary doctor and hospice immediately of the fall but was not sure if she informed them of the medication error on the same day. The DON said the fall or medication error was not care planned because Resident #7 did not go back to facility after being discharged from hospital. Interview on 08/11/2023 at 3:30 p.m., The Administrator said facility's policy regarding medication error was for the nurses to let the DON know immediately after discovering a medication error was occurred. The Administrator said depending on how the resident was feeling, DON will instruct of appropriate action. The Administrator said it was the DON's responsibility to inform her of any medication errors immediately after being notified of one. The Administrator was asked how a morphine medication error could negatively affect Resident #7; her response was I don't know how to answer that question. Observation on 08/11/2023 at 1:41 p.m. RN A texted picture to surveyor and it showed a thin syringe with 4 lines (0.25 ml, 0.50 ml, 0.75 ml, and 1 ml). Record review of print out facility provided revealed five residents who were currently receiving Morphine. Record review sample audit conducted by DON showed five resident who were currently receiving Morphine. Record review of facility's policy Notification of Changes dated 01/10/2020 revealed: policy To provide guidance on when to communicate acute changes in status to MD, NP, and/responsible party. The facility will immediately inform the resident: consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family member(s) of the following: An accident resulting in injury to the resident that potentially requires physician intervention a significant change in the physical, mental or psychosocial status of the resident The need to significantly alter the resident's treatment The facility documents resident assessment(s), interventions, physician and family notification(s) on SBAR, Nurses Progress Notes, or Telephone Order Form (physician/family notice) as appropriate INTERACT IV may be used as a resource for evaluating resident change of condition for physician notification a. Immediate Physician Notification-the physician is notified immediately and should respond timely (within minutes), the Medical Director will be contacted before the resident will be sent for emergency room evaluation. b. Non-Immediate Physician Notification-the physician is notified and there should be a return call within the same day (worsening of symptoms use Immediate Physician Notification steps) The Administrator was informed the Immediate Jeopardy was removed on 08/13/2023 at 6:54 p.m. The facility remained out of compliance at a severity level of 4 and a scope of J due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 1. Immediate Action Taken On 1/10/2023 resident # 7 was sent to the hospital and never returned to the facility. On 8/11/2023 DON/Designee completed an audit of all residents receiving Morphine in the center to verify that correct dose of Morphine was entered into the computer. This will be completed at 10:00 pm on 8/11/2023. On 8/11/2023 DON/Designee completed rounds on all residents to verify that a physician's notification was completed if a resident was identified with a change of condition. No residents were identified On 8/11/2023 DON/Designee started education with all licensed nurses on: o Policy on Medication Administration Guidelines that provide directions on the process of verifying labels for accuracy, verifying administration accuracy, verifying a focused assessment, administering the medication according to the physician's orders. This will be completed by 10:00 pm on 8/11/2023, and no licensed nurse will be allowed to work until they have received this education. o Policy on Preventing/Detecting adverse consequences and Medications errors that provides directions to license nurses on immediate actions to take for a signification medication related error or adverse consequence: License nurse will notify the attending physician promptly of any significant error or adverse consequence License Nurse will Immplement (that is how it was written on POR) orders as directed by physician, and the resident is monitored closely for 24 to 72 hours or as directed. License Nurse will Communicate with other across shifts as indicated to alert staff of the need to monitor resident License Nurse will Complete an Incident report or Medication error form License Nurse to Report significant error to the DON DON will report significant error to Consultant Pharmacist This will be completed by 3:00 pm on 8/12/2023, and no licensed nurse will be allowed to work until they have received this education. The DON/Designee will be responsible for ensuring all license nurses understand and follow the guidelines for a significant error or adverse consequence. o Policy on Notification Change of Condition that provides directions on notifying family and physician when a change in a resident's conditions occurs. This will be completed by 10:00 pm on 8/11/2023, and no licensed nurse will be allowed to work until they have received this education. o A skills competency on Medication Administration will be completed for all license nurses, validating proficiency in Medication Administration to validate medication administration competency and action to take if a significant error occurs. The DON/Designee will be responsible to ensure all license nurses are proficient in Medication Administration. This will be completed by 10:00 pm on 8/11/2023, and no licensed nurse will be allowed to work until they have received this education. 2. Identification of Residents Affected or Likely to be Affected: On 8/11/2023 DON/Designee started an audit review of all residents with new orders for the past 7 days to verify that correct dose of medications was entered into the computer correctly and no significant error occurred. This will be completed by 10:00 am on 8/12/203. 3. Actions to Prevent Occurrence/Recurrence: The DON/Designee daily will review all new medication orders during the morning meeting to verify all orders were entered correctly x 30 days. The DON/Designee daily will review the 24-hour report daily x 30 days to verify that any resident with a change of condition has physician and family notification. The DON/Designee will do random skills validation reviews with licensed nurses to verify medication administration competency and knowledge on what steps to take if a significant error occurs. The DON/Designee will be responsible to ensure all licenses nurses are proficient in Medication administration. On 8/11/2023 at 8:15pm the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy's the facility received related to residents free from significant medication error and Notification in change of condition and reviewed plan to sustain compliance. Verification: Started on 08/14/2023 at 8:30 a.m. and included: The following observations, record reviews and interviews were conducted by the survey team to ensure licensed staff's understanding of in-service trainings received between 08/11/2023 and 08/13/2023: Observation on 08/16/2023, LVN C was observed during med pass by survey team, no discrepancies were observed. Observation on 08/16/2023, LVN D was observed during med pass by survey team, no discrepancies were observed. Observation on 08/16/2023, LVN D was observed during med pass by survey team, no discrepancies were observed. Observation on 08/16/2023, RN B was observed during med pass by survey team, no discrepancies were observed. Record review of the licensed nurses In-Service Program Attendance Record for the following topic Medication Administration Guidelines conducted by DON. 23 LVN's and 7 RN's were in-serviced between 08/11/2023 and 08/14/2023. Record review of the licensed nurses In-Service Program Attendance Record for the following topic Preventing and detecting adverse consequences and medication errors conducted by DON. 23 LVN's and 7 RNs were in-serviced between 08/11/2023 and 08/13/2023. Record review of the licensed nurses In-Service Program Attendance Record for the following topic Notification Change of Condition conducted by DON 23 LVN's and 7 RN's were in-serviced between 08/11/2023 and 08/14/2023. Record review of facility audits of eMAR's and Narcotic sheets of all residents receiving controlled substance medications were provided to Survey Team. Discrepancies discovered during the audit were reported to resident's PCP, HHSC, police and noted on their progress notes. Interview on 08/15/2023 at 9:30 a.m., LVN D was able to verbalize understanding of the following in-services received: Medication Administration Guidelines, Preventing and detecting adverse consequences and medication errors, and Notification Change of Condition. Interviews on 08/15/2023 between 8:00 am and 5:00 pm, the survey team interviewed 28 licensed staff (23 LVN's and 5 RN's), all 28 licensed staff verbalized understanding of what they learned during in-services they received between 08/11/2023 and 08/13/2023. Interview on 08/15/2023 at 9:45 a.m., RN B was able to verbalize understanding of the following in-services received: Medication