Every finding on record at Comfort Creek Nursing and Rehabilitation Center

Based on observation, interview, and facility policy review, the facility failed to ensure the kitchen's large manual can opener blade and its base, microwave oven, and food preparation pots and pans were clean and/or dry when stored and failed to cover and/or date opened food stored in one of one facility kitchen. The facility also failed to ensure an opened container of thickened apple juice was dated when opened, and discard when its best if used by date had expired in one of two nursing unit resident refrigerators. These failures had the potential to create an environment for food-borne illnesses which could affect 67 residents who consumed food prepared from the facility's kitchen. Findings include: 1. Observation during the initial kitchen inspection on 04/27/2026 from 11:00 AM to 11:40 AM, with the Dietary Manager (DM) present, revealed the following unclean food preparation and service equipment: a. The kitchen's large manual can opener was unclean with accumulated dried and sticky substances on its blade and table base attachment. b. A large stock pot, that was stored and ready for use, was unclean with dried food substances on its interior cooking surface. c. The kitchen's microwave oven was unclean with accumulated dried food substances and splatters in its inner cooking compartment. d. Five food preparation pans, that were stacked tightly on top of other pans and ready for use, had moisture on them. One of these wet food preparation pans was also unclean with grits on its interior cooking surface. During an interview on 04/27/2026 at 11:15 AM, the DM confirmed the kitchen's manual can opener and its base attachment, stock pot, microwave oven, and food preparation pans were stored unclean and/or wet. The DM stated kitchen staff should make sure food preparation equipment was clean and dry prior to storing it for use. 2. Further observation during the initial kitchen inspection on 04/27/2026 from 11:00 AM to 11:40 AM, with the (DM) present, revealed the following concerns with food storage: a. Observation of the kitchen's dry storage area revealed one opened and undated 56-ounce package of dried stuffing, and two opened and undated 16-ounce packages of dried alfredo sauce mix that were stored open to air and unprotected from possible contamination. b. Observation of one of the kitchen's reach-in refrigerators revealed an opened 46-ounce container of thickened tea with lemon flavor did not have a date to indicate when it was opened. During an interview on 04/27/2026 at 11:30 AM, the DM confirmed the above opened and undated food in the dry storage room that was stored open to air and the opened container of thickened tea in refrigeration storage that was undated. The DM stated staff should date food when opened and cover it completely when placing it into storage. 3. During an observation of items stored inside the facility's front hall pantry resident refrigerator on 04/27/2026 at 11:50 AM, with the DM present, revealed an opened and undated 46-ounce container of thickened apple juice with an expired best if used by date of 04/07/2026. During an interview on 04/27/2026 at 11:50 AM, the DM confirmed the container of thickened apple juice was opened, undated and had an expired best if used by date of 04/07/26. The DM stated it was the responsibility of the dietary and nursing staff to date items when opened, to check expiration dates on products, and to discard any food or beverages that had expired dates. Review of the facility's undated policy titled, Cleaning and Sanitizing Areas and Equipment, specified, All kitchen areas and equipment shall be maintained in a sanitary manner and be fee of buildup of food, grease, or other soil. The facility will provide sanitary foodservice that meets state and federal regulations . Review of the facility's undated policy titled, Food Storage, specified, Policy Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by means designed to prevent contamination. Procedure . 15. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated .

Based on observations, record review, and interviews, the facility failed to determine a root cause for two of two residents (R) R1 from eloping from the facility on two separate occasions and R22 wandering into other residents room. The facility's failure to determine a root cause in R1 exiting the facility and R22 entering other resodents room increases the risk of accidents or injury. Findings include: 1. Review of the admission Record found under the Profile tab of the electronic medical record (EMR) revealed R1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, auditory hallucinations, and anxiety. Review of the Elopement Evaluation found under the Assessments tab of the EMR, , dated 01/14/2025 revealed R1 has a history of wandering, wandering aimlessly, and identified R1 as an elopement risk. Review of the High Risk Event-Chart Audit documents, provided by the facility, revealed R1 eloped from the facility on 01/22/2026. Interventions added to prevent additional elopements by R1 included staff education, adding occupational therapy for therapeutic exercise and additional assessments and medical examination. There was no documentation of a root cause analysis of how the resident was able to elope from the building. Review of the Care Plan under the Care Plan tab of the EMR, revealed a focus of care included Risk for wandering/elopement related to exit seeking behaviors. The goal included R1 will not leave the facility unattended, which was created on 01/14/2025. Interventions included 15 minute observation checks, providing purposeful activities, schedule time for walks and to identify triggers for wandering/elopement. Review of the Logbook Observation documents provided by the facility revealed the electronically locked doors, that only open after keypad code is entered monthly. Review of the facility's document titled, Elopement dated 02/09/2026 indicated, This nurse was walking down the hallway and noticed resident walking outside of A- Hall with walker. Immediate Action Taken- Maintenance Director and Project Manager were outside and escorted resident back into building. Skin assessment completed without injuries observed. Review of the Nursing Progress Notes, found under the Prog [Progress] Note tab of the EMR, dated 02/09/2026, revealed R1 was noted to be outside and unaccompanied. Staff immediately went to R1 and assisted her back into the facility. An interview with the Administrator (formerly the Director of Nursing) on 04/29/26 at 11:15 AM confirmed R1 eloped on 01/09/26 with interventions added to R1's care plan which included 15 minutes checks and staff education. The Administrator stated that R1 eloped a second time on 02/09/2026. The Administrator stated that staff were again educated and R1's care plan was reviewed and the resident was placed on one on one observations. The Administrator confirmed the facility did but interventions in place but failed to perform a root cause analysis. Review of the facility's document titled, Elopement Management, dated January 2025, indicated, Clinical process that addresses a resident's risk of elopement from the premises or a safe area without authorization and/or necessary supervision to do so. Identification and implementation of individualized approaches to provide the resident with a safe and secure environment. Evaluation of the resident's individualized plan of care and validation of effectiveness of interventions. 2. Review of the Face Sheet located in the Profile tab of the electronic medical record (EMR) revealed R22 was admitted to the facility on [DATE] with dementia, adjustment disorder with disturbance of conduct, and altered mental status. Review of R22's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/19/2026, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 99 out of 15, which indicated R22's cognitive function was severely impaired. Review of R22's Care Plan, dated 04/07/2026, located under the Care Plan tab of the EMR, revealed that R22 was at risk for wandering/elopement related to exit seeking behaviors, in place of an intervention to check R22's location regularly during and between rounds during waking hours. Review of the Face Sheet located in the Profile tab of the EMR revealed R13 was admitted to the facility on [DATE] with diagnosis of right femur fracture, neuralgia and neuritis, and dysphagia. Review of R13's quarterly MDS with an ARD of 04/09/2026, located in the EMR under the MDS tab, revealed a BIMS score of nine out of 15, which indicated R13's cognitive function was moderately impaired. Review of R13's Care Plan, dated 04/24/2026, located under the Care Plan tab of the EMR, revealed that R13 had the potential to be verbally aggressive related to dementia and schizoaffective disorder, in place of an intervention for staff to intervene as necessary and room change as necessary to avoid verbal abuse. Review of the Face Sheet located in the Profile tab of the EMR revealed R67 was admitted to the facility on [DATE] with diagnosis of cerebral infarction affecting left non-dominant side, contracture on the left hand, and dysphagia. Review of R67's quarterly MDS with an ARD of 02/03/2026, located in the EMR under the MDS tab, revealed a BIMS R67's score of 14 out of 15, which indicated R67's cognitive function was completely intact. Review of R67's Care Plan, dated 02/27/2026, located under the Care Plan tab of the EMR, revealed that R67 was at risk for harm: self-directed or other-directed related to dementia, psychotic disturbance, mood disturbance and anxiety, in place an intervention that if resident poses a potential threat to injure self or others, notify provider and staff to intervene as necessary to protect resident and/or others. During an observation on 04/27/2026 at 11:06 AM, R22 wandered around the hallway, was clean, with non-skid shoes on and not disheveled. During an observation on 04/28/2026 at 1:27 PM, R22 entered R13 and R67's room. R13 yelled at R22 to leave the room, get out of here, leave the room! Staff did not check or monitor R22's location nor responded to R13's yelling. R22 exited the room and there was no sign on the door to deter other residents from entering the room. During an observation on 04/28/2026 at 1:43 PM, R22 was observed touching the medication cart in the B hall and had to be re-directed back to his room. During an interview on 04/28/2026 at 1:37 PM, Certified Nursing Aide (CNA) 3 stated, .R22 would go into other residents' rooms. It happens a lot. When R8 is walking around, he usually speaks to himself. Most of time, he would go into R13 and R67's room, R13 would yell out, come get him out of my room!. During an interview on 04/28/2026 at 3:48 PM, Certified Medication Aide (CMA) 1 stated, R8 may go into other residents' rooms, and we catch him before he goes in. During an interview on 04/30/2026 at 1:18 PM, R67 stated, .He always comes in here. R22, that guy. I always tell him to get out, or I will beat him up! It happens all the time! During an interview with the Administrator on 04/28/2026 at 3:40 PM revealed we do re-orient him back to his room. I have not observed him going into any other residents' rooms. The Administrator confirmed no incidents that happened regarding resident going into other residents' rooms. I don't see any documentation that he is care planned for going into residents rooms, and if this is a new behavior and we will address it. During a review of a video footage on 04/30/2026 at 11:55 AM, the video footage played by the Maintenance Director and the Administrator showed R22 entering R13 and R67's room on 04/28/26 at around 1:27 PM while R22 entered the room. MD and Administrator acknowledged that they observed on the video footage that R22 entered R13 and R67's room.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to respect resident rights when they failed to provide Activities of Daily Living (ADLs) care of their choice for two out of two dependent residents (Resident (R) R15 and R16) reviewed for ADLs assistance out of a total of 24 sampled residents. This failure had the potential to adversely affect residents' dignity, comfort, and quality of life.Findings Include: 1. Review of the facility's policy titled Resident Hygiene, dated January 2025, revealed that residents were to be bathed as needed, to include a sponge bath and/or bed bath, or more often, including a shower at least twice weekly. Review of R15's admission Record, located in the Electronic Medical Record (EMR) under the Profile tab. indicated the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to stiff person syndrome (SPS). Review of R15's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/23/2026, located in the EMR under the MDS tab, indicated the resident's Brief Interview for Mental Status (BIMS) score was 15 out of 15, indicating the resident was cognitively intact. The assessment further revealed under Section F, titled Preferences for Routine and Activities, that bathing, either in a tub, shower, or bed bath, was somewhat important to her. The assessment also revealed the R15 required extensive assistance by two staff for bed mobility and was totally dependent on staff. Review of R15's care plan located in the EMR under the Care Plan tab, dated 04/07/26, indicated R15 required assistance with self care. Review of R15's Kardex located in the EMR under the Tasks tab (used by Certified Nurse Aides (CNA) to direct resident care) under Bath/Shower for the past 30 days revealed R15 had received only bed baths and no showers. Further review of the Kardex revealed R15 had not refused any care. During an interview on 04/27/2026 at 12:45 PM, R15 reported she had not received a shower since February and stated she would like to receive one. During an interview on 04/28/2026 at 2:52 PM, Unit Manager (UM) 2 stated resident showers were scheduled for two days per week or more if needed. UM2 further stated there was no shower book or log and that all documentation was recorded in the EMR under the Tasks tab on the Kardex. UM2 confirmed that R15's Kardex did not indicate any showers for the past 30 days. During an interview on 04/29/2026 at 1:50 PM, CNA 1 confirmed ADL care was documented in the EMR on the Kardex and stated that after three refusals, staff were to indicate the refusal on the Kardex, with the nurse documenting in the EMR. 2. Review of R16's admission Record located in the EMR under the Profile tab indicated the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, quadriplegia (C5–C7 incomplete) and a cervical disorder. Review of R16's quarterly MDS with an ARD of 04/10/2026 indicated the resident's BIMS score was 15 out of 15, indicating the resident was cognitively intact. The assessment further revealed the resident identified bathing, either in a tub, shower, or bed bath, as very important to him. The assessment indicated the R16 required extensive assistance from two staff for bed mobility and was totally dependent on two staff for transfers. Review of R16's care plan located in the EMR under the Care Plan tab, dated 06/23/22, indicated the resident required assistance with bathing. Review of R16's Kardex located in the EMR under the Tasks tab under Bath/Shower for the past 30 days revealed R16 had not received any showers. Further review of the Kardex revealed that R16 had not refused any care. During an interview on 04/27/2026 at 12:23 PM, R16 stated the last time he had received a shower was on 12/08/25. During an interview on 04/28/2026 at 2:52 PM, UM2 stated resident showers were scheduled for two days per week or more if needed and confirmed there was no shower log, with documentation completed in the EMR under the Kardex. UM2 confirmed R16's Kardex did not indicate any showers for the past 30 days. The Kardex however did indicate the resident received a bed bath. During an interview on 04/29/2026 at 1:50 PM, CNA1 confirmed ADL care was documented on the Kardex and that refusals were to be documented after three occurrences. During an interview on 04/29/2026 at 3:45 PM, the facility Administrator stated that all residents were to receive regular hygiene care.

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored in a secure manner for one of one resident (Resident (R)16) out of a sample size of 24. Specifically, medications requiring licensed nursing administration were stored unsecured and accessible in the resident's room, despite the resident not self administering medications. This failure placed the residents at risk for unauthorized access, misuse, and improper medication management. Findings include: Review of the facility policy titled Medication Administration, dated 01/2025, indicated that residents may self administer medications only after an assessment had been completed. The policy further indicated licensed nursing staff are responsible for maintaining medications in a secure area and ensuring safe medication management. Review of R16's admission Record located in the Electronic Medical Records (EMR) under the Profile tab revealed the resident was admitted on [DATE] with diagnoses including, but not limited to, quadriplegia (C5–C7 incomplete) and a cervical disorder. Review of R16's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/10/26 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. The MDS further indicated that the resident required extensive assistance from two staff for bed mobility and was totally dependent on two staff for transfers. Review of R16's Care Plan located in the EMR under the Care Plan tab, dated 06/23/2022, indicated the residents were allowed to keep Ketoconazole shampoo at the bedside, with staff responsible for application. There was no documentation of the Hydrocortisone 2.5% topical cream being able to held at bedside. Review of R16's Physician Orders located in the EMR under the Orders tab, revealed active orders for Hydrocortisone 2.5% topical cream to be applied every 12 hours and Ketoconazole shampoo to be kept at the bedside. Review of R16's Self Administration of Medication Assessment located in the EMR under the Assessment tab, dated 02/02/2023, indicated the resident wished to keep Ketoconazole shampoo received from the Veterans Administration at the bedside for nursing staff to administer. During an observation and interview with R16 on 04/27/2026 at 12:46 PM, revealed two boxed and labeled tubes of Hydrocortisone topical cream resting unsecured on a water dispenser next to R16's bed. R16 stated the topical creams and medicated shampoo were prescribed by his Veterans Administration (VA) physician and kept in his room. The resident further stated he was physically unable to apply the medications or wash his hair due to quadriplegia and confirmed that only nursing staff applied his prescribed creams and shampoo. During an observation and interview on 04/28/2026 at 2:06 PM, the Unit Manager (UM) 1 confirmed the Hydrocortisone topical cream was stored unsecured on the water dispenser in the resident's room along with the Ketoconazole shampoo which is stored in the resident's bathroom. During an interview on 04/29/2026 at 3:45 PM, the Administrator stated R16 was unable to self administer topical medications and that only licensed nursing staff were permitted to apply prescription creams and shampoos. She further stated it was the facility's expectation that medications be stored securely.

Based on observations and interviews, the facility failed to provide a safe and clean environment for residents in the dining room. The facility's failure to maintain dining room chairs with cleanable surfaces without tears in the seating of the chairs has the potential to affect residents who sit in the dining room. An observation of the eating at the dining room tables on 04/27/2026 at 12:15 PM revealed five dining room chairs with tears in the seats. An interview on 04/27/2026 at 11:45 AM with the Director of Nursing (DON) confirmed the five dining room chairs with tears in the seat with the exposed non-cleanable material. The DON confirmed the chairs must be cleanable and the tears in the seats render the seat uncleanable. .

Based on observation, interview, record review, and review of Resident Assessment Instrument (RAI) manual the facility failed to ensure an accurate Minimum Data Set (MDS) assessment was submitted for the usage of side rails for one of one resident (R) R5 reviewed for physical restraints out of a total sample of 28. The failure to code the MDS correctly could potentially lead to inaccurate federal reimbursements, inaccurate resident care planning, and improper use of physical restraints. Findings Include: Review of R5's admission Record, located under the Profile tab of the electronic medical record (EMR), indicated R5 was admitted on to the facility on [DATE] with diagnoses of Alzheimer's disease and cognitive communication deficit. Review of R5's quarterly MDS, with an Assessment Reference Date (ARD) of 03/19/2026 and located under the MDS tab of the electronic medical record (EMR), revealed the assessment specified the resident used side rails daily and had a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated he was severely cognitively impaired. Observation of R5 on 04/27/2026 at 12:27 PM, on 04/28/2026 at 9:58 AM, and on 04/29/2026 at 9:38 AM revealed the resident was in bed without side rails or any physical restraints present. During an interview on 04/29/2026 at 9:46 AM, Licensed Practical Nurse (LPN) 3 stated that she frequently cared for R5 and the resident had never utilized bedside rails or any physical restraints. During an interview on 04/29/2026 at 10:04 AM, the Minimum Data Set Coordinator (MDSC) stated R5 did not utilize bedside rails or any physical restraints. The MDSC reviewed R5's quarterly MDS assessment of 03/19/26 and stated the assessment erroneously coded that the resident used side rails daily. The MDSC states she would submit an immediate correction for this MDS coding error. During an interview on 04/30/2026 at 11:40 AM, the Administrator stated the facility did not utilize physical restraints and confirmed R5's quarterly MDS of 03/19/2026 inaccurately reflected that he was physically restrained with the use of side rails daily. The Administrator stated it was her expectation that MDS assessments would be accurate. The Administrator stated the facility did not have a policy for the accurate completion of MDS assessments but utilized the RAI manual for any MDS issues. Review of the RAI manual, dated 10/2024 and located at https://www.cms.gov/files/document/finalmds-30-rai-manual-v1191october2024.pdf, indicated, . In addition, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment .

Based on interview and record review, the facility failed to ensure one of out one wandering resident's (R) R22 care plan and updated with appropriate interventions. (Cross Reference F689) Findings include: Review of the Face Sheet located in the Profile tab of the electronic medical record (EMR) revealed R22 was admitted to the facility on [DATE] with dementia, adjustment disorder with disturbance of conduct, and altered mental status. Review of R22's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/19/2026, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 99 out of 15, which indicated R22's cognitive function was severely impaired. Review of R22's Care Plan, dated 04/072026, located under the Care Plan tab of the EMR, revealed that R22 was at risk for wandering/elopement related to exit seeking behaviors, in place of an intervention to check R22's location regularly during and between rounds during waking hours. The care plan did not address interventions related to wandering into other residents' room. During an observation on 04/27/2026 at 11:06 AM, R22 wandered around the hallway, was clean, with non-skid shoes on and not disheveled. During an observation on 04/28/2026 at 1:43 PM, R22 was observed touching the medication cart in the B hall and had to be re-directed back to his room. During an interview on 04/28/2026 at 1:37 PM, Certified Nursing Aide (CNA) 3 stated, .R22 would go into other residents' rooms. It happens a lot. When R8 is walking around, he usually speaks to himself. Most of time, he would go into R13 and R67's room, R13 would yell out, come get him out of my room! During an observation on 04/28/2026 at 1:27 PM, R22 entered R13 and R67's room. R13 yelled at R22 to leave the room, get out of here, leave the room! Staff did not check or monitor R22's location nor responded to R13's yelling. R22 exited the room and there was no sign on the door to deter other residents from entering the room. During an interview on 04/28/2026 at 3:48 PM, Certified Medication Aide (CMA) 1 stated, R8 may go into other residents' rooms, and we catch him before he goes in. During an interview on 04/30/2026 at 1:18 PM, R67 stated, .He always comes in here. R22, that guy. I always tell him to get out, or I will beat him up! It happens all the time! During an interview with the Administrator on 04/28/2026 at 3:40 PM indicated, We do re-orient him back to his room. I've not observed him going into any other residents' rooms. The Administrator confirmed no incidents that happened regarding R22 going into other residents' rooms. There is no documentation that he is care planned for going into residents' rooms, and if this is a new behavior and we will address it.

Based on observation interviews and review of the manufactures instructions for use, the facility failed to follow the manufacturer's instructions for the administration of insulin to one resident of one resident, (R) R55, identified by the facility as having orders for insulin administration by an insulin pen. The facility's failure to follow the manufacturer's guidelines placed residents who received insulin from an insulin pen at risk to receive an incorrect dose. Findings include: Observation on 04/29/2026 at 4:30 PM revealed Licensed Practical Nurse (LPN) 4 performed a blood glucose test for sliding scale insulin administration. After blood glucose monitoring, R55 required 10 units of NovoLog insulin. LPN 4 obtained a NovoLog insulin pen, verified the orders, set the dose to be administered to R55 as 10 units, and prepared to administer the insulin. Upon discussion with LPN4, she confirmed she had not primed the disposable needle attached to the insulin pen. LPN 4 stated she had never been told how to prime the pen. Interview with the Administrator/Director Of Nursing on 04/29/26 at 4:35 PM revealed she was unaware of the need to prime the insulin pen. Review of the Manufacturer's Instructions for Use revealed that after the disposable needle is attached to the insulin pen, the pen must be primed by dialing and activating a two-unit dose to expel air from the needle prior to administering the ordered dose to the resident.

Based on interview, record review, and facility policy review, the facility failed to ensure communication sheets were completed for one of one resident (R) R8 reviewed for dialysis out of a total sample of 28 residents. This failure had the potential to affect the current facility census of 70 residents. Review of the Face Sheet located in the Profile tab of the electronic medical record (EMR) revealed R8 was initially admitted to the facility on [DATE] with end stage renal disease, Review of R8's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/04/2026, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated R8's cognitive function was severely impaired. Review of R8's Care Plan, located under the Care Plan tab of the EMR, on page 37 of 46 revealed that R8 required hemodialysis related to renal failure, in place are interventions that included, resident to be provided with lunch in proper storage container to take with him to dialysis on scheduled days and to send communication forms with resident to dialysis as indicated and follow up as needed. Review of Physicians' Orders, located under the Orders tab of the EMR, revealed R8 had an order to schedule medications according to dialysis treatment schedule, so prescribed medications are held or not scheduled before hemodialysis, or are administered, or sent with the resident to be administered at hemodialysis, as appropriate. During an interview on 04/27/2026 at 11:03 AM, Licensed Practical Nurse (LPN) 4 stated, .R8 goes to dialysis every Tuesday, Thursday, and Saturday. We do not have a communication sheet that gets sent to the dialysis clinic. We only do a pre- and post- dialysis evaluation, and we put it in the progress notes. During an interview on 04/29/26 at 9:59 AM, Unit Manager (UM) 2 stated, R8 gets picked up by transport on his dialysis days. We only do a pre- and post- dialysis evaluation. We don't use or have dialysis communication sheets. During an interview on 04/29/26 at 10:34 AM, the dialysis charge nurse stated, .R8 began dialysis treatment with our center on 12/17/25. We do require that the facility send a dialysis communication form. R8 is the only one that doesn't consistently bring a dialysis communication sheet. We required the dialysis communication sheet in case the patient had a change of condition, or our physician wrote a new order for the patient and when the resident arrives at the dialysis center, we need to know what R8's baseline is prior to starting dialysis. During an interview on 04/29/2026 at 11:32 AM, the transport dispatcher stated, .We started transporting R8 on 12/17/2025. The pick-up was at 3:00 PM and chair time was at 4:00 PM. Review of the facility's policy titled, Renal Dialysis Management dated, 10/2017, located in page three of eight, under Procedure D, item two, When resident is sent to renal dialysis unit: Complete the facility dialysis communication record to accompany the resident and under Procedure E, When resident returns from renal dialysis unit, item one, review physician's progress note, new orders and/or test reports and the dialysis communication record – Dialysis center returned with the resident.

Based on family and staff interviews, record review, and review of the facility policy titled, Discharge Plan/Transfers and policy titled, Instructions for Conduction BIMS (Brief Interview for Mental Status), the facility failed to notify the responsible party of the discharge and transfer to a Personal Care Home for one out of eight sampled residents (R) with moderate cognitive impairment. Findings included:Review of the facility's policy titled Discharge Plan/Transfers, with a revised date of 10/20/2025, revealed under the Procedure section: 3. When the facility anticipates a resident's discharge to a private residence or to another nursing care facility, a post-discharge plan will be developed which will help the resident adjust to their new living environment. 4. The post discharge plan will be developed by the care team with the assistance of the resident and his/her family. 6. As a minimum the post discharge plan will include: a. A description of the residents's and family's preference of care. d. A description of specific resident needs after discharge. e. A description of how the resident and family need to prepare for the discharge. f. Social Services will review the plan with the resident and family 24 hours before the discharge is to occur.Review of the Clinical Resident Profile for R E revealed the resident's sister was the resident's responsible party and financial power of attorney.Review of the clinical record revealed that R E had an initial admission date of February 2018 and a discharge date of 2/11/2026. Diagnoses included, but were not limited to, asthma, schizophrenia, schizoaffective disorder, alcohol dependence in remission, intellectual disabilities, and major depressive disorder recurrent.Review of the Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview of BIMS score of 07, indicating severe cognitive impairment.Review of the Discharge Return Not Anticipated MDS assessment dated [DATE] revealed Section C (Cognitive Patterns) documented BIMS score of 05, indicating severe cognitive impairment.Review of the care plan, dated 01/12/2026, revealed a focus area of the resident and his family wish for him to be discharged to a facility closer to them. Interventions included establishing a discharge plan with the resident and family as needed.Review of a Progress Note-Discharge Evaluation dated 02/11/2026 for R E, documented Patient has a planned discharge today to a personal care facility in [named city] at his request. Prescriptions signed and to be sent with patient. He is ambulatory, continent, and independent with all ADLs. Patient continues to experience paranoia and did not allow physical exam today. He did state that feels fine and is ready to go. He voices no concerns at this time. {sic} The Discharge Evaluation was signed by the FNP-C (Family Nurse Practitioner-Clinician).Review of multiple progress notes over the course of R E's stay at the facility documented that the primary RP was notified for consent or notification of changes or new issues. Consent and/or notifications documented in the clinical record included, but were not limited to, psychoactive medication consent, bed hold notification, flu shot consent, COVID vaccine consent, and care conference invites.Review of Discharges for the past three months revealed R E was discharged on 2/11/2026 to [Named] facility.In an interview on 04/02/2026 at 1:13 PM, the Social Services Director (SSD) revealed that R E was alert and oriented, with no signs of confusion or dementia. The SSD stated she was unaware that she should have notified the RP about the discharge to the Personal Care Home.In an interview on 04/08/2026 at 10:03 AM, the Director of Nursing (DON) confirmed R E was discharged and that his family was not notified. She confirmed the RP should have been notified before discharge. The DON stated that the expectation for a resident with a BIMS score of 05 or 07 to be discharged was that the family should be notified and involved.In an interview on 04/08/2026 at 10:15 AM, the Administrator confirmed that she knew R E was being discharged and that she did not notify the RP. She revealed she thought the SSD had notified the RP that R E was being discharged , and that the RP should have been called that same day.In an interview on 04/08/2026 at 4:00 PM, the Nurse Practitioner revealed she was not aware that R E's family was not notified and not involved in his discharge. She revealed that a BIMS score of 05 indicated severe cognitive impairment, and the RP should have been notified of the discharge.

Based on record review, resident and staff interviews, and review of the facility's policy titled, Discharge Plan/Transfers, the facility failed to ensure a written transfer notice that contained all required information was provided to four of four residents and/or their representative (Resident (R) 65, R72, R68, and R25) reviewed for facility-initiated emergent hospital transfer out of 28 sample residents. This failure has the potential to affect the resident and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired. Findings include: Review of the facility's policy titled, Discharge Plan/Transfers, dated October 2023, did not indicate a transfer notice should be provided to the residents and their representative explaining why they were being transferred. 1. Review of R65's admission Record located under the Profile tab in the electronic medical record (EMR) revealed R65 admitted on [DATE] with diagnoses of major depressive disorder, brief psychotic disorder, metabolic encephalopathy, unspecified dementia, bipolar disorder, post-traumatic stress disorder, paranoid schizophrenia, and anxiety disorder. Review of the admission Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 2/12/2025 indicated R65 had a Brief Interview for Mental Status (BIMS) of 12 out of 15, which indicated he was moderately cognitively impaired. Review of the Progress Note located under the Progress Notes tab in the EMR, dated 3/15/2025, revealed R65 was transported to the hospital via 10-13 (signal of immediate help, often due to a dangerous situation) after hitting a staff member in the face. Review of the EMR did not reveal evidence that a written transfer/discharge notice was provided to R65 or his representative on 3/28/2025. During an interview on 4/14/25 at 1:54 pm, R65 stated he went to the hospital at the beginning of the month but could not elaborate on why he was sent. He stated he could not recall receiving any paperwork while he was transferred. During an interview on 4/15/2025 at 12:48 pm, the Director of Nursing (DON) stated R65 did not discharge from the facility. She stated he was gone less than 24 hours and was not gone after midnight. She stated she was not sure if a transfer/discharge notice was provided and would look. She stated she was not aware of the e-interact form not being the same thing as a transfer/discharge notice. 2. Review of R72's admission Record located under the Profile tab in the EMR revealed R72 admitted on [DATE] with diagnoses of monoplegia of lower limb affecting left dominant side, malignant neoplasm of prostate, morbid obesity, major depressive disorder, generalized anxiety disorder, cognitive communication deficit, and peripheral vascular disease. Review of the quarterly MDS located under the MDS tab of the EMR with an ARD of 3/24/2025 revealed R72 had a BIMS of 13 of 15, indicating he was cognitively intact. Review of the Progress Notes located under the Progress Notes tab in the EMR, dated 4/11/2025, revealed he was transferred to the hospital on 4/11/2025. R72 complained of abdominal pain at 12:00 am. Upon examination, his abdomen was distended. Resident stated that he has not been able to sleep and that he needs to go to the ER [emergency room] because he feels so bad. Review of the EMR did not reveal any evidence that R72 received a transfer/discharge notice upon being sent to the emergency room. During an interview on 4/16/2025 at 9:26 am, the Administrator stated a transfer form should be completed by the nurses and the residents and/or their representatives should receive a copy. During an interview on 4/16/2025 at 9:48 am, Licensed Practical Nurse (LPN) 6 stated a transfer form should have been completed when residents were sent to the hospital. During an interview on 4/16/2025 at 9:49 am, Unit Manager (UM) 1 stated the facility had not been sending a transfer discharge notice with the residents, and one was not sent to the responsible party. During an interview on 4/17/2025 at 2:21 pm, the DON stated R72 did not receive a transfer/ discharge notice when he was sent to the hospital. 3. Review of R68's quarterly MDS tab with an ARD of 2/7/2025 revealed a BIMS score of 13 out of 15, which indicated R68 was cognitively intact. Diagnoses included end-stage renal disease, anemia, coronary artery disease, hypertension, peripheral vascular disease, diabetes mellitus, and required dialysis. Review of the EMR located under the Census tab revealed that R68 resident was not in the facility on 7/29/2024, 8/6/2024, 8/28/2024, and 12/30/2024 due to hospitalization. Review of the EMR located under the Miscellaneous (Misc) tab revealed that the facility issued bed holds for each hospital stay, but did not indicate that the written notification of transfer was completed. During an interview on 4/16/2025 at 3:15 pm, the DON stated that the facility was not completing the written notification of transfer/discharge. The DON also stated that the facility would be using a transfer/discharge form from now on to ensure that the notices were completed and sent to the resident and resident responsible party. During an interview on 4/16/2025 at 3:45 pm, the UM1 stated they had not been sending notifications of transfer or discharge to residents' responsible parties and that the facility was educating everyone on how to complete the transfer/discharge form. 4. Review of R25's admission Record located in R25's EMR under the Profile tab revealed R25 was admitted to the facility on [DATE] with diagnoses which included diabetes and absence of left leg below knee. Review of the history listed MDS located in R25's EMR under the MDS tab, documented R25 was discharged Return Anticipated (DRN) and Entry six times as follows: DRN on 5/16/2024, Entry on 5/18/2024. DRN on 8/4/2024, Entry on 8/7/2024. DRN on 8/11/2024, Entry on 8/15/2024. DRN on 9/16/2024, Entry on 9/23/2024. DRN on 10/11/2024, Entry on 10/12/2024. DRN on 1/24/2025, Entry on 1/28/2025. Review of R25's EMR revealed there was no documentation that the facility offered a written transfer/ discharge notice to R25 or a representative upon each discharge. During an interview on 4/17/2025 at 11:25 am, the DON stated R25 was discharged to the hospital for those dates on 5/16/2024, 8/4/2024, 8/11/2024, 9/16/2024, 10/11/2024, and 1/24/2025. During an interview on 4/17/2025 at 12:45 pm, the DON stated there were no written discharge/ transfer summaries provided to R25 or his representative as to why R25 was discharged or transferred for all the record-requested discharge date s.

Based on staff interviews, record review, and review of the facility's policies titled, Behavior Management Standard, and Depression Management, the facility failed to ensure psychotropic medications' efficacy was monitored, and non-pharmacological interventions were offered and included in the care plan for two of two residents (Resident (R) 13 and R49) reviewed for unnecessary and/or psychotropic medications of 28 sample residents. This failure had the potential to affect a physician's decision to prescribe the lowest possible effective dose of medication. Findings include: Review of the facility's policy titled, Behavior Management Standard, dated January 2025, under page three documented Ensuring a thorough and comprehensive assessment of the residents' needs, behaviors .Monitoring the resident's behaviors to establish patterns, determine intensity and behavior frequency, and identifying the specific target behaviors that are distressing to the resident .Planning and implementing appropriate behavior interventions into the resident's plan of care. Evaluating the effectiveness of Pharmacological and non-pharmacological interventions. Monitoring for any adverse side effects of the medications .as per recognized standards of practice. Review of the facility's policy titled, Depression Management, dated January 2025, documented The interdisciplinary Team (IDT) evaluated the resident with symptoms of depression determine potential cause and developed a plan of care None-pharmacological interventions are attempted as appropriate, prior to initiating pharmacological interventions . Review and address potential causes of depression . Develop goals and interventions on the care plan . Evaluate effectiveness of non-pharmacological interventions prior to/or in addition to initiation of pharmacological interventions .Monitor for efficacy, side effects, and/or adverse consequences of the medication. 1. Review of R13's undated admission Record located in the resident's electronic medical record (EMR) under the Profile tab revealed the facility admitted the resident on 3/5/2025 with diagnoses, which included, major depressive disorder, post-traumatic stress disorder, and insomnia. Review of R13's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/11/2025, located in the resident's EMR under the MDS tab, revealed R13 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R13 was cognitively intact. R13 did not exhibit mood or behavioral symptoms. R13 received antidepressant medication. Review of R13's Care Plan Report located in the resident's EMR under the Care Plan tab, included a care plan for depression r/t [related/to] Admission, Disease Process Hx [history] of substance abuse (cannabis abuse) Diagnosis of depression, PTSD [post-traumatic stress disorder], initiated on 3/12/2025. The care plan included the interventions as follows: -Care plan goal: R13 will remain free of signs and symptoms of distress, depression, anxiety, or sad mood by /through review day. -Administer medications as ordered. Observe/document for side effects and effectiveness. -Observe, document, and report as needed any risk for harm to self: suicidal plan, past suicide attempt, risky actions (stockpiling pills, saying goodbye to family, giving away possessions, or writing a note), intentionally harmed or tried to harm self, refusing medication or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. -Observe, document, and report as needed any signs and symptoms of depression, including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, and tearfulness. -Observe, record, and report to the physician as needed for the risk of harming others: increased anger, labile mood, or agitation; feels threatened by others or thoughts of harming someone; possession of weapons or objects that could be used as weapons. -Pharmacy review monthly or per protocol. R13's Care Plan Report included a care plan for R13 for antidepressant medication (Remeron, Trazadone) r/t (related to) Depression, initiated on 3/12/2025. The care plan included the interventions as follows: -Administer antidepressant medications as ordered. -Observe and document side effects and effectiveness every shift. -Educate the resident, family, and caregivers about the risks, benefits, side effects, and/or toxic symptoms of antidepressant drugs. -Observe, document, and report as needed adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicide thoughts, withdrawal; decline in activity daily living [ADL] ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, nausea and vomiting, dry mouth, and dry eyes. Review of R13's EMR revealed there was no documentation that the facility was monitoring antidepressant medication's adverse side effects, as the care plan indicated. R13's care plan did not include what nonpharmacological interventions staff would offer if depression or insomnia symptoms were observed. Review of R13's Physician's Order Medication Administration Record (MAR) and Treatment Administration Record (TAR) for April 2025, located in R13's EMR under the Orders tab revealed R13 received ordered by the physician as follows: -Mirtazapine (antidepressant) 30 milligrams (mg). Give one tablet by mouth at bedtime for depression. Start date, 3/26/2025. Review of R13's EMR revealed there was no documentation that the facility was monitoring R13's depression symptoms as the care plan indicated. -Trazodone (antidepressant) 150 mg, give two tablets by mouth at bedtime for insomnia. Start date, 3/28/2025. Review of R13's EMR revealed there were no hours of sleep monitoring to determine the efficiency of the trazodone used to treat insomnia. -Antidepressant medication monitor for: DROWSINESS, DIZZINESS, NAUSEA, DIARRHEA, HEADACHES. Document: 'N' if monitored and none of the above observed. 'Y' if monitored and any of the above were observed, select chart code 'Other/See Nurses Notes' and document findings. every shift for Medication Monitoring. Start date, 3/26/2025. Review of R13's EMR revealed there was no documentation of whether any nonpharmacological interventions were offered to R13 if depression or insomnia symptoms were presented. During an interview on 4/16/2025 at 1:30 pm, the Director of Nursing (DON) stated there were no target behaviors for R13's antidepressant medication use; the facility was treating R13 because he had a diagnosis of depression. The DON reviewed R13's record and stated there was no depression monitoring in R13's EMR, and there were no resident-specified nonpharmacological interventions listed to offer. The DON further stated there was no documentation about how many hours of sleep R13 had to monitor for the medication efficiency each day for trazodone use. She said the facility documented by exception, and the nurse would report it if R13 did not sleep well. The DON said there was no intervention in the care plan about what nonpharmacological interventions staff would offer if R13 had trouble sleeping or because of depression. During an interview on 4/16/2025 at 3:53 pm, the DON stated the policy and regulations should be followed to initiate non-pharmacological interventions and monitoring. The DON stated there was no policy for insomnia care. 2. Review of R49's undated admission Record located in the resident's EMR under the Profile tab revealed the facility admitted the resident on 3/17/2022 with diagnoses which included suicidal ideation, anxiety disorder, unspecified mood disorder, and mental disorder not specified. Review of R49's annual MDS with an ARD of 1/22/2025, located in the resident's EMR under the MDS tab, revealed R49 had a BIMS score of 14 out of 15, which indicated R49 was cognitively intact. R49 did not exhibit behavioral symptoms, except presenting with Little interest or pleasure in doing things for two to six days. R49 received antipsychotic and antidepressant medication. Review of R49's Care Plan Report, located in the resident's EMR under the Care Plan tab, included a care plan for has the potential to be Depressed, initiated on 1/19/2023. The care plan included the interventions as follows: - Administer medications as ordered. Monitor/document for side effects and effectiveness, - Arrange for psych consultation, follow up as indicated. -Monitor/document/report PRN [as needed] any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. There was no documentation that the facility was monitoring R49's risk for harm to self as the care plan indicated for quetiapine fumarate use to treat Suicidal Ideations. -Monitor/document/report PRN any s/sx [signs and symptoms] of depression, including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. Review of R49's EMR revealed there was no documentation that R49's depression symptoms were being monitored as the care plan indicated. -Pharmacy review monthly or per protocol. R49's care plan did not include what nonpharmacological interventions staff would offer if depression symptoms were observed. Review of R49's EMR revealed there was no documentation of what nonpharmacological intervention to be offered to R49 for depression symptoms and insomnia. Review of R49's Physician's Order MAR and TAR for April 2025, located in R49's EMR under the Orders tab revealed the report documented R49 received orders by the physician as follows: -Sertraline (antidepressant) 50 mg. Give one tablet by mouth one time a day for mood. Start date, 04/26/24. -Trazodone (antidepressant) 50 mg, give one tablet by mouth at bedtime for insomnia. Start date, 05/30/24. Review of R49's EMR revealed there were no hours of sleep monitoring to determine the efficiency of the trazodone used to treat insomnia. -Quetiapine Fumarate (antipsychotic) 25 mg. Give one tablet by mouth two times a day for Suicidal Ideations. Start date, 01/16/23. -Behavior Interventions:1- Redirect 2- 1:1 3- Ambulate 4- Activity 5- Return to room [ROOM NUMBER]- Toilet 7- Give food 8- Give fluids 9- Change position 10- Encourage to rest 12- Refer to nurses notes every shift. Start date, 01/16/23. -ANTI-PSYCHOTIC MEDICATION - Monitor for: DRY MOUTH, CONSTIPATION, BLURRED VISION, DISORIENTATION/ CONFUSION, DIFFICULTY URINATING, HYPOTENSION, DARK URINE, YELLOW SKIN, N/V, LETHARGY, DROOLING, EPS SYMPTOMS (TREMORS, DISTURBED GAIT, INCREASED AGITATION, RESTLESSNESS, INVOLUNTARY MOVEMENT OF MOUTH OR TONGUE). Document: 'N' if monitored and none of the above observed. 'Y' if monitored and any of the above were observed, select chart code 'Other/ See Nurses Notes' and document findings every shift for Medication Monitoring. Start date, 10/03/23. -BEHAVIOR(S) - Monitor for: (1- Verbal Aggression, 2- Refusing Care) ITCHING, PICKING AT SKIN, RESTLESSNESS (AGITATION), HITTING, INCREASE IN COMPLAINTS, BITING, KICKING, SPITTING, CUSSING, RACIAL SLURS, ELOPEMENT, STEALING, DELUSIONS, HALLUCINATIONS, PSYCHOSIS, AGGRESSION, REFUSING CARE. Document: 'N' if monitored and none of the above observed. 'Y' if monitored and any of the above were observed, select chart code 'Other/ See Nurses Notes' and document specific behavior(s) every shift for Behavior Monitoring Document each behavior observed and number of occurrences. Start Date, 1/16/2023. During an interview on 4/16/2025 at 3:53 pm, the DON reviewed R49's record and stated there was no documentation the nonpharmacological interventions were offered and what target behavior was monitored for R49's antidepressant medication use. The DON stated there was no documentation that the adverse side effects of antidepressants and depression symptoms, sleep, and suicidal ideation were being monitored. The DON said the facility should follow the policy and regulations to initiate nonpharmacological interventions and monitoring. The DON stated they should also be included in the care plan. She stated there was no policy for insomnia care.

Based on staff interviews, family interview, record review, and review of the facility's policy titled, Change of Condition/Reporting, the facility failed to provide a timely notification of change in condition for a resident that became unresponsive, breathless, and Cardiopulmonary Resuscitation (CPR) was initiated for one of one resident (Resident (R) 385) reviewed for notification of change in condition of 28 sample residents. This failure had the potential to affect the families' grieving process. Findings include: Review of the facility's policy titled, Change of Condition/Reporting, dated [DATE], revealed when a resident exhibits a change in condition, action will be taken to coordinate appropriate care to meet resident needs and communicate condition change to physician . 3. If there is an actual change in condition, the resident's physician is notified promptly and validated as to information. Family/Responsible Party notified promptly. Review of R385's Admission Record located under the Profile tab of the electronic medical record (EMR), revealed R385 was admitted to the facility on [DATE] with a diagnosis of diffuse traumatic brain injury (TBI), and she was Full Code status. Resident alert to voices, aphasic in a vegetative state. The resident was bedbound and unable to communicate her needs and wants due to her condition, and was total care. Resident had a Brief Interview for Mental Status (BIMS) score of 99, which indicated severe cognitive impairment. Review of the Progress Note located under the Progress Notes tab of the EMR, dated [DATE], revealed on [DATE] at approximately 10:45 pm, Licensed Practical Nurse (LPN) 3 documented being called to R385's room by LPN5 related to no rise and fall of R385's chest and unable to obtain vital signs. (CPR) started by LPN3. At 10:50 pm, emergency medical services (EMS) were called. At 11:01 pm, first responders arrived and continued CPR. EMS stated, unable to get a heart rhythm. LPN3 attempted to notify the Medical Director and received no answer. At 11:07 pm, EMS notified [Name] emergency room (ER) Physician Assistant (PA) and received a stop CPR order. At 11:20 pm, EMS1 notified Deputy Coroner (DC) and refused to come to the facility due to R385 not being pronounced deceased . EMS stated she would not take R385 to [Name] Hospital because she was dead. At 5:19 am, the Director of Nursing was notified. At 5:30 am, R385 was pronounced deceased . At 5:55 am, Mother of R385 was notified. At 6:20 am, the Medical Director was notified. At 8:22 am, Mother and Deputy Coroner (DC) at the Facility. At 9:39 am, R385 out of the Facility with DC. Review of the Emergency Medical Tech (EMT) report, provided by the facility, indicated EMS was notified on [DATE] at 10:51 pm, arrived at the facility at 11:01 pm, last time known well reported on [DATE] at 9:00 pm, first monitored rhythm indicated asystole (absence of heartbeat). During a telephone interview on [DATE] at 2:52 pm, LPN3 indicated she was assigned to R385 the night of [DATE] but was not the one who found R385 unresponsive. LPN3 stated she arrived at the facility between 7:00 pm and 8:00 pm on the evening of [DATE], made rounds to check her residents, and at that time, R385 was in her usual state with no concerns. She stated she started passing the evening medications and was unsure if she had given medication to R385, but checked on her during the medication pass. She stated at approximately 10:45 pm, she was notified by LPN5 that R385 was not breathing. LPN3 stated LPN5 began CPR, and she called 911. LPN3 indicated she was not sure when, but the Medical Director (MD) and Director of Nursing (DON) were called with no answer. LPN3 indicated she attempted to contact the DON approximately ten times through the night with no answer and made contact at 5:30 am the morning of [DATE]. When asked if the family was made aware of R385's change in condition, she stated yes after R385 was pronounced deceased at 5:55 am. When asked if a resident was not breathing, calling EMS and beginning CPR was a change in condition, LPN3 stated yes. During a telephone interview on [DATE] at 8:45 am, LPN5 stated she was working second shift, 7:00 pm to 7:00 am, on the D and E hall, which was at the end of C hall, which gave her a clear view of the C hall. LPN5 indicated she thought she saw someone go into R385's room, and she went in the room, no one was in the room, but she found R385 not breathing. LPN5 stated she notified LPN3 and started CPR. She stated LPN3 made calls and took notes. When asked if the family was made aware of R385's change in condition, she stated, The mother was called after R385 was pronounced deceased . When asked if a resident was not breathing, calling EMS, and beginning CPR was a change in condition, LPN5 stated yes. During an interview on [DATE] at 10:04 am, the DON confirmed that she was called the night of [DATE], and she did not get the call until she woke up the morning of [DATE]. When asked if she was on call, she indicated they did not have a call rotation. When asked why the family was not notified of R385's change of condition, she stated the mother was notified as soon as R385 was pronounced deceased , and when she signed off that she was pronounced, the event was complete. When asked if a resident was not breathing, EMS called and beginning CPR was a change in condition, she indicated the change of condition was not completed because R385 was not pronounced deceased until 5:30 am and then the family was notified. During a telephone interview on [DATE] at 11:09 am, the Family Member (FM) 2 confirmed she was not notified of R385's death until [DATE] at 5:55 am. She stated that the last time she saw R385 was on [DATE], and she was fine. She received a phone call on [DATE] from RN1 to notify her that she was being started on an antibiotic for an upper respiratory infection. FM2 stated she asked RN1 if she was okay, and she stated, Yes. FM2 stated she was told that she was found unresponsive at approximately 10:45 pm in the evening of [DATE]. She stated she was just in shock and confused as to why she wasn't informed before the morning. She stated she found out that R385 was not pronounced deceased until the morning of [DATE], when she died on [DATE]. FM2 stated this had been very traumatic and stressful to her and her family, knowing R385 passed on [DATE], and she wasn't called until [DATE], her death certificate stated [DATE] when in fact she knew she passed on [DATE]. During an interview [DATE] at 12:30 pm, the Unit Manager (UM) 2 indicated she was called and notified by LPN3 that R385 was found not breathing and 911 was called. UM2 indicated she went into the facility at approximately 12:00 am to support the staff. When asked if the family was notified and she stated no. When asked if the family should have been notified, she stated, no because they would want to come in and R385 had not been pronounced deceased yet. When asked if a resident was not breathing, EMS called and beginning CPR was a change in condition, she indicated the change of condition was not completed because R385 was not pronounced deceased .

Based on record review, interviews, and review of the facility's policy titled, Bed Hold, the facility failed to provide a written bed hold notice upon transfer to the hospital for one of four residents and/or representative (Resident (R) 25) reviewed for hospitalization out of 28 sample residents. This failure had the potential to cause R25 confusion or distress regarding returning to the same room after hospitalization. Findings include: Review of the facility's policy titled, Bed Hold, dated 3/3/2020, revealed All Residents are given the option of reserving their bed when leaving the facility with the intent to return .A Bed Hold Authorization Form should be completed and signed by the resident/ responsible party each time a resident leaves the facility. If the resident does not choose to reserve the bed, they will be offered the first appropriate bed that becomes available. Review of R25's admission Record located in R25's electronic medical record (EMR) under the Profile tab revealed R25 was admitted to the facility on [DATE] with diagnoses which included diabetes and absence of left leg below knee. Review of the history listed MDS located in R25's EMR under the MDS tab, documented R25 was discharged Return Anticipated (DRN) and Entry six times as follows: DRN on 5/16/2024, Entry on 5/18/2024. DRN on 8/4/2024, Entry on 8/7/2024. DRN on 8/11/2024, Entry on 8/15/2024. DRN on 9/16/2024, Entry on 9/23/2024. DRN on 10/11/2024, Entry on 10/12/2024. DRN on 1/24/2025, Entry on 1/28/2025. Review of R25's EMR revealed there was no documentation the facility provided a written bed hold notice to R25 or his representative. During an interview on 4/17/2025 at 11:25 am, the Director of Nursing (DON) stated R25 was discharged to the hospital for those dates on 5/16/2024, 8/4/2024, 8/11/2024, 9/16/2024, 10/11/2024, and 1/24/2025. The DON stated the facility did not offer an opportunity to hold the bed for R25 for those discharges because R25's payor source was from Veterans Affairs (VA), and the VA did not pay for the bed hold. During an interview on 4/17/2025 at 11:35 am, the Revenue Cycle Manager (RCM) stated the facility did not offer any written bed hold notice to R25. The RCM stated all the facility beds were licensed and certified under VA and Medicaid, and there was no VA-specified bed in the facility. The RCM said if a resident's payer source was VA, the facility would discharge that resident when that resident was transferred to the hospital and would get the VA's approval again when the resident was ready to return to the facility. The RCM stated if the VA did not approve, the facility would not take the resident back to the facility.

Based on record review, interviews, and review of the facility's document titled, RAI [Resident Assessment Instrument]/Care Planning Management, the facility failed to ensure the residents participated in care conferences for one of 28 sample residents (Resident (R) 65) reviewed for care conferences. This failure had the potential for the residents to have unmet care needs. Findings include: Review of the facility's document titled, RAI [Resident Assessment Instrument]/Care Planning Management, dated October 2023, indicated Invitations are mailed to the family/responsible party one week prior to the conference date. Invitations are completed by social services department. Social services invites each resident to the care conference personally on the morning of the care conference. Review of the Admission Record located under the Profile tab in the electronic medical record (EMR) revealed R65 admitted on [DATE] with diagnoses of major depressive disorder, brief psychotic disorder, metabolic encephalopathy, unspecified dementia, bipolar disorder, post-traumatic stress disorder, paranoid schizophrenia, and anxiety disorder. Review of the admission Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date(ARD) of 2/12/2025 indicated R65 had a Brief Interview for Mental Status (BIMS) of 12 out of 15, which indicated he had moderate cognitive impairment. During an interview on 4/16/2025 at 10:11 am, R65 stated he was not invited to a care plan meeting. He stated he did not know what that was. Review of the Baseline Care Plan Note located under the Documents tab in the EMR, revealed R65's sister was included in the baseline care plan meeting, but the record did not reveal R65 was invited. During an interview on 4/15/2025 at 12:46 pm, the Director of Nursing (DON) stated the responsible party was invited to the care plan meeting. She was not sure if the residents were invited to attend. During an interview on 4/16/2025 at 9:31 am, the Administrator stated that all interdisciplinary team (IDT) members should be included in the care plan meetings, and residents should be invited. The Administrator stated meetings could be held in the residents' room if that accommodated their needs.

Based on staff interview, record review, and review of the facility policy titled, Physician Services, the facility failed to follow the physician's orders for one of eight sampled residents (R) (R5). Findings include: Review of the facility policy titled, Physician Services, revised [DATE], revealed page six included, Physician's Orders: Procedure 8. No medications, treatments, diet orders, therapy, or procedures of any kind are to be administered to a resident without a physician's order. Record review revealed R5 was admitted to the facility on [DATE] with diagnoses including but not limited to type 1 diabetes mellitus, type 1 diabetes mellitus with hyperglycemia, hypertensive heart disease without heart failure, schizoaffective disorder, bipolar type, and non-pressure chronic ulcer of other part of right foot with unspecified severity. Review of R5's Progress Notes revealed an entry dated [DATE] documented Nurse walked into the residents' room at 7:44 pm to administer medication. No respirations, no blood pressure noted. Cardiopulmonary Resuscitation (CPR) initiated at 7:45 pm. 911 notified at 7:48 pm, fire fighters in at 7:55 pm to assist CPR, advised staff that EMS was in [another location]. Medical Director (MD) notified at 7:58 pm, order received to stop CPR. Regional Nurse Consultant (RNC) stated CPR had to continue until EMS [Emergency Medical Services] arrived. EMS arrived at 8:20 pm, notified doctor at [hospital name] at 8:26 pm order received to stop CPR. RN [Registered Nurse] DD arrived at the facility to pronounce at 8:45 pm. EMS left facility at 9:01 pm. Review of R5's medical record revealed an order dated [DATE] to stop CPR. In an interview on [DATE] at 2:00 pm, the Regional Nurse Consultant (RNC) stated that she was not at the facility before, during, or after the code. She stated that the Administrator called her and stated they called the MD, and the MD said to stop CPR. RNC stated that she told them to continue CPR until EMS arrived. She stated that to her knowledge, they never stopped the code. In an interview on [DATE] at 2:40 pm, Licensed Practical Nurse (LPN) CC stated that she was in the room during the code with three other nurses. LPN CC stated that CPR was stopped after the MD gave the order to stop CPR. She further stated that CPR was resumed after the Administrator instructed them to continue CPR until EMS arrived. In an interview on [DATE] at 3:00 pm, the Administrator stated that the night the resident expired, Registered Nurse (RN) FF called and informed her R5 had coded, the MD was notified and gave an order to stop CPR. The Administrator further stated she instructed the staff to continue CPR until EMS arrived at the instruction of the RNC. In an interview on [DATE] at 3:30 pm, LPN BB stated that CPR was initiated on R5, 911 was called, first responders arrived, the MD was called, the MD gave an order to stop CPR, and CPR was stopped. She further stated that when the Administrator was notified, the Administrator instructed staff to continue CPR until EMS arrived, and staff resumed CPR. She further stated that an ambulance arrived, notified their medical director, and stopped CPR. In an interview on [DATE] at 5:00 pm, LPN AA stated that R5 was found unresponsive, she called for help, and R5 was placed on the floor and CPR was initiated. She stated 911, and the MD were called. She further stated that the MD gave an order to stop CPR, and CPR was stopped. She stated the Administrator instructed staff to continue CPR until EMS arrived, and staff resumed CPR and continued until EMS arrived and took over resident care. In an interview on [DATE] at 10:03 am, the Director of Nursing (DON) stated that the nurses should have stopped the code on R5 as ordered by the MD. She stated her expectation of nurses was to follow the physician's orders. In an interview on [DATE] at 10:16 am, the MD stated he was notified by the facility that staff were performing CPR on R5. He stated that he gave an order to stop CPR, and further stated he did not give an order to resume CPR after it had been stopped. In a follow-up interview on [DATE] at 1:30 pm, the RNC stated that she was aware that the nurses received an order from the MD to stop CPR on R5. She stated that she told the nurses that they had to continue CPR until EMS arrived. The RNC acknowledged that CPR should have been stopped per the physician's orders.

Based on observation, resident and staff interviews, and record review, the facility failed to provide tracheostomy care, supervision, and supplies for a resident who was care planned to self-care his own tracheostomy site to one of two residents (Resident (R) 13) reviewed for respiratory care of 28 sample residents. This failure had the potential to contribute to respiratory infection for R13. Findings include: Review of R13's Admission Record located in the electronic medical record (EMR) under the Profile tab, revealed R13 was admitted to the facility on [DATE] with diagnoses which included cervical disc disorder and complete traumatic amputation of level between unspecified hip and knee. Review of R13's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/11/2025 and located in R13's EMR under the MDS tab, revealed R13 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R13 was cognitively intact. Further review revealed R13 received tracheostomy care in the facility. Review of R13's Has a tracheostomy care plan, dated 3/12/2025, documented R13 performs his own trach care per his preference. The care plan included the following: For Inner cannula care, when allowed by resident, observe for Changing as he prefers and, on his terms, and schedule. Ensure all supplies are available timely .Trach care performed by resident as he wishes staff to observe for assistance. Review of R13's physician's order Medication Administration Record (MAR) and Treatment Administration Record (TAR) for April 2025 located in R13's EMR under Orders tab, the report documented R13 received tracheostomy care and monitoring ordered by the physician as follows: Change the inner cannula, size six, daily and as needed, every night shift. Start date, 3/26/2025; Trach care every shift and as needed. Start date, 3/26/2025; Suction tracheostomy as needed for increased secretions. Start date, 3/26/2025; Change tracheostomy tie once weekly on Thursday on every day shift every Thursday. Start date, 3/26/2025. During an observation and interview on 4/14/2025 at 2:44 pm, R13 stated his tracheostomy size was 6G and he took care of his trach care by himself; the staff did not check on him when he cleaned it. R13 said and pointed to his bedside table and was observed there were no tracheostomy care supplies such as a tracheostomy care kit (contains sterile towel, sterile gauze pads, sterile cotton swabs, sterile small brush, sterile gloves.) or additional supplies (sterile 4x4 drain sponge, hydrogen peroxide, sterile water gauze, tracheostomy securing devise or tapes, ties.) per the facility's policy and the care plan instructed. There was no suction machine in R13's room. During an observation and interview on 4/15/2025 at 12:24 pm, when asked, R13 stated he used a special brand of toilet paper to clean the surroundings skin of the tracheostomy tube, rolled a napkin, and put it below the tracheostomy tube to support it. R13 pointed to the white rolled napkin on his neck and said he ran out of the toilet paper about a week ago, so he used the same rolled napkin to clean and support it. R13 said if there was blockage in his tracheostomy tube, he would remove the inner cannula, cough out the mucus, and put it back in. R13 then pulled out his inner cannula and coughed to explain how he cleared his mucus in the tracheostomy tube. R13 was observed to have his inner cannula in his hand, and the entire inner cannula tube looked completely brown throughout the whole tube. When asked, R13 said the inner cannula had not been changed or cleaned since he was admitted to the facility more than a month ago, and it had not been changed or cleaned for more than a year. He said if staff could offer him some supplies, such as clean gauze, it would help. During an interview on 4/15/2025 at 1:05 pm, when the Director of Nursing (DON) was informed about R13's statements and the brownish inner cannula, the DON said she would get some tracheostomy care supplies for R13. During an observation and interview on 4/15/2025 at 2:24 pm, when R13's care nurse, Licensed Practical Nurse (LPN) 8, was asked why there were no tracheostomy care supplies and spare tracheostomy tube in R13's room ready for him to use, LPN8 stated she would look for it in the supply room. During an observation conducted in the supply room with LPN8, LPN8 did not know where the tracheostomy care supplies were in the supply room, and she said she did not know R13's tracheostomy tube size, she needed to check R13's record. LPN8 found some tracheostomy supplies, which included a tracheostomy kit. However, LPN8 was not sure if the tracheostomy tube and inner cannula would fit R13. An observation and interview on 4/15/2025 at 2:50 pm, was conducted with LPN8 in R13's room. There was a box of gauze and a new emergency tracheostomy tube size 6DCFN on R13's table. R13 stated they just brought it here not long ago. R13 said he would not use the tube. R13 stated he was size 6G. No suction was observed in R13's room. During an interview on 4/15/2025 at 3:30 pm, the DON stated tracheostomy care would follow the procedures documented in the policy. During an interview on 4/15/2025 at 4:48 pm, when asked, LPN8 stated she had not observed or performed tracheostomy care or replaced the inner cannula for R13. During an interview on 4/16/2025 at 8:43 am, LPN7 said she never provided tracheostomy care to R13. LPN7 stated the treatment nurse did. During an interview on 4/16/2025 at 9:04 am, the DON stated the facility was in a transition, and currently, there was no treatment nurse, and the nursing staff would provide all treatments to their assigned residents. During an interview on 4/16/2025 at 9:04 am, LPN2 said she had never provided tracheostomy care for R13 when she was assigned to take care of R13. LPN2 said R13 took care of his own tracheostomy care. LPN2 stated if R13 needed assistance and asked, she would be more than willing to help him. She said the order administration documented as completed with a V sign for tracheostomy care meant that the staff asked R13 and verified with him that he completed the tracheostomy care and cleaning. She said the staff asked R13 to make sure R13 did it, if R13 said yes, he did it, the staff would mark the order as administration completed. LPN2 said she never observed R13 perform tracheostomy care for himself, but she did observe if there were any discharges near the tracheostomy area during the shift.

Based on record review, interviews, and review of facility policy titled, Freedom from Abuse Standard Addendum, the facility failed to protect the residents' right to be free from physical abuse by other residents for two of three residents (Resident (R) 65 and R54) reviewed for abuse out of 28 sample residents. The facility's failure to protect residents from abuse placed residents at continued risk of harm. Findings include: Review of the facility's policy and procedure titled, Freedom from Abuse Standard Addendum, effective October 24, 2022, revealed Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Abuse also included deprivation by an individual, employee, care giver of goods and services that are necessary to maintain the physical, mental, and psychosocial wellbeing .Resident to resident abuse of any type should be reviewed as a potential situation of abuse, and .staff should monitor behaviors that can provoke a reaction by residents or others which include verbally aggressive behaviors such as screaming, cursing, bossing around/demanding, insulting, intimidating. 1. Review of R65's Admission Record located under the Profile tab in the electronic medical record (EMR) revealed R65 admitted on [DATE] with diagnoses of major depressive disorder, brief psychotic disorder, unspecified dementia, bipolar disorder, post-traumatic stress disorder, paranoid schizophrenia, and anxiety disorder. Review of the admission Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 2/12/2025 indicated R65 had a Brief Interview for Mental Status (BIMS) of 12 out of 15, indicating he had moderate cognitive impairment. Review of the Care Plan located under the Care Plan tab of the EMR, initiated 2/2025, revealed R65 had impaired cognitive function/dementia or impaired thought processes r/t [related to] dementia. [R65] has a behavior problem related to physical aggression. 3/15/2025-Giver and Receiver of physical aggression. Review of the Incident Note, dated 3/15/2025 at 12:45 pm, and located in the EMR under the Progress Notes tab, revealed: at [approximately] 12:45 pm, it was reported by CNA [Certified Nurse Aide] that this resident got into a fight with another resident this morning. [This] writer went to speak with resident. [The] resident stated, yeah, I hit him because he talks too much smack all the time. I told him to wait until I got my coffee then I'll move. I hit him, [the] resident stated, he followed me to my room and threw water on me, then we started fighting again. [this] Writer completed [a] skin and pain assessment. [The] resident denies any pain or discomfort at this time. [The] writer noted skin tear on left hand middle finger. [The] writer completed first aide care to resident. [The] wound cleansed with normal saline, pat dry and covered with dry dressing. MD [Medical Director], CHE [mental health provider] DON [Director of Nursing], family member [Name] and . PD [police department] notified. [An] Order to begin Zyprexa 5MG [milligrams] PO [by mouth] Q [every] 12 HR [hour] PRN [as needed] x 14 days and place on 1:1. 2. Review of R54's Admission Record located under the Profile tab in the EMR revealed R54 admitted on [DATE] with diagnoses which included muscle weakness and major depressive disorder. Review of the quarterly MDS with an ARD of 3/17/2025 and located under the MDS tab in the EMR, revealed R54 had a BIMS of 13 of 15, indicating he was cognitively intact. Review of the Care plan located in the EMR under the Care Plan tab, revealed R54 [revised date] 3/15/2025 receiver and giver of physical abuse with another resident. Interventions included separating the residents, 1:1 supervision, and notifying all appropriate agencies. Review of the Incident Note located under the Progress Notes tab in the EMR, dated 3/15/2025, revealed R54 stated, yeah, I fought him because he hit me. I told him to move and let me through. Then he just hit me in the head. [The] resident stated, 'I followed him to his room and threw my water on him, then we started fighting again. Review of the police report, included with the facility's reported investigation and provided by the facility, indicated an officer was dispatched on 3/15/2025 to the nursing facility due to an altercation occurring between two residents. According to the nurse, [R54] stated he was waiting for [R65] to retrieve items from the breakfast cart and commented that [R65] needed to hurry up. According to the nurse, [R54] stated that was when [R65] attacked him, punching him. During an interview on 4/15/2025 at 12:41 pm, the DON stated that on 3/15/2025, R65 had a verbal altercation with R54. The DON stated R54 went into R65's room and threw water on him. She stated that the two residents then had a physical altercation. She stated R65 sustained a skin tear on his left middle finger. The DON stated after the incident, he was placed on 1:1 and R65 had a mental health evaluation. She stated the in-house psychiatric provider gave an order for medications if needed. She stated he did not require PRN medication and remained on 1:1 supervision for 72 hours. During an interview on 4/16/2025 at 10:19 am, Licensed Practical Nurse (LPN) 6 stated R65 feeds off of others' energy. She stated he did not like other residents coming into his room. She stated he did not ask for much but when he wanted something he wanted it right then. During an interview on 4/16/2025 at 12:15 pm, the DON stated she did not believe R65 was a threat to other residents. She stated R65 was provoked by R54 on 3/15/2025. She stated R54 followed R65 into his room after R65 did not get out of R54's way fast enough in the hallway. The DON stated R54 went into R65's room, and they exchanged words, then became physical with one another. She stated the residents were separated, assessed, and placed on 1:1 monitoring. She stated that minor injuries were sustained. The DON stated they were aware of R65's history at another facility of having resident-to-resident altercations. She stated orders for a PRN medication were received, but R65 did not require any medication. She stated no further incidents were reported. During an interview on 4/16/2025 at 12:20 pm, Unit Manager (UM) 1 stated private rooms were available if needed. Per her recollection, she stated the staff did not feel like R65 needed a private room since the incident did not occur with his roommate. She stated R65 was provoked by R54. She stated the two residents exchanged words and then had a physical altercation. UM1 stated they were separated and placed on 1:1 monitoring. She stated no further incidents have occurred between the two residents. During an interview on 4/16/2025 at 1:30 pm, the Administrator stated she was not aware of R65's resident-to-resident altercation at another facility. She stated she did not believe he was a threat to others currently. She stated she did not think he needed to be in a private room due to his history of aggression towards others. During an interview on 4/16/2025 at 3:41 pm, LPN3 stated the event did not happen on her shift, but it was reported to her on her shift. LPN3 stated R65's roommate reported R65 and R54 got in a fight earlier that day. She stated R65 told the nurse he had every right to defend himself. She stated R65 told her R54 wanted to leave his room, and R65 was blocking the way because he was getting something off the dietary cart. LPN3 stated R54 followed R65 to his room. She stated they exchanged words and then became physical with one another. She stated that by the time she came on shift and was notified, the residents were in their own rooms and were calm. She stated that no other incident occurred between the two residents.

Based on staff interviews, record reviews, and a review of the facility's policy titled Emergency Response Management Cardiopulmonary Resuscitation (CPR), the facility failed to activate 911 and continue CPR until more aggressive life-sustaining treatment could be initiated for one resident (R1) of 14 residents reviewed for code status. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE] at 10:14 am. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. An Acceptable Removal Plan was received on [DATE]. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. Findings include: A review of the facility's undated policy, Emergency Response Management Cardiopulmonary Resuscitation (CPR), revealed: Standard: To ventilate and establish circulation on a resident with absence of respirations and pulse. Note: Nurses (required) CNAs (suggested) maintain current CPR certification. Procedure: Determine unresponsiveness by briskly rubbing your knuckles against resident's sternum and deliver two rescue breaths to the unresponsive victim who is not breathing and start chest compressions immediately. If the resident wakes, moan or moves then CPR is not necessary. Call out for help. Delegate a specific individual to check physician orders; CPR order/DNR administrative personnel per facility policy and report back to individual as soon as possible. If an AED is immediately available, deliver one shock if instructed by the device, then begin CPR. CPR in three simple steps: 1. Call: Check the victim for unresponsiveness. If the person is not responsive and not breathing or not breathing normally, call for assistance or call 911. 2. Pump: If the victim is still not breathing normally, coughing, or moving, begin chest compressions. Push down the center of the chest 2 inches, 30 times. Pump hard and fast at the rate of 100 compressions per minute. 3. Blow: After 30 chest compressions tilt the head back and lift the chin. Pinch the nose and cover the mouth with yours (may use a mouth guard if available) and blow until you see the chest rise. Give 2 breaths. 4. Continue with 30 pumps and 2 breaths until help arrives. Record review for R1 revealed the resident was admitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease with acute exacerbation. Record review of the most recent Admission Minimum Data Set (MDS) for R1 dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 08, indicating that he had moderate cognitive impairment. Record review revealed a physician's order for R1 dated [DATE] to attempt resuscitation in the event R1 had no pulse and was not breathing. A review of the Nurse's Progress Note dated [DATE] at 4:35 pm revealed that R1 was found not arousable by verbal or physical stimuli and noted to not have any vital signs on [DATE] at 4:35 pm. Licensed Practical Nurse (LPN) AA exited the room, went to the nurse's station, and paged a code. LPN AA returned to the R1 room along with LPN BB and Registered Nurse (RN) CC and initiated CPR. There was no documentation that the facility called 911. LPN BB called the Medical Director (MD) on [DATE] at 4:55 pm. The Medical Director (MD) gave an order to stop CPR. The DON and the Administrator confirmed by DON that the facility staff never called 911. R1 was a full code status and expired in the facility on [DATE]. Interview on [DATE] at 1:32 pm with RN CC revealed the procedure when there is a code is for someone to grab the crash cart, someone calls 911, and someone starts compressions, continuing CPR until EMS arrives. RN CC stated that a nurse was on the phone with the MD, and he gave the order to stop CPR. RN CC stated that they would call EMS back if they did not arrive within 15 minutes. She stated that, as far as she is aware, LPN AA called EMS. RN CC stated that LPN AA called the code, and she and LPN BB took over the code. RN CC verified that there was no documentation that EMS was called. Interview on [DATE] at 1:53 pm with LPN BB revealed that she assisted LPN AA in the code and did chest compressions. LPN BB stated that she had her cell phone in her pocket, and she called the MD because they had been doing CPR for a long time, approximately 20 minutes; she stated that they were exhausted. LPN BB stated that the MD told them to stop CPR. LPN BB further revealed that after the code was stopped, R1 was pronounced by RN CC. LPN BB verified that there was no documentation that EMS was called. Interview on [DATE] at 3:09 pm with non-emergency 911 personnel revealed there were no calls from the facility on [DATE] in reference to an [AGE] year-old male. Interview on [DATE] at 3:20 pm with DON revealed the process for CPR is for everyone to participate. She stated that it is a team effort. The DON stated that one person is responsible for compressions, one person calls EMS, and one person does AMBU (manual breathing). The DON revealed that she was not sure if LPN AA called EMS, but she would call LPN AA and ask if she called EMS. The DON verified that there was no documentation that EMS was called. Interview on [DATE] at 4:10 pm with the MD revealed typically the nurses call EMS but if EMS was not there or if EMS was taking too long to get there, they sometimes call him. The MD was informed that there was no documentation that EMS was called. Interview on [DATE] at 11:40 am with the Administrator revealed he was not sure if the facility has an AED or defibrillator. He stated that he had not been at the facility that long, only a week ago in [DATE]. He stated that he was not sure of the policy for CPR, but he would check with the DON and see what their policy on CPR was. During a phone on [DATE] at 4:50 pm interview with LPN AA revealed she was working the back D and E halls from 7 am -7 pm shift on [DATE]. LPN AA stated that she went to R1's room to give him his medication, and he was not responsive. LPN AA revealed that she left the room, went to the nurse's station, and paged a code. She stated that she went back to the room and started CPR. LPN AA revealed that RN CC and LPN BB responded to the code. She further revealed that RN CC had her cell phone and was supposed to call EMS, but not sure if she contacted EMS. LPN AA further revealed that the normal procedure for a code is that if nobody is around, you yell out for someone to call 911. LPN AA confirmed that she did not yell out for someone to call 911. LPN AA stated that she and LPN BB were switching up doing CPR with compressions and AMBU. LPN AA further revealed that the facility does not have an AED or defibrillator. She stated that no one else came to assist with the code. LPN AA revealed that there are two nurses on the front halls and one nurse on the back halls. She stated that the two front hall nurses were not in the room during the code. She stated that they did not assist with the code. She stated that she had one CNA on D hall and one CNA on E hall. LPN AA stated that to her knowledge, EMS did not come. LPN AA verified that there was no documentation that EMS was called. LPN AA verified that RN CC documented in the chart because she was the RN that pronounced R1. A continued interview on [DATE] at 8:57 am with LPN BB revealed EMS did not arrive at any time during or after the code. LPN BB stated that the facility does not have an AED or defibrillator. She stated that the other two nurses who were in the facility on ,d+[DATE] did not respond to the code. LPN BB stated that she was CPR certified. A continued interview on [DATE] at 9:15 am with RN CC revealed that she was not aware of EMS arriving at the facility during or after the code. RN CC revealed that she did not call EMS. She stated CPR had been in progress for a while, and LPN BB called the MD. RN CC stated that the MD gave an order to stop CPR because it had been over 15 minutes. She stated that she was the RN and pronounced R1 after she got the stop CPR order from the MD. She further revealed that the facility does not have an AED or defibrillator. RN CC stated that there was only one nurse working on the front halls on [DATE] at 4:35 pm and did not participate in the code. RN CC stated that she was CPR certified. Interview on [DATE] at 9:25 am with LPN DD revealed she was working on [DATE] at 4:35 pm. She stated that she heard the code being paged. LPN DD stated that she did not respond to the code because they had LPN BB, RN CC, and LPN AA in the room. LPN DD further revealed that she would tell someone to call 911, or she would call herself, call the doctor, and continue CPR until the arrival of the ambulance. She stated that she would call the doctor to let him know what was going on, and if the doctor decided to stop the code, he would give an order to stop. LPN DD stated that the facility does not have an AED or defibrillator. LPN DD stated that she was CPR certified. Further interview on [DATE] at 9:50 am with LPN AA revealed there was a little mix-up because she thought that RN CC had her cell phone and was making the calls. LPN AA stated that she could not remember who made the calls, but she thought that RN CC called EMS. Further interview on [DATE] at 4:20 pm with the DON revealed she is responsible for the CPR cards and making sure everyone is active. The DON stated that she had a book with the cards. The DON revealed that the course for CPR was online, with no hands-on check-off, only a test after watching the course. The DON further revealed that successfully passing the test after the course indicates competency in CPR. She stated that after staff passes the test, they are issued a card and that means that they have successfully passed the course without return demonstration of compressions. The facility implemented the following actions to remove the IJ: 1. Licensed Nurses LPN AA and RN CC failed to continue Cardiopulmonary resuscitation until 911 services were called on [DATE] on R1. 2. On [DATE], Licensed Nurse LPN AA and RN CC received CPR certification to include continuing CPR until 911 services arrive. 3. On [DATE], Senior [NAME] President of Clinical Services reviewed the policy Emergency Response Management policies and procedures and concluded no revisions were made. 4. On [DATE], the Medical Director was educated on the policy and procedure for the Emergency Response Management by the Administrator. 5. On [DATE], The Regional Nurse Consultant educated Director of Nursing and Administrator on Emergency Response Management policy and procedure. 6. On [DATE], Education for the Emergency Response Management policy and procedure was completed by Director of Nursing and/or licensed staff. 3 of 4 RNs, 16 of 17 LPNs, 40 of 44 CNAs, 9 of 9 Dietary Staff, 9 of 14 Therapy staff, 3 of 3 Maintenance Director, 1 of 1 Business office Manager, 1 of 1 Social Service Director, 1 of 1 Activities Director, 1 of 1 Director of Nursing, 1 of 1 Administrator, 7 of 11 Housekeeping, 1 of 1 Admission Director, and 1 of 1 Human Resource Director 86.20 % of education was completed for all staff. 7. All staff not educated on Emergency Response Management will be in-serviced prior to working their next scheduled shift by the Administrator, Director of Nursing, and or Licensed Nurse. All new hires will be educated during their onboarding process. 8. On [DATE], an Advance Directive audit was completed by the Social Service Director to include the Physician Orders for Life-Sustaining Treatment (POLST), physician order, and care plan is accurate. 58 Residents elected to receive Cardiopulmonary resuscitation, and 21 residents elected to be a Do Not Resuscitate status for a total of 79, with one resident currently in the hospital. The Administrator and/or Director of Nursing will update daily the Advance Directive Audit tool and the Event Monitoring tool (to include residents who receive CPR) including weekends and holidays [DATE]. 9. On [DATE], 10 of 10 licensed staff received Cardiopulmonary Resuscitation Certification provider whose training includes hands-on practice and in person skills assessment. The additional 11 licensed nurses had CPR Certification prior to compliance date of [DATE]. The total of licensed nurses with CPR certification is 100%. 10. On [DATE], The Regional Nurse Consultant and or Regional MDS Nurse reviewed 79 of 79 resident's records of the Advance Directive audit to ensure orders, POLST, and care plans are completed accurately in the resident record. 11. The Regional Nurse Consultant and Regional [NAME] President of Operation visited the facility on [DATE]. 12. On [DATE], the Administrator conducted an Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting which consists of the Medical Director, Regional [NAME] President of Operations, Business Office Manager, Social Service Director, MOS nurse, Certified Nurse Assistant, and licensed nurse to review the results of the most recent survey outcomes. The IDT (interdisciplinary Team) will review daily during morning clinical meeting to ensure compliance with following the Clinical Emergency Response Policy to include notifying 911 during CPR, auditing Advance Directives, Physician orders, and Care Plans. 13. All corrective actions were completed by [DATE]. 14. All immediacy of the IJ was removed on [DATE]. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Review of CPR certifications for LPN AA, and RN CC revealed LPN AA, and RN CC received CPR certification effective [DATE] through expiration date [DATE]. 2. Interview with LPN AA on [DATE] at 9:00 am revealed she received CPR certification at the facility on [DATE] provided by a certified CPR instructor to include a CPR course, hands on skills competency check off, and a written test. Interview with RN CC on [DATE] at 9:15 am revealed she received CPR certification at the facility on [DATE] provided by certified CPR instructor to include a CPR course, hands on skills competency check off, and a written test. Observation of CPR training in progress on [DATE] at 3:30 pm. 3. Interview with the Senior [NAME] President (SVP) of Clinical Services on [DATE] at 9:40 am revealed she reviewed the Emergency Response Management policies and procedures, and no revisions were made. Review of Emergency Response Management policies and procedures reviewed with policies and procedures on Cardiopulmonary Resuscitation (CPR) standards and procedures to include emergency crash cart standards and procedures. Policy review date [DATE] in response to citation of Immediate Jeopardy with SVP of Clinical Services signature. 4. A review of the sign-in sheet dated [DATE] revealed an in-service conducted by the Administrator provided to the Medical Director. Review of education provided to the Medical Director by the Administrator on the policy and procedure for Emergency Response Management, including, but not limited to, Cardiopulmonary Resuscitation (CPR) and Emergency Crash Carts. Interview with Director of Nursing on [DATE] at 11:20 am revealed the Medical Director was educated via phone on [DATE]. Phone interview with the Medical Director on [DATE] at 11:50 am revealed he received education from the Administrator on [DATE] on Emergency Response Management including Cardiopulmonary Resuscitation (CPR), Calling 911, and Emergency Crash Cart. 5. Review of the sign-in sheet dated [DATE] revealed an in-service conducted by the Regional Nurse Consultant provided to the DON and Administrator. Education included handouts on Clinical Emergency Response Management, Cardiopulmonary Resuscitation (CPR) standards and procedures, and Emergency Crash Cart standards and procedures. Interview with the DON on [DATE] at 8:45 am revealed she received education from the Regional Nurse Consultant on [DATE] on the Emergency Response Management Policy and Procedure. Interview with the Administrator on [DATE] at 11:30 am revealed he received education provided by the Regional Nurse Consultant on [DATE] on the Emergency Response Management Policy and Procedure. 6. Review of sign in sheet dated [DATE] revealed an in-service conducted by the Director of Nursing provided to 3 of 4 RNs, 16 of 17 LPNs, CNAs, 9 of 9 Dietary Staff, 9 of 14 Therapy staff, 3 of 3 Maintenance Director, 1 of 1 Activities Director, 1 of 1 Director of Nursing, 1 of 1 Administrator, 7 of 11 Housekeeping, 1 of 1 Admission Director, and 1 of 1 Human Resource Director 86.20 % of education was completed for all staff. Education included a review of the Clinical Emergency Response Management standard, reviewing the steps to administer CPR with good staff participation. Staff interviews conducted on [DATE] confirming receiving education as previously stated above with LPN AA at 9:00 am, RN CC at 9:15 am, LPN BB at 9:25 am Maintenance Director at 10:00 am, Activity's Director at 10:15 am, Dietary Staff at 10:15 am, Human Resource Director at 10:30 am, CNA GG at 10:45 am, CNA HH at 11:00 am, CNA II at 11:10 am, LPN DD at 11:35 am, Housekeeper LL at11:40 am, Laundry /Housekeeping JJ at 11:50 am. 7. All staff not educated on Emergency Response Management will be in-serviced prior to working their next scheduled shift by the Administrator, Director of Nursing, and or Licensed Nurse. All new hires will be educated during their onboarding process. During validation the facility did not have any new hires. 8. Review of Advance Directive Audit completed by the Social Service Director to include POLST, physician order, and care plan reviewed. The audit form is dated [DATE]. The audit revealed 21 residents with a Do Not Resuscitate order and 58 residents with a full code order to resuscitate. The audit form indicated if the face sheets were correct and the date of correction of [DATE]. 9. Review of CPR certifications for 10 of 10 licensed staff revealed licensed staff received CPR certification on [DATE], including a course provided by a certified CPR instructor, hands-on skills check off, and a written test. Effective date of certification [DATE] through an expiration date of [DATE]. A review of 11 licensed nurses' CPR certifications revealed 11 licensed nurses with current CPR certifications with expiration dates of ,d+[DATE] through ,d+[DATE]. Observation of CPR training in progress on [DATE] at 3:30 pm. 10. A review of 20 Advance Directive audits revealed audits with a completion and correction date of [DATE]. Audits indicated the resident's name, care plan, and code status. 11Confirmed with LPN DD on [DATE] at 11:55 pm revealed she saw the Regional Nurse Consultant and the Regional [NAME] President of Operations at the facility on Wednesday, [DATE] during day shift. 12. An Ad HOC sign form dated [DATE] Emergency Notifications/Emergency Response Management revealed the Administrator, Director of Nursing, Activity Director, Business Office Manager, Dietary Manager, Director of Business Development, Director of Rehab, HR/MR/Payroll, HSKP Supervisor, Maintenance Director, Social Services, and Unit Manager. A phone interview with the Medical Director on [DATE] at 11:50 am revealed he attended the Ad HOC meeting via phone. 13. All corrective actions were completed by [DATE]. 14. All immediacy of the IJ was removed on [DATE].

Based on staff interviews, record review, and a review of the Administrator and Director of Nursing (DON) Job Description, the Administration failed to ensure that staff were following appropriate procedure when providing Cardiopulmonary Resuscitation (CPR) for one resident (R1) of 14 residents reviewed for code status. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and DON were informed of the Immediate Jeopardy (IJ) on [DATE] at 10:14 a.m. The noncompliance related to the IJ was identified to have existed on [DATE]. An Acceptable Removal Plan was received on [DATE]. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. Findings include: The facility had a Job Description for the job title of Administrator. The description included that the Administrator's primary purpose is to oversee the day-to-day operation of the facility and to review organizational performance. Oversee that residents receive care in a manner and in an environment that maintains or enhances their quality of life without abridging the safety and rights of other residents. Monitor competence of the work force and make necessary adjustments/corrections as required or that may become necessary. Ensure that policies and procedures are developed, implemented, monitored, and evaluated in order to maintain compliance with federal, state, and local rules and regulations. The facility had a Job Description for the job title of DON. The description included that the Director of Nursing primary purpose is to plan, organize, develop, and direct the overall operation of the Nursing Department to ensure that the highest degree of quality care is maintained at all times. Review nurses' notes to ensure that they are informative, descriptive of the nursing care and consistent with therapy care being provided, that they reflect the resident's response to the care, and that such care is provided in accordance with the resident's wishes. Direct the Nurse Educator in the planning, conducting, and scheduling of timely in-service training classes to ensure a well-educated nursing services department. Training would include OSHA, CDC, TB management and blood borne pathogens as well as other in-service training required by state/federal regulations. The facility failed to provide effective oversight and monitoring of facility procedures related to Full Code residents requiring CPR. The facility provided an undated policy Emergency Response Management Cardiopulmonary Resuscitation (CPR), revealed: Standard: To ventilate and establish circulation on a resident with absence of respirations and pulse. Note: Nurses (required) CNAs (suggested) maintain current CPR certification. Procedure: Determine unresponsiveness by briskly rubbing your knuckles against resident's sternum and deliver two rescue breaths to the unresponsive victim who is not breathing and start chest compressions immediately. If the resident wakes, moan or moves then CPR is not necessary. Call out for help. Delegate a specific individual to check physician orders; CPR order/DNR administrative personnel per facility policy and report back to individual as soon as possible. If an AED is immediately available, deliver one shock if instructed by the device, then begin CPR. CPR in three simple steps: 1. Call: Check the victim for unresponsiveness. If the person is not responsive and not breathing or not breathing normally, call for assistance or call 911. 2. Pump: If the victim is still not breathing normally, coughing, or moving, begin chest compressions. Push down the center of the chest 2 inches, 30 times. Pump hard and fast at the rate of 100 compressions per minute. 3. Blow: After 30 chest compressions tilt the head back and lift the chin. Pinch the nose and cover the mouth with yours (may use a mouth guard if available) and blow until you see the chest rise. Give 2 breaths. 4. Continue with 30 pumps and 2 breaths until help arrives. R1 had a physician's order dated [DATE] to attempt resuscitation in the event he had no pulse and was not breathing. Record review of the Nurse's Progress Note dated [DATE] at 4:35 pm revealed that R1 was found not arousable by verbal or physical stimuli and noted not to have any vital signs on [DATE] at 4:35 pm. Licensed Practical Nurse (LPN) AA exited the room, went to the nurse's station, and paged a code. LPN AA returned to R1's room along with LPN BB and Registered Nurse (RN) CC and initiated CPR. LPN BB called the Medical Director (MD) on [DATE] at 4:55 pm. The MD gave the order to stop CPR. RN CC pronounced R1 on [DATE] at 4:55 pm. There was no documentation that the facility staff contacted Emergency Medical Services (EMS). Record review revealed on [DATE] at 4:35 p.m., R1 had a change of condition. LPN AA, LPN BB, and RN CC started CPR at 4:40 p.m. and continued until 4:55 p.m. when CPR was stopped, and RN CC pronounced the resident deceased . Interview on [DATE] at 3:20 pm with the DON revealed that one person is responsible for compressions, one person calls EMS, and one person does AMBU (manual breathing). She stated that she was not sure if LPN AA called EMS. The DON verified that there was no documentation that EMS was called. Interview on [DATE] at 11:40 am with the Administrator revealed he was not sure if the facility has an AED or defibrillator. He stated that he had not been at the facility that long. The Administrator further revealed that he was not sure of the policy for CPR, but he would check with the DON and see what their CPR policy stated. Cross refer to F678. The facility implemented the following actions to remove the IJ: 1. The administration failed to notify emergency management while providing Cardiopulmonary Resuscitation on [DATE]. The licensed nurse failed to notify 911 during CPR. It was identified the facility failed to implement all components of the Clinical Emergency Response Policy that included notifying 911 during CPR. 2. The Administrator and DON were re-educated on [DATE] by the Regional [NAME] President of Operation on Clinical Emergency Response Policy. 3. On [DATE], the Regional Nurse Consultant re-educated the Administrator and DON on the job description. 4. The Administrator will have daily calls with the Regional [NAME] President of Operations regarding process of the plan, identified concerns and non-compliance identified items beginning on [DATE]. The Administrator and/or DON will update daily the Advance Directive Audit tool and the Event Monitoring tool (to include residents who receive CPR) including weekends and holidays. 5. The Regional Nurse Consultant and Regional [NAME] President of Operations will visit the facility daily beginning [DATE] to ensure compliance and identify any areas of concern with not notifying emergency management (9I I) during CPR, beginning on [DATE]. A review of the findings will be placed in a weekly trip report by the Regional Nurse Consultant and Regional [NAME] President of Operations. 6. All corrective action was completed on [DATE]. 7. The immediacy of the IJ was removed on [DATE]. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. The Administration failed to notify emergency management while providing Cardiopulmonary Resuscitation on [DATE]. The licensed nurse failed to notify 911 during CPR. It was identified the facility failed to implement all components of the Clinical Emergency Response Policy that included notifying 911 during CPR. 2. A review of the sign-in sheet dated [DATE] revealed an in-service conducted by the Regional [NAME] President of Operation provided to the Administrator and DON. Education included handouts on Clinical Emergency Response Management, Cardiopulmonary Resuscitation (CPR) standards and procedures, and Emergency Crash Cart standards and procedures. Confirmed education with DON on [DATE] at 8:45 am, and Administrator on [DATE] at 11:30 am. 3. A review of the sign-in sheet dated [DATE] revealed an in-service conducted by the Regional Nurse Consultant provided to the Administrator and DON. Confirmed education with the DON on [DATE] at 11:00 am. 4. Beginning on [DATE], the Administrator will have daily calls with the Regional [NAME] President of Operations regarding the plan's process, identified concerns, and non-compliance items. The Administrator and/or DON will update daily the Advance Directive Audit tool and the Event Monitoring tool (to include residents who receive CPR), including weekends and holidays. Interview on [DATE] at 8:30 am with the DON revealed there was a change in leadership. The DON stated that the Administrator who was there is no longer there, and she has stepped into the role of the Administrator, and her Administrator license was verified. 5. Regional Nurse Consultant and Regional [NAME] President of Operations were observed at the facility on [DATE], [DATE], and [DATE]. Confirmed with LPN DD on [DATE] at 11:55 am revealed she saw the Regional Nurse Consultant and the Regional [NAME] President of Operations at the facility. 6. All corrective action was completed on [DATE]. 7. The immediacy of the IJ was removed on [DATE].