Every finding on record at Copperas Cove Nursing & Rehabilitation

Based on observation, interview, and record review, the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for one (Resident #1) of five residents reviewed for medical records. The facility failed to ensure the Medication Administration Record for Resident #1 was accurately documented for the month of July 2026. MA A signed off Resident #1's night medications on 07/21/2026 without giving the medication. This failure could place residents at risk for decreased quality of care and quality of life.Findings included:Review of Resident #1's face sheet, dated 08/19/26, revealed Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of insomnia (a common sleep disorder that makes it hard to fall asleep, stay asleep, or get restful sleep despite having the time and a safe environment to do so), Dementia (a decline in mental ability severe enough to interfere with daily life, including losses in memory, language, and problem-solving) , CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE (a chronic condition where the heart muscle cannot pump blood and oxygen effectively to meet the body's needs), Glaucoma (a group of eye diseases that damage the optic nerve, often due to high fluid pressure inside the eye, and can lead to permanent vision loss), high blood pressure and reflux disease (a chronic condition where stomach acid frequently flows back into the tube connecting your mouth and stomach, irritating its lining), Ectropion an eye condition where the lower eyelid sags and turns outward, exposing the inner surface Review of Resident #1's MDS Assessment, dated 06/26/26, revealed Resident #1 had a BIMS score of 03 to indicate severe cognitive impairment. Resident #1 was noted to currently take antipsychotic medications (prescription drugs primarily used to treat mental health conditions), antibiotics (prescription medicines that treat bacterial infections), opioids (a class of powerful drugs that block pain signals in the brain and nervous system.), and antiplatelet medications (medications that stop blood cells called platelets from sticking together to prevent dangerous blood clots.) Review of Resident #1's MAR, dated 07/21/26, revealed the following medications were signed as given by MA A but were not given: Melatonin Oral Tablet 10 MG (Melatonin) Give 1 tablet by mouth at bedtime for insomnia Pravastatin Sodium Oral Tablet 10 MG (Pravastatin Sodium) Give 1 tablet by mouth at bedtime related to CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE SEROquel Oral Tablet 50 MG (Quetiapine Fumarate) Give 1 tablet by mouth at bedtime related to UNSPECIFIEDDEMENTIA, UNSPECIFIED SEVERITY, WITH AGITATION Erythromycin Ophthalmic Ointment 5 MG/GM (Erythromycin (Ophth)) Instill 3.5 gram in right eye three times a day for Ectropion Apply 1/2 inchLatanoprost Ophthalmic Solution 0.005 % (Latanoprost) Instill 1 drop in both eyes at bedtime for Glaucoma Review of Resident #1's care plan, dated 03/19/26, revealed Resident #1 required use of medications for high blood pressure including hydralazine, lisinopril, coreg, clonidine, Nitroglycerin, Spironolactone and torsemide with the intervention of give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (a sudden drop in blood pressure that happens when you stand up from a sitting or lying position) and increased heart rate (tachycardia) and effectiveness. During an interview on 08/19/26 at 9:31 AM, Resident #1's FM stated she was concerned about Resident #1 receiving her medications as ordered. She stated on 07/21/2026 during the afternoon hours Resident #1 needed her blood pressure medications. She stated she spoke with the Treatment Nurse and he stated Resident #1 had not received her blood pressure medication yet. She stated the Treatment Nurse took Resident #1's blood pressure and then administered the blood pressure medications. Resident #1's FM stated the Treatment Nurse stated MA A would then administer the night medications to Resident #1.s. She stated the shift changed and no one gave Resident #1 her bedtime medication. She stated she asked LVN B about giving the nighttime mediations and LVN B reported MA A had already signed off that Resident #1's medications were given earlier. Resident #1's FM stated she was with Resident #1 the whole time and the nighttime medications were not given. She stated the facility looked into it and MA A signed off that the medications were given and they were not. She stated LVN B gave Resident #1 the medications. She stated she was concerned medications were checked off as given and then not administered. During an interview on 08/19/26 at 10:02 AM, MA A stated she would not sign off on a medication unless she gave the medication and the resident took the medication. She stated that she signed off the medication as given once the resident took the medication. She stated that if she was signed into a computer a nurse could sign out medications as given under her log in name. She stated on 07/21/2026 the Treatment Nurse was the one who popped the medications for Resident #1 and then did not sign them off as given under his name. She stated she did not normally work that hall and was not familiar with giving the medications. She stated she thought the Treatment Nurse gave all of Resident #1's nighttime medications when he gave blood pressure medication. She stated she signed off the rest of the nighttime medications as given because she thought the Treatment Nurse had given them and just forgot to sign the record. MA A stated she did not help Resident #1 routinely because the family members complained about her and so the nurses mainly work with Resident #1. MA A stated she had only worked with Resident #1 three times prior to this incident, and she has not worked with Resident #1 since 07/21/2026. During an interview on 08/19/26 at 11:47 AM, the ADON stated a nurse, or med aide, should not sign off on medications as administered unless they were given to the resident. She stated she would ensure the medication was correct in the cup that was being given to the residents. The ADON stated there was a section in the MAR for notes if there was a change or alteration in the medication regimen. During an interview on 08/19/26 at 1:00 PM, LVN B stated there was a mix up one night over Resident #1's nighttime medications not being given but documented as given. She stated MA A thought the Treatment Nurse gave Resident #1 all of her nighttime medications, so MA A signed them all out as given under MA A's name. She stated she called the Treatment Nurse when Resident #1's FM brought the concern to her that Resident #1 had not received her nighttime medications. She stated she checked the MAR and MA A had signed off that the medications were given by her that evening. She stated MA A should not have signed off that the medications were given if MA A did not administer the medications. She stated she confirmed with the Treatment Nurse that he did not give Resident #1 her nighttime medications and then administered the medications to Resident #1 that evening. She stated Resident #1 was administered her blood pressure medications, melatonin and Seroquel at bedtime. During an interview on 08/19/26 at 2:42 PM, the DON stated they were short of a medication aide which contributed to the confusion of whether Resident #1 received her nighttime medications. She stated the Treatment Nurse was helping out by giving Resident #1 her blood pressure medication. She stated she spoke with MA A, Treatment Nurse and LVN B and determined the confusion arose with MA A assuming the Treatment Nurse gave the nighttime medications with the blood pressure medications. She stated MA A should not have signed out the medications as given if MA A did not administer the medications. She stated it was false documentation if you signed that you gave medication and did not. She stated Resident #1's nighttime medications were on the liberalized medication schedule which means they could be administered anytime between 6 PM and 10 pm daily. During an interview on 08/19/26 at 3:42 PM, Treatment Nurse stated he assisted Resident #1 and Resident #1's FM with a medication and administered Resident #1's blood pressure medication on 07/21/2026 during the afternoon hours. He stated he signed off on administering the blood pressure medication and knew the LVN B would give Resident #1 her nighttime medication later that evening. He stated he received a call later that evening from LVN B in which he was asked if he gave Resident #1 her nighttime medications as they were signed off as given by MA A. He stated he did not give the nighttime medications. The Treatment Nurse stated LVN B then gave Resident #1 her nighttime medications. He stated he did not know why MA A signed off that the nighttime medications were administered. During an interview on 08/19/26 at 4:09 PM, the Admin stated no one should sign off on a medication as administered unless they administered the medication themselves. The Admin stated it could be misleading to whoever was reading it. The Admin stated ultimately you were responsible for what actually happened, it could be falsifying even if you did not intend to do it. Review of facility's policy title Medication Administration revised April 2019 reflected: Policy Statement-Medications are administered in a safe and timely manner, and as prescribed.Policy Interpretation and ImplementationOnly persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so.The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions.Medications are administered in accordance with prescriber orders, including any required time frame.Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include:Enhancing optimal therapeutic effect of the medication;Preventing potential medication or food interactions; andHonoring resident choices and preferences, consistent with his or her care plan.Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose.The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.As required or indicated for a medication, the individual administering the medication records in the resident's medical record:The date and time the medication was administered;The dosage;The route of administration;The injection site (if applicable);Any complaints or symptoms for which the drug was administered;Any results achieved and when those results were observed; andThe signature and title of the person administering the drug

Based on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrates they were unavoidable, and a resident with pressure ulcers received necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 5 Residents (Resident #1) reviewed for quality of care. The facility failed to complete wound care treatment for Resident #1 on 01/03/2026, 01/30/2026, 02/05/2026, 02/07/2026, 02/08/2026. This failure could place residents at risk of rapid wound deterioration.Findings included:A record review of Resident #1's face sheet, dated 04/11/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included pressure ulcer of sacral region,(shield -shaped bone at the base of the lumbar spine connecting the spine to the pelvis) stage 4 (full thickness wound extending to muscle, tendon, or bone), pressure ulcer of unspecified site, unspecified stage, multiple sclerosis (immune system destroys the myelin sheath (protective layer fatty tissue) protecting nerves in the brain and spinal cord), anemia (deficiency of healthy blood cells), and paraplegia(impairment motor of sensory function in the lower half of the body)A record review of Resident #1's care plan, dated 04/11/2026, reflected Resident #1 had a pressure injury or potential for pressure injury development r/t immobility. Stage 4 wound to Coccyx (tailbone) related to being paralyzed from the waist down, wound to lateral foot(outside of foot), blood blister the left toe, and unstageable deep tissue injury(severe wound classifications where the true dept is hidden) on the side of the right planter lateral fifth(common site for foot pain), . resistive(refusing) to turning/repositioning, refuse repositioning and offloading while in bed, despite ongoing education and encouragement, refusing to get out of bed and wound care with interventions of air mattress, wound cleansing, monitor dressing every shift to ensure it is intact(not broken) and adhering(sticking firmly), notify a nurse immediately of any new areas of skin breakdown discoloration, educate Resident # 1 of the possible outcome of not complying with treatment or care, encourage, frequent change positions, weekly treatment to document to include measurement of the area of skin breakdown width, length, dept type of tissue, if Resident #1 resist(refuse) give a clear explanation of care, leave, return 5-10 minutes later and try againA record review of Resident #1's admission MDS assessment, dated 10/28/2026 , reflected Resident #1 had BIMS score of 14,indicated cognitive intact. Resident # 1 was at risk of developing pressure ulcers/injuries and had one stage 4 pressure ulcer and one or more unhealed pressure ulcers/injuries.A record review of Resident #1's Quarterly MDS assessment, dated 02/14/2026 , reflected Resident #1 had BIMS score of 11,indicated moderate cognitive impairment. Resident # 1 was at risk of developing pressure ulcers/injuries and had one stage 4 pressure ulcer and one or more unhealed pressure ulcers/injuries.A record review of Resident #1's physician's order dated 11/18/2025 reflected cleanse the Stage 4 pressure wound to coccyx (tailbone) with wound cleaner every day shift. Apply Medihoney (treatment for wounds), cover with calcium alginate (highly absorbent dressing), and place a dressing start date 11/18/2025. A record review of Resident #1's Physician's order dated 12/18/2025 reflected cleanse the wound on the lateral foot every day shift with normal saline or wound cleaner, pat dry with 4x4 gauze, apply Xeroform (sterile, non-adhering petrolatum dressing) to the wound bed then cover with a foam dressing start date 12/18/2025. The Physician's order dated 12/18/2025 reflected to change the dressing every day shift per protocol or as needed for soiling or dislodgement and continue treatment until healed or as directed by the provider start date 12/18/2025. A record review of Resident #1's Physician's order dated 12/18/2025 reflected cleanse blood blister every day shift on the left foot, above the heel and below the ankle, with normal saline or approved wound cleaner. Gently apply Betadine (antiseptic used to kill bacteria) to the blister and surrounding intact skin. Leave the blister open to air start date 12/18/2025.A record review of Resident #1's TAR dated 01/03/2026, 02/05/2026, 02/07/2026, and 02/08/2026 reflected cleanse the wound on the lateral foot every day shift with normal saline or wound cleaner, pat dry with 4x4 gauze, apply Xeroform (antiseptic used to kill bacteria) to the wound bed then cover with a foam dressing was not signed off completed in PCC (Electronic Health Record)by LVN C on the 6:00 AM - 6:00 PM shift.A record review of Resident #1's TAR dated 01/30/2026, 02/05/2026, 02/07/2026, and 02/08/2026 reflected cleanse blood blister every day shift on the left foot, above the heel and below the ankle, with normal saline or approved wound cleaner. Gently apply Betadine (antiseptic used to kill bacteria) to the blister and surrounding intact skin. Leave the blister open to air was not signed off completed in PCC by LVN C on the 6:00 AM - 6:00 PM shift.A record review of Resident #1's TAR dated 01/03/2026, 01/30/2026, 02/05/2026, 02/07/2026, and 02/08/2026 reflected cleanse the Stage 4 pressure wound to coccyx (tailbone) with wound cleaner every day shift. Apply Medihoney (treatment for wounds), cover with calcium alginate (highly absorbent dressing), and place a dressing was not signed off completed in PCC by LVN C on the 6:00 AM - 6:00 PM shift.A record review of Resident #1's weekly wound care assessments and skin sheets dated 03/11/2026, 03/18/2026, and 3/25/2026 revealed no wound infections. Resident #1 was sent out to the hospital on [DATE] and there was no wound care assessmentA record review of Wound Care Doctor Visit on 04/02/2026 reflected the Wound Care Doctor done a debridement on Resident #1's right planter(bottom foot) lateral(outer edge extending from the heel to the little toe) fifth MTP(joint where the long bones of the foot meet). Resident # 1 had experienced discomfort and requested for the Wound Care Doctor to stop.Review of Hospital records dated 04/04/2026 reflected Resident #1 was admitted to the hospital for Sepsis secondary to UTI and possible pneumonia borderline hypotensive(low blood pressure) on 04/04/2026 but blood pressure improved Resident #1 remained confused encephalopathic(altered function of brain)During an interview with Resident #1's RP on 04/11/2026 at 9:59 AM stated that facility staff would contact her when Residdent #1 would refuse care. Resident #1's RP stated that Resident #1 had admitted to the facility with wounds and had wound care orders. Resident#1's RP stated she was lead to believe wound care orders was not being followed due to Resident #1's recent hospitalization when it was determined the resident had sepsis.During an interview with the Wound Care Doctor on 04/12/2026 at 12:20 PM the Wound Care Doctor stated that if Resident #1 had missed or refused any wound care treatments he would have identified any change of condition and would have identified any infections The Wound Care Doctor stated that Resident # 1 was not sent out for wounds on 04/04/2026 and he had did a debridement on Resident #1's right planter(bottom foot) lateral(outer edge extending from the heel to the little toe) fifth MTP(joint where the long bones of the foot meet) on 04/02/2026. Resident # 1 had experience some discomfort and asked him to stop.Attempted an interview with LVN C on 04/13/2026 at 1:20 PM, 2:00 PM, and 4:13 PM and was unsuccessful. Left LVN voice mail messages and no return call was received by exit 04/13/2026. LVN C was no longer employed with the facility.During an interview with the DON on 04/13/2026 at 3:35 PM, the DON stated it was expected for LVN C to have completed wound care for Resident #1 on 01/03/2026, 01/30/2026, 02/05/2026, 02/07/2026, and 02/08/2026. The DON stated it was expected for LVN C to have followed the physician's order. The DON stated if orders were not followed a resident's condition could worsen.During an interview with the ADM on 04/13/2026 at 3:55 PM, the ADM stated it was expected for LVN C to have completed the wound care for Resident #1. The ADM stated that LVN was expected to follow the doctor's order to prevent any further complications.Record review of the facility's policy, dated 2001 revised 10/2010 , titled wound care reflected The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. The following information should be recorded in the resident's medical record:The type of wound care givenThe date and time the wound care was givenThis position in which the resident was placedThe name and title of the individual performing wound careAny change in the resident's conditionAll assessment data (i.e., wound bed color, size, drainage, etc) obtained when inspecting the woundHow the resident tolerated the procedureAny problems or complaints made by the resident related to the procedureIf the resident refused the treatment and the reason(s) whyThe signature and title of the person recording the data

Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for complete and accurate records.The facility failed to ensure Resident #1's wound care cleaning was documented completed in PCC for 01/10/2026, 01/25/2026, 02/14/2026, 02/17/2026, 02/19/2026, 02/21/2026, 02/23/2026, 02/26/2026, 03/06/2026, 03/07/2026, 03/10/2026, 03/11/2026, 03/13/2026, 03/16/2026, 03/17/2026, 03/22/2026, 03/23/2026, and 03/30/2026.This failure could place residents of staff not knowing whether treatment and services were provided for. Findings include:A record review of Resident #1's face sheet, dated 04/11/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included pressure ulcer of sacral region,(shield -shaped bone at the base of the lumbar spine connecting the spine to the pelvis) stage 4 (full thickness wound extending to muscle, tendon, or bone), pressure ulcer of unspecified site, unspecified stage, multiple sclerosis (immune system destroys the myelin sheath (protective layer fatty tissue) protecting nerves in the brain and spinal cord), anemia (deficiency of healthy blood cells), and paraplegia(impairment motor of sensory function in the lower half of the body)A record review of Resident #1's care plan, dated 04/11/2026, reflected Resident #1 had a pressure injury or potential for pressure injury development r/t immobility. Stage 4 wound to Coccyx (tailbone) related to being paralyzed from the waist down, wound to lateral foot(outside of foot), blood blister the left toe, and unstageable deep tissue injury(severe wound classifications where the true dept is hidden) on the side of the right planter lateral fifth(common site for foot pain), resistive(refusing) to turning/repositioning, refuse repositioning and offloading while in bed, despite ongoing education and encouragement, refusing to get out of bed and wound care with interventions of air mattress, wound cleansing, monitor dressing every shift to ensure it is intact(not broken) and adhering(sticking firmly), notify a nurse immediately of any new areas of skin breakdown discoloration, educate Resident # 1 of the possible outcome of not complying with treatment or care, encourage, frequent change positions, weekly treatment to document to include measurement of the area of skin breakdown width, length, dept type of tissue, if Resident #1 resist(refuse) give a clear explanation of care, leave, return 5-10 minutes later and try againA record review of Resident #1's admission MDS assessment, dated 10/28/2026 , reflected Resident #1 had BIMS score of 14,indicated cognitive intact. Resident # 1 was at risk of developing pressure ulcers/injuries and had one stage 4 pressure ulcer and one or more unhealed pressure ulcers/injuries.A record review of Resident #1's Quarterly MDS assessment, dated 02/14/2026 , reflected Resident #1 had BIMS score of 11,indicated moderate cognitive impairment. Resident # 1 was at risk of developing pressure ulcers/injuries and had one stage 4 pressure ulcer and one or more unhealed pressure ulcers/injuries.A record review of Resident #1's physician's order dated 11/18/2025 reflected cleanse the Stage 4 pressure wound to coccyx (tailbone) with wound cleaner everyday shift. Apply Medihoney (treatment for wounds), cover with calcium alginate (highly absorbent dressing), and place a dressing start date 11/18/2025.A record review of Resident #1's Physician's order dated 12/18/2025 reflected cleanse the wound on the lateral foot every day shift with normal saline or wound cleaner, pat dry with 4x4 gauze, apply Xeroform (sterile, non-adhering petrolatum dressing) to the wound bed then cover with a foam dressing start date 12/18/2025. The Physician's order dated 12/18/2025 reflected to change the dressing every day shift per protocol or as needed for soiling or dislodgement and continue treatment until healed or as directed by the provider start date 12/18/2025. A record review of Resident #1's Physician's order dated 12/18/2025 reflected cleanse blood blister every day shift on the left foot, above the heel and below the ankle, with normal saline or approved wound cleaner. Gently apply Betadine (antiseptic used to kill bacteria) to the blister and surrounding intact skin. Leave the blister open to air start date 12/18/2025.A record review of Resident #1's Physician's order dated 2/26/2026 reflected cleanse the wound on the right lateral foot every day shift with normal saline or approved wound cleaner, pat dry, apply calcium alginate (highly absorbent dressing) and gauze border dressing start date 02/26/2026.A record review of Resident #1's Physician's order dated 11/14/2025 reflected cleanse the unstageable deep tissue injury on the side of the right planter lateral fifth MTP(joint where the long bones of the foot meet) with wound cleaner. Apply Betadine daily and leave open to air. Every day shift for wound healing start date 11/14/2025.A record review of Resident # 1's Physician's order date 04/05/2026 reflected for 23 days, cleanse wound to non-pressure wound of the right planter(bottom of foot), lateral(extend from heel to the little toe)MTP(joint where the long bones of the foot meet) toe with wound cleanser and apply alginate calcium(highly absorbent sterile pad) QD and PRN if saturated, soiled, or dislodged, and cover with BDR. Apply skin prep to peri-wound area QD and PRN for dislodgement or soiled dressing one time a day for wound healing related to pressure ulcer of unspecified site , unspecified stage start date 04/05/2026.A record review of Resident #1's TAR dated 01/10/2026 reflected cleanse blood blister every day shift on the left foot, above the heel and below the ankle, with normal saline or approved wound cleaner. Gently apply Betadine (antiseptic used to kill bacteria) to the blister and surrounding intact skin. Leave the blister open to air was not signed off completed in PCC (electronic health record)by LVN A on the 6:00 AM - 6:00 PM shift.A record review of Resident #1's TAR dated 01/10/2026 reflected cleanse the wound on the lateral foot every day shift with normal saline or wound cleaner, pat dry with 4x4 gauze, apply Xeroform (sterile, non-adhering petrolatum dressing) to the wound bed then cover with a foam dressing was not signed off completed in PCC by LVN A on the 6:00 AM - 6:00 PM shift.A record review of Resident #1's TAR dated 01/10/2026 reflected cleanse the Stage 4 pressure wound to coccyx (tailbone) with wound cleaner everyday shift. Apply Medihoney (treatment for wounds), cover with calcium alginate (highly absorbent dressing), and place a dressing was not signed off completed in PCC by LVN A on the 6:00 AM - 6:00 PM shift.A record review of Resident #1's TAR dated 01/25/2026 reflected cleanse blood blister every day shift on the left foot, above the heel and below the ankle, with normal saline or approved wound cleaner. Gently apply Betadine (antiseptic used to kill bacteria) to the blister and surrounding intact skin. Leave the blister open to air was not signed off completed in PCC by LVN B on the 6:00 AM - 6:00 PM shift.A record review of Resident #1's TAR dated 01/25/2026 reflected cleanse the wound on the lateral foot every day shift with normal saline or wound cleaner, pat dry with 4x4 gauze, apply Xeroform (sterile, non-adhering petrolatum dressing) to the wound bed then cover with a foam dressing was not signed off completed in PCC by LVN B on the 6:00 AM - 6:00 PM shift.A record review of Resident #1's TAR dated 01/25/2026 reflected cleanse the Stage 4 pressure wound to coccyx (tailbone) with wound cleaner everyday shift. Apply Medihoney (treatment for wounds), cover with calcium alginate (highly absorbent dressing), and place a dressing was not signed off completed in PCC by LVN B on the 6:00 AM - 6:00 PM shift.A record review of Resident #1's TAR dated 02/14/2026 and 02/23/2026 reflected cleanse the wound on the lateral foot every day shift with normal saline or wound cleaner, pat dry with 4x4 gauze, apply Xeroform (highly absorbent dressing) to the wound bed then cover with a foam dressing was not signed off completed in PCC by LVN A on the 6:00 AM - 6:00 PM shift.A record review of Resident #1's TAR dated 02/14/2026 and 02/23/2026 reflected cleanse the Stage 4 pressure wound to coccyx (tailbone) with wound cleaner every day shift. Apply Medihoney (treatment for wounds), cover with calcium alginate (highly absorbent dressing), and place a dressing was not signed off completed in PCC by LVN A on the 6:00 AM - 6:00 PM shift.A record review of Resident #1's TAR dated 02/23/2026 reflected cleanse blood blister every day shift on the left foot, above the heel and below the ankle, with normal saline or approved wound cleaner. Gently apply Betadine (antiseptic used to kill bacteria) to the blister and surrounding intact skin. Leave the blister open to air was not signed off completed in PCC by LVN A on the 6:00 AM - 6:00 PM shift.A record review of Resident #1's TAR dated 02/17/2026, 02/19/2026, 02/21/2026, and 02/23/2026 reflected cleanse the wound on the lateral foot every day shift with normal saline or wound cleaner, pat dry with 4x4 gauze, apply Xeroform (to the wound bed then cover with a foam dressing was not signed off completed in PCC by LVN B on the 6:00 AM - 6:00 PM shift.A record review of Resident #1's TAR dated 02/17/2026, 02/19/2026, and 02/21/2026 reflected cleanse the Stage 4 pressure wound to coccyx (tailbone) with wound cleaner every day shift. Apply Medihoney (treatment for wounds), cover with calcium alginate (highly absorbent dressing), and place a dressing was not signed off completed in PCC by LVN B on the 6:00 AM - 6:00 PM shift.A record review of Resident #1's TAR dated 02/17/2026, 02/19/2026, 02/21/2026, and 02/23/2026 reflected cleanse blood blister every day shift on the left foot, above the heel and below the ankle, with normal saline or approved wound cleaner. Gently apply Betadine (antiseptic used to kill bacteria) to the blister and surrounding intact skin. Leave the blister open to air was not signed off completed in PCC by LVN B on the 6:00 AM - 6:00 PM shift.A record review of Resident #1's TAR dated 02/26/2026 reflected cleanse the wound on the lateral foot every day shift with normal saline or wound cleaner, pat dry with 4x4 gauze, apply Xeroform (antiseptic used to kill bacteria) to the wound bed then cover with a foam dressing was not signed off completed in PCC by LVN D on the 6:00 AM - 6:00 PM shift.A record review of Resident #1's TAR dated 02/26/2026 reflected cleanse blood blister every day shift on the left foot, above the heel and below the ankle, with normal saline or approved wound cleaner. Gently apply Betadine (antiseptic used to kill bacteria) to the blister and surrounding intact skin. Leave the blister open to air was not signed off completed in PCC by LVN D on the 6:00 AM - 6:00 PM shift.A record review of Resident #1's TAR dated 03/06/2026, 03/07/2026, 03/13/2026, and 03/16/2026 reflected cleanse the wound on the right lateral foot every day shift with NS/WC, pat dry, apply calcium alginate (highly absorbent dressing) and gauze border dressing was not signed off completed in PCC by LVN D on the 6:00 AM - 6:00 PM shift.A record review of Resident #1's TAR dated 03/06/2026, 03/07/2026, 03/13/2026, 03/30/2026and 3/22/2026 reflected cleanse the Stage 4 pressure wound to coccyx (tailbone) with wound cleaner every day shift. Apply Medihoney (treatment for wounds), cover with calcium alginate (highly absorbent dressing), and place a dressing was not signed off completed in PCC by LVN D on the 6:00 AM - 6:00 PM shift.A record review of Resident #1's TAR dated 03/10/2026, 03/11/2026, 03/16/2026 andreflected cleanse the wound on the right lateral foot every day shift with NS/WC, pat dry, apply calcium alginate (highly absorbent dressing ) and gauze border dressing was not signed off completed in PCC by LVN A on the 6:00 AM - 6:00 PM shift.A record review of Resident #1's TAR dated 03/10/2026, 03/11/2026, and 03/16/2026 reflected cleanse the Stage 4 pressure wound to coccyx (tailbone) with wound cleaner every day shift. Apply Medihoney (treatment for wounds), cover with calcium alginate (highly absorbent dressing), and place a dressing was not signed off completed in PCC by LVN A on the 6:00 AM - 6:00 PM shift.A record review of Resident #1's TAR order dated 03/17/2026 reflected cleanse the Stage 4 pressure wound to coccyx (tailbone) with wound cleaner every day shift. Apply Medihoney (treatment for wounds), cover with calcium alginate (highly absorbent dressing), and place a dressing was not signed off completed in PCC by LVN A on the 6:00 AM - 6:00 PM shift.A record review of Resident #1's TAR dated 03/17/2026 reflected cleanse the wound on the right lateral foot with NS/WC pat dry , apply xeroform(antiseptic used to kill bacteria) and gauze border dressing every day shift was not signed off completed in PCC by LVN A on the 6:00 AM - 6:00 PM shift.A record review of Resident #1's TAR dated 03/22/2026 and 03/23/2026 reflected cleanse the wound on the right lateral foot with NS/WC pat dry , apply xeroform(antiseptic used to kill bacteria) and gauze border dressing every day shift was not signed off completed in PCC by LVN D on the 6:00 AM - 6:00 PM shift.A record review of Resident #1's weekly wound care assessments and skin sheets dated 03/11/2026, 03/18/2026, and 3/25/2026 revealed no wound infections. Resident #1 was sent out to the hospital on [DATE] and there was no wound care assessmentA record review of Wound Care Doctor Visit on 04/02/2026 reflected the Wound Care Doctor done a debridement on Resident #1's right planter(bottom foot) lateral(outer edge extending from the heel to the little toe) fifth MTP(joint where the long bones of the foot meet). Resident # 1 had experienced discomfort and requested for the Wound Care Doctor to stop.Review of Hospital records dated 04/04/2026 reflected Resident #1 was admitted to the hospital for Sepsis secondary to UTI and possible pneumonia borderline hypotensive(low blood pressure) on 04/04/2026 but blood pressure improved Resident #1 remained confused encephalopathic(altered function of brain)During an interview with Resident #1's RP on 04/11/2026 at 9:59 AM stated that facility staff would contact her when Residdent #1 would refuse care. Resident #1's RP stated that Resident #1 had admitted to the facility with wounds and had wound care orders. Resident#1's RP stated she was lead to believe wound care orders was not being followed due to Resident #1's recent hospitalization when it was determined the resident had sepsis.During an interview with the Wound Care Doctor on 04/12/2026 at 12:20 PM stated that nursing staff should be signing off in PCC when Resident #1 had refused wound care. The Wound Care Doctor stated that he had did a debridement on Resident # 1's right planter(bottom foot) lateral(outer edge extending from the heel to the little toe) fifth MTP(joint where the long bones of the foot meet) on 04/02/2026. The Wound Care Doctor stated Resident #1 had experienced discomfort and Resident # 1 had requested for him to stop. The Wound Care Doctor stated there was not any infections with Resident #1's wounds and he did see the Resident once a week and sometimes twice and Resident #1 's wounds had improved. The Wound Care Doctor was responsible for staging the wounds and determined if the wounds were infected. The Wound Care Doctor stated that he would have identified any change of condition with Resident #1's wounds if wound care had not been provided. The Wound Care Doctor stated that Resident # 1 was not sent out to the hospital on [DATE] for wounds. During an interview with LVN D on 04/13/2026 at 11:45 AMstated that Resident #1 was not compliant in wound care and she would give Resident #1 some time to agree to wound care during her work hours 6:00 AM- 6:00 PM. LVN D stated that she did not sign off in the TAR when Resident # 1 refused wound care on 02/26/2026, 03/6/2026, 03/07/2026, 03/13/2026, 03/22/2026, 03/23/2026, and 03/30/2026, LVN D stated she did not sign off at end of her shift when Resident # 1 had refused the wound care. LVN D stated she was responsible for monitoring the wounds for any change of condition. LVN D stated documentation was important to validate the services had been completed .During an interview with LVN A on 04/13/2026 at 12:19 PM stated that Resident #1 refuses wound care pretty regularly and he gives Resident #1 several opportunities throughout the day to see if Resident # 1 would eventually let him provide the wound care. LVN A stated the TAR in PCC was not signed off on for the dates 01/10/2026, 02/14/2026, 02/23/2026, 03/10/2026, 03/11/2026, 03/16/2026, and 03/17/2026 due to at the end of his shift he failed to document that Resident # 1 had refused wound care. LVN A stated it was important to sign off the TAR in PCC to show the wound care was completed.During an interview with LVN B on 04/13/2026 at 1:30 PM stated that she had completed the wound care for Resident # 1 on 01/25/2026, 02/17/2026, 02/19/2026, and 02/21/2026. LVN B stated at the end of her shift she did not sign off the wound care was completed in PCC. LVN B stated documentation was important because it was the best way to track services provided . LVN B stated if the wound treatment was not documented it would indicate it was not done.During an interview with the Wound Care Nurse on 04/13/2026 at 3:01 PM stated she started with the facility the last week in March (not able to recall exact date). The Wound Care Nurse stated it was expected for LVN A, LVN B, and LVN D to have signed off in PCC that the treatments were refused by Resident #1. The Wound Care Nurse stated when wound treatments were not signed off on it would look like the wound treatments were not completed.During an interview with the DON on 04/13/2026 at 3:35 PM, the DON stated it was expected for LVN A, LVN B, and LVN D to have signed off on the TAR on 01/10/2026, 01/25/2026, 02/14/2026, 02/17/2026, 02/19/2026, 02/21/2026, 02/23/2026, 02/26/2026, 03/06/2026, 03/07/2026, 03/10/2026, 03/11/2026, 03/13/2026, 03/16/2026, 03/17/2026, 03/22/206, 03/23/2026, and 03/30/2026 on the 6:00 AM-6:00 PM P shift The DON stated the LVNs should document Resident #1's refusals in PCC and failed to go back and sign off at the end of their shift. The DON stated if the TAR was not signed off on it would indicate it did not happen.During an interview with the ADM on 04/13/2026 at 3:55 PM, the ADM stated it was expected for LVN A, LVN B, and LVN D to have signed off wound care completed on the TAR in PCC for the dates . The ADM stated that LVN A, LVN B, and LVN D should have signed off Resident #1 refused wound care treatment in PCC. The ADM stated if the TAR was not signed off on it would have indicated that the treatment was not completed and would not verify if the wound care treatment was completed or not.Record review of the facility's policy, revised 07/2017 , titled Charting and Documentation reflected All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response care. 7.Documentation of procedures and treatments will include care-specific details including:The date and time the procedure/treatment was providedThe name and title of the individual(s) who provided the careThe assessment data and/or any unusual findings obtained during the procedure/treatmentHow the resident tolerated the procedure/treatmentWhether the resident refused the procedure/treatmentNotification of family , physician or other staff, if indicated; andThe signature and title of the individual documenting.

Based on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodations of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 3 of 8 residents (Residents #1, #2, & #3) reviewed for resident rights.The facility failed to ensure Residents #1, #2, & #3's call lights were within reach on 12/09/2025.This failure could place residents at risk of their needs not being metFindings include:Record review of Resident #1's admission record, dated 12/10/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Epilepsy (a brain disorder causing recurrent seizure), Alzheimer's disease (progressive brain disorder that slowly destroys memory and thinking skills), and muscle weakness (loss of strength in muscles making it difficult to move or perform physical task).Record review of Resident #1's admission MDS assessment, dated 10/15/2025, reflected Resident #1 had a BIMS score of 99, which indicated severe cognitive impairment. Resident #1 was dependent in the areas of shower/bathe self, upper body dressing, lower dressing, putting on/taking off footwear and personal hygiene. Record review of Resident #1's care plan, dated 12/10/2025, reflected Resident #1 was care planned for high risk for fall r/t unaware of safety needs, gait/balance problems, and seizure activity. Resident #1 had an intervention of be sure the resident's call light is within reach and encourage the resident to use it. During observations on 12/09/2025 at 10:29am and 2:47pm, Resident #1's call light was observed hanging towards the ground on the right side of her bed Resident #1 could not be interviewed due to her cognitive status. Record review of Resident #2's admission record, dated 12/10/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: chronic idiopathic constipation (long last/frequent constipation), essential primary hypertension (high blood pressure), unsteady feet (feeling wobbly, off balance, or like you might fall while walking or standing), and muscle weakness (loss of strength in muscles making it difficult to move or perform physical task).Record review of Resident #2's Quarterly MDS assessment, dated 10/08/2025, reflected Resident #2 had a BIMS score of 07, which indicated severe cognitive impairment. Resident #2 was dependent in the areas of toileting hygiene, shower/bathe self, upper body dressing, lower dressing, putting on/taking off footwear and personal hygiene. Record review of Resident #2's care plan, dated 12/10/2025, reflected Resident #2 was care planned for at risk for falls. Resident #2 had an intervention of be sure the resident's call light is within reach and encourage the resident to use it. During an observation on 12/09/2025 at 10:31am, Resident #2's call light was observed hanging towards the ground on the left side of his bed. During an interview with Resident #2 on 12/09/25 at 10:31am, Resident #2 stated that he could not reach his call light, and he would have to yell for assistance if he needed it. Resident #2 stated his call light was never in reach and must wait for staff to pass by to get assistance. Record review of Resident #3's admission record, dated 12/10/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included: type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood without any common health problems associated with the disease), gastro esophageal reflux disease without esophagitis (when stomach acid frequently flows back up into food pipe causing irritation, heartburn, and a sour taste), and Alzheimer's disease (progressive brain disorder that slowly destroys memory and thinking skills)Record review of Resident #3's admission MDS assessment, dated 10/06/2025, reflected Resident #3 had a BIMS score of 15, which indicated Resident #3 was cognitively intact. Resident #3 required partial/moderate assistance in the areas of oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower dressing, putting on/taking off footwear and personal hygiene. Record review of Resident #3's care plan, dated 12/10/2025, reflected Resident #3 was care planned for ADL self-care performance deficit r/t Alzheimer's with an intervention of encourage the resident to use bell to call for assistance. During an observation on 12/09/2025 at 10:58am, Resident #3's call light was observed approximately 3 feet away from him and out of reach. During an interview with Resident #3 on 12/09/25 at 10:58am, Resident #3 stated that he could not reach his call light, and he would have to get out of bed and crawl to get it. Resident #3 stated he did not know how long his call light had been out of reach. During an interview with CNA A on 12/09/2025 at 2:10 PM, CNA A stated she was providing care for Resident #3 during the time his call light was not within reach. CNA A stated she moved the call light when she was assisting Resident #3 and forgot to put it back within reach. CNA A stated a negative outcome could be that the resident would not be able to call for assistance if he needed. During an interview with CNA B on 12/09/2025 at 2:30 PM, CNA B stated she was providing care for Resident #2 during the time his call light was not within reach. CNA B stated she was not aware that Resident #2's call light was not within his reach. CNA B stated a negative outcome could have been the resident could have fallen attempting to get assistance from staff. During an interview with the DON on 12/09/2025 at 3:45 PM, the DON stated all residents' call lights should be always within reach. The DON stated it was everyone's responsibility to ensure residents call lights were always within reach. The DON stated if a resident's call light was not within reach, the resident would not be able to call for assistance.During an interview with the ADM on 12/09/2025 at 4:00 PM, the ADM stated call lights should always be within reach. The ADM stated it was everyone's responsibility to ensure the call lights were within reach. The ADM stated if a resident's call light was not within reach, then the residents would not be able to express their needs nor have their needs met. The ADM stated her expectation was for staff members to ensure call lights were within reach prior to existing the resident's rooms.A record review of the facility's Answering the Call Light policy, dated 2001, reflected The purpose of this procedure is to ensure timely responses to the resident's requests and needs.General Guidelines5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen reviewed for food service safety. The facility failed to ensure food safety by not consistently monitoring, discarding expired food, maintaining sanitary kitchen. These failures can place residents at risk for foodborne illness. Findings included:Observation in the kitchen on 9/23/2025 at 9:15 AM of refrigerator #1 reflected a bag of Pepperoni was not sealed. Observation in the kitchen on 9/23/2025 at 9:20 AM of refrigerator #2 reflected the Ready Care Thickening water that had an expiration date of 4-9-2025. Observation in the kitchen on 9/23/2025 at 9:26 AM of refrigerator #3 reflected the Sour cream and ketchup in individualized containers were in a zip-lock bag dated 9/17/25 with no expiration date. Observation in the kitchen and interview on 9/23/2025 at 9:35 AM revealed the one pantry in the kitchen reflected a bag of Hot dog buns opened labeled date of 9-12-2025, and the DM said that bread has a 7-day shelf life. Observation in the kitchen on 9/23/2025 at 10:20 AM of the hot food serving station and food prep counter reflected the following: - Dust builds up hanging above the hot food serving station. - Dust builds up on the wall close to the prep table. An interview on 9/25/2025 at 1:57 PM, The DA said it was everyone's responsibility to check the dates of food in the kitchen. The DA said they use labels and stickers to put on food products so they can tell the date when it should be used. The DA said she uses the first-out method, which means all the old food items should be in front of the new items. The DA stated everyone in the kitchen was responsible for cleaning. The DA said this includes the walls and the ceilings, he was not aware that the ceiling was dirty. The DA said they get training for food safety, then for cleaning. The DA stated if outdated food was served to the residents, they could get sick. The DA stated if you went from the wall to the ceiling and fell into the food, residents could get sick. Interview on 9/25/2025 at 2:09 PM, the CK said it is everyone's responsibility to check the dates of food in the kitchen. The CK said if she sees items out of date, she throws them away. The CK said when they get a grocery truck, she checked the date on the items. CK said new food items go in the back, old ones in the front. CK said everyone is responsible for cleaning the kitchen. The CK said she did not realize the wall and ceiling were that dirty. The CK said if she cannot reach somewhere that needs to be cleaned, then she will get some help. The CK said they had in-service training on food safety and cleaning the kitchen a week ago. The CK said residents could get sick if out-of-date food was served or if dust debris fell into the food. Interview on 9/25/2025 at 2:20 PM, the DM it is everyone's responsibility to clean the kitchen and check for out-of-date food. dates. Food in the refrigerator should be checked daily, and the rest of the food is checked weekly. The DM said there is a log for cleaning the kitchen signed when a task is done. The DM said the walls and ceiling should be cleaned weekly. In-service training on labeling & dating and cleaning the kitchen was done a week ago. Residents could get sick if out-of-date food was served or if dust fell into the food. Interview on 9/25/2025 at 2:30 PM, the ADM said all kitchen staff should be checking for holiday food items and cleaning the entire kitchen. The ADM said she just had an in-service on food safety and cleanliness with the kitchen staff a week ago, not sure why there were issues. The ADM said the DM should be checking these things. Record review of the facility's food storage policy that was updated on 9-25-2025.Policy Interpretation and Implementation 1. All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects.2. All food is appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) are marked on cases and on individual items removed from cases for storage. Use by dates are completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food are observed and use by dates are indicated once food is opened.

Based on observation, interview and record review the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 1 of 1 days reviewed (9/23/2025) for nurse staffing posting.The facility failed to post accurate daily staffing information on 9/23/2025. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.Findings included:During an observation on 9/23/2025 at 12:45 PM, the daily staffing census information was posted on the wall outside the DON office dated 8/21/2025; 8/22/2025; 8/26/2025, 8/27/2025; 8/29/2025.During an interview on 9/25/2025 at 11:30 a.m., the DON stated it was her job or the ADON to post the staffing on the daily basis. The negative outcome would be no one knows what the staffing was for the day.During an interview on 9/25/2025 at 11:35 a.m., the ADON stated it was her job or the DONs job to post the daily staffing. She stated nobody would know what the staffing would be. During an interview on 9/25/2025 at 1:40 p.m., the ADM stated it was the DON job to post the daily schedule, and the negative outcome was staff would not know their hours and where to go. There was no policy regarding the daily posting of the schedule.

Based on interview and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the need of each resident. On 2 of the 4 medication carts reviewed the facility failed to establish a system of record of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation at each shift change. This failure could place residents at risk of drug diversions and could result in diminished health and well-being.Findings Include: Record review of the change of shift narcotic count sheets for the medication cart on B Hall reflected missing documentation on the Narcotic count sheet for the following:*9/17/2025 1st shift on-coming and off -going shifts, *9/18/2025 1st shift off-going,*9/22/2025 1st shift on-coming and off- going shift, and *9/23/2024 1st shift on-coming and off-going. Record review of Narcotic count sheet for the mediation cart on D hall reflected missing documentation for the following:*9/15/25/2025 1st shift on-coming and off-going shift, *9/17//2025 1st shift on-coming shift and off-going shift, *9/18/2025 1st and 2nd shift off-going and on-coming shift, and *9/22/2025 1st and 2nd shift on-coming and off-going shift.During an interview with CMA A on 09/25/2025 at 1:37PM, she stated it was required for the off going and oncoming staff to count narcotic medications together and signed the narcotic count sheet.During an interview with LVN A on 09/24/2025 at 10:42AM, she stated it was required for the off going and oncoming staff to count narcotic medications together and signed the Narcotic Count Sheet.During an interview with DON on 09/24/2025 at 11:28AM, she stated it was the expectation the off-going and on-coming shifts counted narcotics and sign the Narcotic Count sheet at each shift change. She stated staff were trained at this expectation in new employee orientation. The DON stated nurses and CMAs have recently been in serviced on ensuring they are counting narcotics at change of shift. A negative outcome of not counting narcotics at shift change was the possibility of drug diversion.During an interview with Administrator on 09/25/2025 at 1:48PM, she stated it was her expectation that the off-going nurse and the on-coming nurse counted the narcotics together at the change of shift. She stated a negative outcome of not consistently following the narcotic count expectations was a possibility of drug diversion.Record review of In-service sign in sheet over narcotic count dated 9/9/2025, stated nurses and CMA was the audience. Please ensure you are counting the cart at change of shift. This is not optional. Record review of the Controlled Substances policy stated, Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together.

Based on observation, interview, and record review, the facility failed to ensure drugs and biological were stored under proper temperature for 1of 1 Medication Rooms reviewed for medication storage. The facility failed to ensure the correct temperature for the storage of refrigerated medications for 4 days in Medication room [ROOM NUMBER]. The facility failed to check the medication storage temperature for 10 of 23 days for the month of September 2024.This failure could place residents receiving medication at risk for lack of drug efficacy.Findings included:During an observation and record review of the Refrigerator Temperature Log for the month of September 2025 in Medication room [ROOM NUMBER] on 09/24/2025 at 10:19AM temperature readings were below 36 degrees Fahrenheit for 4 days.*9/4/2025 34 degrees F*9/13/2025 32 degrees F*9/14/2025 30 degrees F*9/15/2025 32 degrees F The out-of-range temperatures read from 30 degrees Fahrenheit to 34 degrees Fahrenheit. The temperature of the medication refrigerator was not checked and documented on the following dates:*9/3/2025, *9/11/2025, *9/16/2025, *9/17/2025, *9/18/2025, *9/19/2025, *9/20/2025, *9/21/2025, *9/22/2025 and *9/23/2025. During an interview with the DON on 09/24/2025 at 10:50AM the DON stated the medication refrigerator temperatures should be checked daily. The medication aides on the day shift are responsible for checking the medication refrigerator temperatures and documenting them on the log. The DON stated if the medication refrigerator temperature was out of range there was the potential for medications to be compromised and lose their efficacy. The DON stated if medication refrigerator temperature was not checked daily there was the potential for the temperatures to be out of range.During an interview with Pharmacist on 09/25/2025 at 2:10PM the Pharmacist stated in his professional opinion, temperatures being out of range 4-6 degrees did not adversely affect the medications being stored. During an interview with the Administrator on 09/25/2025 at 1:48PM, she stated the medication refrigerator temperatures were to be checked and documented daily. If there were out of range temperatures, the staff were expected to notify Maintenance. She stated if the medication refrigerator was not checked daily there was the potential the temperature could be out of range and the medication could be compromised and lose their efficacy. During an interview with CMA A on 09/25/2025 at 1:37PM, she stated the medication aides on the day shift was responsible for checking the medication refrigerator temperatures daily and documenting it on the log. If the temperature was out of range or the temperature was not checked daily there was the potential for the medication to be compromised and lose their efficacy.During an interview with LVN A on 09/24/2025 at 10:42AM, she stated the medication refrigerator was checked daily by the night nurse.Record review of the policy entitled; Refrigerators and Freezers- Medication Room read:The facility will ensure safe refrigerators and freezers maintenance, temperatures, and sanitation, and will observe medication specifications for temperature control:1. Refrigerators and/or freezers are maintained in good working condition. Refrigerators keep medications at 37 degrees or below 40 degrees F and freezers keep frozen solid temperatures2. Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures.3. Monthly tracking sheets include time and refrigerator temperature.4. Charge nurses are responsible for checking refrigerator temperatures.5. The supervisor takes immediate action if temperatures are out of range. Actions necessary to correct the temperatures are recorded on the tracking sheet, including the repair personnel and/or department contacted.

Based on record review and interviews, the facility failed to respect a resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 1 (Resident #1) of 5 residents reviewed for resident rights.The facility failed to obtain a valid DNR for Resident #1 which resulted, on [DATE], in Resident #1 receiving CPR when she was found unresponsive. This failure could place residents at risk of their rights to refuse or discontinue treatment being disrespected, being resuscitated against their wishes or placed on life support.Findings included:Record review of Resident #1's face sheet, dated [DATE], revealed an eighty-four-year-old female who was admitted to the facility on [DATE]. Her admitting diagnoses included adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol), fracture of the right femur (a break in the thigh bone, which is the longest and strongest bone in the human body), recurrent depressive disorders (the person has a history of at least two depressive episodes (depressed mood or loss of pleasure or interest in activities) for long periods of time).Record review of Resident #1's MDS (clinical assessment to determine resident's strength and needs) Quarterly assessment dated [DATE] revealed a BIMS score of zero indicating severe cognitive issues.Record review of Resident #1's care plan revealed a focus dated [DATE] reflected Resident #1 had an order for Do Not Resuscitate (DNR) with interventions dated [DATE]: 1. All aspects of DNR will be explained to Resident #1 or responsible party.2. In absence of blood pressure, pulse, respiration, CPR will not be initiated.3. Notify MD of change of condition.4. Resident #1 will be maintained at a level of comfort as ordered by physician.5. Social Services to consult with resident and RP regarding their decision to continue DNR.Record review of Resident #1's Out-of-hospital Do-Not-Resuscitate (OOH-DNR) order Texas Department of State Health Services dated [DATE] revealed it was unsigned by a physician. Record review of page 28 of Resident #1's facility admission papers dated [DATE] signed by Resident #1's RP reflected Informed Consent - I have been informed of my rights to make advanced directives for health care decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives such as Directive to Physicians and/or Living Will or Durable Power of Attorney for Health Care. Beig so informed, it is my decision to: I have previously executed a document and will supply copies to the facility for my or my relative's clinical record and physician use. Record review of Resident #1's order dated [DATE] by RN H reflected order summary DNR advance directive status current and verified. Interview on [DATE] 10:47 am with the DON reflected that she was alerted by a CNA (name of CNA unknown) that Resident #1 was unresponsive. A family member of Resident #1 was in the building. The DON said they assumed that Resident #1 was a full code because she did not have a DNR. The DON said the Resident #1 was not on hospice. The DON said she began placing her hands on Resident #1 to do chest compressions, and the family member told her to stop because Resident #1 had a DNR. She said EMS arrived and were informed by the DON that Resident #1 did not have a DNR and they began to attempt to do chest compressions and again the family member told them to stop because Resident #1 had a DNR. She said the family member received a copy of the DNR via his telephone from another family member, but the DNR did not have the signature of a MD. She said EMS received approval from a member of their team to not proceed with compressions. Interview on [DATE] at 3:38 pm with a family member of Resident #1, who was present when she died, reflected the facility did not have the correct DNR because the former nursing facility did not send it when Resident #1 was transferred to the current facility. The family said the MD's name was printed on the DNR, but it had no MD signature. He said the former nursing facility was to forward all the information about Resident #1 to her current facility. Interview on [DATE] at 10:57 am with the ADON reflected she had been the ADON at the facility for 1 (one) month. The ADON did not know the facility policy regarding resident DNRs. She said she did not know if the facility required residents to have either a DNR or full code established when they came into the facility, she stated she would hope so, but she did not know. She said she did not know who was responsible for making sure that the residents had the correct code status information when they were admitted to the facility, her first thought would be the nurse, but she did not know which nurse, she would have to look at the policy. She said it was very important to have the residents correct and complete code status because it was a matter of life and death.Interview on [DATE] at 11:32 am with LVN F reflected the charge nurse upon a residents' admission was responsible for checking the residents' code status. LVN F said the resident code status was documented in PCC (an electronic health record designed for long-term care providers, including nursing homes and senior living communities). She said she thought the admission coordinator and the social worker were responsible for making sure that the residents' code status was accurate, correct, with a completed copy in the residents' file. She said the negative effect of not knowing the residents' code status was you would not know what the resident wanted if they were unresponsive and could be violating their wishes if it was incorrect. Interview on [DATE] at 12:10 pm via phone with LVN G reflected she no longer worked at the facility. LVN G believed that the DON was responsible for making sure that the code status for residents was requested and accurate. LVN G said Hospice was also responsible. She said the negative effect of not having a clear DNR for the residents was it would go against resident rights if staff did the opposite of what the resident wanted; either to be resuscitated or not resuscitated if they coded. Interview on [DATE] at 12:58 pm with the SWD reflected she looked over the DNRs for accuracy then uploaded them into the residents' electronic file. She said sometimes the DNRs were incomplete and did not have a signature and she had to wait to upload it. She said the DON was responsible for making sure it was in the facility. She said if staff did not know a residents' code status, the resident was considered a full code and resuscitation efforts would be attempted. She said if a resident had a DNR, and resuscitation efforts were attempted, staff might go against the residents' rights and that was, a big mess up.Interview on [DATE] at 2:59 pm with the RCD reflected the nurse on admission entered in the eMAR either the residents' full code or DNR code. The admitting nurse could have asked the family what the code was when the resident admitted . She said the DON and the social worker were supposed to follow up and confirm that the facility had the correct paperwork for the code status entered by the admitting nurse. She did not know how this was missing. She said it was a big deal because the resident could have been brought back or placed on life support against her wishes. She said it was the responsibility of the social worker and the DON to confirm code status and obtain complete paperwork. She said the DON personally uploaded the DNRs into the resident's record to make sure they were there. Interview on [DATE] at 3:44 pm with the RDO reflected when a resident was referred to their facility from another facility, they had to have the DNR in hand prior to admitting the resident. The RDO did not know what happened that they did not have a completed signed DNR on hand for Resident #1. She said the nurse should not have placed the DNR order unless there was a complete signed DNR on hand. She said it should have been followed up on chart audits by the DON or the ADON. She said the negative outcome was that the resident received CPR (emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped) and it was against the wishes of the resident. It was a resident rights issue.Interview on [DATE] at 4:58 pm with the Administrator reflected nurse managers and the DON had the responsibility of checking the admission orders within the first 24 hours of a resident's admission to make sure all documents and the admission was complete. She said there was a process that began with the charge nurse when the resident was admitted , to the admissions coordinator and the DON. She said the worst-case scenario if there was kink in the process of confirming if a resident had a DNR, was the resident could be resuscitated against their wishes, and when the resident's ultimate wishes were not respected, it was a violation of resident rights.Interview on [DATE] at 6:02 pm with the DON reflected when the charge nurse admitted a resident, the nurse needed a hard copy of the DNR that was signed and executed, and if there was not a fully executed hard copy DNR, the resident was automatically a full code. She said she did not know what happened regarding Resident #1's DNR. The DON said RN H admitted Resident #1 and RN H would have had to have had the DNR in her hand to enter the DNR order for Resident #1. The DON said she never saw a DNR for Resident #1. She said it caused Resident #1's family emotional distress when staff was going to provided Resident #1 CPR. She said a family member threatened bodily harm to the staff if they did not cease CPR because Resident #1 was a DNR.Record review of the facility's policy Do Not Resuscitate Order dated [DATE] revealed Policy Statement - our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. Policy Interpretation and Implementation - Do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet maintained in the resident's medical record. A Do Not Resuscitate (DNR) order form must be completed and signed by the attending physician and resident (or resident's legal surrogate, as permitted by state law) and placed in the front of the resident's medical record. Do not resuscitate (DNR) orders will remain in effect until the resident (or legal surrogate) provides the facility with a signed and dated request to end the DNR order. Verbal orders to cease the DNR will be permitted when two (2) staff members witness such request. Both witnesses must have heard the request and both individuals must document such information on the physician's order sheet. The attending physician must be informed of the resident's request to cease the DNR order. The interdisciplinary care planning team will review advance directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives. The resident's attending physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident's condition changes in an effort to clarify and adhere to the resident's wishes.

Based on observation, record reviews, and interviews, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for one (Resident #1) of 7 (seven) residents reviewed for weight loss.The facility failed to follow its procedures and provide effective interventions to prevent weight loss in Resident #1, who had a 10.39% weight loss between 10/09/25 and 11/03/25. Resident #1 was not weighed when she was admitted to the facility on [DATE]. Resident #1 was not weighed weekly x 4 weeks after her admission to the facility. Nutritional supplements were recommended by the RD on 10/15/25. They were ordered 11/14/25. Resident #1 died on [DATE].This failure could place residents at risk of dehydration, malnutrition, functional decline and death.Findings included:Record review of Resident #1's face sheet, dated 11/20/25, revealed an eighty-four-year-old female who was admitted to the facility on [DATE]. Her admitting diagnoses included adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol), fracture of the right femur (a break in the thigh bone, which is the longest and strongest bone in the human body), recurrent depressive disorders (the person has a history of at least two depressive episodes (depressed mood or loss of pleasure or interest in activities) for long periods of time).Record review of Resident #1's MDS (clinical assessment to determine resident's strength and needs) Quarterly assessment dated [DATE] revealed a BIMS score of zero indicating severe cognitive issues. Record review of Resident #1's care plan revealed a focus dated 10/20/25 of Resident #1 refused to eat/resisted feeding with interventions dated 10/20/25 of 1. Administer medications as ordered. Monitor/document for side effects and effectiveness.2. Resident #1 needed encouragement/support to be independent with eating. Allow Resident #1 to feed self if desired, regardless of skill.3. Empower Resident #1 by allowing choices in mealtime, menu selection, dining location.4. Invite Resident #1 to food-related activities and offer food, beverages of choice to encourage intake. Record review of Resident #1's facility weights reflected two weight records 10/09/25 scale mechanical lift value 129.0 pounds and 11/03/25 scale mechanical lift value 115.6 pounds representing a weight loss of 10.39 percent in 25 days. Record review of Resident #1's progress notes dated 10/15/25 reflected Resident #1 refused meals. RD recommended providing supplemental support house supplement 2.0 120 ml QID in between meals; update related to food preferences to provide meals and snacks of choice. Record review of Resident #1's order dated 11/14/25 reflected diet supplement of house supplement order type medication aide supplement four times a day for house supplement 2.0 (a nutrient-dense supplement for managing weight loss, malnutrition) four times a day. Resident #1's November 2025 MAR for House Supplement four times a day for house supplement 2.0 four times a day reflected no refusals of supplement by Resident #1.Interview on 11/20/25 at 10:47 am with the DON reflected Resident #1 died on [DATE], and she was not on hospice care. The DON said Resident #1 died from failure to thrive. She said the RA did the facility weights and if the RA was not there, CNA B did resident weights. The DON said it was the responsibility of the ADON to make sure that the weights were taken. The DON said Resident #1 should have been weighed on 10/03/25 when she was admitted to the facility. The DON did not see documentation that Resident #1 refused to be weighed during Resident #1's time at the facility. She said the facility did not follow its policy for weighing residents. The DON said the possible negative effects of not weighing residents according to facility policy was that staff could not tell if residents had a significant amount of weight loss. She said when the RD entered the facility on 10/15/24, it would have been important to have given the RD the correct weight information for a resident who was not eating. The DON said the facility should have been on top of the weights. The DON said the RD recommended a supplement, but the supplement was not ordered until 11/14/25. She was not sure why it took so long for the order to be placed. She said Resident #1's supplement was not received timely and Resident #1's weight loss was not appropriately addressed. The DON said she knew the responsibility for weights and monitoring the ordering of supplements, fell on her. The DON said they did not know Resident #1 had that amount of weight loss, and had she known, she would have tried to get more supplements and spoken with the family to see if they would have been interested in hospice. The DON said she would have done a lot of things differently. She said the lack of addressing the weight loss could have led to Resident #1's failure to thrive and ultimately her death. Interview on 11/20/25 at 10:47 am with the RD reflected she saw Resident #1 on 10/15/25 and Resident #1 was not flagging for a significant weight loss. The RD said she saw Resident #1 on 11/11/25 for a significant weight loss. The RD said that Resident #1's weight loss would have given her a better picture of what was happening with Resident #1's nutrition. The RD said Resident #1 should have been weighed when she entered the facility. For some reason there was a gap in Resident #1's weights, and she did not know why. The RD said if the intervention she made 10/15/25 for supplements had been implemented, it might have made a difference, but she could not say for sure. The RD said she notified the DON that her recommendation made on 10/15/25 for Resident #1 to have a supplement was not ordered, the DON corrected it right away. The first weight The RD received for Resident #1 was 11/11/25. The RD stated had she known about Resident #1's weight loss, she might have added an intervention. Interview on 11/20/25 at 12:51 pm with the NP reflected Resident #1 came from another skilled nursing facility and the family wanted to hold off on hospice. The NP said she was aware that Resident #1 refused to eat. The NP said she did prescribe Resident #1 an appetite stimulate, but Resident #1 refused the medication. The NP said she ordered labs for Resident #1, and they all came back fine but Resident #1 refused food. The NP said she did not feel nutritional stimulants would have helped Resident #1, but she would have liked to have had more weights. The NP stated she had phone calls from the DON that consistently discussed Resident #1's refusal to eat. Interview on 11/21/25 at 10:57 am with the ADON reflected she had been the ADON at the facility for 1 (one) month. The ADON said CNA B, who was also responsible for transportation, was responsible for doing weights and the RA was also responsible for weights. She stated she would have to look at the weight policy before she was able to state the facility's policy for when residents should be weighed. She said maybe she was responsible for making sure residents were weighed according to facility policy, but she was unsure because she was still learning her role. She stated it was important to weigh residents and track their weight to see if they had lost weight because weight could affect everything. She stated weight can affect resident wound care, and their overall nutrition. If a resident lost weight, the facility should notify the family and the dietician to incorporate a change to the residents' diet, find out what the resident liked to eat, and encourage them to eat. In her experience, she had not been the person who was having to get resident weights. She would guess residents would be weighed on either a weekly or a monthly basis. She just knew the basics without referring to the policy. She did not do what she was supposed to do when the RD recommended supplements for Resident #1. She now knows the process of getting a RD recommended supplement ordered for a resident. If they did not check weights, residents could get malnourished and lose weight and a significant amount of weight loss could be determinantal. Even if a resident was refusing meals, weight should still be tracked so they can implement supplements accordingly. She said the possible negative effect of not implementing supplements for a resident who was not eating would be possible loss of weight. She did not know why Resident #1 died. Interview on 11/21/25 at 11:32 am with LVN F reflected it was important to weight residents to see if they were gaining or losing weight because the resident might have failure to thrive and may need a supplement. Residents should be weighed upon admission, then once a week, for 2 weeks, then 1 time a month if things were going well. The possible negative effect of not weighing a resident, who was not eating, was that you would not know the amount of weight lost, and it could be a significant change. If there was significant weight loss, the facility could bring in the RD and notify the NP or the MD, and they could add an order for supplements. If an order for a supplement was not entered for approximately a month, the resident could continue to lose weight. Interview on 11/21/25 at 12:01 pm with RA reflected she did the monthly weights for the residents. Some residents had weekly weights, but she did weights for the residents who had monthly weights. She did not know who did the resident weekly weights. She began working as the RA on 11/01/25. She did not enter the weights in the EMR. She was given a list of residents to weight, and she wrote their weight on a paper list and gave it to the DON. She did not know who entered the weights into the EMR. If a resident refused to be weighed, she told the nurse. Interview on 11/21/25 at 12:40 pm with CNA B reflected she did the weekly weights. No one asked her to do weights on Resident #1. She knew residents were weighed upon admission and every Monday for the next four weeks if they were under 100 pounds. It was important to take resident weights to see if they were losing or gaining weight. Residents might need to have an adjustment to their diet. You cannot tell if they need a food change if you do not take their weights. She said it was the responsibility of her and the DON to make sure weights were done. The facility had a change in management, and she was not sure if things had changed.Interview on 11/21/25 at 2:59 pm with the RCD reflected the facility policy on weights for residents was for residents to be weighed on admission and then once a week for the next 4 (four) weeks. She said the facility did not follow the policy, The policy was in place to make sure residents were not losing weight and to make sure residents' weight were stable. If they have this information the facility can intervene before residents lose too much weight. She said absolutely the interventions for the supplements recommended by the RD should have been put in place sooner. She said it was a system failure and the facility did not follow its policy with getting weights on admission and putting appropriate interventions in place when a weight trigger was noticed. The ADON was responsible for the dietary recommendations and did not follow through and notify the NP when the supplements were recommended by the RD. When the DON found out that the dietary recommendations were not put in place, the DON had the orders placed for the supplements. The ADON was responsible for doing the weights and she was aware she was responsible because she herself trained the ADON on the facility weight policy at the end of September. The DON thought the ADON was doing the weights. The failure was did not following the weight policy and a failure to delegate. Interview on 11/21/25 at 3:44 pm with the RDO reflected the weight policy was in place to monitor for weight loss, and weight gain and to provide the necessary interventions prior to weight becoming an issue. it was the responsibility of the ADON to make sure Resident #1's supplement was ordered on 10/15/25. She did not know why it did not get ordered on 10/15/25. Because the supplement was not ordered, Resident #1 did not receive timely supplement for nutritional support.Interview on 11/21/25 at 4:58 pm with the Administrator reflected the issues with not following facility weight and nutrition policy, not weighing Resident #1, and Resident #1 not receiving the recommended RD supplements when they were first recommended, was a system and communication failure. There was a communication breakdown between the RD and the facility nursing staff. The DON was responsible for the weights, and Resident #1's supplements should have been started earlier. It was the responsibility of the ADON to look at the RD recommendations and communicate the recommendation to the physician. It would have been Resident #1's right to refuse the supplement, but it was the facility's responsibility to offer the supplements. Record review of the facility's undated Weight Assessment and Intervention policy revealed Policy Statement - The nursing staff and the Dietitian will cooperate to prevent, monitor, & intervene for undesirable weight loss for our residents. Policy Interpretation and Implementation - The nursing staff will measure resident weights on admission and weekly x 4 weeks. If no weight concerns are noted at this point, weights will be measured monthly thereafter. Significant weight loss will continue to be weighed weekly. All residents will be weighed monthly by the 10th. Weights will be recorded in Weight Record chart in the individual's medical record. The dietician will also review the Weight Record by the 30th of the month to follow individual weight trends over time. Negative trends will be assessed and addressed by the Dietitian whether or not the definition of Significant Weight Change is met. Significant Weight Changes are defined as: more or less than 5 percent within 30 days, more or less than 7.5 percent in 3 months; and more or less than I0 percent within 6 months. If a weight loss meets the definition of Significant, the Dietitian should discuss with the Interdisciplinary Team if a Significant Change MDS is necessary. Care Plan interventions will consider Severity of change, medical diagnosis (e.g., condition, prognosis, and stability); activities of daily living status, medications, psychological status, family input, resident preferences, and input from direct care givers. All team members will provide relevant information from their discipline to provide an interdisciplinary approach. Interventions for undesirable weight loss should focus first on food (example extra food, snacks, calorie-dense food), liquid nutritional supplements, per facility formulary may be considered if resident caloric intake remains inadequate to stabilize or increase weight. Interdisciplinary Team members should consider possible interventions relevant to their discipline. The physician my order tests. Appetite stimulants, or medications as appropriate. A weight loss regimen should not be initiated for a cognitively capable resident without his/her approval and involvement. The Dietitian will discuss the weight issue with the resident and/or family. If a resident declines to participate in a weight loss goal, the Dietitian will document the resident's wishes, and those wishes will be respected.

Based on observation, record review, and interviews, the facility failed to provide the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 (Resident #2) of 4 residents reviewed for resident rights.The facility failed to follow their policies and procedures and provide full-time translation or interpretation services to Resident #2, a [NAME] speaking resident.This failure could place residents at risk of miscommunication between the resident and staff, lead to misunderstandings about a resident's medical condition and treatment options, and improper care or inappropriate treatments or prescriptions.Findings include:Record review of Resident #2's face sheet, dated 11/14/25, revealed a seventy-four-year-old female who was admitted to the facility on [DATE]. Her admitting diagnoses included Alzheimer's disease (progressive decline in episodic memory, with variable involvement of other cognitive domain), dementia (a decline in brain function), and major depressive disorder (a mental health condition characterized by persistent feelings of sadness, hopelessness, and a lack of interest or pleasure in activities).Record review of Resident #2's MDS (clinical assessment to determine resident's strength and needs) Quarterly assessment dated [DATE] reflected a BIMS score of zero indicating severe cognitive issues, and Resident #2's preferred language was Korean. Record review of Resident #2's care plan dated 05/30/25 reflected Resident #2 had a communication problem related to language barrier. Resident #2 spoke Korean and needed an interpreter with interventions dated 05/30/25 to be conscious of Resident #2's position when in groups, activities, dining room to promote proper communication with others. Resident #2 preferred communicating while family was present to translate in Korean, and for staff to anticipate and meet Resident #1's needs.Observation and attempted interview on 11/20/25 at 6:43 pm with Resident #2 reflected, CNA A knocked on the door to Resident #2's room asking in English to enter to room. Resident #2 was laying in her bed. Surveyor was unable to communicate with Resident #2. Resident #2's room and Resident #2 appeared clean.Interview on 11/21/25 at 8:40 am with CNA C reflected he worked in the facility's secured unit for about 1 (one) year and had worked with Resident #2. He said Resident #2 only spoke Korean. He thought Resident #2 understood a little bit of English, but not a great deal. He said he communicated with her using body language and hand gestures. He felt like he communicated with her effectively about 50 percent of the time, but it was hard to know her ability to communicate because her dementia played a role. They did not have a communication board for Resident #2. He said there was a nurse, LVN F, who worked in another hall who spoke Korean. They got LVN F to talk to Resident #2 when Resident #2 was being aggressive, hurting, and staff needed an explanation of where she was hurting. Sometimes they called LVN F on the phone to talk to Resident #2 when LVN F was not in the building. He did not know if a communication board would help Resident #2 because of her dementia. He felt like they could at least try a communication board. Interview on 11/21/25 at 9:08 am with CNA D reflected she had worked in secured unit for 10 (ten) years. CNA D said they used hand gestures when they communicated with Resident #2. When they took Resident #2 to the restroom, they pointed to the restroom. When it was time to eat, they gestured eating. Staff had nothing that would help them communicate in Resident #2's language. CNA D said sometimes she thought Resident #2 did understand a little bit of English. When Resident #2 was really upset or hurting, they asked LVN F to talk to her. LVN F spoke Resident #2's language and could communicate with Resident #2 successfully. She thought having more communication in Korean might be more successful for Resident #2, but no one tried that.Interview on 11/21/25 at 9:51 am with LVN F reflected she helped communicate for Resident #2 when they needed something conveyed to her, and the staff could not get her to understand. Staff in the secured unit would come and grab her to communicate with Resident #2, but this was not too often. Resident #2 was pretty directable with hand gestures. When Resident #2 was admitted to the facility, they realized she did not understand English. LVN F had never seen a communication board for Resident #2. LVN F said she was always accessible if they needed her to speak with Resident #2 and always kept her phone on her. The facility should have tried to provide a way to communicate with the residents who speak another language. The possible negative effect of not being able to communicate with a resident who speaks another language would be an unwitnessed fall. Staff could not communicate with Resident #2 to find out what happened or where she might be injured. It was everyone's responsibility to make sure they could communicate with a resident. Staff needed to tell the ADON and DON if there was a communication issue and it needed to be addressed. Interview on 11/21/25 at 10:57 am with the ADON reflected she had been the ADON at the facility for 1 (one) month. She knew Resident #2 spoke Korean, but the staff communicated with her in English. She thought it was effective because there was no other way to communicate with Resident #2. Resident #2 would sometimes randomly say words in English. If a resident who did not speak her language had an unwitnessed accident, she would speak with them in English and do the best she could to communicate with the resident. She thought it was important for effective communication to speak with residents in a way they could understand. If Resident #2 was provided a communication board, it would not hurt. Because of Resident #2's dementia, she was not sure if a communication board would be helpful, but she thought, it is worth the shot to put out the effort to help with the language barrier.Interview on 11/21/25 at 2:59 pm with the RCD reflected the facility should have absolutely have had a communication board that was customized for Resident #2. She said the negative effect of not having a communication board or using a telephone translation application was that Resident #2 could get frustrated and it was not good quality of care. Interview on 11/22/25 at 11:22 am with the Administrator reflected they had a staff member, LVN F, who spoke Korean, and she translated for Resident #2. When LVN F was not at the facility, LVN F gave them permission to call her to interpret for Resident #2. Some of the staff used the language translation application on their phones and some staff used gestures to communicate with Resident #2. She knew gestures were not the most effective. It was the responsible of the Administer to make sure that residents had access to translation or interpretation services. The negative effect of not having a translation service for LEP (limited English proficiency) residents was miscommunications of resident care services were not provided, and residents needs might not be met.Record review of the facility's policy Translation and/or Interpretation of Facility Services dated November 2020 revealed This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. Policy Interpretation and Implementation - The coordinator of this facility's language access program is the Social Service Designee or Administrator. Family members and friends shall not be relied upon to provide interpretation services for the resident, unless explicitly requested by the resident. If family or friends are used to interpret, the resident must provide written consent for disclosure of protected health information.When written translation of vital information is unavailable, or impractical (i.e., an infrequently encountered language), the facility shall attempt to provide oral translation of vital documents.Interpreters and translators must be appropriately trained in medical terminology, confidentiality of protected health information, and ethical issues that may arise in communicating health-related information.Written notification of language access rights may be provided by AI (a set of technologies that empowers computers to learn, reason, and perform a variety of advanced tasks in ways that used to require human intelligence) services online for communication via translation. Competent oral translation of vital information that is not available in written translation, and non-vital information shall be provided in a timely manner and at no cost to the resident through the following means (as available to the facility):A staff member who is trained and competent in the skill of interpreting;A staff interpreter who is trained and competent in the skill of interpreting;Contracted interpreter service;Voluntary community interpreters who are trained and competent in the skill of interpreting; andTelephone interpretation service.It is understood that providing meaningful access to services provided by this facility requires also that the LEP resident's needs and questions are accurately communicated to the staff. Oral interpretation services therefore include interpretation from the LEP resident's primary language back to EnglishIt is understood that in order to provide meaningful access to services provided by this facility, translation and/or interpretation must be provided in a way that is culturally relevant and appropriate to the LEP individual. Staff shall be trained upon hire and at least annually on how to provide language access services to LEP residents.

Based on interview and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of three residents reviewed for accidents and hazards. The facility failed to ensure CNA A did not provide personal care for Resident #1 without another staff member (which he required) on 07/27/25. She yanked on his right arm when attempting to roll him to his side, and he heard a pop. He was in excruciating pain and was subsequently diagnosed with a shoulder sprain at the hospital. The noncompliance was identified as PNC. The IJ began on 07/27/25 and ended on 07/29/25. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk of pain, injury, and hospitalization. Findings included:Review of Resident #1's undated face sheet reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including morbid obesity, PTSD, major depressive disorder, and unspecified lack of coordination. Review of Resident #1's quarterly MDS assessment, dated 06/26/25, reflected a BIMS score of 15, indicating he was cognitively intact. Section GG (Functional Abilities) reflected he required extensive assistance (2+ personal physical assist) with toileting/repositioning. Review of Resident #1's quarterly care plan, dated 06/28/25, reflected he required total care with all aspects of daily care with an intervention of staff assisting him in daily care. Review of Resident #1's progress note, dated 07/27/25 at 11:15 AM and documented by RN B, reflected the following: While in to see resident and bring his meds, noted facial grimace and he was rubbing his right upper arm and shoulder. [Resident #1] explained that he had a bad, rough night and thinks he got hurt at his rt shoulder (his bad arm), after hearing and feeling a pop while being repositioned in bed. Rated pain 8-9/10. Review of Resident #1's progress note, dated 07/27/25 at 2:33 PM and documented by the ADM, reflected the following: Received information resident upset regarding the care that was provided during the night shift. He further reports as the CNA finally came in early this morning towards the end of her shift around 5:45 - 6AM she was distracted while providing care and yanked on his right arm causing pain to his shoulder. He heard a pop and told her she had hurt him. Review of Resident #1's progress note, dated 07/27/25 at 9:40 PM and documented by RN B, reflected the following: NP was notified earlier regarding [Resident #1]'s situation and orders were ok'd for rt shoulder x ray. [Resident #1] stated the tramadol for pain and the bio freeze helped ‘a lot!' Review of Resident #1's hospital records, dated 07/28/25, reflected a right shoulder sprain. During an interview on 07/30/25 at 11:32 AM, Resident #1 stated he had recently had his pain medication, so he was not experiencing pain. He stated in the morning of 07/27/25, CNA A was in a rush to change his brief and was not paying attention to him. She stated when going to turn him, she yanked on his right arm, and he heard a pop. He stated he saw stars in his eyes while he was screaming and telling her she hurt him. He stated his pain was over a 10 and he felt pain from his shoulder to his wrist. He stated he was supposed to have two people providing him care, and he normally did. He stated he got an x-ray the same day, the results came back the next day saying he had a fracture. He stated the staff sent him to the hospital where he was told it was just a sprain. He stated the staff had been giving him pain medication when he needed it which was managing his pain, and he was happy CNA A got fired. He did not have any further concerns. During an interview on 07/30/25 at 11:40 AM, the CRN, the ADM, and the DON stated CNA A was suspended the same day (07/27/25) and texted the DON the following day stating she had quit. They were unable to get a statement from her. The ADM stated Resident #1's RP, NP, and the Ombudsman were notified of the incident immediately. The DON stated a STAT x-ray was immediately ordered, they conducted safe surveys on all residents, emotional assessments were being conducted for Resident #1 every shift by nursing staff, and all staff were in-serviced on abuse and neglect, resident rights, and ADL self-care. During an interview on 07/30/25 at 11:52 AM, RN B stated on 07/27/25 in the morning she asked Resident #1 how his night was, and he told her he had a rough night. She asked him to explain further, and he told her CNA A was really rough with him and he felt a pop when she yanked his right arm. She stated she assessed him, administered him pain medication, applied bio freeze, and notified the ADM, his RP, and the NP. The NP ordered a STAT x-ray which was done that day. She stated she was in-serviced that day on abuse and neglect and safe ADL care. She stated no one should provide care to a resident alone when they required two people. During an interview on 07/30/25 at 1:18 PM, MA C stated she was recently in-serviced by the DON and ADM on abuse and neglect and two-person assistance. She stated the ADM was their abuse and neglect coordinator and types of abuse could be stealing, verbal, or physical. She stated if a resident required two people for any kind of care, they must find someone to assist them, no matter what. She stated the aides looked in the Kardex (documentation system) to determine how much assistance a resident needed. During an interview on 07/30/25 at 1:26 PM, LVN D stated she was recently in-serviced on safe ADL care, abuse and neglect, and resident rights. She stated her abuse and neglect coordinator was their ADM and different types of abuse were physical, emotional, or negligence. She stated the aides looked in the Kardex to locate what kind of assistance the residents needed, and the nurses would look in their care plans. She stated if a resident needed two people for care, utilizing one person would never be acceptable. She stated she told the aides all the time that if they needed help with transfers or care, she was always available to assist. During a telephone interview on 07/30/25 at 1:58 PM, Resident #1's NP stated she was notified of the incident between him and CNA A in the morning of 07/27/25 and ordered a STAT x-ray. She stated she assessed him the following morning, 07/28/25. She stated she believed the facility handled the situation appropriately and had no concerns. During an interview on 07/30/25 at 2:04 PM, CNA E stated she was recently in-serviced on resident rights, safety, abuse and neglect, and checking the Kardex. She stated the abuse and neglect coordinator is the ADM, and different types of abuse could be verbal, emotional, or physical. She stated no one should ever provide care to a resident by themselves when they required two people because anything could happen. She stated she could get hurt or the resident could get hurt. During an interview on 07/30/25 at 2:11 PM, CNA F stated she was recently in-serviced on abuse and neglect and checking the Kardex to check the assistance level needed for residents. She stated their ADM was the abuse and neglect coordinator and types of abuse were sexual, physical, verbal, emotional, and financial. She stated if a resident needed two people with care, she would never provide care by herself. She stated it could risk her life, their life, and her license. On 07/30/25 at 11:58 AM and 2:45 PM, telephone calls were made to CNA A. A call was not returned prior to exit. Review of the facility's self-report to HHSC, dated 07/27/25, reflected the ADM reported the incident between Resident #1 and CNA A the same day it occurred. Review of CNA A's suspension form, dated 07/27/25, reflected she was on an unpaid suspension due to the incident between herself and Resident #1. Review of an in-service, dated 07/27/25 and conducted by the ADON, reflected all staff were in-serviced on their resident rights policy. Review of an in-service, dated 07/27/25 and conducted by the ADON, reflected all staff were in-serviced on their ADL policy. Review of an in-service, dated 07/27/25 and conducted by the ADON, reflected all staff were in-serviced on their abuse and neglect policy and recognizing signs of abuse and neglect. Review of an in-service, dated 07/27/25 and conducted by the ADON, reflected all staff were in-serviced on the following: It is critically important to use the right amount of staff for safe resident transfers and repositioning, protecting both residents from falls and injuries, and staff from bodily injuries. Review of safe survey's conducted for all residents, dated 07/28/25, reflected no concerns or issues. Review of an in-service, dated 07/29/25 and conducted by the DON, reflected all staff were in-serviced on professionalism. Review of the facility's QAPI agenda, dated 07/29/25, reflected the ADM, the MD, the DON, the ADON, the BOM, the SW, and the AD were in attendance. Review of the facility's Resident Rights Policy, dated 2021, reflected employees shall treat all residents with kindness, respect, and dignity and residents had the right to be free from abuse and neglect. Review of the facility's ADL Policy, revised March 2018, reflected appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care. Review of the facility's Identifying Abuse Policy, date April 2021, reflected it defined the different types of abuse such as physical, verbal, mental, and sexual. Review of the facility's Abuse and Neglect Policy, revised March 2018, reflected any allegations of abuse or neglect will be investigated followed through with a cause identification, treatment/management, and monitoring and follow-up. Review of the facility's Performance Expectations Policy, dated 01/01/25, reflected conduct that was dishonest, insubordinate, immoral, or illegal would not be tolerated.

Based on interview and record review the facility failed to ensure the resident's right to be free from abuse, neglect, misappropriation of resident property and exploitation for three of five residents (Resident #1, Resident #2, and Resident #3 ) reviewed for drug diversion. 1. The facility failed to ensure LVN A did not take 100 (one hundred) Torsemide 100 mg tablets prescribed for Resident #1.2. The facility failed to ensure LVN A did not take 100 (one hundred) Torsemide 100 mg tablets prescribed for Resident #2.3. The facility failed to ensure LVN A did not take 30 (thirty) Torsemide 100 mg tablets prescribed for Resident #3. These failures could place residents at risk of misappropriation, medication errors and compromised health conditions. Findings include: Record review of the facility's self-report intake, dated 5/5/2025, revealed the following: Narrative of The IncidentSame nurse entered orders for three different residents for the same medication, Torsemide. The medications were then discontinued after the pharmacy delivered the medications. Medications were signed in by same nurse and facility unable to locate three of the four medication cards that were delivered. The Medical Director and NP deny giving nurse orders for Torsemide on any of the identified residents.1. Record review of Resident #1's face sheet, dated 7/9/2025, revealed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Her diagnoses included: Hypothyroidism (thyroid produces too much thyroid hormone), Hypertension (high blood pressure), Age-related decline (natural changed in thinking speed, memory and cognitive abilities that occur when people age, Cerebral Infarction. Record review of Resident #1's Quarterly MDS assessment, dated 6/26/2025, revealed she had a BIMS score of 3, which indicated severely impaired cognition. Record review of Resident #1's Care Plan, initiated 4/10/2025, revealed focus areas which included: I have a Vitamin/Mineral deficiency. Intervention listed as Administer medication as ordered by M.D Record review of Resident #1's Order Summary, dated 3/8/2025 at 12:40 AM, revealed an unauthorized order entered in PCC by LVN-A for Torsemide Oral Tablet 100mg. Give (1) tablet by mouth two times a day for fluid overload. A verbal order was entered in PCC by LVN-A on 3/8/2025 at 9:24 PM to discontinue the Torsemide 100mg. Record review of the Delivery Manifest Report Details, Manifest ID: M412308X0000638512, dated 3/8/2025, revealed LVN-A received sixty (60) Torsemide 100mg tablets order for Resident #1. 2. Record review of Resident #2's face sheet, dated 7/9/2025, revealed a [AGE] year-old female resident who was admitted to the facility on [DATE]. Her diagnoses included: Senile Degeneration of the Brain (cognitive decline), Major Depressive Disorder (persistent sadness and loss of interest in activities) and Hyperlipidemia (high cholesterol). Record review of Resident #2's Quarterly MDS assessment, dated 5/16/2025, revealed she had a BIMS score of 7, which indicated severely impaired cognition. Record review of Resident #2's Care Plan, initiated 5/4/2025, revealed focus areas which included: I have a Vitamin/Mineral deficiency. Intervention listed as Administer medication as ordered by M.D. Record review of Resident #2's Order Summary, dated 4/23/2025 at 9:16 PM, revealed an unauthorized verbal order was entered in PCC by LVN-A for Torsemide Oral Tablet 100mg. Give (1) tablet by mouth two times a day for edema. A verbal order was entered in PCC by LVN-A on 4/23/2025 at 9:16 PM to discontinue the Torsemide 100mg. Record review of Delivery Manifest Report Details, Manifest ID: M412308X0000640574, dated 4/26/2025, revealed LVN-A received ten (10) Torsemide 100mg tablets order for Resident #2. Record review of Resident #2's Physician's Order, dated 4/29/2025 at 3:22 AM, revealed an unauthorized verbal order was entered in PCC by LVN-A for Torsemide Oral Tablet 100mg. Give (1) tablet by mouth two times a day for edema. A verbal order was entered in PCC by LVN-A on 4/29/2025 at 3:22 AM to discontinue the Torsemide 100mg. Record review of Resident #2's Physician's Order, dated 4/29/2025 at 5:03 PM, revealed an unauthorized phone order was entered in PCC by LVN-A to discontinue the Torsemide 100mg. Record review of Delivery Manifest Report Details, Manifest ID: M412308X0000640770, dated 5/1/2025, revealed LVN-A received thirty (30) Torsemide 100mg tablets order for Resident #2. 3. Record review of Resident #3's face sheet, dated 7/9/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: Type 2 Diabetes (body does not produce enough insulin), Hypertension (high blood pressure and Hyperlipidemia (high cholesterol). Record review of Resident #3's Quarterly MDS assessment, dated 5/16/2025, revealed she had a BIMS score of 7, which indicated severely impaired cognition. Record review of Resident #3's Order Summary, dated 5/2/2025 at 9:55 PM, revealed an unauthorized verbal order was entered in PCC by LVN-A for Torsemide Oral Tablet 100mg. Give (1) tablet by mouth two times a day for edema. A verbal order was entered in PCC by LVN-A on 5/3/2025 at 10:46 PM to discontinue the Torsemide 100mg. Record review of the Delivery Manifest Report Details, Manifest ID: M412308X0000640825, dated 5/3/2025 revealed LVN-A received thirty (30) Torsemide 100mg tablets order for Resident #3. During an interview on 7/9/2025 at 4:45 PM, the CMA employed with the facility for one-year, stated she was in-serviced on misappropriation within the last month. She said she would report misappropriation and/or drug diversions to the DON and ADM. She said she had not seen any medications that were not been locked in the medication cart or room.During an interview on 7/9/2025 at 5:10 PM, CNA employed at the facility for 18 months, stated she received monthly training on misappropriation and stated she would report to the charge nurse, DON, and ADM. She said she had not seen any medications that had not been locked in the medication cart or room. During an interview on 7/9/2025 at 5:25 PM, LVN-C employed at the facility for three-years, stated she received monthly in-services on misappropriation. She said if she had identified something was missing, she would have tried to locate it and then report to the DON if it could not be located. She said when medications were received from the pharmacy, the nurse was responsible to receive them, sort and verify all medications were accounted for and they were passed off to the CMAs to put them into the medication cart. She said nurses were only allowed to enter standing orders and should have obtained an approval from the nurse practitioner or medical director for all other medication orders. She said, It was illegal to enter medication orders if we did not have approval from the medical director. During an interview on 7/9/2025 at 5:40 PM, LVN-D employed at the facility for ten-years, stated when medications were delivered by the pharmacy, the nurse checked the medications against the inventory and then it was handed-off to the medication aide and placed on the medication cart. She said narcotics were placed in the locked narcotics box by the nurse. She said nurses were only allowed to enter standing orders into PCC. She identified potential harm as, We could kill someone. During an interview with the DON on 7/9/2025 at 6:00 PM, the DON employed at the facility for three-months, stated she had placed at the nurses' station a misappropriation in-service and staff were reviewing. She reviewed the process for receiving medications when the pharmacy delivered them. She said only nurses were approved to sign for the medications and the nurse was to ensure the medication count was correct. She said two signatures were required when narcotics were received. She said she ran a report from the pharmacy system and could see that LVN-A signed for the missing Torsemide, which required only one signature. She said all mediation orders were reviewed daily by the DON and ADON. Three of the four medication cards for Torsemide remained missing at the time of the interview. She said she spoke with LVN-A who admitted she entered the orders and discontinue orders into PCC to check the functionality of the system. She said LVN-A denied receiving the Torsemide from the pharmacy and she did not know the whereabouts of the medication. During an interview with the ADM on 7/9/2025 at 6:30 PM, the ADM employed at the facility for eighteen-months, stated when the pharmacy dropped of medications, the nurses were responsible to verify each medication that was delivered and sign for the medication. She said nurses were not allowed to enter medication orders without an order from the nurse practitioner or medical director. She identified harm as the resident could have been double-dosed, had an allergic reaction, potentially overdosed, and had drug to drug interactions. She said the DON and ADON were responsible to review the medication orders during the week and the RN Supervisor was responsible on the weekends. She said the process had been tightened up (improved) since the Torsemide drug diversion. An interview was attempted on 7/9/2025 with LVN-A and was unsuccessful. Interviews were attempted on 7/10/2025 and 7/14/2025 with the Medical Director and were unsuccessful. Record review of the facility's in-service titled, Discontinued Medications, 2001 MED-PASS Revised April 2007, reflected the following: Policy statement - Staff shall destroy discontinued medications or shall return them to the dispensing pharmacy in accordance with facility policy. Policy Interpretation and Implementation:1. A practitioner's order to discontinue a resident's medication must be documented in the resident's clinical record and on the medication administration record (MAR).2. The nurse receiving the order to discontinue a medication is responsible for recording the information (e.g., writing discontinued date, dating, and initialing MAR) and notifying the dispensing pharmacy of the discontinuation.3. Discontinued medications must be destroyed or returned to the issuing pharmacy in accordance with established policies.

Based on observations, interviews, and record review the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen and food sanitation. 1. The facility failed to ensure food in the refrigerator was properly sealed from air-borne contamination. 2. The facility failed to ensure food stored in 1 of 1 reach in freezer and 2 of 2 reach in refrigerators were labeled and dated with use by date. These failures could place residents at risk for food contamination and foodborne illness. Findings Included: Observations on 02/12/25 at 09:32 AM in the facility's only kitchen revealed: 1 of 1, 3-door reach in refrigerator contained: - 1 large metal tray of cheesecake was not covered or sealed from air-borne contaminants or labeled with use by date. - 1 large metal tray of gelatin, 1 medium plastic container of diced tomatoes, 1 medium plastic container of grape jelly, 1 medium plastic container of caramel, 1 medium plastic container of pumpkin filling, 1 medium plastic container of ketchup, 2 medium plastic containers marked BKF, 2 large zip-sealed bags of tortillas, and 1 large zip-sealed bag containing individually wrapped sandwiches were not labeled or dated with use by date. 2 of 2 reach in freezers contained 1 medium zip-sealed bag of enchiladas, 3 large bags of okra, 3 large bags of French fries, 1 large bag of French toast sticks, and 1 small zip-sealed bag of ice cream that were not labeled or dated with use by date. In an interview on 02/12/25 at 09:40 AM with the DM, she stated it was her expectation that all items stored in the refrigerator and freezers were covered and sealed off from contaminants. She stated the cheesecake tray should've been covered and not exposed. She stated it was her expectation that all food items were labeled to identify what the item was and dated with the open date or the prepared date. She stated she did not believe items needed to have the use by date. She stated the dietary staff were trained on when to throw items out. She stated a potential negative outcome to not having food items covered or dated was that's how you get sick from items not being covered or knowing when it's made. In an interview on 02/12/25 at 03:21 PM with [NAME] A, she stated that items stored in the refrigerator and freezers should be completely covered and have the date the item was opened or prepared as well as the use by date. She stated items were rotated every 3 days and said, I am not sure why they don't have the use by date, but I am sure we will get penalized for it . In an interview on 02/12/25 at 4:44 PM with the ADM, she stated it was her expectation that items stored in the freezers and refrigerator were covered, labeled, and dated with the date the item was prepared or placed in the refrigerator/ freezer. She stated she did not believe items needed to be labeled with the use by date and said she didn't think the facility policy stated that either. She stated that food items that were left uncovered could cause food borne illness. She stated food borne illnesses have the potential to affect all residents when food items were not dated. Review of the facility Food Receiving and Storage policy last revised November 2022 reflected: Food shall be received and stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date). Refrigerated foods are labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded. Review of the 2022 U.S. Food and Drug Administration Food Code revealed: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: P if (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Of and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (2) Is in a container or PACKAGE that does not bear a date or day; or 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. FOOD shall be protected from cross contamination by: (4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings.

Based on record review and interviews the facility failed to ensure that one (1) resident (Resident #1) of eight residents reviewed for transfer or discharge had the required documentation in the resident's medical record made by the physician and failed to provide information to the receiving health care provider for a safe and effective transition of care. The facility discharged Resident #1 on 9/18/2025 without physician documentation in the EMR and without providing any clinical information for continuity of care to the receiving provider. This failure could put residents at risk for inappropriate discharge from the facility and cause psychological harm. The findings included: Review of Resident #1's Face Sheet dated 2/7/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included acute kidney failure, anemia (low iron count in the blood), anxiety disorder, sleep disorder, chronic pain syndrome, hypertension (high blood pressure), and traumatic brain injury. Review of Resident # 1's order dated 9/18/2025 reflected Discharge immediately to law enforcement after assault and resisting arrest. Resident is a danger to herself and others. Review of the MD letter dated 2/11/2025 reflected: By allowing [Resident #1] to remain in the facility I felt it would pose an immediate threat to the safety and wellbeing of the other residents residing in the facility. Review of Resident #1's progress notes dated 9/18/2025 at 12:20 pm reflected MD called regarding residents' behavior and new order given to immediately discharge resident [due to] her being a danger to herself and others. Further review reflected Resident #1 had become verbally and physically aggressive towards staff by ramming her walker into the staff. The police were called and had come to the facility and arrested Resident #1. Additional review of progress notes reflected no progress note from the MD regarding clinical or medical reasons for immediate discharge of Resident #1. During an interview on 2/12/2025 at 10:50 am the former MD stated Resident #1 had an escalation of behaviors on 9/18/2025 where she verbally and physically assaulted staff. He had given an order for her immediate discharge because the police had come to the facility and arrested Resident #1. The MD stated he had not provided any progress note in the EMR explaining how resident was a danger to herself or others until 2/12/2025. The MD provided a written letter regarding Resident #1's discharge at the time of this interview on 2/12/2025. During an interview on 2/12/2025 at 12;30 pm, the ADM stated the police did not tell the facility where Resident #1 was being taken, so no medical records or clinical information was provided for Resident #1 at the time of her arrest and discharge. She stated to her knowledge, no one from the behavioral health hospital contacted the facility for information and no nursing staff from the facility had contacted the behavioral health hospital where Resident #1 was admitted providing medical or clinical records for continuity of care. The ADM also stated she was not aware the former MD had not put a progress note in the EMR when Resident #1 was discharged . During an interview on 2/12/2025 at 12:35 pm, the DON stated that Resident #1 left with the police, she did not attempt to find out what behavior health facility Resident #1 had been taken to for treatment. The DON stated she did not provide any clinical information or medical records to the behavior health hospital where Resident #1 was taken after she was arrested. The DON stated the facility never heard from the behavior health hospital and once [Resident #1] was discharged I didn't think about it. It wasn't something we thought we needed to do. The DON stated a safe discharge was important to keep residents safe and ensure they would get the care they need. During an interview on 2/12/2025 at 1:01 pm, the MR staff stated she had not been contacted by anyone from the behavioral health hospital for medical records for Resident #1 and MR staff stated she had not provided any medical records for continuity of care when Resident #1 was arrested. MR staff stated the place where Resident #1 would not have known anything about her care without the facility providing medical records. During an interview on 2/12/2025 at 4:49 pm, the ADM stated her expectation was that all residents receive a safe discharge. The ADM stated her concerns with an unsafe discharge included a resident having adequate living space and adequate care. The ADM further stated for emergency discharges there should have been a progress note from the former MD to address the safety concerns with having Resident #1 on the facility. Review of the facility policy Transfer or Discharge, Emergency revised August 2018 reflected: Residents will not be transferred unless: c. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident, d. The health of individuals in the facility would otherwise be endangered. Further review of the policy reflected: 4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the resident's Attending Physician; b. Notify the receiving facility that the transfer is being made; c. Prepare the resident for transfer; d. Prepare a transfer form to send with the resident.

Based on interviews and record review, the facility failed to provide the necessary care and service to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for 1 (Resident # 1) of 6 (Resident's 2.3.4.5.amd 6) residents reviewed for following hospital discharge orders. The facility failed to follow hospital discharge orders for follow up with Urology secondary to a urethral stent (a thin tube placed between the kidney and bladder to help urine flow) placement on 4/26/2024. On 10/12/24 at 5:10 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/16/24, the facility remained out of compliance at a scope of Isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure resulted in Resident # 1 with worsening medical condition and hospitalization . Finding included: Review of Resident # 1's face sheet reflected a [AGE] year old male originally admitted on [DATE] with a readmission on 8/16/2024 with diagnoses that included type 2 diabetes mellitus without complications (is a chronic condition that happens when you have persistently high blood sugar levels effecting your body not to use insulin properly), obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional, which can cause a backup of urine into the kidneys), and discharged to the hospital on 10/10/2024. Review of Resident # 1 Quarterly MDS dated [DATE] reflected a BIMS score of 10 (10-12 suggests moderate cognitive impairment). Review of Resident #1's Care plan dated 9/18/2024 ad 10/11/2024 reflected in part: Focus: Resident # 1 has a hx of UTI's (infection that affects the urinary tract, the system for drainage of urine), urinary retention (the inability to completely empty the bladder), obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional, which can cause back up of urine into the kidneys.) Goal: Resident will not have an UTI through the review date. Target Date 12/6/2024. Interventions/Task Check at least every 2 hours for incontinence, wash, rinse, and dry soiled areas. Encourage adequate fluid intake, monitor/document/report to MD PRN for s/sx of UTI: Frequency, urgency, malaise (a vague feeling of bodily discomfort), foul smelling urine, dysuria (pain with urination), fever, nausea, vomiting, flank( lower back) pain, supra-pubic (area around the genitals), hematuria (blood in the urine), cloudy urine, altered mental status, loss of appetite, and behavioral changes. Review of Resident # 1's medical record of Hospital A's history and physical and discharge orders dated 8/16/2024 reflected an order for follow up with urology in 1 week. The discharge diagnosis was a ureteral stone (stone in the urethra (a thin tube leading from the bladder) with hydronephrosis (a swelling of one or both kidneys due to urine build up). Review of Resident # 1's medical records reflected no order for urology follow up from readmission (8/6/2024) through discharge (10/10/2024 ). Resident was assessed on 10/9/2024 for weakness, found to have a low-grade temperature all other vitals, resident was offered to go to emergency room and refused, MD was notified. On 10/10/2024 resident was found unresponsive with low blood pressure, emergency phone line was contacted, resident was transferred to the hospital. MD was notified. ADON notified Daughter of transfer. Review of outside medical records of Resident # 1's for Hospital B's admitting history and physical dated 10/10/2024 by Physician C reflected Abdominal CT scan showed the presence of severe left-sided hydronephrosis (an accumulation of urine around the kidney) in spite of the presence of a stent. It was felt the patient likely septic shock is from the left Pyelonephritis (kidney infection). Admitting diagnosis to Hospital B on 10/10/2024 include Septic shock (a potentially fatal medical condition that occurs when sepsis, which is organ injury or damage in response to infection, leads to a dangerously low blood pressure and other abnormalities), occlusion of ureteral stent, acute renal failure, left pyelonephritis, and respiratory failure (the result of inadequate oxygen flow). Resident was incubated (a tube placed in the airway to assist with oxygen flow) and placed in ICU upon admission . In an interview with the ADON on 10/12/2024 at 1:30 PM he stated that the readmission process was similar to the admission process. After report was received by the nurse and the resident has returned to the building and an assessment has been completed, the orders were reviewed. All new orders were to be verified with the resident's physician, medication orders were then sent to the pharmacy, and any follow up appointments sent to transportation for scheduling. He was not sure how the appointment for Resident # 1 was missed and he admitted he reviewed the orders again and was not able to locate the orders. It was his expectation that all orders to be confirmed with resident doctor and followed . He stated that after the orders are uploaded to the electronic medical record it is review by the DON or himself. He stated that not setting up the follow up appointment could result in worsening medical condition and failure of interventions that may have occurred during the appointment or hospital stay. Interview with RN Weekend supervisor on 10/12/2024 at 1:00 PM she stated that she also works are the charge nurse during the week at times. She stated when a resident returns from the hospital the nurse assigned to the hall , completes a head to toe assessment, reviews the discharge information and calls the doctor with any changes, sends any medication to pharmacy, any follow up appointments are sent to the transportation coordinator and the discharge paperwork is placed in the medical records basket. She stated missing an order could be harmful to the resident. Interview with DON on 10/14/2024 at 9:30 am she stated that when a resident is returned to the facility from a medical appointment or hospital stay the nurse assigned to their hall will do an physical assessment, review the discharge or review of medical appointment and call to verify with the doctor any new orders, fax new medications to pharmacy and notify transportation of any new appointments. She or the ADON will review the discharge or review of medical appointment once uploaded to the medical record which can be sometimes 2-3 later depending on when the resident returned to the building. She stated that potential harm is possible when doctors' appointment is missed either not scheduled or not attended. In an interview with CNA E who was responsible for transportation on 10/14/2024 at 1:30 PM she stated that she was not notified of an appointment for Resident # 1 for urology consult in August and she reviewed her book to verify. Attempted a phone interview with the agency nurse that readmitted Resident # 1 on 8/16/2024, no answer, and no voicemail set up . Interview with the ADM on 10/12/2024 at 3 PM revealed her expectations were that when a resident returned from the facility after seeing a medical provider, either a doctor visit, emergency room visit, or hospital stay that the order was to be reviewed and carried out . Nursing is responsible for carrying out physician orders, the nurse assigned to the hall does the assessment and order review when the resident returns to the facility. Review on 12/12/2024 at 1:00 PM of the policy titled Admission Assessment and Follow up: Role of the Nurse revised September 2012 revealed 7. Conduct an admission assessment (history and physical) including a. A summary of the individual's recent medical history, including hospitalization , acute illness, and overall status prior to admission. B. Relevant medical, social, and family history C. a list of active medical diagnoses and patient problems (such as recurrent fall or impaired mobility) especially those most related to reasons for admission to the facility and those that are affecting function. This was determined to be an Immediate Jeopardy (IJ) on 10/12/2024 at 5:10 PM. The Administrator was notified. The Administrator was provided with the IJ template on 10/14/2024 at 6:00 PM. The following Plan of Removal submitted by the facility was accepted on 10/16/24 at 8:07 am: Plan of Removal for Immediate Jeopardy F 684. Action Taken The following is a plan of removal, which was immediately implemented at the facility, to remedy the immediate jeopardy which was imposed on 10/14/2024 at 5:10 PM. On 10/12/2024 an abbreviated survey was initiated at the facility. On 10/14/2024 the surveyor provided an immediate Jeopardy (IJ) Template notification the regulatory services have determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to follow physician orders regarding a follow up appointment that needed to be completed for the resident. The follow actions will be completed by 5:00 PM on 10/15/2024 with continued follow-up scheduled staff. 1. An Inservice regarding Physician orders policy and procedure of admission/readmission was initiated with licensed clinical staff on 10/14/2024 by the DON and ADON. Scheduled staff will be completed before allowing patient assignment/care. 2. The past 90 days of active admissions/readmission will have a full chart order review by the Regional Corporate nurse, the DON, and the ADON to ensure compliance with applicable physician orders in place. 41 residents' readmission/admission orders were reviewed for accuracy. Of the 41 residents 12 residents required physician contact/order review to ensure accuracy. This will be completed by 10/15/2024. 3. Regional nurse-corporate completed an in-service with the DON and ADON regarding review of physician orders and implementation of orders per policy and procedure. This was completed 10/14/2024. 4. A review of the policy titled Admission assessment and follow up- Role of the Nurse was reviewed on 10/14/2024 at 5:45 PM by the regional director of operation and the Regional Nurse Consultant with the following changes in response to this identified immediate jeopardy: * Title change to include readmissions as part of the policy with definition that admission in the policy represents readmission as well as defined. * The policy has been reviewed and updated to define who is responsible for the initial step of the admission/readmission process and implementation of a follow up process for compliance review. Monitoring for complaint ,(IJ) the DON and/designee will review all admission/readmissions and follow up accordingly regarding orders daily during the weekdays. The weekend RN supervisor will be responsible for Saturday and Sunday admission/readmission audit reviews. The IDT will review and assess the admissions/readmissions weekly to determine what further actions/ interventions or changes were needed if necessary. Members of the meeting were to include the ADM, the DON, the ADON, the MDS Coordinator, the Social Worker, the Therapy representative, the RNC, and RDO. Record review of in-service dated 10/15/2024 and 10/16/2024 revealed all licensed staff that were on duty between 10/12/2024 and 10/16/2024 signed the in-service for Physician orders and Admission/readmission policy . All staff not in serviced will complete the training prior to the start of their shift. Record review of audit of charts reviewed by the RNC and the DON revealed 12 residents which needed order verification . All residents' physicians were notified, and order clarification obtained. In an interview on 10/16/2024 at 10:15 am the DON and the ADON stated they were in-serviced by the RNC on physician orders and the changes to the admission policy on 10/15/2024. Interview on 10/16/2024 from 10:30 to 1:30 PM with 6/ 11 of Clinical staff from the AM staff, revealed they were in-serviced by the DON or the ADON on Physician orders and Admission policy prior to the start of their shift. All staff interviewed were able to verbalize understanding and changes to policies . An attempt was made to contact a PM shift staff member with no answer and no returned phone call. On 10/12/24 at 6:00 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/16/24, the facility remained out of compliance at a scope of Isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Based on observations, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. 1. The facility failed to ensure foods in the refrigerator were properly sealed from air-borne contaminations. 2. The facility failed to ensure a pitcher containing juice, located in the refrigerator, was cleaned. 3. The facility failed to ensure the ice scoop holder, located in the kitchen area, was cleaned. 4. The facility failed to ensure the food stored in the refrigerator and freezer were labeled with the use by date. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on 09/17/24 from 8:30 AM to 8:38 AM in the facility's only kitchen reflected: One large zip locked bag of frozen fries did not have a use by date. One large zip locked bag of frozen chicken parts did not have a use by date. One large zip locked bag of frozen pancakes did not have a use by date. One large zip locked bag of frozen okra did not have a use by date. One large container of refrigerated rice was wrapped in aluminum foil and was not sealed from air-borne contaminants. One large container of refrigerated tuna was wrapped in aluminum foil and was not sealed from air-borne contaminants. One large, refrigerated pitcher, containing a red beverage had a blue lid that had white, brownish, and black stains all over the lid and in the pouring spout. The ice scoop holder, next to the ice machine in the kitchen area, had yellowish fluids in the bottom of the scoop holder. In an interview on 09/19/24 at 09:00 AM, the Dietary Manager stated she had been at the facility nearly [AGE] years. She was shown the pictures of the concerns observed in the facility's only kitchen. She stated all staff, including herself were responsible for storing and dating food. She stated the food should be labeled and dated properly and staff should not have wrapped the food in aluminum foil to store it. She stated the kitchen staff cleaned the kitchen daily and the items observed should not have been in those conditions. She stated these issues could cause an infection within residents. In a follow up interview with the Dietary Manager on 09/12/24 at 10:00 AM, she stated she was the person overall responsible for ensuring the kitchen was meeting guidelines for food storage and kitchen sanitization. She was shown images of all the concerns observed in the kitchen. The DM advised she spoke with the staff about ensuring the tea was covered once it was prepared. She stated she did a full in-service for food rotation and storage pertaining to what the proper procedures were dealing with food rotation and storage. Further they completed a customer satisfaction training in reference to resident rights, and options on the food items. The DM advised a full in-service was done regarding proper labeling and cleaning logs of food items. She stated everyone in the kitchen was responsible for ensuring items such as the pitcher, and whoever prepares the tea was responsible for ensuring the cover was placed on it once the tea was done. In an interview on 09/19/24 at 11:00 AM, the Administrator stated she had been at the facility for 4 months. She was advised of all the findings in the facility kitchen, and she stated that she expected her dietary manager to ensure that those concerns were not in the kitchen. She stated the concerns observed would cause food-borne illnesses. Record review of the facility's policy Food Receiving and Storage (November 20222) revealed Food shall be received and stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date). Record review of the facility's policy Kitchen Sanitization (November 20222) revealed The food service area is maintained in a clean and sanitary manner. Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. Review of TITLE 21--FOOD AND DRUGS CHAPTER I--FOOD AND DRUG ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES. SUBCHAPTER B - FOOD FOR HUMAN CONSUMPTION PART 110 -- CURRENT GOOD MANUFACTURING PRACTICE IN MANUFACTURING, PACKING, OR HOLDING HUMAN

Based on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for six (Resident #10, Resident #11, Resident #52, Resident #61, Resident #68, and Resident #222) of twelve residents reviewed for Respiratory Care. 1. The facility failed to ensure that Resident #10, #11, #52, and #68's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) were properly stored. 2. The facility failed to ensure that Resident #61's CPAP (continuous positive airway pressure: machine use to deliver pressurized air through a mask to keep airways open) was stored properly. 3. The facility failed to ensure that Resident #222's nebulizer (machine that turns liquid medication into a mist and breathed directly into the lungs) was stored properly. The facility failed to provide humidified (moistened) oxygen to Resident #222. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Review of Resident #10's Face Sheet, dated 09/18/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #10's pertinent diagnoses included chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and history of COVID. Review of Resident #10's Quarterly MDS Assessment, dated 07/05/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 09. The Quarterly MDS Assessment indicated the resident was on oxygen therapy while a resident of the facility. Review of Resident #10's Comprehensive Care Plan on 08/21/2024 reflected no care plan for oxygen therapy. Review of Resident #10's Physician Order, dated 01/28/2023, reflected May apply O2 per nasal cannula at 2-4L when in room for shortness of breath every shift for Shortness of Breath. Observation and interview with Resident #10 on 09/17/2024 at 9:09 AM revealed Resident #10 was in his bed, awake. It was observed that he had a nasal cannula connected to an oxygen concentrator at 3 liters per minute. According to Resident #10, he was on oxygen all day and all night. The nasal cannula was on the floor. He said staff went inside the room to check on him but did not notice the nasal cannula was on the floor. Review of Resident #11's Face Sheet, dated 09/18/2024, revealed Resident #11 was a [AGE] year-old female who was admitted to the facility 12/21/2022. Relevant diagnoses included hypertension and anemia (a problem of not having enough healthy red blood cells to carry oxygen to the body's tissue). Review of Resident #11's Quarterly MDS Assessment, dated 07/28/24, revealed Resident #9 had a moderate impairment in cognition with a BIMS score of 12. The Quarterly MDS Assessment indicated the resident was on oxygen therapy during admission and while a resident of the facility. Review of Resident #11's Comprehensive Care Plan on 08/21/2024 reflected no care plan for oxygen therapy. Review of Resident #11's Physician Order, dated 06/28/2024, revealed O2 @2LPM per nasal cannula at HS, at bedtime. Observation and interview with Resident #11 on 09/04/2024 at 8:46 AM revealed Resident #11 was in her wheelchair, awake. It was observed that she had a nasal cannula connected to an oxygen concentrator. The nasal cannula was coiled on top of the oxygen concentrator. The nasal cannula was not bagged. According to Resident #11, she would seldom use the oxygen and she never saw a bag for the nasal cannula. Review of Resident #52's Face Sheet, dated 09/18/2024, revealed Resident #52 was a [AGE] year-old female who was admitted to the facility 07/25/2024. Relevant diagnoses included asthma (lung disorder caused by narrowing of the airways) and anemia. Review of Resident #52's Quarterly MDS Assessment, dated 07/28/24, revealed Resident #52 was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident was on oxygen therapy while a resident of the facility. Review of Resident #52's Comprehensive Care Plan on 08/21/2024 reflected no care plan for oxygen therapy. Review of Resident #52's Physician Order, dated 07/25/2024, revealed O2 @ 2L/min via NC every 1 hours as needed for SOB or SAT > 92%. Observation and interview with Resident #52 on 09/04/2024 at 9:19 AM revealed that Resident #52 was in her bed, awake. It was observed that she had an oxygen concentrator at the side of her bed with a nasal cannula connected to it. The nasal cannula was hanging on top of the oxygen concentrator. The nasal cannula was not bagged. According to Resident #52, she usually wore oxygen at night but would leave it inside the room every time she would go out of the room. Review of resident #68's Face Sheet, dated 09/19/24, reflected that Resident #68 was a [AGE] year-old female admitted [DATE]. Resident #68 had a diagnoses of left tibia (long bone in lower leg) fracture and subsequent encounter for closed fracture (surgery to repair fracture). Resident #68 also had a diagnosis of COPD. Review of Resident #68's Comprehensive MDS Assessment, dated 08/27/24, reflected that Resident #68 had intact cognition with a BIMS score of 15. Resident #68 had a diagnosis of COPD and was administered oxygen therapy. Review of Resident #68's Care Plan, dated 09/03/2024, reflected that Resident #68 had COPD. An intervention was to identify and eliminate sources of respiratory irritation such as cigarette smoke, pollen, perfumes. An observation and interview on 09/17/24 at 08:52 AM revealed that Resident #68 was sitting up in bed. Resident #68's nasal cannula was looped over the bedrail and not secured in a bag. The humidifier bottle was connected to the oxygen concentrator. The humidifier bottle had about 15 ml of water in it. There was no date on the oxygen tubing or humidifier bottle. Resident #68 stated they have been saying they will add water to the humidifier bottle. Resident #68 stated that she has told different staff members that it's drying me out. 2. Review of Resident #61's Face Sheet, dated 09/19/2024, reflected that Resident #61 was a [AGE] year-old female. Resident #61 admitted on [DATE] with COPD (lung disease that blocks airflow and makes it difficult to breathe) and frontotemporal neurocognitive disorder (damage to the frontal and temporal lobes of the brain). Review of Resident #61's Physician Orders, dated 02/02/24, reflected CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) per settings on machine at bedtime. Review of Resident #61's Quarterly MDS Assessment, dated 09/03/2024, reflected a BIMS Assessment was not appropriate because the resident was rarely/never understood and that Resident #61 was severely impaired - never/rarely made decision regarding tasks of daily life. Resident #61's Quarterly MDS Assessment reflected that Resident #61 had not used a CPAP within the last 14 days. Review of Resident #61's Comprehensive Care Plan, dated 07/15/2024, reflected that Resident #61 was using a CPAP and one interventions for this focus included Staff will continue to apply CPAP as ordered. Staff will continue to monitor her for decline in respiratory status and report to doctor. An observation on 09/17/24 at 09:25 AM revealed that Resident #61's CPAP machine was on the table next to her bed. The attached tubing and face mask was lying on the floor beside the resident's bed. 3. Review of Resident #222's Face Sheet, dated 09/19/24, reflected that Resident #222 was a [AGE] year-old male. Resident #222 admitted on [DATE] with COPD and pneumonia (infection in the lungs). Review of Resident #222's Comprehensive MDS Assessment, dated 09/09/24, reflected that Resident #222 had severe cognitive impairment with a BIMS score of 6. Resident #222 had a diagnosis of COPD and was administered oxygen therapy. An observation on 09/17/24 at 8:45 am revealed that Resident #222 was lying in bed with his eyes closed. Resident #222's nebulizer mask was on the bedside table and not stored in a bag. Resident #222's nasal cannula tubing was connected to the oxygen concentrator (medical device that provides extra oxygen) and not to the humidifier bottle (adds moisture to air to help prevent nasal and throat irritation). The empty humidifier bottle was secured to the front of the oxygen concentrator. There was no date on the nebulizer tubing, the nasal cannula tubing, or the empty humidifier bottle. During an interview with LVN G on 09/17/24 at 09:35 AM, she stated that the nasal cannula should have been bagged. LVN G stated that the nebulizer mask and CPAP should have also been bagged when the resident was not using them. She stated that because these items were not covered, they could have gotten bacteria on them and potentially caused the residents to get sick. Observation and interview with LVN F on 09/17/2024 at 10:21 AM, LVN F stated the nasal cannula should not be exposed nor touching anything because it could cause cross contamination and infection. LVN F said the nasal cannula should be bagged when not in use. LVN F said she would go to Resident #10, #11, and #52's room, would disconnect the nasal cannula, and would throw it in the trash can. She said she was going to change all of it and put it in a bag if the residents were not using it. In an interview with the DON on 09/18/2024 at 12:36 PM, the DON stated the nasal cannula should be bagged when not in use to keep it clean. She said if the nasal cannulas were not bagged, were exposed, or touching surfaces that were not clean, there could be cross contamination, respiratory infection, or compromised oxygen administration. The DON said the staff, including her, were responsible in monitoring if the nasal cannula, the breathing mask, and the CPAP were bagged when not in use. She said there should be water in the humidifier to prevent irritation in the nose and throat. She said the expectation was for the staff to be mindful in making sure that the nasal cannula, the breathing mask, and the CPAP mask of the residents would be bagged when not in use. The DON said she would conduct an in-service and check-off about the respiratory care. She said she would personally monitor if the staff were bagging the nasal cannula the breathing mask, and the CPAP. In an interview with the Administrator on 09/18/2024 at 12:49 PM, the Administrator stated everything that the residents were using should be kept clean to prevent infection. She said, for this incident, the nasal cannula the nasal cannula the breathing mask, and the CPAP should be bagged every time the resident was not using it. The Administrator said she would coordinate with the DON on how to go forward about the issue of respiratory care. In an interview with the ADON on 07/19/2024 at 8:49 AM, the ADON stated the nasal cannula, the nasal cannula, the breathing mask, and the CPAP mask should be bagged when not in use. He said the purpose for bagging the nasal cannula was to prevent it from being exposed and touching surfaces that were dirty. He said cross contamination and possible respiratory infections could occur. He said the humidifier should have water in it to prevent dryness of the nasal passage. He said the expectation was for the staff to bag the nasal cannula when not in use. He said she would coordinate with the DON pertaining to respiratory care. Record review of facility's policy, Departmental (Respiratory Therapy) - Prevention of Infection MED-PASS, Inc. revised November 2011 revealed Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy . Steps . 4. Check water levels of refillable humidifier units daily . d. refill with distilled water . 7. Change the oxygen cannulae and tubing every seven days . 8. Keep the oxygen cannula and tubing . in a plastic bag when not in use . Nebulizer . 7. Store the circuit in plastic bag, marked with date.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for three (Resident #10, Resident #11, and Resident #52) of eight residents reviewed for Care Plans. The facility failed to ensure Residents #10, #11, and #52 were care planned for oxygen administration. This failure could place the residents at risk of not receiving the necessary care and services. Findings included: Review of Resident #10's Face Sheet, dated 09/18/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #10's pertinent diagnoses included chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and history of COVID. Review of Resident #10's Quarterly MDS Assessment, dated 07/05/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 09. The Quarterly MDS Assessment indicated the resident was on oxygen therapy while a resident of the facility. Review of Resident #10's Comprehensive Care Plan on 08/21/2024 reflected no care plan for oxygen therapy. Review of Resident #10's Physician Order, dated 01/28/2023, reflected May apply O2 per nasal cannula at 2-4L when in room for shortness of breath every shift for Shortness of Breath. Observation and interview with Resident #10 on 09/17/2024 at 9:09 AM revealed Resident #10 was in his bed, awake. It was observed that he had a nasal cannula connected to an oxygen concentrator at 3 liters per minute. According to Resident #10, he was on oxygen all day and all night. Review of Resident #11's Face Sheet, dated 09/18/2024, revealed Resident #11 was a [AGE] year-old female who was admitted to the facility 12/21/2022. Relevant diagnoses included hypertension and anemia (a problem of not having enough healthy red blood cells to carry oxygen to the body's tissue). Review of Resident #11 Quarterly MDS Assessment, dated 07/28/24, revealed Resident #9 had a moderate impairment in cognition with a BIMS score of 12. The Quarterly MDS Assessment indicated the resident was on oxygen therapy during admission and while a resident of the facility. Review of Resident #11's Comprehensive Care Plan on 08/21/2024 reflected no care plan for oxygen therapy. Review of Resident #11's Physician Order, dated 06/28/2024, revealed O2 @2LPM per nasal cannula at HS, at bedtime. Observation and interview with Resident #11 on 09/04/2024 at 8:46 AM revealed Resident #11 was in her wheelchair, awake. It was observed that she had a nasal cannula connected to an oxygen concentrator. The nasal cannula was coiled on top of the oxygen concentrator. According to Resident #11, she would only use it if she was having difficulty in breathing. She said she seldom used the oxygen. Review of Resident #52's Face Sheet, dated 09/18/2024, revealed Resident #52 was a [AGE] year-old female who was admitted to the facility 07/25/2024. Relevant diagnoses included asthma (lung disorder caused by narrowing of the airways) and anemia. Review of Resident #52 Quarterly MDS Assessment, dated 07/28/24, revealed Resident #52 was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident was on oxygen therapy while a resident of the facility. Review of Resident #52's Comprehensive Care Plan on 08/21/2024 reflected no care plan for oxygen therapy. Review of Resident #52's Physician Order, dated 07/25/2024, revealed O2 @ 2L/min via NC every 1 hours as needed for SOB or SAT < 92%. Observation and interview with Resident #52 on 09/04/2024 at 9:19 AM revealed that Resident #52 was in her bed, awake. It was observed that she had a nasal cannula connected to an oxygen concentrator. According to Resident #52, she usually wore oxygen at night but would leave it inside the room every time she would go out of the room. In an interview with the DON on 09/18/2024 at 12:36 PM, the DON stated it was important that every resident had a comprehensive care plan to make sure they received the appropriate and suitable care they needed. The DON said the care plan should be in place so that the staff providing care would be on the same page. The DON stated the care plan was important because it reflected the resident's needs. She said the care plan should be resident-centered and should show what specific care the resident needed. She said without the care plan, there could be confusion on the care of the residents. She said the expectation was for all residents to have a complete and detailed care plan. She said she would coordinate with the ADON and the MDS Nurse to audit the care plans of the residents and make sure all the care provided were care planned. In an interview with the Administrator on 09/18/2024 at 12:49 PM, the Administrator stated all the residents should have a care plan appropriate to their needs. She said without the care plan, the staff would not know the goals and the interventions needed by the residents. She said without the care plan, there could be confusion on the care and services of the residents. The Administrator concluded that the expectation was for the staff to ensure the residents were care planned accordingly. She said she would coordinate with the DON and the MDS Nurse to make sure all the residents were care planned. In an interview with the MDS Nurse on 09/19/2024 at 8:38 AM, the MDS Nurse said she was responsible in making the care plans for the residents. She opened Resident #10's care plan and saw that Resident #10 did not have a care plan for oxygen administration. She said she would make a care plan for Resident #10. After finishing Resident #10's care plan for oxygen therapy, she opened Resident #52's care plan, and saw she did not have a care plan for oxygen. She said she would make a care plan for Resident #52's oxygen, as well. After doing Resident #52's care plan for oxygen, she opened Resident #11's care plan, and saw Resident #52 did not have a care plan for oxygen. She said she would make a care plan for Resident #52's oxygen. The MDS Nurse stated care plans were important to ensure the residents were getting the care needed. She said care plans served as guides on how the staff would take care of the residents. The MDS Nurse said without the care plans, the staff could miss significant interventions needed by the residents. She concluded that she would review the care plans of the residents and would make changes accordingly. In an interview with the ADON on 07/19/2024 at 8:49 AM, the ADON stated it was important that residents have a care plan to fully provide the care and services the residents needed. The ADON said that for this case, there should be a care plan for oxygen administration. He said without the care plan, there could be confusion on the care of the residents, and their needs would not be addressed. She said she was responsible in making the care plan. She said the expectation was all the issues of the residents were care planned. Record review of facility's policy, Care Plans, Comprehensive Person-Centered MED-PASS, Inc. revised December 2016 revealed Policy statement: A comprehensive care plan, person-centered care plan . to meet the resident's physical, psychological, and functional needs is developed and implemented for each resident . 8. Describe services that are to be furnished.

Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 7 (room [ROOM NUMBER], #2, #3, #4, #5, #6, and #7) of 20 resident rooms reviewed for cleanliness and sanitization. The facility failed to ensure that Resident Rooms #1, #2, #3, #4, #5, #6, and #7 were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings included: An observation on 09/17/24 at 10:38 AM of Resident room [ROOM NUMBER] reflected the windowsill had black dirt particles on it. The air vent on the upper portion of the wall had thick dust between the vents. An observation on 09/17/24 at 10:44 AM of Resident room [ROOM NUMBER] reflected the air vent on the upper portion of the wall had thick dust between the vents. An observation on 09/17/24 at 10:46 AM of Resident room [ROOM NUMBER] reflected the windowsill had black dirt particles on it. The air vent on the upper portion of the wall had thick dust between the vents. An observation on 09/17/24 at 10:50 AM of Resident room [ROOM NUMBER] reflected the air vent on the upper portion of the wall had thick dust between the vents. An observation on 09/17/24 at 11:01 AM of Resident room [ROOM NUMBER] reflected the handrails in the resident bathroom had white stains all over it. The front of the toilet seat was cracked and chipped. There were dark stains near the connection of the base of the toilet and the toilet tank. An observation on 09/17/24 at 11:16 AM of Resident room [ROOM NUMBER] reflected the air vent on the upper portion of the wall had thick dust between the vents. The drain hole in the bathroom sink had rust around the outer portion of the ring. The top to the toilet tank was slightly off. An observation on 09/17/24 at 11:26 AM of Resident room [ROOM NUMBER] reflected the air vent on the upper portion of the wall had thick dust between the vents. The air condition unit in the resident's room had dark dirt and dust all over the front of the unit. The shower floor in the resident bathroom had black marks near the shower wall. In an interview on 09/19/24 at 10:34 AM, Housekeeping M stated she had been at the facility for 4 months. She stated they had trained her to clean all parts of the bathroom and all parts of the room. She was shown pictures of the concerns observed in Resident rooms #1, #2, #3, #4, #5, #6, and #7. She stated they were supposed to ensure that the air vents in the resident rooms were cleaned. She stated they were to clean all the areas she had observed in the pictures. She stated that the risk of not cleaning the air vents was it could cause some residents to have breathing problems and for the dirt, yeah, not good. In an interview on 09/19/24 at 11:00 AM, the Administrator stated she had been at the facility for 4 months. She was advised of all the findings in the resident rooms. She stated that her housekeeping supervisor was on medical leave, and she had the maintenance director responsible for managing the housekeeping department. She was shown pictures of the concerns observed in Resident rooms #1, #2, #3, #4, #5, #6, and #7, and she stated that she would have the maintenance director address the concerns. She stated the concerns observed could cause breathing issues and infection. In an interview on 09/19/24 at 12:00 PM, the Maintenance Director stated that he was responsible for supervising the housekeeping in the facility during the absence of the Housekeeping Supervisor. He was shown pictures of the concerns observed in Resident rooms #1, #2, #3, #4, #5, #6, and #7, and he stated housekeeping should clean all those areas daily. He stated housekeeping was supposed to clean the air vents at least once a week, and they should clean all areas of the resident room, including the bathroom floors and the handrails. He stated it was just him in maintenance, so he had not been able to check housekeeping's cleaning effort. He advised that not cleaning the room thorough could cause an infection. Review of the facility's policy on Cleaning and Disinfection of Environmental Surfaces (08/2019) reflected Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard.

Based on observation, interviews, and record reviews, the facility failed to provide treatment and care in accordance with professional standard of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care in that: LVN A and LVN B failed to assess, monitor, and provide Resident #1 with appropriate medical intervention after she sustained unwitnessed falls on [DATE] and [DATE] and had a change in her condition. An Immediate Jeopardy (IJ) was identified on [DATE] at 7:07 p.m. While the IJ was removed on [DATE] at 6:32 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of decreased quality of life, hospitalization , or death. The findings include: Review of Resident #1's face sheet revealed a [AGE] year-old female with an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's quarterly MDS assessment, dated [DATE], revealed a BIMS score of 07 indicating severe cognitive impairment. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Aspirin Tablet 81 MG Give 1 tablet by mouth one time a day related to Essential Hypertension dated [DATE]. [MEDICATION(S)] Tablet 75 MG (Used to prevent heart attacks and strokes in persons with heart disease) Give 1 tablet by mouth one time a day for preventative, dated [DATE]. Reviewed of the facility's incident reports reflected Resident #1 had a fall on [DATE] at approximately 8:50 a.m. and on [DATE] at approximately 1:45 a.m. Record review of the Neurological Flow sheet presented by the facility reflected neuro checks and vital signs checks were to be conducted as follows: Vital signs and Neuro Checks: -Every 15 minutes x 1 hour; -every 30 minutes X 1 hour; -every hour X 4 hours; and -every four hours x 24 hours. Review of an article by Nurse Theory dated [DATE], Neuro checks assess an individual's neurological functions and level of consciousness to determine whether the individual is functioning properly and reacting appropriately to the tests. These assessments allow medical professionals to diagnose potential neurological conditions and identify where an individual may fit on the level of consciousness scale. The purpose of a neurological assessment is to make sure an individual's neurological functions aren't impaired or non-responsive after an injury or surgery. Review of Resident #1's neuro assessments initiated on [DATE] indicated neuro checks were completed on [DATE] at 8:50 a.m., 9:05 a.m., 9:20 .am., 9:35 a.m., 10:35 a.m., and 11:05 a.m. and indicated she had confusion. There was no additional monitoring or interventions related to possible head trauma documented after the first fall . Review of Resident #1's neuro assessments initiated on [DATE] at about 1:45 a.m. revealed missing vitals for 6:30 a.m., 7:30 a.m., 11:30 a.m., and 3:30 p.m. Resident #1 was transferred to the local hospital emergency department on [DATE] at about 5:45 p.m. Review of Resident #1's clinical hospital records, dated [DATE], indicated the chief complaint was trauma -falls with Altered Metal Status. Review of Resident #1's C-T scan of the head, dated [DATE], slight increased enlargement of the right occipital lobe intraparenchymal hematoma with increased mass effect. Hospital report indicated Resident #1 was diagnosed with subdural hematoma (SDH), intraparenchymal hematoma (IPH) and ST-Segment Elevation [CONDITION(S)] (STEMI). It was also noted Resident #1 expired on [DATE] at about 12:38 p.m According to Mayo Clinic Family Health Book fifth edition----A subdural hematoma (SDH) is a common neurosurgical disorder that often requires surgical intervention. It is a type of [CONDITION(S)] that occurs beneath the dura (essentially, a collection of blood over the surface of the brain) and may be associated with other brain injuries A pool of blood between the brain and its outermost covering. Subdural hematoma can be a medical emergency. It's usually caused by a head injury strong enough to burst blood vessels. This can cause pooled blood to push on the brain. Age, blood-thinning drugs, and [CONDITION(S)] increase risk. Headache, confusion, vomiting, slurred speech, or coma may appear immediately or weeks after a head injury. In some cases, a subdural hematoma may not cause symptoms. Small or symptomless subdural hematomas may not need treatment and only need to be watched over time. For severe cases, surgery is often needed. According to Mayo Clinic Family Health Book fifth edition---IPH-- This type of hematoma, also known as intraparenchymal hematoma, occurs when blood pools in the tissues of the brain. There are many causes, including trauma, rupture of a bulging blood vessel (aneurysm), poorly connected arteries and veins from birth, high blood pressure, and tumors. According to Mayo Clinic Family Health Book fifth edition---A STEMI (ST-Segment Elevation [CONDITION(S)]) is the most severe type of heart attack. A heart attack or [CONDITION(S)] happens when an artery supplying blood to the heart suddenly becomes partially or completely blocked by a blood clot.) In an interview on [DATE] at 1:13 p.m. LVN A stated she was alerted by MA A that Resident #1 was found on the floor on [DATE] at about 08:50 a.m She stated she assessed Resident #1 after the first fall and initiated neuro assessments. She stated Resident #1 said she fell . She stated Resident #1 was alert and oriented but confused. She stated she did not have any other neuro checks documented except for what was presented. She stated neuros were supposed to be done according to what was on the neuro's assessment sheet. She stated, Doing neuros after a fall is very important because you want to look for change in condition and change in level of consciousness. The risk is the resident would have a serious injury that you are not aware of. If you are not monitoring the patient, you will not know. As the day continued, I noticed her eye couldn't open, I called the RN Weekend Supervisor and told her I wanted her (Resident #1) to get to the hospital because she did not look right. I called 911. I sent the resident to the hospital the next days because I could not get PERRLA (Pupil Round Reactive to Light and Accommodation) in the right. In an interview on [DATE] at 2:35 p.m. MA A stated she found Resident #1 on the floor and thought she put herself on the floor because she was lying there comfortably. She sated she asked Resident #1 and she stated she put herself on the floor. MA A stated when LVN A got to the room Resident #1 told her she fell . She stated LVN A assessed Resident #1 and the resident was confused; all Resident #1 could say was I don't know. MA A stated usually Resident #1 would tell you everything. She stated, On the day she went to the hospital she looked horrible with a capital H. MA A stated she knew the nurse kept saying she was talking, and her vitals were fine, but she looked horrible. She stated when she told the nurse she didn't look good she said she was talking and she was okay, she had just checked her. MA A stated CNA A came and said the same thing that she didn't look good. MA A stated CNA A was her CNA that shift. She stated it was rough getting Resident #1 to take her morning medications, usually she would take the cup and hold it but that day she couldn't hold the cup. MA A stated she told LVN A Resident #1's feet were already yellow. MA stated LVN A was aware, but she is LVN. In an interview on [DATE] at 2:55 p.m. CNA A stated he worked with Resident #1 on Saturday,[DATE] the 6 a.m. to 6:00 p.m. shift. He stated, [Resident #1] was off on Saturday. Her eyes were crossing. One of the reasons I was pushing for her to go to the hospital. On Saturday when I came to work I noticed something was not right. [Resident #1] went from the only person walking on my hall to not knowing what happened; equilibrium was off, no balance and she was at increased risk of fall. I really wanted [LVN A] to send [Resident #1] to the hospital when I saw her that day.[ LVN A] said she was going to see how [Resident #1] is doing but right now she didn't think [Resident #1] should go to the hospital. [LVN A] did some assessment, she was back and forth, that was her judgement to send the [Resident #1] out to the hospital or not. [LVN A] saw the full decline of [Resident #1], there was no miscommunication. This is someone who was walking, and her lights just started going off just like that. Everyone was noticing that [Resident #1] had a change of condition.[CNA B], [MA] and I tried talking to [LVN A] on Saturday during the 6:00 a.m. to 6:00 p.m. shift to send [Resident #1] to the hospital, but she didn't. I respect [LVN A], but she should have sent [Resident #1] sooner on Saturday, it would have prevented the fall on Sunday. [Resident #1] went from continent to incontinence just like that, the nurse was made aware of that. [LVN A] should have sent [Resident #1] out to the hospital that day. [Resident #1] was bad on Sunday. She went to the hospital at about 5:45, just before I left, dinner trays were coming out. In an interview on [DATE] at 3:18 p.m. CNA B stated, I realized Resident #1 was not fine on Saturday, the 6:00 a.m. to 6:00 p.m. shift. She asked me to put a pillowcase on her for jean and that was not right. I explained it was a pillowcase. When Resident #1 wanted to get up she couldn't; she needed full help to get in her chair, that was off. She needs help but not that extensive. I remember going to both nurses (LVN A and LVN C) to tell them Resident #1 needed to go to the hospital because something was off. I was told by LVN A that might be a [CONDITION(S)] and in older people it makes them look like that. It hurts to see someone go from doing everything and just slipping away. Resident #1 had BM next to her mouth. I wipe the BM from her mouth and notified both nurses. I was supposed to help Resident #1 get dressed, and I ended up helping her to change. Resident #1 could not do anything for herself. She was continent (was aware of her bowel and bladder needs) but at this point she was incontinence (unaware of bowel and bladder needs). I notified LVN A about that also. I told LVN A Resident #1 was off, her skin cold, she was not walking. I asked if we could send Resident #1 out to the hospital because I didn't know the protocol. I was told they wanted to monitor Resident #1 first and make sure it was not a [CONDITION(S)]. The day Resident #1 was rolled out of the facility on a stretcher to the hospital, she was very pale, she did not respond, no facial expression, she was curled up. In an interview on [DATE] at 4:21 p.m. LVN C stated she was told by the CNAs on Sunday [DATE] the 6:00 a.m. to 6:00 p.m. shift that Resident #1 had 2 falls within 24 hours. She stated LVN A asked about the process, and she explained the company's policy to LVN A regarding falls and change of condition, notifying the doctor, DON and family. She also stated, The CNAs told me Resident #1 didn't look good and I asked LVN A who stated Resident #1's vitals were good. After lunch the MA told me Resident #1's eyes were crossed. I asked the nurse and she said yes. Again, she (LVN A) told me Resident #1's vitals were fine and they were waiting on X-Ray result. LVN C stated the Weekend Supervisor stated she asked LVN A to send Resident #1 to the hospital after the Weekend Supervisor assessed Resident #1. She stated, I told [LVN A] if [Resident #1's] eyes are crossed it's not a baseline. I was busy with a patient I was sending out for [CONDITION(S)] exacerbation. If it was me, I would have sent her out earlier. To me every second counts. I don't know what would have happened. Maybe it would have helped. Knowing it's not her baseline I would have sent her out immediately. In an interview on [DATE] at 9:57 a.m. LVN B stated she worked with Resident #1 on Saturday night to Sunday morning, [DATE] from 6:00 p.m. to [DATE] 6:00 a.m. She stated she was somewhat familiar with Resident #1 before that weekend. She stated usually Resident #1 was up, walking and was able to tell staff what she wanted. She stated she was told by LVN A on Saturday Resident #1 had a fall that morning and that neuros were being done but she did not get a paper from LVN A with the neuro assessments. She stated, I usually do neuro assessments on paper to be able to keep track. I believe we were starting on q-shift; I can't recall. If the neuros are in the system you can look at the time and see where the previous person stop. I can't remember if I check to know what frequency we were at. LVN B stated she was told by the CNA that night, [DATE], at about 1:45 a.m. Resident #1 was on the floor and the fall was unwitnessed so she restarted the neuro checks. She stated, I initiated the neuros, every 15 minutes X4, 30 mins x4, 1 hours x4, 4 hours x4, and then the q shift. From 6 p.m. to 1:45 a.m. I did my neuros for the first fall on paper, and I can't see where it was. I did not document it. If it is not documented that means it was not done. We do neuros after unwitnessed fall to monitor changes in the resident. It will put the patient in a risk of change of condition. I did the neuro, and it was on a piece of paper. LVN B stated the following neuro assessments were missing on [DATE]: 10:05 a.m., 11:35 a.m., 12:35 p.m , 1:35 p.m., 2:35 p.m., 3:35 p.m., 7:35 p.m. and 11:35 p.m. In an interview on [DATE] at 10:30 a.m. the RN Weekend Supervisor stated she was not made aware of Resident #1's the first fall and thus the order for a UA from the physician made sense that day. She stated Resident #1 was found on the floor and had fallen with a possible head injury and was not given proper assessment for head trauma from 11:35 AM on [DATE] until she fell a second time over 14 hours later. She also stated, There should have been more neuro assessments done for Resident #1. You will not be able to know if there were changes or the patient is the same. She stated she didn't find out from the CNAs Resident #1 looked different until [DATE], and she went to assess her. She stated during her assessment she noticed Resident #1 was slower to respond and was asked if she thought she needed to go to the hospital, but she said no. The RN Weekend Supervisor stated Resident #1 was staring like she didn't understand what was happening. She also stated she did not know Resident #1 had a change of condition until on [DATE] at about 5:40 p.m., that was when she asked the doctor for the resident to be sent out for further evaluation. The RN Weekend Supervisor stated her role was not defined; she was not always notified of incidents when they happened. She stated the nurses take care of everything and notify the DON, ADON and the Administrator as needed. Record review of Resident #1' ADLs tasks documented by the CNAs on [DATE] and [DATE] for ambulation and toileting reflected her normal behaviors. In an interview on [DATE] at 4:41 p.m. the ADON stated the fall protocols was as follows: If someone falls and they are found on the floor it is considered unwitnessed fall. The CNAs are to stay with the resident, call the nurse. They are supposed to assess for pain, ROM, make sure they can extend their legs. If the fall is unwitnessed they initiate the neuro process (a set of vitals while in the same position, 15 mins x 4, then 30 mins x4, 1hr x2 and every shift). I think that's what it is It is on the fall neuros sheet. It is my expectation for nurses to do neuros accordingly, if not, it can cause a lot of impact like brain bleed that we do not know about. It could have been something we can catch from signs and symptoms. If we think there is something going on we will send the resident out to the hospital to be on the safe side. I rather be safe than sorry. The neuro assessments for Resident #1 are missing an hour and then it stopped. The rest from after 11:05 p.m. until the second fall is missing. There is a problem with the assessment from the first fall to the second fall. I think LVN A should have sent Resident #1 out because when I received the call, just from what I was told, even if the vitals were stable and her baseline was off, she should have been sent out. I got the call after a whole day had gone by. If she had a change of condition on Saturday she should have been sent out on Saturday. The RN Weekend Supervisor and LVN C called me. The ADON stated Resident #1's task document did not match what the CNAs told her Resident #1's condition was. She stated she was told on one of those days that Resident #1 had BM all over her, but the task sheet reflected she was continent. In an interview on [DATE] at 11:28 a.m. the DON stated, according to the policy, neuro assessments were done after unwitnessed falls. She stated, The first fall on [DATE] at 8:50 a.m. is missing a lot of neuro assessments. I do not know what the problem was, why Resident #1 was not sent to the hospital. The neuros from the second fall look normal but because they were not done for so long so you cannot tell what was happening in that time period. She stated, Subdural hematoma could be from a fall, car accident, medications you take. It is a slow bleed that progresses. If a clot broke off it could lead to a stroke. In an interview on [DATE] at 5:06 p.m. the Administrator stated that as of [DATE], no QAPI activity had been initiated for the situation involving Resident #1. She also stated she found out the resident had a brain bleed on [DATE], and she was not sure how it happened, what happened while she was in the care of EMS. She stated she consulted with her corporate and was told the incident was not reportable to state. She also stated she felt the nursing staff did everything they were supposed to do to care for Resident #1 and they provided the best care. She also stated, because Resident #1 made a pile on the floor to sleep, it was not normal for her. In an interview with the facility's Medical Director, he stated he was informed of the first fall when Resident #1 made a pile on the floor to sleep. He stated it was clear Resident #1 was confused because no one makes a pile on the floor to sleep and so he ordered a UA to clarify the confusion. He stated, I was not aware of that much confused time without assessment between the possible fall ([DATE]) and the time she fell again ([DATE]) or that much time after the second fall with confusion before she was sent to the hospital. He said when the RN Weekend Supervisor called him and said let's send Resident #1 out because the lab was taking long and Resident #1 was very confused, he knew there was a change in the resident. He stated, I rely on the nurses. I am not there. They are the ones seeing and assessing the resident. Review of facility's policy, dated [DATE], titled Change in a Resident's condition or status, reflected the following: Our facility shall properly notify the resident, his or her attending physician and representative (sponsor) of changes in the resident's medical/mental condition and/or status . --A significant change is a decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions .ultimately is based on the judgement of the clinical staff and the guidelines outline in the Resident Assessment Instrument and 42 CFR 483.20(b)(ii). Review of facility's policy, dated [DATE], titled Fall Risk Assessment, reflected the following: The nursing staff, in conjunction with the attending Physician, consultant Pharmacist, therapy staff and others, will seek to identify and document resident risk factors for falls. Policy Interpretation and Implementation---Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls (such as [CONDITION(S)]). Review of facility's policy, dated [DATE], titled Fall and Fall Risk Managing, reflected the following: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent from falling and to try to minimize complications from falling. Review of facility's policy, dated [DATE], titled Neurological Assessment, reflected the following: The purpose of this procedure is to provide guidelines for a neurological assessment-upon physician order, when following an unwitnessed fall, subsequent to a fall with a suspected head injury when indicated by Resident condition. ---when assessing neurological status always include frequent vital signs. Particular attention should be paid to widening pulse pressure .this is indication of increasing intracranial pressure. ---Any change in vital signs or neurological status in a previously stable resident should be reported to the physician immediately. An Immediate Jeopardy was identified on [DATE] at 7:07 p.m. due to the above failures. The Administrator and DON were notified of the Immediate Jeopardy and the IJ template was provided and a Plan of Removal was requested. The plan of Removal was accepted on [DATE] at 6:32 p.m. Record review of the facility's Plan of Removal reflected the following: [DATE] Re: Plan of Removal of Immediate Jeopardy The following is a plan of removal, which has been immediately implemented at [facility name], to remedy the immediate jeopardy which was imposed on [DATE]. All policies and procedures related to incident reports, neurological assessments, notification protocol, change of condition, abuse/neglect and timely reporting have been reviewed and re-education of the policies have been re-initiated with all licensed nursing staff for understanding and competency. The following in-services were began immediately on [DATE] to include all licensed nurses on staff and will be completed by [DATE] for all current scheduled staff; and will not be permitted to return to work until all in-services have been reviewed and signed for understanding. The in-services are as follows: Falls/Interventions/Documentation Fall assessment to be completed after each fall and quarterly. Neuro checks must follow any unwitnessed fall or evidence of head trauma. Incident reports completed for each fall. Documentation of incident must be charted in the progress note, and must contain investigation of cause of fall, interventions to prevent further falls, assessment summary including injuries, vitals, and initiation of neuros indicated. Specific interventions will be determined by the Charge Nurse and IDT team. These interventions will be reviewed, and the Care plan will be updated to reflect changes by MDS Nurse. The Administrator and IDT will review each fall, possible cause, and interventions for effectiveness-and change accordingly if not effectual. All falls will be reviewed by the DON, and all documentation will be reviewed for completion in the Incident Report in Point Click Care (PCC) to ensure compliance. The DON will be responsible for documenting review of incident reports to ensure policy and procedure followed in daily Stand-Up Meeting 5x per week for a period of 90 days and randomly thereafter. Proper chain of command must be notified to include Medical Director, Director of Nursing, Assistant Director or Nursing, Administrator, and Responsible Representative/Emergency Contact. In addition, if On-Site Supervisor is available, notification must be made. Charge Nurse to monitor and document resident response to interventions on the Incident Report, and the MDS Nurse will update the Care Plan. Changes to be reported to Medical Director, Director of Nursing, Assistant Director of Nursing, Administrator, and Responsible Representative/Emergency Contact. Intervention review occurs daily in the morning Stand Up Meeting; and weekly in Standards of Care (SOC) with IDT. Changes will be noted in the progress note by the nurse, as well as the Standards of Care document by DON. Resident Assessment After all incidents the licensed nurse will completely fill out the incident report to include all portions of are completed: o Nursing Description o Resident Description if applicable o Description of immediate action taken o Injuries observed o Pain Assessment o Mental status, o Mobility status, o Environmental factors, o Predisposing physiological factors, o Witness statements if applicable, o Agencies and people notified o Fall nurses note, o Fall risk assessment, o Neuros if applicable, o Administer first aid if applicable. DON will ensure all documentation is completed on incident reports in Point Click Care and will sign the Incident Report after completion by Charge Nurse. Abuse and Neglect (All Staff) Types of Abuse: Physical, Verbal, Sexual, Neglect, and Misappropriation/Exploitation Recognizing signs/symptoms of abuse Reporting Abuse to the Abuse Coordinator to the Administrator. At any time if staff is reporting a concern, and it does not appear to be taken seriously-the staff member is to notify the Abuse Coordinator. This information will remain confidential and investigated to ensure safety of resident and staff. Change of Condition All abnormal findings including change of vital signs, change of mobility, change of mental status, and/or decline in ADL's and must be reported to the Medical Director, Director of Nursing, Assistant Director of Nursing, Administrator, and Responsible Representative/Emergency Contact immediately. To assess baseline, the Charge Nurse may utilize previous assessment and/or the comprehensive care plan in Point Click Care. DON/Designee to monitor effectiveness of knowledge of utilizing tools available to assess resident's baseline for change of condition based on review of resident records/documentation and re-educate on a case-by-case basis when needed. Progress notes must reflect the changes observed, interventions, and notification. Post fall neuros must be conducted for 30 hours. ? Q 15 minutes for a duration of 1 hour ? Q 30 minutes for a duration of 1 hour ? Q 1 hour for a duration of 4 hours ? Q 4 hours for a duration of 24 hours All neuros MUST be completed for falls with head injury and unwitnessed fall. Abnormal findings will be reported to Medical Director, Director of Nursing, and Assistant Director of Nursing; and will be extended for an additional 24 hours to be monitored Q 4 hours (unless otherwise directed by physician). DON/Designee will review neuros daily for a period of 90 days, and randomly thereafter. Review & Reporting The Administrator and DON, along with IDT will review each incident in the Stand-Up meeting to determine possible cause, interventions, documentation, follow-up, and reporting status according to HHSC reporting guidelines 5x per week and randomly thereafter. The DON/Designee will track these incidents on the Standards of Care (SOC) log and review weekly with IDT during SOC meeting. The identification of residents with a change of condition will occur by the Charge Nurse making rounds on all residents daily, the Director of Nursing, Assistant Director of Nursing, or Designee will make daily rounds on all residents, the Weekend Supervisor will conduct rounds on all residents daily. Any changes of condition reported by floor staff that is observed will be documented and assessed by Charge Nurse; the Medical Director, Director of Nursing, Assistant Director of Nursing, Administrator, and Responsible Representative/Emergency Contact will be notified. Interventions will be implemented; new orders if indicated; and the resident will be referred to the hospital for evaluation if applicable. The DON/Designee will monitor for compliance by Residents Rounds Log being completed daily for a period of 90 days and randomly thereafter. Residents at risk for falls will be identified utilizing the Fall Risk Assessment tool in Point Click Care (PCC) that is completed after any fall occurs, and quarterly. The MDS Coordinator compiled the list of High-Risk Falls and updated comprehensive care plans if indicated. The DON/Designee will be responsible for reviewing this process, ongoing. To monitor for compliance the Administrator or Designee will report all incident reports involving a Fall/Change of Elevation to the Regional Director of Operations; and the Director of Nursing or Designee will report all incident reports involving a Fall/Change of Elevation to the Regional Clinical Director for a period of 90 days. In addition, the Administrator, Director of Nursing, or Designee will review all Incidents in both Stand Up Meeting and Stand Down meeting 5x per week for a period of 90 days to ensure all processes are being followed. This plan was implemented on [DATE] and will be monitored for compliance personally by Regional Director of Operations and Regional Clinical Director weekly until cleared by Report of Contact, and randomly thereafter. Monitoring of the plan of removal was completed from [DATE] through [DATE]. Interview with the RN Weekend supervisor, LVN A, LVN C, LVN D, RN A and ADON all reflected they had been in-serviced and educated on Fall assessment, neuro checks, risk management, specific interventions, monitoring, and documentation. It was also revealed they were educated on reporting, baseline assessment, completing fall assessments, Post fall neuros accordingly, abuse and neglect. Interview with CNA B, CNA C, CNA D, CNA E, and CNA F all reflected they had been educated and trained on documentation, ADLs task and Abuse and Neglect. In an interview on [DATE] at 5:52 p.m. the DON stated in-services, education and training were initiated on [DATE] and all full-time staff completed training on fall assessments, neuro checks, risk managements, specific interventions, monitoring, and documentation, reporting, baseline assessment, completing fall assessments, post fall neuros accordingly, abuse and neglect. She also stated she was responsible to make sure the staff were following the process and doing what needs to be done. She stated she is monitoring daily. Review of facility's in-services reflected the following in-services were initiated on [DATE]: -Falls interventions and documentation; -Reporting and Documenting; -Reducing falls; -Neuro Checks; and -Abuse and Neglect. It was also reflected the DON was doing a daily log for monitoring the nursing staff as they document on falls and neuro assessments. Observation on [DATE] at 6:19 p.m. revealed a binder at the nurse's station titled: Nurse Resources containing the following, recognizing signs and symptoms of abuse and neglect, falls prevention-potential intervention, care of resident with dementia, change in resident's condition or status, and fall risk assessment. All nurses spoken to were able to reference the binder being at the nurse's station. Review of Facility's QAPI committee report, dated [DATE], revealed the following was discussed: Falls, Change of Condition, Documentation, Abuse and Neglect and Reporting. On [DATE] at 6:30 p.m. the Administrator and DON were notified the IJ was removed. The facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the POR.

Based on observation, interview and record review, the facility failed to implement their policies and procedures for abuse prevention for one (Resident #5) of seventeen residents reviewed for abuse. Resident #5 was restricted to his room and the facility's young adult activity room. The door to Resident #5's room was a dutch door. The bottom half of the door was secured in the doorframe with a child safety cover on the interior doorknob that prevented Resident #5 from being able to exit his room independently. Resident #5's closet and bathroom doors had hook and eye locking mechanisms attached to the upper portion of the door, out of reach of Resident #5. Resident #5's wheelchair, into which he could transfer himself and self-propel, was stored in the bathroom and his toys were stored in the closet, neither of which he was able to access independently due to the locks. Resident #5's movement while in the young adult activity room was restricted by an activity cart that blocked the main entrance, closed doors that restricted exit from the room, and staff that prevented Resident #5 from freely moving about the room or exiting the room. This failure resulted in an identification of an immediate jeopardy (IJ) on 10/13/16 at 4:40 PM. While the IJ was removed on 10/15/16, the facility remained out of compliance at a level of harm with a scope identified as pattern. This failure could affect fifteen residents in the facility that required special assistance and an increase in monitoring by placing them at risk for unidentified abuse or neglect. Findings included: Record review of the facility's policy titled Resident Abuse Policy, revealed The resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and/or involuntary seclusion and/or injury from an unknown source. In the event of any evidence or cause to believe that a resident has suffered any of the above abuses, the employee, visitor, or family members are requested to report all allegations, suspicions, or incidents to the administrator of the facility or to State officials posted in the facility. Section 16, Senate Bill #9, July 1997, Report of Abuse and Neglect .1. Persons required to report: a. Any person or any owner or employee of a nursing home having cause to believe that a nursing home resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person or persons shall report in accordance with Section 16 (a) b. Each nursing home employee shall be required to sign a statement that he or she realizes his or her criminal liability for failure to report such abuses as a condition of employment by the nursing home. In an interview with the DON, on 10/16/16 at 4:00 PM, she stated that each staff member participates in an in-service about restraints entitled Creating A Restraint Free Environment. The DON stated that staff received the Creating a Restraint Free Environment upon hire and annually. Record review of the facility's in-service entitled Creating a Restraint Free Environment, dated 2015, revealed Learning Objectives . Identify physical and chemical restraints create a restraint-free environment. Definitions Physical restraints are any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body Remove easily means that the resident can intentionally remove the restraint in the same manner as the staff applied it considering the resident's physical condition and ability to accomplish the objective, such as getting to the bathroom in time. Freedom of movement means any change in place or position for the body or any part of the body that the resident is physically able to control Convenience is any action that controls a resident's behavior or manages a resident's behavior with a lesser amount of effort by the staff and not in the resident's best interest Real Life Consequences Any type of restraint, whether physical or chemical, can have serious physical and emotional consequences for the resident. The use of restraints impairs a resident's functional ability, independence, and quality of life. Additionally, restraint use can lead to decreased mobility, pressure ulcers, incontinence, constipation, fecal impaction, falls, social isolation, depression, agitation, and feeling of humiliation Summary physical restraint is anything that the resident cannot easily remove and restricts their freedom of movement or normal access to their body Always be on the lookout for the less obvious forms of restraints. Remember, asking Can the resident easily remove the device? and Does the device restrict freedom of movement? will help you determine if something is a physical restraint. Record review of the facilities policy, titled Use of Restraints dated 2001 and revised April 2006, revealed Policy Statement .Chemical/ Physical restraint shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully Policy Interpretation and Implementation 1. Chemical/Physical restraints shall only be used up on the written order of a physician and after obtaining consent from the resident and/or representative sponsor with the exception of temporary emergency use as outlined in this policy. 2. Restraints with locking devices shall not be used. 3. Seclusion, which is defined as the placement of a resident alone in a room shall not be unless less short-term monitored separation becomes necessary because the resident exhibits combative or aggressive behavior that poses a threat to the resident or other residents/staff in the facility. 4. Physical restraints shall be used in such a way as not to cause injury to the resident and to ensure the least possible discomfort. 5. Physical restraints shall be applied in such a manner that they can be quickly removed by staff in case of fire or other emergency. 6. . 7. Physical restraints for behavioral control shall only be used on the signed order of a physician, except in an emergency that threatens to bring immediate injury to the residence or others. In such an emergency, an order may be given by the Director of Nursing services. Such order must be counter-signed by the Attending Physician within 48 hours. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time, and the name of the individual applying such measures shall be entered in the resident's medical record. 8. Physical restraints for behavior control shall only be used with a written order designed to lead a less restrictive way of managing, and ultimately the elimination of, the behavior for which they were restraint was applied. There shall be no PRN orders for behavioral restraints. 9. Care plans that include the use of physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used, and the time limit for the use of the method. 10. When drugs are used to restrain or control behavior or to treat a disorder thought process the following shall apply: a) The specific behavior or manifestation of disordered thought process to be treated with the drug is identified in the resident's medical record; b) The plan of care for each resident specifies data to be collected for use in evaluating the effectiveness of the drugs and the occurrence of adverse reactions; c) The data collected shall be made available to the physician in a consolidated manner at least monthly and; d) PRN orders for such drugs she'll be subject to the requirements of established pharmaceutical policies and procedures 11. 12. Should a resident not be capable of making a decision concerning the use of a restraint, the surrogate or sponsor may exercise the right of the use or non-use of a restraint. Note: The surrogate/sponsor may not give permission to use restraints for the sake of discipline or staff convenience or when the restraint is not necessary to treat the resident's medical symptoms. Record review of the facilities policy, titled Resident Right's dated 2001 and Revised September 2003, it revealed Resident Rights Policy statement .Employees shall treat all residents with kindness, respect, and dignity .Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain rights to all residents of this facility. 2. Residents are entitled to exercise their rights and privileges to the fullest extent possible. 3. Our facility will make every effort to assist each resident in exercising his or her rights to assure that the resident is always treated with respect, kindness, and dignity. 6. Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents' rights'. (27.) The resident has the right to be free from any physical restraint imposed or psychoactive drugs administered for the purposes of discipline or convenience and not required to treat the resident's medical symptoms. Record review of Resident #5's Admission Record, dated 10/16/16, revealed he was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. According to the Mayo Clinic, [MEDICAL CONDITION] is a condition that robs you of the ability to communicate. It can affect your ability to speak, write and understand language, both verbal and written. <http://www.mayoclinic.org/diseases-conditions/[MEDICAL CONDITION]/basics/definition/CON- 061>). (Accessed 10/18/16) Record review of Resident #5's quarterly MDS 3.0 (Minimum Data Set), dated 09/26/16, revealed he was unable to complete the BIMS (Brief Interview for Mental Status), which indicated severe cognitive impairment. Section G revealed Resident #5 was totally dependent on staff for all activities of daily living. Record review of Resident #5's care plan dated 10/03/16, revealed (Resident #5) is dependent on staff for activities, cognitive stimulation, social interaction related to cognitive deficits. Goal: (Resident #5) will maintain involvement in cognitive stimulation, social activities as desired through review date. Intervention/Tasks: .The resident's preferred activities are being wheeled outside for fresh air. He is in young adult room when out of bed, he enjoys being on the floor, he likes any toys that makes noise. He has a habit of twisting a clothing protector. (Resident #5) is a wanderer has impaired safety awareness. (Resident #5) ambulates on his knees and /or wheelchair with staff assist. He has a history of pulling hair and being rough with others. He has a history of getting out of his room and wandering through hall way. He has a history of disrobing and pulling bedding off bed. Goal: (Resident #5) safety will be maintained through the review date. Intervention/Tasks: .Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Resident has safety door knobs on all doors per family and caregiver request. Observation on 10/10/16 at 3:46 PM, during initial tour, revealed Resident #5 lying in his bed with his blanket pulled over his face. Resident #5's room had a dutch door, the top half which was open. A child safety cover was over the doorknob on the interior side of the door preventing Resident #5 from being able to open his door and leave the room independently. Observations revealed a hook and eye locking mechanism located on the upper portion his closet and bathroom doors, preventing the doors from opening. After unlocking the bathroom door, Resident #5's wheelchair was observed in the bathroom. Resident #5 did not have a call light present in his room, and no other monitoring system was noted in the room. The room was dim, there was one toy rattle observed in the corner of room, and the television was not on. According to Dictionary.com a dutch door is a door consisting of two units horizontally divided so that each half can be opened or closed separately. <http://www.dictionary.com/browse/dutch-door> (accessed on 10/24/16) In an interview on 10/10/16 at 3:50 PM, the minimum data set (MDS) Coordinator stated that Resident #5 could not get out of his room due to the child safety covers on the doorknob, which prevented him from being able to open the door. The MDS Coordinator stated the hook and eye locking mechanisms on the bathroom and closet door prevented him from opening those doors as well. She explained that Resident #5 had known behaviors of pulling other residents hair, climbing in bed with other residents, and getting out of his room and wandering through the hallway. She also identified he has a known behavior of wrapping the call light around his neck and it had been removed sometime ago but did not know the exact date. The MDS Coordinator stated Resident #5's family member provided the child safety covers and the hook and eye locking mechanisms in order to prevent Resident #5 from hurting himself or other residents. She stated these were provided a long time ago, but she was not sure when. Observation on 10/10/16 at 5:49 PM, revealed CNA I wheeled Resident #5 in his wheelchair from the young adult activity room to his room after eating supper. CNA I assisted Resident #5 with transferring to his bed, and then placed his wheelchair in the bathroom. CNA I locked the bathroom door with the hook and eye latch, and then closed the bottom portion of the dutch door. The top portion of the door remained open. The television was not on and Resident #5 was sitting on his bed, twirling a clothing protector, and staring at the floor. One toy rattle was seen in the corner of the room. The child safety cover was in place over Resident #5's interior door knob and the hook and eye locking mechanisms on the closet was securely fastened. Observation on 10/11/16 at 8:55 AM, Resident #5 was in the young adult activity room, crawling on the floor and twirling a clothing protector. The activity cart (measuring approximately 4 foot in height and four foot in length) blocked the main entrance and exit to the young adult activity room, preventing Resident #5 from leaving the room. Observation on 10/11/16 at 6:20 PM, revealed Resident #5 was once again in his room. He was observed to be lying under the covers on his bed. The bottom portion of the dutch door was closed with the child safety cover over the doorknob on the interior side. The top portion of the door was open. The lights were off and his room was dim. His television was not on. One toy rattle remained in the corner of his room. Resident #5's wheelchair was not observed in his room. Observation on 10/12/16 at 8:49 AM, revealed Resident #5 in the young adult activity room crawling on his knees across the floor. The activity cart was observed blocking the entry and exit for the young adult activity room. Observation on 10/12/16 at 9:35 AM, revealed Resident #5 in his wheelchair, propelling self with feet in the young adult activity room. The activity cart was blocking the main entry and exit to the young adult activity room. In an interview on 10/12/16 at 1:20 PM, with Family Member A, she said that she was aware of the child safety covers and hook and eye locking mechanisms that were on his doors that purposely secluded him from access to the hallway, bathroom, and his closet. She said (Resident #5) has a known behavior of pulling other residents hair and occasionally will climb in bed with other residents. At the time of the interview, Family Member A expressed concerns due to a recent visit to the facility that her son was not being cared for properly and she felt as though staff were leaving him in his room and drugging him so they did not have to mess with him. She indicated on October 2nd, she was in the facility visiting (Resident #5) and found him in his room with heavily soiled linens and foul body odor. Family member A said when they visit and enter the building Resident #5 is found to be in his room. Family Member A said that her expectation when Resident #5 is in his room is to have his toys and television available to him. She did say that a lot of his toys are always found in the young adult play room or behind his locked closet door and they will round them up and put them in his room for him. Family member A was also aware that the call light had been taken out of his room due to (Resident #5) liked to pull it out of the wall and play with it. Observation on 10/12/16 at 3:18 PM, revealed Resident #5 in bed. The travel channel was displayed on the television. One toy rattle remained in the corner of his room. Observation behind Resident #5's locked closet door, revealed multiple toys that made noise, lighted up and played music, balls and stuffed animals. In an interview on 10/12/16 at 3:20 PM, CNA D said that she did not realize his toys were in his closet. She did say that he enjoyed playing with toys and twirling a clothing protector; however CNA D did not attempt at this time to get any of his toys out from the closet and left the room. In an observation on 10/12/16 at 3:22 PM, Resident #5 was lying in his bed. The bottom portion of the dutch door was closed and the child safety cover was covering the interior doorknob. Hook and eye locking mechanisms were on the bathroom and closet doors and were securely fastened. Observation on 10/12/16 at 4:34 PM, revealed Resident #5 in his room, lying in bed with eyes closed. The bottom portion of the dutch door was closed and the child safety cover was covering the interior doorknob. Hook and eye locking mechanisms were on the bathroom and closet doors and were securely fastened. No call light observed in resident #5's room. Observation on 10/13/16 at 9:30 AM, revealed Resident #5 was in his wheelchair, propelling self with feet in the young adult activity room. The activity cart was blocking the main entry and exit for the young adult activity room. Observation on 10/13/16 at 10:21 AM, revealed Resident #5 on his knees crawling on the floor in the young adult activity room. The activity cart was blocking the main entry and exit for the young adult activity room. In an interview on 10/13/16 at 10:23 AM, CNA E stated he has worked in the facility for five months. He said that he rarely worked with Resident #5 and the other residents from Hall 2. CNA E said that the activity cart was placed in front of the entrance of the young adult activity room, so that Resident #5 would stay in the young adult activity room. CNA E said that they kept most all the residents from Hall 2 in the young adult activity room and could not leave the room unless another staff member relieved them. He said that residents on Hall 2 received rounds every two hours and that he had not received any special instruction for any resident that was on hall 2. He did not identify any residents from hall 2 that were a danger to themselves or others. He was not aware of any issues that would be a safety issue. CNA E said there were not any restraints located in any of the resident's rooms. He did say Resident #5 occasionally tried to grab other resident's hair, but that redirection was offered. If Resident #5 becomes extremely agitated he is taken to his room. When asked why to his room, CNA E responded because he cannot get out. Observation on 10/13/16 at 10:25 AM, revealed Resident #5 was in his wheelchair turning a door handle on a door that provided an exit from the young adult activity room into the hallway. Resident #5 was told by CNA E Can't do that (Resident #5), No! while attempting to open the door. The activity cart continued to block the main entry/exit from the young adult activity room. In an interview on 10/13/16 at 10:35 AM, CNA F stated that the activity cart was placed in front of the entrance to the young adult activity room to help Resident #5 stay in the young adult activity room. Observation on 10/13/16 at 10:38 AM, revealed CNA F speaking to Resident #5 in a direct firm tone saying No! You do not go that way; (Resident #15) does not want to play with you. At this time CNA F placed a wheelchair between the wall and another resident that was in a wheelchair, creating a barrier for Resident #5 to be unable to access the other area of the young adult activity room. In an interview on 10/13/16 at 10:42 AM, CNA F stated that residents are checked on every two hours. CNA F said that Resident #5 grabs hair of other residents and that if needed he has as needed (PRN) medications that the nurse can give him for behavior. CNA F stated that (Resident #5) is taken to his room when the staff are behind on showers or if call lights need to be answered. When asked why he is taken to his room she replied, He has toys in his room and there are child safety locks that prevent him from getting out of his room. She also said, we try not to put him in his room because he is so confined. In an interview on 10/13/16 at 11:05 AM, LVN B confirmed Resident #5's call light is not in his room, but was not sure why his call light had been removed. LVN B stated they monitor Resident #5 by checking on him, and denied any other monitoring system being in place. LVN B confirmed Resident #5 could not open his door from the inside due to the child safety locks on the door. Observation on 10/13/16 at 11:50 AM, revealed Resident #5 to be sitting in his wheelchair in the young adult activity room, twirling a clothing protector. The activity cart was blocking the main entry and exit for the young adult activity room. In an interview on 10/13/16 at 3:41 PM, CNA A stated that he never realized Resident #5 did not have a call light and he never paid attention to be honest. CNA A said that when Resident #5 is done with his evening meal and tries to exit the young adult activity room in his wheelchair, staff will put him in his room and he generally will go to sleep. He stated there are child safety locks on his door so that he stays in his room. In an interview on 10/13/16 at 4:00 PM, CNA D said she had worked at the facility for approximately 7 years. She said she normally worked Hall B on the 2 p.m. to 10 p.m. shift. She said she was responsible to check on the residents every 2 hours. She said Resident #5 and Resident #15 liked to get out of play room so cart with supplies was placed in front of door opening to keep them in the play room. She said Resident #5 could not be in play room unless staff was in there. She said Resident #5 was left in his room until last so they could get showers and get residents up for mealtime because he would pull hair and remove other resident's bibs. In an interview on 10/15/16 at 5:35 PM, the Administrator stated the facility has policies in place to ensure that the residents are free from Abuse/ Neglect such as mental, verbal, etc . by staff , visitors, family. She stated that staff were in-serviced about Abuse/Neglect on hire and then at least annually thereafter and encouraged to report any suspicions. She said that staff were educated about what might constitute Abuse/Neglect such as tone of voice, being condescending or abrupt, commanding, physical, etc . She further stated that she did not feel that anyone had been secluded. She stated that the staff would not separate a resident as a negative consequence. (Resident #5) needs to be removed from stimulus. She said that the staff had gotten tripped up in the questioning and felt that when (Resident #5) was taken to his room because staff were busy it was for his safety and not for staff convenience. She said that the child locks were initiated by (Resident #5 ' s) parents because he is curious and has no safety awareness. In an interview on 10/15/16 at 5:55 PM, the DON stated staff have been educated about aggression vs. instinctual behaviors specific to Fred. CNA ' s are educated about Abuse/Neglect in CNA School and then in-serviced on hire and at minimum twice per year but it is something that is continually addressed. She further stated that there was no one in seclusion and the staff had not secluded Resident #5 for their convenience but for safety reasons. (Resident #5's) parents requested that he have alone time when he was over stimulated. An IJ was identified on 10/13/16 at 4:40 PM. The facility's ADM, DON and ADON, Regional Director of Operations and Regional Director of Clinical Operations were notified at 4:40PM on 10/13/16 of the IJ and a Plan of Removal was requested. The facility submitted the following plan of removal which was accepted on 10/14/16: The following is a plan of removal, which has been immediately implemented at (the facility), to remedy the immediate jeopardy which was imposed on October 13th, 2016. 1) The latch on the closet door was removed, as well as the child safety mechanism on the entrance door to resident #5's room. A single action lock was installed on the closet door for the safety of resident #5. A wheelchair was placed outside resident's room, or made accessible for personal use and for use during an emergency evacuation when resident is in room. All wiring in resident's room was covered with wire channeling to hide wires for safety. The door knob was changed to a passage door handle for ease of opening. A door chime was placed on the resident's entrance door and resident's closet door that can be heard down the hall to alarm staff of opening. An infant video/audio monitor is in place in resident #5's room and at nurses station for use aid in monitoring of resident, and resident is on one-on-one supervision as well. An in service has been started regarding usage of video/ audio equipment to aid in monitoring of resident #5 by the Director of Nursing. An in service on resident rights and that seclusion of residents for convenience or to decrease workload is a violation of resident rights has been started immediately for all staff by the Director of Nursing. These in services will be complete on 10/14/2016 with current scheduled staff, any staff not scheduled will not be permitted to return to work until completing the in service and signing for understanding, this also includes any new hires. The resident's RP was notified of changes, and care plan updated to reflect changes. 2) All residents' PASRR status were reviewed to identify the Pre-Admission Screening and Resident Review (PASSR) positive residents with intellectual disabilities and there are 15 that are identified in current census. This is to determine how many residents are identified as needing special assistance and an increase in monitoring from every 2 hours to hourly daily that could be potentially affected. 3) In addition to immediate implementations listed above, a 100% audit of the building was completed to determine the location and removal of any additional restrictive locking devices that may inhibit residents from freely moving about facility at their will, other than resident #5's room. As the resident is non-verbal and his body language and facial expressions do not clearly project his needs; staff will watch for triggers that incite agitation and remove resident from said stimuli. The resident will be redirected to alternate activities to alleviate further distress. Staff will be in serviced on appropriate interventions to redirect resident from stressors and stimuli when behavior exhibits by the director on nursing to be started immediately 10/14/16 for all scheduled staff, and other staff will be unable to return to work until in serviced and sign for understanding, this includes new hires. Monitoring to be provided by Charge Nurse, and behavior charting to follow each episode. The following in services were began immediately by the Director of Nursing on 10/13/2016 to include all staff and will be completed by 10/14/2016 for current scheduled staff. All other staff will not be allowed to return to work until in services have been reviewed and signed for understanding, this includes new hires . A) All staff on ensuring resident #5's wheelchair is outside resident's room, or readily accessible when resident is in room for personal use or evacuation. B) All staff on resident rights and that seclusion of residents for convenience, or to decrease workload, is a violation of resident rights. C) Nursing staff on increasing rounds from every 2 hours to every hour of residents with intellectual disabilities that are unable to voice concerns or needs, and document on Point of Care software for ADLs. D) All staff on the use of equipment to prevent residents from moving around freely at will is a violation of resident rights. E) All staff on ensuring door chimes are present on resident #5's entrance door and closet door and working properly, and can be heard on hall and on video/audio monitor at nurse's station, to alert staff of doors opening. F) All staff on not placing any latches, locking mechanisms, or door knob coverings anywhere that inhibit the freedom of residents to move around at will and to report to administrator immediately if discovered. G) All staff on never placing resident #5, or any resident, in their room or seclusion to attend to others, or because they become difficult or agitated. Also, if resident #5 becomes excited, or agitated, to remove from stimuli and redirect with alternate activity that alleviates this behavior. H) Nursing staff on audio/video equipment location and usage of equipment to aid in the monitoring of resident #5. 4) To monitor for compliance the Administrator/ or designee will monitor daily x 90 days, then randomly thereafter to ensure no locking devices, latches, or door knob coverings that inhibit the freedom of resident movement about facility at will are present, that resident #5's wheelchair is accessible to resident at all times, that resident #5's door to room and closet door have chimes in place and are functioning correctly to notify staff of opening, that all wires are securely covered with wire channeling for resident safety, that resident #5's audio/video monitoring system is in place and functioning properly, and will ensure that frequent monitoring of residents with intellectual disabilities is being completed, and resident rights are being upheld that no seclusion of residents is being performed in facility. Any negative findings will be corrected and reported to the quality assurance(QA) committee. This monitoring will take effective immediately 10/13/2016. This plan was initially implemented on 10/13/2016 and will be monitored for compliance personally by Regional Director of Operations and Regional Director of Clinical Operations weekly until cleared by report of contact, then randomly thereafter effective immediately. As the resident is non-verbal and his body language and facial expressions do not clearly project his needs; staff will watch for triggers that incite agitation and remove resident from said stimuli. The resident will be redirected to alternate activities to alleviate further distress. Staff will be in serviced on appropriate interventions to redirect resident from stressors and stimuli by the director on nursing to be started immediately 10/14/16 for all scheduled staff, and other staff will be unable to return to work until in serviced and sign for understanding, this includes new hires. Monitoring to be provided by Charge Nurse, and behavior charting to follow each episode. New interventions will require in services to train staff on how to respond to resident with appropriate redirection. The facility's implementation of their Plan of Removal was monitored through the following: Observations on 10/15/16 at 4:55 PM, revealed the child safety mechanism on the entrance door to resident #5's room had been removed. All

Based on observation, interview and record review, the facility failed to ensure residents were free from involuntary seclusion for one (Resident #5) of 17 residents reviewed for involuntary seclusion. Resident #5 was restricted to his room and the facility's young adult activity room. The door to Resident #5's room was a dutch door. The bottom half of the door was secured in the doorframe with a child safety cover on the interior doorknob that prevented Resident #5 from being able to exit his room independently. Resident #5's closet and bathroom doors had hook and eye locking mechanisms attached to the upper portion of the door, out of reach of Resident #5. Resident #5's wheelchair, into which he could transfer himself and self-propel, was stored in the bathroom and his toys were stored in the closet, neither of which he was able to access independently due to the locks. Resident #5's movement while in the young adult activity room was restricted by an activity cart that blocked the main entrance, closed doors that restricted exit from the room, and staff that prevented Resident #5 from freely moving about the room or exiting the room. This failure resulted in an identification of an immediate jeopardy (IJ) on 10/13/16 at 4:40 PM. While the IJ was removed on 10/15/16, the facility remained out of compliance at a level of harm with a scope identified as pattern. This failure could cause emotional distress, loss of dignity and physical and psychosocial harm to fifteen residents in the facility that requires special assistance and an increase in monitoring. The findings were: Record review of Resident #5's Admission Record, dated 10/16/16, revealed he was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. According to the Mayo Clinic, [MEDICAL CONDITION] is a condition that robs you of the ability to communicate. It can affect your ability to speak, write and understand language, both verbal and written. <http://www.mayoclinic.org/diseases-conditions/[MEDICAL CONDITION]/basics/definition/CON- 061>). (Accessed 10/18/16) Record review of Resident #5's quarterly MDS 3.0 (Minimum Data Set), dated 09/26/16, revealed he was unable to complete the BIMS (Brief Interview for Mental Status), which indicated severe cognitive impairment. Section G revealed Resident #5 was totally dependent on staff for all activities of daily living. Record review of Resident #5's care plan dated 10/03/16, revealed (Resident #5) is dependent on staff for activities, cognitive stimulation, social interaction related to cognitive deficits. Goal: (Resident #5) will maintain involvement in cognitive stimulation, social activities as desired through review date. Intervention/Tasks: .The resident's preferred activities are being wheeled outside for fresh air. He is in young adult room when out of bed, he enjoys being on the floor, he likes any toys that makes noise. He has a habit of twisting a clothing protector. (Resident #5) is a wanderer has impaired safety awareness. (Resident #5) ambulates on his knees and /or wheelchair with staff assist. He has a history of pulling hair and being rough with others. He has a history of getting out of his room and wandering through hall way. He has a history of disrobing and pulling bedding off bed. Goal: (Resident #5) safety will be maintained through the review date. Intervention/Tasks: .Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Resident has safety door knobs on all doors per family and caregiver request. Observation on 10/10/16 at 3:46 PM, during initial tour, revealed Resident #5 lying in his bed with his blanket pulled over his face. Resident #5's room had a dutch door, the top half which was open. A child safety cover was over the doorknob on the interior side of the door preventing Resident #5 from being able to open his door and leave the room independently. Observations revealed a hook and eye locking mechanism located on the upper portion his closet and bathroom doors, preventing the doors from opening. After unlocking the bathroom door, Resident #5's wheelchair was observed in the bathroom. Resident #5 did not have a call light present in his room, and no other monitoring system was noted in the room. The room was dim, there was one toy rattle observed in the corner of room, and the television was not on. According to Dictionary.com a dutch door is a door consisting of two units horizontally divided so that each half can be opened or closed separately. <http://www.dictionary.com/browse/dutch-door> (accessed on 10/24/16) In an interview on 10/10/16 at 3:50 PM, the Minimum Data Set (MDS) Coordinator stated that Resident #5 could not get out of his room due to the child safety covers on the doorknob, which prevented him from being able to open the door. The MDS Coordinator stated the hook and eye locking mechanisms on the bathroom and closet door prevented him from opening those doors as well. She explained that Resident #5 had known behaviors of pulling other residents hair, climbing in bed with other residents, and getting out of his room and wandering through the hallway. She also identified he has a known behavior of wrapping the call light around his neck and it had been removed sometime ago but did not know the exact date. The MDS Coordinator stated Resident #5's family member provided the child safety covers and the hook and eye locking mechanisms in order to prevent Resident #5 from hurting himself or other residents. She stated these were provided a long time ago, but she was not sure when. Observation on 10/10/16 at 5:49 PM, revealed CNA I wheeled Resident #5 in his wheelchair from the young adult activity room to his room after eating supper. CNA I assisted Resident #5 with transferring to his bed, and then placed his wheelchair in the bathroom. CNA I locked the bathroom door with the hook and eye latch, and then closed the bottom portion of the dutch door. The top portion of the door remained open. The television was not on and Resident #5 was sitting on his bed, twirling a clothing protector, and staring at the floor. One toy rattle was seen in the corner of the room. The child safety cover was in place over Resident #5's interior door knob and the hook and eye locking mechanisms on the closet was securely fastened. Observation on 10/11/16 at 8:55 AM, Resident #5 was in the young adult activity room, crawling on the floor and twirling a clothing protector. The activity cart (measuring approximately 4 foot in height and four foot in length) blocked the main entrance and exit to the young adult activity room, preventing Resident #5 from leaving the room. Observation on 10/11/16 at 6:20 PM, revealed Resident #5 was once again in his room. He was observed to be lying under the covers on his bed. The bottom portion of the dutch door was closed with the child safety cover over the doorknob on the interior side. The top portion of the door was open. The lights were off and his room was dim. His television was not on. One toy rattle remained in the corner of his room. Resident #5's wheelchair was not observed in his room. Observation on 10/12/16 at 8:49 AM, revealed Resident #5 in the young adult activity room crawling on his knees across the floor. The activity cart was observed blocking the entry and exit for the young adult activity room. Observation on 10/12/16 at 9:35 AM, revealed Resident #5 in his wheelchair, propelling self with feet in the young adult activity room. The activity cart was blocking the main entry and exit to the young adult activity room. In an interview on 10/12/16 at 1:20 PM, with Family Member A, she said that she was aware of the child safety covers and hook and eye locking mechanisms that were on his doors that purposely secluded him from access to the hallway, bathroom, and his closet. She said (Resident #5) has a known behavior of pulling other residents hair and occasionally will climb in bed with other residents. At the time of the interview, Family Member A expressed concerns due to a recent visit to the facility that her son was not being cared for properly and she felt as though staff were leaving him in his room and drugging him so they did not have to mess with him. She indicated on October 2nd, she was in the facility visiting (Resident #5) and found him in his room with heavily soiled linens and foul body odor. Family member A said when they visit and enter the building Resident #5 is found to be in his room. Family Member A said that her expectation when Resident #5 is in his room is to have his toys and television available to him. She did say that a lot of his toys are always found in the young adult play room or behind his locked closet door and they will round them up and put them in his room for him. Family member A was also aware that the call light had been taken out of his room due to (Resident #5) liked to pull it out of the wall and play with it. Observation on 10/12/16 at 3:18 PM, revealed Resident #5 in bed. The travel channel was displayed on the television. One toy rattle remained in the corner of his room. Observation behind Resident #5's locked closet door, revealed multiple toys that made noise, lighted up and played music, balls and stuffed animals. In an interview on 10/12/16 at 3:20 PM, CNA D said that she did not realize his toys were in his closet. She did say that he enjoyed playing with toys and twirling a clothing protector; however CNA D did not attempt at this time to get any of his toys out from the closet and left the room. In an observation on 10/12/16 at 3:22 PM, Resident #5 was lying in his bed. The bottom portion of the dutch door was closed and the child safety cover was covering the interior doorknob. Hook and eye locking mechanisms were on the bathroom and closet doors and were securely fastened. Observation on 10/12/16 at 4:34 PM, revealed Resident #5 in his room, lying in bed with eyes closed. The bottom portion of the dutch door was closed and the child safety cover was covering the interior doorknob. Hook and eye locking mechanisms were on the bathroom and closet doors and were securely fastened. No call light observed in resident #5's room. Observation on 10/13/16 at 9:30 AM, revealed Resident #5 was in his wheelchair, propelling self with feet in the young adult activity room. The activity cart was blocking the main entry and exit for the young adult activity room. Observation on 10/13/16 at 10:21 AM, revealed Resident #5 on his knees crawling on the floor in the young adult activity room. The activity cart was blocking the main entry and exit for the young adult activity room. In an interview on 10/13/16 at 10:23 AM, CNA E stated he has worked in the facility for five months. He said that he rarely worked with Resident #5 and the other residents from Hall 2. CNA E said that the activity cart was placed in front of the entrance of the young adult activity room, so that Resident #5 would stay in the young adult activity room. CNA E said that they kept most all the residents from Hall 2 in the young adult activity room and could not leave the room unless another staff member relieved them. He said that residents on Hall 2 received rounds every two hours and that he had not received any special instruction for any resident that was on hall 2. He did not identify any residents from hall 2 that were a danger to themselves or others. He was not aware of any issues that would be a safety issue. CNA E said there were not any restraints located in any of the resident's rooms. He did say Resident #5 occasionally tried to grab other resident's hair, but that redirection was offered. If Resident #5 becomes extremely agitated he is taken to his room. When asked why to his room, CNA E responded because he cannot get out. Observation on 10/13/16 at 10:25 AM, revealed Resident #5 was in his wheelchair turning a door handle on a door that provided an exit from the young adult activity room into the hallway. Resident #5 was told by CNA E Can't do that (Resident #5), No! while attempting to open the door. The activity cart continued to block the main entry/exit from the young adult activity room. In an interview on 10/13/16 at 10:35 AM, CNA F stated that the activity cart was placed in front of the entrance to the young adult activity room to help Resident #5 stay in the young adult activity room. Observation on 10/13/16 at 10:38 AM, revealed CNA F speaking to Resident #5 in a direct firm tone saying No! You do not go that way; (Resident #15) does not want to play with you. At this time CNA F placed a wheelchair between the wall and another resident that was in a wheelchair, creating a barrier for Resident #5 to be unable to access the other area of the young adult activity room. In an interview on 10/13/16 at 10:42 AM, CNA F stated that residents are checked on every two hours. CNA F said that Resident #5 grabs hair of other residents and that if needed he has as needed (PRN) medications that the nurse can give him for behavior. CNA F stated that (Resident #5) is taken to his room when the staff are behind on showers or if call lights need to be answered. When asked why he is taken to his room she replied, He has toys in his room and there are child safety locks that prevent him from getting out of his room. She also said, we try not to put him in his room because he is so confined. In an interview on 10/13/16 at 11:05 AM, LVN B confirmed Resident #5's call light is not in his room, but was not sure why his call light had been removed. LVN B stated they monitor Resident #5 by checking on him, and denied any other monitoring system being in place. LVN B confirmed Resident #5 could not open his door from the inside due to the child safety locks on the door. Observation on 10/13/16 at 11:50 AM, revealed Resident #5 to be sitting in his wheelchair in the young adult activity room, twirling a clothing protector. The activity cart was blocking the main entry and exit for the young adult activity room. In an interview on 10/13/16 at 3:41 PM, CNA A stated that he never realized Resident #5 did not have a call light and he never paid attention to be honest. CNA A said that when Resident #5 is done with his evening meal and tries to exit the young adult activity room in his wheelchair, staff will put him in his room and he generally will go to sleep. He stated there are child safety locks on his door so that he stays in his room. In an interview on 10/13/16 at 4:00 PM, CNA D said she had worked at the facility for approximately 7 years. She said she normally worked Hall B on the 2 p.m. to 10 p.m. shift. She said she was responsible to check on the residents every 2 hours. She said Resident #5 and Resident #15 liked to get out of play room so cart with supplies was placed in front of door opening to keep them in the play room. She said Resident #5 could not be in play room unless staff was in there. She said Resident #5 was left in his room until last so they could get showers and get residents up for mealtime because he would pull hair and remove other resident's bibs. In an interview on 10/15/16 at 5:35 PM, the Administrator stated that she didn ' t feel that anyone had been secluded. She stated that the staff would not separate a resident as a negative consequence. (Resident #5) needs to be removed from stimulus. She said that the staff had gotten tripped up in the questioning and felt that when (Resident #5) was taken to his room because staff were busy it was for his safety and not for staff convenience. She said that the child locks were initiated by (Resident #5 ' s) parents because he is curious and has no safety awareness. In an interview on 10/15/16 at 5:55 PM, the DON stated that there was no one in seclusion and the staff had not secluded Resident #5 for their convenience but for safety reasons. (Resident #5's) parents requested that he have alone time when he was over stimulated. Record review of the facilities policy, titled Use of Restraints dated 2001 and revised April 2006, revealed Policy Statement .Chemical/ Physical restraint shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully Policy Interpretation and Implementation 1. Chemical/Physical restraints shall only be used up on the written order of a physician and after obtaining consent from the resident and/or representative sponsor with the exception of temporary emergency use as outlined in this policy. 2. Restraints with locking devices shall not be used. 3. Seclusion, which is defined as the placement of a resident alone in a room shall not be unless less short-term monitored separation becomes necessary because the resident exhibits combative or aggressive behavior that poses a threat to the resident or other residents/staff in the facility. 4. Physical restraints shall be used in such a way as not to cause injury to the resident and to ensure the least possible discomfort. 5. Physical restraints shall be applied in such a manner that they can be quickly removed by staff in case of fire or other emergency. 6. . 7. Physical restraints for behavioral control shall only be used on the signed order of a physician, except in an emergency that threatens to bring immediate injury to the residence or others. In such an emergency, an order may be given by the Director of Nursing services. Such order must be counter-signed by the Attending Physician within 48 hours. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time, and the name of the individual applying such measures shall be entered in the resident's medical record. 8. Physical restraints for behavior control shall only be used with a written order designed to lead a less restrictive way of managing, and ultimately the elimination of, the behavior for which they were restraint was applied. There shall be no PRN orders for behavioral restraints. 9. Care plans that include the use of physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used, and the time limit for the use of the method. 10. When drugs are used to restrain or control behavior or to treat a disorder thought process the following shall apply: a) The specific behavior or manifestation of disordered thought process to be treated with the drug is identified in the resident's medical record; b) The plan of care for each resident specifies data to be collected for use in evaluating the effectiveness of the drugs and the occurrence of adverse reactions; c) The data collected shall be made available to the physician in a consolidated manner at least monthly and; d) PRN orders for such drugs she'll be subject to the requirements of established pharmaceutical policies and procedures 11. 12. Should a resident not be capable of making a decision concerning the use of a restraint, the surrogate or sponsor may exercise the right of the use or non-use of a restraint. Note: The surrogate/sponsor may not give permission to use restraints for the sake of discipline or staff convenience or when the restraint is not necessary to treat the resident's medical symptoms. Record review of the facilities policy, titled Resident Right's dated 2001 and Revised September 2003, it revealed Resident Rights Policy statement .Employees shall treat all residents with kindness, respect, and dignity .Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain rights to all residents of this facility. 2. Residents are entitled to exercise their rights and privileges to the fullest extent possible. 3. Our facility will make every effort to assist each resident in exercising his or her rights to assure that the resident is always treated with respect, kindness, and dignity. 6. Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents' rights'. (27.) The resident has the right to be free from any physical restraint imposed or psychoactive drugs administered for the purposes of discipline or convenience and not required to treat the resident's medical symptoms. In an interview with the DON, on 10/16/16 at 4:00 PM, she stated that each staff member participates in an in-service about restraints entitled Creating A Restraint Free Environment. The DON stated that staff received the Creating a Restraint Free Environment upon hire and annually. Record review of the facility's in-service entitled Creating a Restraint Free Environment, dated 2015, revealed Learning Objectives . Identify physical and chemical restraints create a restraint-free environment. Definitions Physical restraints are any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body Remove easily means that the resident can intentionally remove the restraint in the same manner as the staff applied it considering the resident's physical condition and ability to accomplish the objective, such as getting to the bathroom in time. Freedom of movement means any change in place or position for the body or any part of the body that the resident is physically able to control Convenience is any action that controls a resident's behavior or manages a resident's behavior with a lesser amount of effort by the staff and not in the resident's best interest Real Life Consequences Any type of restraint, whether physical or chemical, can have serious physical and emotional consequences for the resident. The use of restraints impairs a resident's functional ability, independence, and quality of life. Additionally, restraint use can lead to decreased mobility, pressure ulcers, incontinence, constipation, fecal impaction, falls, social isolation, depression, agitation, and feeling of humiliation Summary physical restraint is anything that the resident cannot easily remove and restricts their freedom of movement or normal access to their body Always be on the lookout for the less obvious forms of restraints. Remember, asking Can the resident easily remove the device? and Does the device restrict freedom of movement? will help you determine if something is a physical restraint. Record review of the facility's policy titled Resident Abuse Policy, revealed The resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and/or involuntary seclusion and/or injury from an unknown source. In the event of any evidence or cause to believe that a resident has suffered any of the above abuses, the employee, visitor, or family members are requested to report all allegations, suspicions, or incidents to the administrator of the facility or to State officials posted in the facility. Section 16, Senate Bill #9, July 1997, Report of Abuse and Neglect .1. Persons required to report: a. Any person or any owner or employee of a nursing home having cause to believe that a nursing home resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person or persons shall report in accordance with Section 16 (a) b. Each nursing home employee shall be required to sign a statement that he or she realizes his or her criminal liability for failure to report such abuses as a condition of employment by the nursing home. An IJ was identified on 10/13/16 at 4:40 PM. The facility's ADM, DON and ADON, Regional Director of Operations and Regional Director of Clinical Operations were notified at 4:40PM on 10/13/16 of the IJ and a Plan of Removal was requested. The facility submitted the following plan of removal which was accepted on 10/14/16: The following is a plan of removal, which has been immediately implemented at (the facility), to remedy the immediate jeopardy which was imposed on October 13th, 2016. 1) The latch on the closet door was removed, as well as the child safety mechanism on the entrance door to resident #5's room. A single action lock was installed on the closet door for the safety of resident #5. A wheelchair was placed outside resident's room, or made accessible for personal use and for use during an emergency evacuation when resident is in room. All wiring in resident's room was covered with wire channeling to hide wires for safety. The door knob was changed to a passage door handle for ease of opening. A door chime was placed on the resident's entrance door and resident's closet door that can be heard down the hall to alarm staff of opening. An infant video/audio monitor is in place in resident #5's room and at nurses station for use aid in monitoring of resident, and resident is on one-on-one supervision as well. An in service has been started regarding usage of video/ audio equipment to aid in monitoring of resident #5 by the Director of Nursing. An in service on resident rights and that seclusion of residents for convenience or to decrease workload is a violation of resident rights has been started immediately for all staff by the Director of Nursing. These in services will be complete on 10/14/2016 with current scheduled staff, any staff not scheduled will not be permitted to return to work until completing the in service and signing for understanding, this also includes any new hires. The resident's RP was notified of changes, and care plan updated to reflect changes. 2) All residents' PASRR status were reviewed to identify the Pre-Admission Screening and Resident Review (PASSR) positive residents with intellectual disabilities and there are 15 that are identified in current census. This is to determine how many residents are identified as needing special assistance and an increase in monitoring from every 2 hours to hourly daily that could be potentially affected. 3) In addition to immediate implementations listed above, a 100% audit of the building was completed to determine the location and removal of any additional restrictive locking devices that may inhibit residents from freely moving about facility at their will, other than resident #5's room. As the resident is non-verbal and his body language and facial expressions do not clearly project his needs; staff will watch for triggers that incite agitation and remove resident from said stimuli. The resident will be redirected to alternate activities to alleviate further distress. Staff will be in serviced on appropriate interventions to redirect resident from stressors and stimuli when behavior exhibits by the director on nursing to be started immediately 10/14/16 for all scheduled staff, and other staff will be unable to return to work until in serviced and sign for understanding, this includes new hires. Monitoring to be provided by Charge Nurse, and behavior charting to follow each episode. The following in services were began immediately by the Director of Nursing on 10/13/2016 to include all staff and will be completed by 10/14/2016 for current scheduled staff. All other staff will not be allowed to return to work until in services have been reviewed and signed for understanding, this includes new hires . A) All staff on ensuring resident #5's wheelchair is outside resident's room, or readily accessible when resident is in room for personal use or evacuation. B) All staff on resident rights and that seclusion of residents for convenience, or to decrease workload, is a violation of resident rights. C) Nursing staff on increasing rounds from every 2 hours to every hour of residents with intellectual disabilities that are unable to voice concerns or needs, and document on Point of Care software for ADLs. D) All staff on the use of equipment to prevent residents from moving around freely at will is a violation of resident rights. E) All staff on ensuring door chimes are present on resident #5's entrance door and closet door and working properly, and can be heard on hall and on video/audio monitor at nurse's station, to alert staff of doors opening. F) All staff on not placing any latches, locking mechanisms, or door knob coverings anywhere that inhibit the freedom of residents to move around at will and to report to administrator immediately if discovered. G) All staff on never placing resident #5, or any resident, in their room or seclusion to attend to others, or because they become difficult or agitated. Also, if resident #5 becomes excited, or agitated, to remove from stimuli and redirect with alternate activity that alleviates this behavior. H) Nursing staff on audio/video equipment location and usage of equipment to aid in the monitoring of resident #5. 4) To monitor for compliance the Administrator/ or designee will monitor daily x 90 days, then randomly thereafter to ensure no locking devices, latches, or door knob coverings that inhibit the freedom of resident movement about facility at will are present, that resident #5's wheelchair is accessible to resident at all times, that resident #5's door to room and closet door have chimes in place and are functioning correctly to notify staff of opening, that all wires are securely covered with wire channeling for resident safety, that resident #5's audio/video monitoring system is in place and functioning properly, and will ensure that frequent monitoring of residents with intellectual disabilities is being completed, and resident rights are being upheld that no seclusion of residents is being performed in facility. Any negative findings will be corrected and reported to the quality assurance(QA) committee. This monitoring will take effective immediately 10/13/2016. This plan was initially implemented on 10/13/2016 and will be monitored for compliance personally by Regional Director of Operations and Regional Director of Clinical Operations weekly until cleared by report of contact, then randomly thereafter effective immediately. As the resident is non-verbal and his body language and facial expressions do not clearly project his needs; staff will watch for triggers that incite agitation and remove resident from said stimuli. The resident will be redirected to alternate activities to alleviate further distress. Staff will be in serviced on appropriate interventions to redirect resident from stressors and stimuli by the director on nursing to be started immediately 10/14/16 for all scheduled staff, and other staff will be unable to return to work until in serviced and sign for understanding, this includes new hires. Monitoring to be provided by Charge Nurse, and behavior charting to follow each episode. New interventions will require in services to train staff on how to respond to resident with appropriate redirection. The facility's implementation of their Plan of Removal was monitored through the following: Observations on 10/15/16 at 4:55 PM, revealed the child safety mechanism on the entrance door to resident #5's room had been removed. All cords and wiring in resident #5's room was covered with wire channeling to hide wires for safety, door chimes were on Resident #5's closet door and entry door into his room, alerting the staff of an opened door. An infant video/audio monitor was in place in resident #5's room and at nurse's station for use aid in monitoring of resident, and resident was observed with one-on-one supervision. Interviews were conducted on 10/15/16 starting at 4:45 PM through 10/15/16 ending at 6:26 PM, with the following staff: ADM, DON, RN A, RN B, LVN B, MA B, CNA G, CNA D, CNA H, CNA I, and CNA J. Staff were present from all three shifts and all revealed they had received training

Based on observation, interview and record review, the facility failed to ensure the drug regimen was free from unnecessary drugs for 2 of 17 (Residents #5 and #15) residents reviewed for medications. The facility failed to ensure: A. Resident #5 had a documented clinical indication, an appropriate diagnosis, and other documented non-pharmacological interventions for the routine use of [MEDICATION NAME] (an antipsychotic medication). B. Resident #15 did not receive an excessive dose of antipsychotic medication and [MEDICATION NAME]. Resident #15 was receiving both [MEDICATION NAME] and [MEDICATION NAME], medications that are in the same class of antipsychotic drugs, for an extended period of time without adequate clinical rationale as to why a gradual dose reduction was not attempted. Resident #15 received both [MEDICATION NAME] and [MEDICATION NAME], for an excessive duration. Resident #15 was prescribed [MEDICATION NAME] on 06/14/16 for three days, but continued to receive it for four months past the order date along with the [MEDICATION NAME]. This failure resulted in Resident #5 and #15 exhibiting flat affects, limited social interactions, and lethargy, and could affect the thirty five residents receiving antipsychotic medications by placing them at risk for receiving unnecessary doses of medication and experiencing undesirable side effects and cause a physical or psychosocial decline in health. The findings included: Record review of Resident #5's Admission Record, dated 10/16/16, revealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #5's quarterly Minimum Data Set (MDS), dated [DATE], revealed that he was unable to complete the interview for the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Section E did not indicate any behaviors (physical, verbal or other). Section I did not identify any active [DIAGNOSES REDACTED].#5 received an antipsychotic and at least one day of during a 7 day look back had received an antianxiety medication. Record review of Resident #5's care plan with a revision date of 09/26/16 revealed Focus: medications [MEDICATION NAME] related to Intellectual Disabilities and behavior management. Goal: drug related complications, including movement disorder, discomfort, [MEDICAL CONDITION], gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. Interventions: Consult with pharmacy, medical doctor (MD) to consider dosage reduction when clinically appropriate, Monitor/record occurrence of for target behavior symptoms, pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. Etc. and document per facility protocol. Monitor/record/report to MD prn side effects and adverse reactions of psychoactive medications: [REDACTED]. Record review of Resident #5's computerized Physician order [REDACTED]. Discontinue Date/Reason: 06/17/16 at 4:42 PM Increased ordered dose. Order date: 06/17/16 at 4:50 PM [MEDICATION NAME] Tablet 2MG ([MEDICATION NAME]) Give 1 tablet by mouth two times a day related to Attention Deficit [MEDICAL CONDITION] Disorder, Predominantly Inattentive Type and unspecified intellectual disabilities The order was received by RN A. According to The Federal Drug Administration (FDA) labeling guidelines from 2014(the most recent labeling update), [MEDICATION NAME] (generic: [MEDICATION NAME]) is an atypical antipsychotic indicated for treatment of [REDACTED]. Dosage increases in these patients should be in increments of no more than 0.5 mg twice daily. Increases to dosages above 1.5 mg twice daily should generally occur at intervals of at least 1 week. In some patients, slower titration may be medically appropriate. <http://www.accessdata.fda.gov/drugsatfda_docs/label/2014/ 2s073, 8s062, 4s048lbl.pdf> (Accessed on 10/20/16) Record review of Resident #5's Nurses' Notes revealed the following entries: 6/17/16 at 10:41 AM Resident very aggressive and agitated making loud high pitched noises and pulling other residents hair. Medicated resident with [MEDICATION NAME] at around 9am, with good results. Resident is now calm sitting in w/c in playroom. Will continue to monitor. Signed by LVN C 06/17/16 at 7:11 PM (Physician A) here and changed resident's resperdol dosage and ordered labs. Signed RN B. Record review of Resident #5's Treatment Administration Record March 2016. April 2016, June 2016 revealed no documentation of behavioral issues, including aggression, agitation, or combativeness. Record review of Resident #5's Medication Administration Record [REDACTED]. Record review of Resident #5's Antipsychotic Behavior and Side Effecting Monitoring flow-sheet for June 2016 indicated during the month of June the resident did not display any behaviors identified on the flow sheet, including continual screaming/yelling, continual pacing, paranoia, hallucinations, delusional, wandering, tardive dyskinesia, postural [MEDICAL CONDITION], cognitive/behavior impairment, parkinsonism, akathisia(restless/urgent need for movement). Observation on 10/10/16 at 3:46 PM with the MDS Coordinator upon initial tour, revealed Resident #5 to be in his bed with a blanket covering his face. When the blanket was removed, Resident #5 opened eyes and affect was noted to be flat. In an interview on 10/10/16 at 3:48 PM with the MDS Coordinator, she said that Resident #5 could not speak, he walks around on his knees, he likes his head rubbed and has known behaviors of grabbing staff and other residents, pulling hair, and climbing in bed with other residents at times. She said he generally does not show much emotion. Observation on 10/10/16 at 5:49 PM revealed CNA I placing Resident #5 in his bed after dinner. Observation on 10/10/16 at 6:09 AM revealed Resident #5 sitting in bed twirling clothing protector with flat affect, staring downward towards floor. Observation on 10/11/16 at 9:21 AM revealed Resident #5 in young adult activity room twirling clothing protector with a downward stare towards floor, flat affect noted. Observation on 10/11/16 at 6:20 PM revealed Resident #5 in bed with blanket covering face. The room was dark; no lights were on in the room. Observation on 10/12/16 at 3:08 PM revealed Resident #5 in bed with eyes open, flat affect. Observation on 10/12/16 at 4:34 PM revealed Resident #5 in bed with eyes closed. In an interview with Family Member A, (Legal Guardian of Resident #5) on 10/12/16 at 1:20 PM, she said that she had not been made aware of the dosage increase to her son's [MEDICATION NAME] on June 17, 2016, however she did say That make's sense because the last few times I have visited him he seems drunk. Family Member A expressed concerns that the facility was drugging my son she said that when he pulls someone's hair they just give him medication instead of trying to redirect him. Family Member A said that Resident #5 has known responses of crying when he is in pain, jumping up and down on knees if he is excited, when he is distressed or upset he will squeal or grunt and is able to smile and laugh. Family Member A said that she had not been able to visit for several months and noticed a big change in him when she visited 10/02/16. In an interview on 10/13/16 at 10:23 AM with CNA E, he said Resident #5 tries to grab other resident's hair sometimes and when he is extremely agitated we take him to his room because he is not able to get out. CNA E said that his affect is usually flat and does not show much emotion or facial expressions. In an interview on 10/13/16 at 10:35 AM with CNA F, she said that Resident #5 has a known behavior of grabbing hair. She said that usually when Resident #5 displays aggressive behaviors the nurse will give him a PRN medication (not sure what it was) and if that does not help, he is taken to his room. When asked why his room, CNA F replied Because he can't get out. He has baby proof knobs and locks on his door. CNA F said Resident #5 cannot speak and usually does not show much emotion. In an interview on 10/14/16 at 11:28 AM with LVN A, he said that behaviors are noted on the treatment administration record and nurse's notes. LVN A said that he monitors for drowsiness, face twitching and changes in behaviors. In a telephone interview on 10/14/16 at 12:00 PM with Physician A, he said that he recalled increasing Resident #5's [MEDICATION NAME], however he did not recall increasing it that much He then asked if he could come to the facility and speak in person and look at Resident #5's clinical record. In an interview on 10/14/16 at 12:14 PM the DON said that behavior monitoring is done on the behavior charting located in the Treatment Administration Record, nurses notes or on weekly assessments. She verified that there was not a behavior assessment done on Resident #5 the week of June 17, 2016 or any other behavior monitoring put in place when his dose was increased. In an interview on 10/14/16 at 1:55 PM with Physician A he said I did increase his [MEDICATION NAME] to 2mg twice a day from 0.5mg twice a day but should not have increased the [MEDICATION NAME] that much, he is a small guy. He said he increased the dose for restlessness and provided a sheet titled Doctor's Rounds dated 06/17/16 showing the increased [MEDICATION NAME] to Resident #5. He said that the side effects are that it can make him sleepy, have a flat affect, and even kill him Physician A clarified that the [DIAGNOSES REDACTED]. He said that [MEDICATION NAME] does treat restlessness with patients who have [MEDICAL CONDITION]. He said that when increasing [MEDICATION NAME] it should be done 0.5mg at a time gradually. Physician A confirmed that staff from the facility did not question the significant dose increase when he wrote the order on 06/17/16. In an interview on 10/14/16 2:33 PM with the DON she said that her expectation would be for her nursing staff to have questioned Physician A for the [MEDICATION NAME] being increased that much and all at once for Resident #5 when the order was received. Record review of Physician A's Progress note dated 07/12/16 revealed Active Problems: [MEDICAL CONDITION], Intellect Disability, Convulsions, [MEDICAL CONDITION], Attention Deficiency, Lack of Normal Physical Development, [MEDICAL CONDITION], Joint Contracture, [MEDICAL CONDITION]. The current medications did not identify that Resident #5 was taking [MEDICATION NAME]. Plan of Treatment was to continue on above medications plus all other supportive PRN therapy plus physical therapy. Electronically signed by (Physician A) on 09/02/2016 at 11:26 AM. Record review of Resident #5's Consent for Psychoactive Medication Therapy dated 12/17/12, revealed a consent obtained by telephone on 12/17/12 at 1:00 PM by Family Member A for [MEDICATION NAME] treating impulse control and aggressive behavior. Resident #15 Record review of Resident #15's Admission Record, dated 10/14/16, revealed she was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #15's Quarterly MDS, dated [DATE], revealed Resident #15 was unable to complete the BIMS due to severely impaired cognitive function. The MDS also revealed Resident #15 did not display any signs or symptoms of [MEDICAL CONDITION] or [MEDICAL CONDITION]. The MDS indicated Resident #15 had not exhibited any physical, verbal, or other behavioral symptoms directed towards others. The MDS identified Resident #15 as requiring the physical assistance of at least one staff member for bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. The MDS also revealed Resident #15 had received an antipsychotic for the seven days prior to the date of the MDS. Record review of Resident #15's clinical record revealed a computerized physician's telephone order, dated 06/14/16, that prescribed the following: [MEDICATION NAME] Tablet 25 MG ([MEDICATION NAME][MEDICATION NAME] HCI) Give 1 tablet by mouth three times a day for allergic reaction until 06/17/16 . for 3 days. The order was confirmed by RN B. No additional telephone orders dated after 06/14/16 related to [MEDICATION NAME] were identified. Record review of Resident #15's clinical record from 2013 to present did not reveal the original order for [MEDICATION NAME] or [MEDICATION NAME]. Record review of Resident #15 Order Summary Report, dated 10/04/16 and signed by Physician A, revealed the following orders: [MEDICATION NAME] Tablet ([MEDICATION NAME][MEDICATION NAME] HCI) Give 25 mg by mouth three times a day for allergy Order Status: Active, Order Date: 06/20/16, Start Date: 06/20/16 [MEDICATION NAME] HCI Tablet 25 MG Give 1 tablet by mouth four times a day for itching Order Status: Active, Order Date: 11/02/15, Start Date: 11/02/15 [MEDICATION NAME] Tablet 400 MG (Quetiapine [MEDICATION NAME]) Give 1 tablet by mouth two times a day related to UNSPECIFIED [MEDICAL CONDITION] Order Status: Active, Order Date: 11/02/15, Start Date: 11/02/15 Ziprasidone HCI (generic of [MEDICATION NAME]) Capsule 20 MG Give 1 capsule by mouth two times a day related to UNSPECIFIED [MEDICAL CONDITION] Order Status: Active, Order Date: 11/02/15, Start Date: 11/02/15 The U.S. National Library of Medicine identified [MEDICATION NAME][MEDICATION NAME] (generic name of [MEDICATION NAME]) as a medication used to relieve red, irritated, itchy, watery eyes; sneezing; and runny nose caused by hay fever, allergies [REDACTED]. [MEDICATION NAME][MEDICATION NAME] is also used to relieve cough caused by minor throat or airway irritation.[MEDICATION NAME][MEDICATION NAME] will relieve the symptoms of these conditions but will not treat the cause of the symptoms or speed recovery. [MEDICATION NAME][MEDICATION NAME] is in a class of medications called [MEDICATION NAME]. It works by blocking the action of [MEDICATION NAME], a substance in the body that causes allergic symptoms. <https://medlineplus.gov/druginfo/meds/a 9.html> (accessed on 10/21/16) The U.S. National Library of Medicine identified [MEDICATION NAME] as a medication prescribed to relieve itching caused by allergic skin reactions. It is also used alone or with other medications in adults and children to relieve anxiety and tension . [MEDICATION NAME] is also used along with other medications in adults and children as a sedative before and after general anesthesia for surgery. [MEDICATION NAME] is in a class of medications called [MEDICATION NAME]. It works by blocking the action of [MEDICATION NAME] a substance in the body that causes allergic symptoms. It also works by decreasing activity in the brain. <https://medlineplus.gov/druginfo/meds/a 6.html> (accessed on 10/21/16) The U.S. National Library of Medicine identified Quetiapine (generic of [MEDICATION NAME]) as a medication used to treat the symptoms of [MEDICAL CONDITION] (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). Quetiapine tablets and extended-release tablets are also used alone or with other medications to treat episodes [MEDICAL CONDITION](frenzied, abnormally excited or irritated mood) or depression in patients with [MEDICAL CONDITION] disorder (manic [MEDICAL CONDITION]; a disease that causes episodes of depression, episodes of mania, and other abnormal moods). In addition, quetiapine tablets and extended-release tablets are used with other medications to prevent episodes [MEDICAL CONDITION] depression in patients with [MEDICAL CONDITION] disorder. Quetiapine extended-release tablets are also used along with other medications to treat depression. Quetiapine is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. <https://medlineplus.gov/druginfo/meds/a 9.html> (accessed on 10/21/16) The U.S. National Library of Medicine identified Ziprasidone (generic name of [MEDICATION NAME]) as a medication used to treat the symptoms of [MEDICAL CONDITION] (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). It is also used to treat episodes [MEDICAL CONDITION](frenzied, abnormally excited or irritated mood) or mixed episodes (symptoms [MEDICAL CONDITION] depression that happen together) in patients with [MEDICAL CONDITION] disorder (manic [MEDICAL CONDITION]; a disease that causes episodes of depression, episodes of mania, and other abnormal moods). Ziprasidone is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. <https://medlineplus.gov/druginfo/meds/a 2.html> (accessed on 10/21/16) Record review of Resident #15's Consultation Report (review of psychiatric medication by the pharmacy consultant), dated 02/10/16, revealed the following: Comment: (Resident #15) receives two or more antipsychotic medications concomitantly: [MEDICATION NAME] 400mg BID (twice a day) and [MEDICATION NAME] 20mg BID. Recommendation: The combined use of two or more antipsychotic medications complicates the drug regimen and increases the potential for adverse events. Recommend re-evaluation of therapy to determine if duplicate antipsychotic orders are needed at this time. If therapy is continued unchanged, it is recommended that the prescriber document an assessment of risk versus benefit, indicating that is continues to be a valid therapeutic intervention for this individual and patient-specific rationale why dose reduction is CLINICALLY CONTRAINDICATED at this time. Physician's Response: . I have re-evaluated this therapy and DO NOT wish to implement any changes due to the reasons below. [MEDICAL CONDITION] (not a current [DIAGNOSES REDACTED]. The document is signed by Physician A. Record review of Resident #15's Medication Administration Record [REDACTED]. The June 2016 MAR indicated [REDACTED]. D/C (discontinued) Date-06/20/16. According to the June 2016 [DATE] MG of [MEDICATION NAME] was administered once on 06/18/16, twice on 06/19/16, and once on 06/20/16. [MEDICATION NAME] was not documented as being administered on any other dates in June 2016. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Record review of the Treatment Administration Record (TAR) for June 2016 revealed no behaviors related to the [DIAGNOSES REDACTED]. Record review of Resident #15's MAR for the month of July 2016 revealed an order for [REDACTED]. Give 25 mg by mouth three times a day for allergy (no start date was identified). and [MEDICATION NAME] HCI Table 25 mg Give 1 tablet by mouth four times a day for itching. The MAR indicated [REDACTED].The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Record review of the Treatment Administration Record (TAR) for July 2016 revealed no behaviors related to the [DIAGNOSES REDACTED]. Record review of Resident #15's MAR for the month of August 2016 revealed an order for [REDACTED]. Give 25 mg by mouth three times a day for allergy (no start date was identified) and [MEDICATION NAME] HCI Table 25 mg Give 1 tablet by mouth four times a day for itching. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Record review of the Treatment Administration Record (TAR) for August 2016 revealed no behaviors related to the [DIAGNOSES REDACTED]. Record review of Resident #15's MAR for the month of September 2016 revealed an order for [REDACTED]. Give 25 mg by mouth three times a day for allergy (no start date was identified) and [MEDICATION NAME] HCI Table 25 mg Give 1 tablet by mouth four times a day for itching. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Record review of the Treatment Administration Record (TAR) for September 2016 revealed no behaviors related to the [DIAGNOSES REDACTED]. Record review of Resident #15's MAR for the month of October 2016, from 10/01/16-10/14/16, revealed an order for [REDACTED]. Give 25 mg by mouth three times a day for allergy (no start date was identified) and [MEDICATION NAME] HCI Table 25 mg Give 1 tablet by mouth four times a day for itching. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Record review of the Treatment Administration Record (TAR) for October 2016, from 10/01/16-10/14/16, revealed no behaviors related to the [DIAGNOSES REDACTED]. Observation on 10/13/16 at 10:44 AM revealed Resident #15 asleep on a floor mat in young activity room. Observation on 10/13/16 at 1:33 PM revealed Resident #15 asleep in bed. Observation and interview on 10/16/16 at 12:10 PM revealed Resident #15 was receiving assistance with eating in the young adult activity room. Resident #15 kept falling asleep while staff was trying to assist her with eating. CNA C, who was assisting Resident #15, stated she was going to put the resident in her bed because she was so sleepy she wasn't interested in eating. CNA C stated that it is not uncommon for Resident #15 to stay up for days at a time and then sleep for days at a time. In an interview on 10/13/16 at 10:45 CNA F stated that Resident #15 was asleep on the floor mat in the young activity room because if they tried to move her to her room she would wake up. In an interview on 10/13/16 at 5:00 PM the DON stated Resident #15 will often be awake for several days in a row and then sleep for days at a time. The DON stated she did not know why they allowed Resident #15 to sleep on the floor in the activity room floor because if she is moved to her bed she will fall right back to sleep. In an interview on 10/14/16 at 2:09 PM Physician A, Resident #15's primary care physician, stated the [MEDICATION NAME] for Resident #15 should have been no more a couple of days. He stated the order was for a short period of time only for a skin issue the resident was having. Physician A indicated he was not sure why the medication had been continued, and that the combination of these two medications could have sedating effects in Resident #15. Physician A stated the [MEDICATION NAME] was to be replaced by the [MEDICATION NAME]. He stated the [MEDICATION NAME] should have been tapered off within a month of Resident #15 receiving the [MEDICATION NAME]. Physician A indicated a combination of the [MEDICATION NAME] and [MEDICATION NAME] could cause sedation, flat affect, and even death. In an interview on 10/14/16 at 3:52 PM the DON stated they had not been able to find the initial orders for Resident #15's [MEDICATION NAME] or [MEDICATION NAME]. The DON stated they had reviewed back until 2013 and it could not be located. The DON stated when they began utilizing a computer system for physician orders [REDACTED]. The DON stated the prescriptions should have also been questioned when the decline of a gradual dose reduction was justified by Physician A with a [DIAGNOSES REDACTED]. The DON also acknowledged the need for more documentation related to the facility's attempts to obtain a gradual dose reduction or a change in the medication. The DON stated she did not know why the [MEDICATION NAME] was continued after the discontinue date or why it continued on the physician's orders [REDACTED]. The DON stated they have obtained an order to discontinue the [MEDICATION NAME] and to taper off the [MEDICATION NAME]. Record review of Resident #15's Care Plan, undated, revealed the following: Focus: (Resident #15) requires [MEDICAL CONDITION] medications [MEDICATION NAME] AND ZIPRASIDONE for Behavior management/UNSPECIFIED [MEDICAL CONDITION]. She has a history of rocking side to side and yelling out at times Date Initiated: 01/07/15 Revision on 04/01/16 Goal: (Resident #15) will be/remain free of drug related complications through review date. Date Initiated: 01/07/15 Revision on: 10/01/15 Target Date: 10/03/16 Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. (Date Initiated: 01/07/15); Consult with pharmacy, MD to consider dosage reduction when clinically appropriate. (Date Initiated: 01/07/15) Record review of the facility provided policy titled Administering Medications, dated 2001 and revised April 2006, revealed Medications will be administered in a timely manner and as prescribed by the resident's attending physician or the facility's medical director.4. Should a dosage seem excessive considering the resident's age and medical condition, or a medication order seems to be unrelated to the resident's current [DIAGNOSES REDACTED]. Director for further instructions. 9. The individual administering the medication must initial the resident's MAR indicated [REDACTED]. Record review of the facility provided policy entitled Use of Restraints, dated 2001 and updated April 2006, revealed Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Policy Interpretation and Implementation . 1. Chemical/Physical restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and /or representative (sponsor) with the exception of temporary emergency use as outlined in this policy. 12. Should a resident not be capable of making a decision concerning the use of a restraint, the surrogate or sponsor may exercise the right of the use or non-use of a restraint. (Note: The surrogate/sponsor may not give permission to use restraints for the sake of discipline or staff convenience or when the restraint is not necessary to treat the resident's medical symptoms. Record review of the facility provided policy entitled Antipsychotic Drug Use, dated 2001 and revised 01/01, revealed Antipsychotic drug therapy shall be used only when it is necessary to treat a specific condition. Policy Interpretation and Implementation 3. Nursing documentation must include a description of target symptom(s), their frequency and expected outcomes so that the attending physician can determine if the medications are working effectively. 4. The attending physician will evaluate and document conclusions about the effectiveness of the medication and the need to continue or adjust the current dosage, or to discontinue or change the medication. 5. Unless the resident's medical record clearly indicates that the resident has one (1) or more of the following specific conditions, antipsychotic drugs should not be used. These specific conditions include: a. [MEDICAL CONDITION]; b. Schizo-affective disorder; c. Delusional disorder; d. Psychotic mood disorders ([MEDICAL CONDITION] depression with psychotic features); e. Acute psychotic episodes; f. Brief reactive [MEDICAL CONDITION]; g. Schizophreniform disorder; h. Atypical [MEDICAL CONDITION]; i. [MEDICAL CONDITION]'s disorder; j. [MEDICAL CONDITION]'s disease; and k. Organic mental syndromes (now called [MEDICAL CONDITION], and amnestic and other cognitive disorders by the Diagnostic Statistic Manual (DSM-IV) with associated psychotic and/or agitated behaviors: 1. Which have been quantitatively and objectively documented; .6. Antipsychotics should not be used if one (1) or more of the following is/are the only indication(s):a. Wandering, b. Poor self-care; c. Restlessness; d. impaired memory; e. anxiety; f. depression (without psychotic features); g. [MEDICAL CONDITION]; h. Unsociability; i. Indifference to surroundings; j. Fidgeting; k. Nervousness; l. Uncooperativeness; or m. agitated behaviors which do not represent danger to the resident or others. Record review of the Medication Classification Report for Antipsychotics received from the DON on 10/16/16 at 1:30 PM revealed thirty five residents received antipsychotic medications.

Based on interview and record review, the facility failed to ensure residents were free from chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for one (Resident #5) of twenty residents reviewed for chemical restraints. On 06/17/16 Resident #5 displayed a single episode of agitated behavior that was addressed through the administration of a PRN (as needed) dose of [MEDICATION NAME], which was documented as effective in addressing the behavior. In response to the single episode of behavior on 6/17/16, Physician A increased Resident #5's [MEDICATION NAME] (antipsychotic) from 0.5mg b.i.d.(twice a day) to 2mg b.i.d. This failure resulted in Resident #5 exhibiting a flat affect, limited social interaction, and lethargy, and could place the thirty five residents on antipsychotic medications at risk for life threatening side effects and psychological harm. The findings included: Record review of Resident #5's Admission Record, dated 10/16/16, revealed he was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #5's quarterly MDS 3.0 (Minimum Data Set), dated 09/26/16, revealed that he was unable to complete the interview for the BIMS (Brief Interview for Mental Status), indicating severe cognitive impairment. Record review of Resident #5's care plan with a revision date of 09/26/16 revealed Focus: medications [MEDICATION NAME] related to Intellectual Disabilities and behavior management. Goal: drug related complications, including movement disorder, discomfort, [MEDICAL CONDITION], gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. Interventions: Consult with pharmacy, medical doctor (MD) to consider dosage reduction when clinically appropriate, Monitor/record occurrence of for target behavior symptoms, pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. Etc. and document per facility protocol. Monitor/record/report to MD prn side effects and adverse reactions of psychoactive medications: [REDACTED]. Record review of Resident #5's computerized Physician order [REDACTED]. Discontinue Date/Reason: 06/17/16 at 4:42 PM Increased ordered dose. Order date: 06/17/16 at 4:50 PM [MEDICATION NAME] Tablet 2MG ([MEDICATION NAME]) Give 1 tablet by mouth two times a day related to Attention Deficit [MEDICAL CONDITION] Disorder, Predominantly Inattentive Type and unspecified intellectual disabilities The order was received by RN A. According to The Federal Drug Administration (FDA) labeling guidelines from 2014(the most recent labeling update), [MEDICATION NAME] is an atypical antipsychotic indicated for treatment of [REDACTED]. Dosage increases in these patients should be in increments of no more than 0.5 mg twice daily. Increases to dosages above 1.5 mg twice daily should generally occur at intervals of at least 1 week. In some patients, slower titration may be medically appropriate. <http://www.accessdata.fda.gov/drugsatfda_docs/label/2014/ 2s073, 8s062, 4s048lbl.pdf> (Accessed on 10/20/16) Record review of Resident #5's Nurses' Notes revealed the following entries: 6/17/16 at 10:41 AM Resident very aggressive and agitated making loud high pitched noises and pulling other residents hair. Medicated resident with [MEDICATION NAME] at around 9am, with good results. Resident is now calm sitting in w/c in playroom. Will continue to monitor. Signed by LVN C 06/17/16 at 7:11 PM (Physician A) here and changed resident's resperdol dosage and ordered labs. Signed RN B. Record review of Resident #5's Treatment Administration Record March 2016. April 2016, June 2016 revealed no documentation of behavioral issues, including aggression, agitation, or combativeness. Record review of Resident #5's Medication Administration Record [REDACTED]. Record review of Resident #5's Antipsychotic Behavior and Side Effecting Monitoring flow-sheet for June 2016 indicated during the month of June the resident did not display any behaviors identified on the flow sheet, including continual screaming/yelling, continual pacing, paranoia, hallucinations, delusional, wandering, tardive dyskinesia, postural [MEDICAL CONDITION], cognitive/behavior impairment, parkinsonism, akathisia(restless/urgent need for movement). Observation on 10/10/16 at 3:46 PM with the MDS Coordinator upon initial tour, revealed Resident #5 to be in his bed with a blanket covering his face. When the blanket was removed, Resident #5 opened eyes and affect was noted to be flat. In an interview on 10/10/16 at 3:48 PM with the MDS Coordinator, she said that Resident #5 could not speak, he walks around on his knees, he likes his head rubbed and has known behaviors of grabbing staff and other residents, pulling hair, and climbing in bed with other residents at times. She said he generally does not show much emotion. Observation on 10/10/16 at 5:49 PM revealed CNA I placing Resident #5 in his bed after dinner. Observation on 10/10/16 at 6:09 AM revealed Resident #5 sitting in bed twirling clothing protector with flat affect, staring downward towards floor. Observation on 10/11/16 at 9:21 AM revealed Resident #5 in young adult activity room twirling clothing protector with a downward stare towards floor, flat affect noted. Observation on 10/11/16 at 6:20 PM revealed Resident #5 in bed with blanket covering face. The room was dark; no lights were on in the room. Observation on 10/12/16 at 3:08 PM revealed Resident #5 in bed with eyes open, flat affect. Observation on 10/12/16 at 4:34 PM revealed Resident #5 in bed with eyes closed. In an interview with Family Member A, (Legal Guardian of Resident #5) on 10/12/16 at 1:20 PM, she said that she had not been made aware of the dosage increase to her son's [MEDICATION NAME] on June 17, 2016, however she did say That make's sense because the last few times I have visited him he seems drunk. Family Member A expressed concerns that the facility was drugging my son she said that when he pulls someone's hair they just give him medication instead of trying to redirect him. Family Member A said that Resident #5 has known responses of crying when he is in pain, jumping up and down on knees if he is excited, when he is distressed or upset he will squeal or grunt and is able to smile and laugh. Family Member A said that she had not been able to visit for several months and noticed a big change in him when she visited 10/02/16. In an interview on 10/13/16 at 10:23 AM with CNA E, he said Resident #5 tries to grab other resident's hair sometimes and when he is extremely agitated we take him to his room because he is not able to get out. CNA E said that his affect is usually flat and does not show much emotion or facial expressions. In an interview on 10/13/16 at 10:35 AM with CNA F, she said that Resident #5 has a known behavior of grabbing hair. She said that usually when Resident #5 displays aggressive behaviors the nurse will give him a PRN medication (not sure what it was) and if that does not help, he is taken to his room. When asked why his room, CNA F replied Because he can't get out. He has baby proof knobs and locks on his door. CNA F said Resident #5 cannot speak and usually does not show much emotion. In an interview on 10/13/16 at 11:05 AM LVN B stated he is the nurse for the 200 hall during the 6:00 AM to 2:00 PM shift. LVN B stated he has worked at the facility for four years. LVN B stated he is very familiar with Resident #5, and described Resident #5 as inactive a lot of the time. LVN B stated Resident #5 got a hold of an aide's hair a couple of years ago, but denied any recent incidents. LVN B stated Resident #5 has never hurt anyone. LVN B stated that Resident #5 enjoys being in his wheelchair and moving about, but stated Resident #5 is mainly in his room or in the young adult activity room. LVN B stated Resident #5 does have some behaviors, but they come and go. He stated when Resident #5 displays behaviors staff redirect him, but if that does not work they take him to his room and give him a toy to play with. In an interview on 10/14/16 at 11:28 AM with LVN A, he said that behaviors are noted on the treatment administration record and nurse's notes. LVN A said that he monitors for drowsiness, face twitching and changes in behaviors. In a telephone interview on 10/14/16 at 12:00 PM with Physician A, he said that he recalled increasing Resident #5's [MEDICATION NAME], however he did not recall increasing it that much He then asked if he could come to the facility and speak in person and look at Resident #5's clinical record. In an interview on 10/14/16 at 12:14 PM the DON said that behavior monitoring is done on the behavior charting located in the Treatment Administration Record, nurses notes or on weekly assessments. She verified that there was not a behavior assessment done on Resident #5 the week of June 17, 2016 or any other behavior monitoring put in place when his dose was increased. In an interview on 10/14/16 at 1:55 PM with Physician A he said I did increase his [MEDICATION NAME] to 2mg twice a day from 0.5mg twice a day but should not have increased the [MEDICATION NAME] that much, he is a small guy. He said he increased the dose for restlessness and provided a sheet titled Doctor's Rounds dated 06/17/16 showing the increased [MEDICATION NAME] to Resident #5. He said that the side effects are that it can make him sleepy, have a flat affect, and even kill him Physician A clarified that the [DIAGNOSES REDACTED]. He said that [MEDICATION NAME] does treat restlessness with patients who have [MEDICAL CONDITION]. He said that when increasing [MEDICATION NAME] it should be done 0.5mg at a time gradually. Physician A confirmed that staff from the facility did not question the significant dose increase when he wrote the order on 06/17/16. In an interview on 10/14/16 at 2:33 PM with the DON she said that her expectation would be for her nursing staff to have questioned Physician A for the [MEDICATION NAME] being increased that much and all at once for Resident #5 when the order was received. In an interview on 10/15/16 at 5:55 PM with the DON, she thinks that it is likely that the orders were clarified by the nurses verbally while the physician was in the building and not documented. They audited all the orders and are working on clarifying medication orders and diagnoses. Record review of Physician A's Progress note dated 07/12/16 revealed Active Problems: [MEDICAL CONDITION], Intellect Disability, Convulsions, [MEDICAL CONDITION], Attention Deficiency, Lack of Normal Physical Development, [MEDICAL CONDITION], Joint Contracture, [MEDICAL CONDITION]. The current medications did not identify that Resident #5 was taking [MEDICATION NAME]. Plan of Treatment was to continue on above medications plus all other supportive PRN therapy plus physical therapy. Electronically signed by (Physician A) on 09/02/2016 at 11:26 AM. Record review of Resident #5's Consent for Psychoactive Medication Therapy dated 12/17/12, revealed a consent obtained by telephone on 12/17/12 at 1:00 PM by Family Member A for [MEDICATION NAME] treating impulse control and aggressive behavior. In an interview with the DON on 10/16/16 at 4:00 PM, she stated that each staff member participates in an in-service about restraints entitled Creating A Restraint Free Environment. The DON stated that staff received the Creating a Restraint Free Environment upon hire and annually. Record review of the facilty's in-service entitled Creating a Restraint Free Environment, dated 2015, revealed Learning Objectives Identify physical and chemical restraints .create a restraint-free environment. Definitions .Chemical restraints are any drugs used for discipline or convenience, which are not required to treat a medical symptom .Convenience is any action that controls a resident's behavior or manages a resident's behavior with a lesser amount of effort by the staff and not in the resident's best interest .Medical Symptoms is an indication or characteristic of a physical or psychological condition .Real Life Consequences Any type of restraint, whether physical or chemical, can have serious physical and emotional consequences for the resident. The use of restraints impairs a resident's functional ability, independence, and quality of life. Additionally, restraint use can lead to decreased mobility, pressure ulcers, incontinence, constipation, fecal impaction, falls, social isolation, depression, agitation, and feeling of humiliation .Summary A chemical restraint is any drug not required to treat a medical symptom that staff use for discipline or convenience Risks associated witht he use of restraints include both physical and emotional consequences including severe injury and death. Because of these serious consequences, restraints should always be used as a last resort and have a limited role in a resident's care. Record review of the facility provided policy titled Administering Medications, dated 2001 and revised April 2006, revealed Medications will be administered in a timely manner and as prescribed by the resident's attending physician or the facility's medical director.4. Should a dosage seem excessive considering the resident's age and medical condition, or a medication order seems to be unrelated to the resident's current [DIAGNOSES REDACTED]. Director for further instructions. 9. The individual administering the medication must initial the resident's MAR indicated [REDACTED]. Review of the facilities policy titled Use of Restraints dated 2001 and revised April 2006, revealed Policy Statement/Chemical/ Physical restraint shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully.Policy Interpretation and Implementation 1. Chemical/Physical restraints shall only be used up on the written order of a physician and after obtaining consent from the resident and/or representative sponsor with the exception of temporary emergency use as outlined in this policy. 10. When drugs are used to restrain or control behavior or to treat a disorder thought process the following shall apply: a) The specific behavior or manifestation of disordered thought process to be treated with the drug is identified in the resident's medical record; b) The plan of care for each resident specifies data to be collected for use in evaluating the effectiveness of the drugs and the occurrence of adverse reactions; c) The data collected shall be made available to the physician in a consolidated manner at least monthly and; d) PRN orders for such drugs she'll be subject to the requirements of established pharmaceutical policies and procedures 11. . 12. Should a resident not be capable of making a decision concerning the use of a restraint, the surrogate or sponsor may exercise the right of the use or non-use of a restraint. Note: The surrogate/sponsor may not give permission to use restraints for the sake of discipline or staff convenience or when the restraint is not necessary to treat the resident's medical symptoms. Record review of the facility provided policy entitled Antipsychotic Drug Use, dated 2001 and revised 01/01, revealed Antipsychotic drug therapy shall be used only when it is necessary to treat a specific condition. Policy Interpretation and Implementation 3. Nursing documentation must include a description of target symptom(s), their frequency and expected outcomes so that the attending physician can determine if the medications are working effectively. 4. The attending physician will evaluate and document conclusions about the effectiveness of the medication and the need to continue or adjust the current dosage, or to discontinue or change the medication. 5. Unless the resident's medical record clearly indicates that the resident has one (1) or more of the following specific conditions, antipsychotic drugs should not be used. These specific conditions include: a. [MEDICAL CONDITION]; b. Schizo-affective disorder; c. Delusional disorder; d. Psychotic mood disorders ([MEDICAL CONDITION] depression with psychotic features); e. Acute psychotic episodes; f. Brief reactive [MEDICAL CONDITION]; g. Schizophreniform disorder; h. Atypical [MEDICAL CONDITION]; i. [MEDICAL CONDITION]'s disorder; j. [MEDICAL CONDITION]'s disease; and k. Organic mental syndromes (now called [MEDICAL CONDITION], and amnestic and other cognitive disorders by the Diagnostic Statistic Manual (DSM-IV) with associated psychotic and/or agitated behaviors: 1. Which have been quantitatively and objectively documented; .6. Antipsychotics should not be used if one (1) or more of the following is/are the only indication(s):a. Wandering, b. Poor self-care; c. Restlessness; d.impaired memory; e. anxiety; f. depression (without psychotic features); g. [MEDICAL CONDITION]; h. Unsociability; i. Indifference to surroundings; j. Fidgeting; k. Nervousness; l. Uncooperativeness; or m. agitated behaviors which do not represent danger to the resident or others. Record review of the Medication Classification Report for Antipsychotics received from the DON on 10/16/16 at 1:30 PM revealed thirty five residents received antipsychotic medications.

Based on observation, interview and record review, the facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the plan of care for one (1) of nine (9) residents (Resident #11) reviewed for pain management during care. Resident #11 expressed pain by grimacing, tensing up, and shouting out multiple times during a transfer with a hoyer lift and incontinent care. This deficient practice contributed to ineffective pain control for Resident # 11 and had the potential to affect 38 residents that triggered for pain.. Findings included: Review of Resident # 11 ' s Face Sheet reflected a [AGE] year old male who entered the facility on 9/13/13 and readmitted on [DATE]. Resident # 11 ' s [DIAGNOSES REDACTED]. Resident was non interviewable. Observation on 10/28/13 at 12:45 pm revealed Resident #11 being transferred from a chair with a Hoyer lift (mechanical lifting device) to the bed. The Resident shouted out ouch multiple times during the transfer. The resident then received incontinent care. During Resident # 11 ' s incontinent care, when the resident was rolled onto his left side, he tensed up and shouted, "Ouch!" multiple times. When the resident was rolled to his right side he seemed to calm down and did not shout out. Then after incontinent care Certified Nurse Aide (CNA) A placed both side rails up in the bed. Review of Resident # 11 ' s Admission Minimum Data Set (MDS) assessment dated [DATE] reflected that the Resident ' s cognitive status was not rated at the time the assessment was completed. The assessment reflected Resident # 11 required total dependence for bed mobility and transfers. The assessment reflected no pain management for Resident # 11. Review of Resident # 11 ' s Immediate Needs Care Plan dated 10/17/13 reflected no plan for pain management. The Care Plan did identify Resident # 11 having Behaviors of Resident yelling out. The goals were Resident will have decreased yelling out in 90 days. Interventions included: encourage activity for socialization, remove from public area when behavior is disruptive, and talk in a calm voice. Review of Resident #11's Pain Management Flow Sheet reflected on 10/26/2013 at 11:05 am and on 10/28/2013 at 4:00 pm Resident #11 to have a pain rating of ten (10) using a pain scale of one (1) to 10 with 10 being the greatest. Cause of Pain/Origin of pain documented as "general." on both dates. Review of Resident # 11's clinical record reflected a Physician order [REDACTED]. During an interview on 10/28/13 at 3:50 pm, Medication Aide (MA) A stated that he (Resident # 11) had the last dose of [MEDICATION NAME] on 10/26/13 at 11:00 am. During an interview on 10/29/2013 at 3:55 pm Registered Nurse (RN) A stated, "Resident # 11 hollers a lot, but a lot of the time it is just to get attention." When this surveyor asked about the resident yelling, "Ouch!" and tensing up, RN A stated, "That sounds like pain." During an interview on 10/28/13 at 4:03 pm the Nursing Supervisor stated that she would expect her staff to stop the transfer or treatment and get a nurse to assess Resident #11 if he was shouting out in pain. The facility was asked for a policy on pain management/control, but did not provide one to the survey team prior to or at the time of exit. Review of CMS 802 provided by facility reflected 39 residents triggered for pain.

Based on observation, interview and record review the facility failed to implement their written policies and procedures to prohibit abuse and neglect when: A). The facility failed to report and investigate the the elopement for one (1) of four (4) residents with known wandering and elopement behaviors eloped from the facility for the third time on [DATE] without staff knowledge, was picked up by local police at a convenience store and returned to the facility (Resident #7). This deficient practice was identified as a Past Immediate Jeopardy (IJ) that existed [DATE] through [DATE] for Resident #7. Although, the facility relocated Resident #7 to the Secured Unit on [DATE], which removed the immediacy, the facility remained out of compliance at a Severity level of potential for more than minimal harm at a pattern that is not IJ due to an additional three (3) residents with known wandering behaviors identified and residing in the open area of the facility at risk for elopement. This deficient practice had the potential to place the additional three (3) residents at risk for elopement, injuries, harm and possible death if elopements are not thoroughly documented, investigated, and reported in a timely manner. B). The facility failed to investigate and report injuries of unknown origin for 3 of 3 residents who sustained fractures of unknown origin (Residents #7, #11 and #12). 1. Resident #7, who was non-interviewable, had an X-Ray on [DATE] that revealed a fractured middle finger on her right hand. There was no documentation in the Nurse's Notes, no incident report and no investigation available to determine what may have caused the fracture. The incident was not reported to the State Regulatory Agency. 2. Resident #11 who, was non-interviewable, sustained a fractured knee of unknown origin on or about [DATE] and a shoulder fracture of unknown origin on or about [DATE]. No incident report for [DATE] could be located. There were no Nurse's Notes reflecting the possible cause of either of the fractures, no investigation into the fractures could be located and no report to the State Regulatory Agency had been made by the facility. 3. Resident #12 had right arm swelling and bruising on [DATE]. X-ray results identified a fractured right elbow. No investigation into the fracture cause and no report to State Regulatory Agency had been made by the facility. This resulted in an IJ on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a Severity level of Actual Harm and Scope of Pattern that is not IJ as the facility had not had time to implement, monitor and evaluate the effectiveness of their Plan of Removal. This deficient practice had the potential to affect 62 residents with cognitive impairment in the facility placing them at risk for injuries and fractures when incidents are not thoroughly investigated, and reported in a timely manner. The findings include: Review of the facility's undated procedure for a Missing Resident reflected the following: " Reporting Guidelines When Resident is not Located " If the resident was not located during a search of the facility, facility grounds, and the immediate vicinity, and there are circumstances which place the resident ' s health, safety, and/or welfare at risk, the Police and/or other Law Enforcement must be notified immediately. The Texas Department on Ageing and Disability Services must be notified via the Incident Reporting telephone number. Examples include but are not limited to: 2. Extreme weather conditions exposes the resident to the potential of freezing, heat prostration or drowning from flooding; 3. A resident is confused or otherwise is incapable of assessing potential danger. Investigation An investigation will begin immediately and will be documented including: 1. Observations, interviews and record reviews of all residents involved; 2. Interviews of all witnesses, including residents, staff and family members; 3. Document all relevant findings. QA & A Follow-Up 1. Review incident, determine causative factors. 2. Discuss methods of prevention, training needs, systems, policies, etc. 3. What could be done better or differently? Review of the facility's policy and procedure dated ,[DATE] for Reporting Abuse and Neglect reflected the following: Neglect 1. The facility must determine if an injury or harm of a resident was due to facility failure to provide services, treatment or care to a resident. Conduct an Investigation Investigate the facility actions when conducting an investigation and initiate the corporate Incident/Accident Report form. - Observations of the situation (resident(s), the surroundings, etc.), interviews and record reviews of all residents involved; - Interviews of all witnesses, including residents, staff, and family members & obtain written statements; PROCEDURES FOR TELEPHONE REPORTS When reporting an incident by telephone, the following information is needed: facility name, vendor #, resident name(s), time and date of incident, what occurred, condition of resident(s), person(s) involved (other then resident), and action taken by facility authority to date. Within five working days of making oral report, send the written investigation report. OTHER REPORTABLE INCIDENTS Injuries of Unknown Source - No one saw the incident that resulted in the injury or the source of the injury could not be explained by the resident; AND, The injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observe at one particular point in time or the number of the injuries over time. A). Review of the Facesheet for Resident #7 reflected she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a significant change Minimum Data Set ((MDS) dated [DATE] reflected Resident #7 exhibited continuously exhibited inattention, and disorganized thinking. She exhibited feelings of depression and hopelessness. She had wandering behavior that was exhibited on a daily basis that placed her at significant risk of getting into a potentially dangerous place and was worse compared to the previous assessment. It was somewhat important to her to go outside to get fresh air. She was independently ambulatory without the use of mobility devices. She carried active [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE] reflected Resident #7 had a short term and long term memory problem. She had moderately impaired decision making skills. She continuously exhibited inattention and disorganized thinking. She had wandering behavior that was exhibited on a daily basis that placed her at significant risk of getting into a potentially dangerous place. Her ambulation was not steady and required the assistance of one for transfers and ambulation on and off the unit. Her active [DIAGNOSES REDACTED]. She received Anti-psychotic and Diuretic medications. Review of the Elopement Risk Review for Resident #7 dated [DATE] reflected the following: 1. Cognitively impaired with poor decision making skills=yes 2. Pertinent diagnosis (i.e. Dementia ...Depression [MEDICAL CONDITION])=yes 3. Ambulate independently, with or without the use of assistive devices=yes 4. 5. Express intent to leave or desire to go home=yes 5. 9. Receive medications that increase restlessness or agitation=yes Interventions/approaches included: Exit alarms, Activities; Music; Exercise; Personalization of room with familiar objects and photos. There were no initiation dates to these interventions. Review of the Quarterly MDS dated [DATE] reflected Resident #7 reflected the same assessment as [DATE] with the added behavior of rejecting care and the use of an Antidepressant medication. Review of the Elopement Risk Review for Resident #7 dated [DATE] reflected she was disoriented times two; she had Dementia and [MEDICAL CONDITION]; at times she stated that she wanted to go back home and had made several attempts to leave the facility. The back page of the risk assessment for documentation of interventions/approaches and the date initiated, as well as, the Summary/Conclusion/recommendations were blank. Review of an undated Elopement Risk Review for Resident #7 reflected that expression or intent to leave or desire to go home was not noted prior to this date. She did voice she was going home today. She stated that she was going home. Her family member stated that Resident #7 had attempted to leave the facility about a year ago. The back page of the risk assessment for documentation of interventions/approaches and the date initiated, as well as, the Summary/Conclusion/recommendations; signature and title of the person completing the form and the date the form was completed were blank. Review of the Care Plan date [DATE] reflected Resident #7 had short term and long term memory deficits and required assistance with decision making. She had poor communication and had poor safety awareness. She was to be monitored for changes in condition that may warrant increased supervision/assistance. She had episodes of sadness due to missing living with her son. She was at risk for dehydration due to the use of Diuretics. Resident #7 has a [DIAGNOSES REDACTED]. Resident #7 ' s wandering intruded on other resident ' s privacy. She had a history of [REDACTED]. On [DATE] she was moved to the " Memory Care Unit " (Secure Unit). The original problem onset was documented as [DATE]. The goal was that Resident #7 would not wander into unsafe situations and would not suffer any injuries related to her wandering. Approaches included the following: ? Place in area where frequent observation is possible. ? Alert staff to wandering behavior. ? Provide diversional activities. ? Approach positively and in a calm accepting manner. ? Monitor and document behavior. Review of Nursing Summary/7-day look back dated [DATE], [DATE], and [DATE], reflected that Resident #7 was wondering daily. Review of Social Services assessment dated [DATE] reflected Resident #7 continued to wander through the facility having to be redirected at times. Review of an Incident/Accident Report dated [DATE] at 1:55 PM reflected Resident #7 was alert to self, unable to understand directions and confused/disoriented. She attempted elopement and was located in the facility ' s parking lot. The actions to minimize reoccurrence reflected " closer monitoring ". The DON and Administrator signed the report on [DATE]. Review of Nurse ' s Notes dated [DATE] reflected at 1:55 PM Resident #7 was noted in the parking lot almost to the street. She stated that she was going home to Alabama. Her responsible party was notified and stated that Resident #7 had tried to leave the facility before and may need her medication adjusted and she needed to be more included in activities. Review of an Incident/Accident Report dated [DATE] reflected Resident #7 wandered from the facility and was located in front of the building, outside. The actions to minimize reoccurrences reflected " closer monitoring ". The DON and Administrator did not sign the report until [DATE]. Review of Nurse ' s Notes dated [DATE] reflected Resident #7 exited the building at approximately 1:25 PM while visitors were entering the building. She was noted by a staff person outside and was immediately perused and returned to the safety of the inside of the facility by two staff persons. The Assistant Director of Nurses was notified. Resident #7's physician was notified and there were no new orders. "Monitoring. " Review of the Social Services assessment dated [DATE] reflected Resident #7 had been found wandering around the facility. Review of an Incident/Accident Report dated [DATE] at 2:10 PM reflected Resident #7 was ambulatory, confused/disoriented and unable to understand directions. She was alert to self only and had difficulty following commands. She wandered from the facility, off the premises and was returned to the facility by the local police at 2:10 PM after being picked up at a local gas station. Fluids were encouraged and she was placed on frequent checks. The report was signed by the Director of Nurses (DON) and Administrator on [DATE]. Review of Nurse ' s Notes dated [DATE] at 2:10 PM reflected Resident #7 was returned to the facility by the local police department and their statement was she was at the convenient store requesting rides from consumers at the store. Resident #7 was brought into the facility and given adequate amounts of water. She was without injury from the incident. The Administrator, DON and Responsible Party were notified. She sat in the dining room for the evening meal. She consumed less than 25 percent of her meal. She vomited one time consisting of clear liquid. She was assisted to bed and remained ambulatory this shift with frequent visual checks to maintain her safety and to monitor her for signs and symptoms of injury related to heat outdoors. Review of Nurse ' s Notes dated [DATE] at 3:50 PM Resident #7 attempted to leave the facility two times through the service hall door (in the back of the building). She was redirected to her room and immediately returned to the door. At 4:15 PM Resident #7 was noted at the B Hall fire exit. She had gone under the stop sign and pushed the door open. She was not easily redirected back into the facility. Review of a Concern Resolution Record dated [DATE] reflected a family member of Resident #7 was quite concerned about the potential danger facing Resident #7 because she had left the faciity on her own on [DATE]. She was returned by the police after being found at a local convenience store. This was the third incident of this nature in a month. The family member was extremely upset and had not received a satisfactory answer as to why this kept happening. The concern was referred to the social worker (SW) who notified the family on [DATE] that Resident #7 needed to be transferred to the secure unit and Resident #7 ' s family member agreed to the transfer. Observation on [DATE] at 6:55 a.m. revealed the distance from the convenience store to the facility was 0.5 miles. Further observation revealed there was a two lane street that intersected at a stop light with heavy traffic with approximate speed limits of 40 miles per hour (mph). There is also a railroad track that runs behind the facility located about one-half a football field length away. Review of Nurse ' s Notes dated [DATE] reflected Resident #7 was transferred to the Secured Unit on D Hall. There were no updated interventions or approaches related to Resident #7 ' s exit seeking behavior and elopements that occurred on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. There were also no investigation reports for the above incidents that included observations, interviews, witness statements, or new interventions to prohibit further elopement for Resident #7. In an interview on [DATE] at 3:55 PM Licensed Vocational Nurse (LVN) E stated that she worked the 6:00 AM to 2:00 PM shift on [DATE]. She was assigned to Resident #7 ' s hall that day. She stated that she went to lunch late at approximately 1:00 PM. She stated that she had seen Resident # 7 just finish eating in the main dining room at approximately 12:45 PM. She stated that she had given report to the oncoming nurse at 2:00 PM and Resident #7 was brought back to the facility by local police at 2:10 PM. LVN E stated that she was not aware that Resident #7 had left the facility. She stated that Resident #7 had eloped from the facility one other time that she was aware of. It was in [DATE] and she had left the facility through the front door, along with a group of visitors. She stated that she never got past the parking lot with that incident. LVN E stated that she started working at the facility in [DATE] and as not aware at that time that Resident #7 was an exit seeker. She didn't ' t ' know how Resident #7 could have left the facility through the front door on [DATE] because there was always office staff in that area. She stated that Resident #7 must have gotten out the back door but she was not sure at all. She stated that Resident #7 resided on the 200 hall, in the general population at the time of the incident. LVN E stated that Resident #7 was only alert to herself. She was not sure if she knew her full name or where she lived. She had told the police officer that she was trying to get home or someplace like that. She stated that Resident #7 did not have good judgment and would not be able to judge when to cross the road safely, who to take a ride from or what cloths would be appropriate for the weather. She stated that there were many dangers out there for Resident #7. In an interview on [DATE] at 3:55 PM LVN D stated that she worked the 2:00 PM to 10:00 PM shift on [DATE] and had just received shift report from LVN E when Resident #7 was brought to the facility by local police. The local police stated that Resident #7 was found up the road at a gas station. LVN D stated that she assessed Resident #7 and sat her at a table in the dining room across from the Nurse ' s station where staff was giving her fluids. The police officer stated that she was at the gas station asking people for a ride home but she didn't know where home was. She stated that she notified the DON, Administrator and Resident #7 ' s family. She was instructed by the DON to monitor Resident #7 frequently. LVN D stated that the DON instructed her to monitor Resident #7 every 15 minutes but she told the DON that monitoring that frequently was not feasible. She stated the DON instructed her to check on Resident #7 as frequently as possible. She stated that she did not document 15 minute monitoring but only that Resident #7 was being monitored frequently. She stated that when she asked Resident #7 her name, Resident #7 gave the name of her deceased husbands name, not her own. She stated that Resident #7 ' s short term memory was very poor. She stated that Resident #7 would not be able to make good decisions on her own. LVN D stated that she was not aware of Resident #7 having exit seeking behavior or prior elopements. She stated that she was never asked to give or write a statement about the incident by the facility. In an interview on [DATE] at 4:15 PM the Administrator stated that she started working at the facility on [DATE] and was not there when Resident #7 eloped. She stated that she could not locate an investigation into Resident #7 ' s elopement and did not think one had been done. She stated that a complete investigation should have been done and that it would not be safe for Resident #7 to leave the facility on her own. She stated that the DON was no longer working at the facility as of last week due to many reasons. She stated that the Assistant Director of Nurses (ADON) was employed by the facility at that time and may be able to answer some questions. In an interview on [DATE] at 4:55 PM the ADON stated that she was a floor nurse at the time of the incident on [DATE] and had only been the ADON now for about one month. She stated that she didn't work on [DATE] when Resident #7 eloped. She stated that she only heard about the incident by other staff. She stated that she did not know Resident #7 to be a wanderer or exit seeker but that Resident #7 had gotten out of the facility on one occasion that she was aware of but did not get off the premises. She stated she did not know how many times Resident #7 had left the facility unattended. She stated that when she came back to work, Resident #7 had been moved from the general population to the secured unit. In an interview on [DATE] at 4:00 PM the Administrator stated that at other facility's they had implemented a plan for residents that wander and were at risk for elopement called "Happy Feet". She stated that the program had not yet been fully implemented at this facility. She stated that part of the "Happy Feet" program was posting the pictures of the residents at risk for elopement in the employee break room and in the focus room. She stated that staff was in-serviced last night on the "Happy Feet" program and now the Policy and Procedure and pictures of the residents at risk were in a binder at the nurse's station for all of the staff. She further stated that the Elopement Risk Review assessment was to be completed on all newly admitted residents and reassessed quarterly and as needed. She further stated that there was nothing on the assessment that would guide the staff into a decision as to whether the resident was at high risk for elopement or not at high risk. She stated that the former DON was not completing Incident/Accident reports and she thinks that the charge nurses did not have good leadership. The Administrator stated that Incident/Accident reports were forgotten and not followed up on. The facility's Administrator, interim DON and ADON were informed on [DATE] at 3:45 PM that a Past Immediate Jeopardy had been identified to exist existed [DATE] through [DATE] for Resident #7. Although, the facility relocated Resident #7 to the Secured Unit on [DATE], which removed the immediacy, the facility remained out of compliance at a Severity level of potential for more than minimal harm at a pattern that is not IJ due to an additional three (3) residents with known wandering behaviors identified and residing in the open area of the facility at risk for elopement. The facility identified 3 wandering residents in the general population. B). 1. Review of an X-Ray of Resident #7's right hand dated [DATE] reflected Resident #7 had a chipped fracture through the base of the long finger. Review of a Follow Up X-Ray of Resident #7's right hand due to pain dated [DATE] reflected that the small fracture fragment had been partially reabsorbed. Review of Nurse's Notes for Resident #7 reflected that there were no notes between [DATE] and [DATE]. On [DATE] Resident #7's X-Ray was positive for a [MEDICAL CONDITION] through the base of the right middle finger. Resident #7 complained of pain and was medicated with two Tylenol 325 milligrams. Nurse's Notes dated [DATE] reflected Resident #7 complained that her finger "it still aches." On [DATE], her right middle finger was swollen and painful. On [DATE] Resident #7 continued to have slight swelling and tenderness to touch in her right middle finger. An X-Ray was obtained. Review of Incident/Accident reports from ,[DATE] reflected no incident report for Resident #7. Review of the facility's investigations from ,[DATE] to current reflected no investigations related or reports to the state regulatory agency in regard to Resident #7. In an interview on [DATE] at 2:30 PM the Interim DON stated that she was unable to locate an investigation into Resident #7's fractured finger. She stated, "I can't find anything." In an interview on [DATE] at 4:15 PM the Administrator stated that she started working at the facility on [DATE] and was not there when Resident #7 was found to have a fractured right middle finger. She stated that she could not locate an investigation into Resident #7 ' s fractured middle finger and did not think one had been done. She further stated that any injuries of unknown origin should be investigated and she had brought all the investigations that she had to the surveyors. She stated that the DON was no longer working at the facility as of last week due to many reasons. She stated that the ADON was employed by the facility at that time and may be able to answer some questions. In an interview on [DATE] at 10:20 AM the Administrator again stated that she was unable to find investigations related to Residents #7. B.) Review of the Face sheet for Resident #11 reflected he was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the consolidated physician's order [REDACTED]. Observation on [DATE] at 4:15 PM revealed Resident #11 sitting in a Geri-chair in his room with an arm brace on his right arm. Review of Resident 11 ' s Significant Change Minimum Data Set ((MDS) dated [DATE], reflected the resident was totally dependent on staff for activities of daily living (ADLs). Resident 11 ' s was assessed as requiring two staff, extensive assistance, for transfers. Review of the Fall Risk Evaluation for Resident #11 reflected a score of 14 for [DATE] through [DATE]; a score of 13 on [DATE]; and a score of 12 on [DATE] (A total score of 10 or above represents high risk). Review of the Care Plan updated according to the care plan sign in sheet on [DATE] reflected the following: Resident #11 required total assistance with ADL ' s. He had a history of [REDACTED]. He required assistance with bed mobility, transfers and locomotion. He exhibits unclear, garbled speech. He had Short term and long term memory deficits and required assistance with decision making. He had a potential for complications of immobility related to contractures secondary to [MEDICAL CONDITION]. He had a history of [REDACTED]. A history of sliding out of his wheelchair related to leaning forward and restless movements and he had intermittent episodes of pain. On [DATE] he had an acute fracture of his right humerus related to Osteopenia. Review of the hospital History and Physical dated [DATE] reflected Resident #11 was sent from the nursing home for having right knee swelling and pain. He was non-verbal and severely demented. Resident #11 ' s family member reported that Resident #11 had the swelling in his right knee for the past four days. Resident #11 was seen by his primary physician in the nursing home who started him on antibiotics for possible [MEDICAL CONDITION]; however; resident #11's knee was getting worse. Further review reflected, in the emergency room (ER) a CT scan of the knee was done and showed an old [MEDICAL CONDITION] part of the femur. Resident #11 was not a surgical candidate and his knee was casted. Also in the ER Resident #11 was found to have black tarry stool and was admitted to the hospital for a [MEDICAL CONDITION]. Review of a hospital Consultation Report dated [DATE] reflected Resident #11 was being admitted to the hospital due to a right femoral fracture. He was wheelchair bound and now, because of the right femoral bone fracture, Resident #11 was bedbound. Review of Nurse ' s Notes for Resident #11 reflected the following: [DATE]-9:00 AM-Alert and oriented to person, unable to make needs known. Total care with ADL ' s (Activities of Daily Living). Incontinent of B/B (bowel and bladder) care provided as needed. Resident hollers out when care provided and sitting up in a wheel chair and when someone comes close to him. [DATE]-2:00 AM ...Yelling out ...looks painful and given [MEDICATION NAME] (medication for pain) at 12:00 AM. [DATE]-10:00 AM-Agitated this AM. Yelling out and fighting, refusing care. [DATE]-2:00 PM-Encourage out of bed daily, resident was unable to sit in wheelchair longer than one hour. Continue to monitor right knee and leg. [DATE]-1:30 PM-Continue antibiotic therapy due to right knee [MEDICAL CONDITION]. Resident alert and lethargic. [DATE]-9:00 PM-Right knee swollen and warm to touch. [DATE]-2:30 PM-Noted resident ' s right leg jaundice from the groin to the ankle. Swollen, warm to touch from knee to ankle. Unable to palpate pedal pulse. 3:00 PM Received order to send to ER for evaluation. 9:15 PM Resident being admitted [DIAGNOSES REDACTED]. Review of " Emergency Services Discharge Instructions " dated [DATE] reflected Resident #11 ' s chief complaint was an arm injury. He was given educational material for a shoulder fracture. Review of the facility's investigations from ,[DATE] to current reflected no investigations related or reports to the state regulatory agency in regard to Resident #11. Review of an Incident/Accident report dated [DATE] reflected Resident #11 had an acute comminuted [MEDICAL CONDITION] humerus. His current mobility was assisted with transfers and assisted with wheelchair mobility. The nurse was called to Resident #11 ' s room by Certified Nurse Aides. Resident hollers out when his right arm is moved. There was no bruising, swelling or discoloration noted. With passive range of motion he hollers when his wrist is touched. He is able to move his shoulder with mild distress. He was transferred to the ER. Review of Nurse ' s Notes dated [DATE] at 10:00 AM reflected to continue to monitor Resident #11 ' s fractured right shoulder. On [DATE] at 10:00 AM Resident #11 ' s family member requested that they get Resident #11 up in a Geri-chair (a specialized chair on wheels that reclines). Continue to monitor right shoulder fracture. Received results of right shoulder X-Ray. Mildly displaced acute [MEDICAL CONDITION] neck of the proximal right humerus. On [DATE] at 2:30 PM Resident #11 ' s right shoulder remained in a sling. The referral request was completed today for a Geri-chair. Review of Nurse ' s Notes dated [DATE] at 12:00 AM reflected [MEDICATION NAME] (a narcotic [MEDICATION NAME]) was administered for complaints of right shoulder pain. Resident #11 was yelling and screaming at staff when his sheet barely touched his arm. The next Nurse ' s Note was dated [DATE] for the 2:00 PM to 10:00 PM shift and reflected that Resident #11 screams out when he is touched to take vital signs for instance. Nurse ' s Notes dated [DATE] reflected Resident #11 was noted up in a Geri-chair. C.) Review of the Facesheet reflected Resident #12 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Discharge Minimum Data Sheet ((MDS) dated [DATE] reflected for Resident #12 the following: - Transfer - Supervision - Ambulation - Supervision - Dressing - Limited Assistance - One person physical assist - Fall [DATE] tripped by another resident Review of the Change of Condition MDS dated [DATE] reflected for Resident # 12 the following: - Transfer - Extensive Physical Assistance - One person physical assist - Ambulation - Limited Assistance - One person physical assistant - Dressing - Extensive Physical Assistance - One person physical assist - Hygiene - Extensive Physical Assistance - One person physical assist - Pain Intensity of 8 on a 0 to 10 scale - on a scheduled pain regimen and frequent pain Review of the Quarterly MDS dated [DATE] reflected Resident # 12 - Ambulation - Extensive Physical Assistance - One person physical assist (No longer independent with ambulation, now uses walker/wheelchair) Review of the [DATE] Incident/Accident Report for Resident # 12 reflected the following: - Location of Incident: Shower Room - Brief Description of Incident: Resident was tripped by another resident - Treatment Disposition: Nose bleed and bruised knee - Describe Aid Provided: Pressure to stop nose bleed and X-Ray for left swollen knee - Final Disposition (Actions to Minimize Recurrence): Sent to the emergency room (ER) - admitted - Fracture Right Femur to have surgery. Review of Resident #12's History and Physical, Final Report dated [DATE] reflected a history of frequent falls. It further reflected that on the day of the admission to the hospital she was tripped by another resident, fell over on the front, hit her head on the hard floor and sustained injury to the right knee. Initially she had been kept under

Based on observation, interview and record review the facility failed to provide adequate supervision and assistive devices to prevent elopement for one (1) of four (4) residents with known wandering and elopement behaviors eloped from the facility multiple times without staff knowledge (Resident #7). Resident #7 eloped from the facility on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. On [DATE], Resident #7 wandered from the facility without staff knowledge, and was returned to the facility by the local police at 2:10 PM after being picked up at a local convenient store. This deficient practice was identified as a Past Immediate Jeopardy (IJ) that existed [DATE] through [DATE] for Resident #7. Although, the facility relocated Resident #7 to the Secured Unit on [DATE], which removed the immediacy, the facility remained out of compliance at a Severity level of potential for more than minimal harm at a pattern that is not IJ due to an additional three (3) residents with known wandering behaviors identified and residing in the open area of the facility at risk for elopement. This deficient practice had the potential to place the additional three (3) residents at risk for elopement, injuries, harm and possible death if elopements are not thoroughly documented, investigated, and reported in a timely manner. The findings include: Review of the Facesheet for Resident #7 reflected she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a significant change Minimum Data Set ((MDS) dated [DATE] reflected Resident #7 exhibited continuously exhibited inattention, and disorganized thinking. She exhibited feelings of depression and hopelessness. She had wandering behavior that was exhibited on a daily basis that placed her at significant risk of getting into a potentially dangerous place and was worse compared to the previous assessment. It was somewhat important to her to go outside to get fresh air. She was independently ambulatory without the use of mobility devices. She carried active [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE] reflected Resident #7 had a short term and long term memory problem. She had moderately impaired decision making skills. She continuously exhibited inattention and disorganized thinking. She had wandering behavior that was exhibited on a daily basis that placed her at significant risk of getting into a potentially dangerous place. Her ambulation was not steady and required the assistance of one for transfers and ambulation on and off the unit. Her active [DIAGNOSES REDACTED]. She received Anti-psychotic and Diuretic medications. Review of the Elopement Risk Review for Resident #7 dated [DATE] reflected the following: 1. Cognitively impaired with poor decision making skills=yes 2. Pertinent diagnosis (i.e. Dementia ...Depression ...Schizophrenia)=yes 3. Ambulate independently, with or without the use of assistive devices=yes 4. 5. Express intent to leave or desire to go home=yes 5. 9. Receive medications that increase restlessness or agitation=yes Interventions/approaches included: Exit alarms, Activities; Music; Exercise; Personalization of room with familiar objects and photos. There were no initiation dates to these interventions. Review of the Quarterly MDS dated [DATE] reflected Resident #7 reflected the same assessment as [DATE] with the added behavior of rejecting care and the use of an Antidepressant medication. Review of the Elopement Risk Review for Resident #7 dated [DATE] reflected she was disoriented times two; she had Dementia and Schizophrenia; at times she stated that she wanted to go back home and had made several attempts to leave the facility. The back page of the risk assessment for documentation of interventions/approaches and the date initiated, as well as, the Summary/Conclusion/recommendations were blank. Review of an undated Elopement Risk Review for Resident #7 reflected that expression or intent to leave or desire to go home was not noted prior to this date. She did voice she was going home today. She stated that she was going home. Her family member stated that Resident #7 had attempted to leave the facility about a year ago. The back page of the risk assessment for documentation of interventions/approaches and the date initiated, as well as, the Summary/Conclusion/recommendations; signature and title of the person completing the form and the date the form was completed were blank. Review of the Care Plan date [DATE] reflected Resident #7 had short term and long term memory deficits and required assistance with decision making. She had poor communication and had poor safety awareness. She was to be monitored for changes in condition that may warrant increased supervision/assistance. She had episodes of sadness due to missing living with her son. She was at risk for dehydration due to the use of Diuretics. Resident #7 has a [DIAGNOSES REDACTED]. Resident #7 ' s wandering intruded on other resident ' s privacy. She had a history of [REDACTED]. On [DATE] she was moved to the " Memory Care Unit " (Secure Unit). The original problem onset was documented as [DATE]. The goal was that Resident #7 would not wander into unsafe situations and would not suffer any injuries related to her wandering. Approaches included the following: ? Place in area where frequent observation is possible. ? Alert staff to wandering behavior. ? Provide diversional activities. ? Approach positively and in a calm accepting manner. ? Monitor and document behavior. Review of Nursing Summary/7-day look back dated [DATE], [DATE], and [DATE], reflected that Resident #7 was wondering daily. Review of Social Services assessment dated [DATE] reflected Resident #7 continued to wander through the facility having to be redirected at times. Review of an Incident/Accident Report dated [DATE] at 1:55 PM reflected Resident #7 was alert to self, unable to understand directions and confused/disoriented. She attempted elopement and was located in the facility ' s parking lot. The actions to minimize reoccurrence reflected " closer monitoring ". The DON and Administrator signed the report on [DATE]. Review of Nurse ' s Notes dated [DATE] reflected at 1:55 PM Resident #7 was noted in the parking lot almost to the street. She stated that she was going home to Alabama. Her responsible party was notified and stated that Resident #7 had tried to leave the facility before and may need her medication adjusted and she needed to be more included in activities. Review of an Incident/Accident Report dated [DATE] reflected Resident #7 wandered from the facility and was located in front of the building, outside. The actions to minimize reoccurrences reflected " closer monitoring ". The DON and Administrator did not sign the report until [DATE]. Review of Nurse ' s Notes dated [DATE] reflected Resident #7 exited the building at approximately 1:25 PM while visitors were entering the building. She was noted by a staff person outside and was immediately perused and returned to the safety of the inside of the facility by two staff persons. The Assistant Director of Nurses was notified. Resident #7's physician was notified and there were no new orders. "Monitoring. " Review of the Social Services assessment dated [DATE] reflected Resident #7 had been found wandering around the facility. Review of an Incident/Accident Report dated [DATE] at 2:10 PM reflected Resident #7 was ambulatory, confused/disoriented and unable to understand directions. She was alert to self only and had difficulty following commands. She wandered from the facility, off the premises and was returned to the facility by the local police at 2:10 PM after being picked up at a local gas station. Fluids were encouraged and she was placed on frequent checks. The report was signed by the Director of Nurses (DON) and Administrator on [DATE]. Review of Nurse ' s Notes dated [DATE] at 2:10 PM reflected Resident #7 was returned to the facility by the local police department and their statement was she was at the convenient store requesting rides from consumers at the store. Resident #7 was brought into the facility and given adequate amounts of water. She was without injury from the incident. The Administrator, DON and Responsible Party were notified. She sat in the dining room for the evening meal. She consumed less than 25 percent of her meal. She vomited one time consisting of clear liquid. She was assisted to bed and remained ambulatory this shift with frequent visual checks to maintain her safety and to monitor her for signs and symptoms of injury related to heat outdoors. Review of Nurse ' s Notes dated [DATE] at 3:50 PM Resident #7 attempted to leave the facility two times through the service hall door (in the back of the building). She was redirected to her room and immediately returned to the door. At 4:15 PM Resident #7 was noted at the B Hall fire exit. She had gone under the stop sign and pushed the door open. She was not easily redirected back into the facility. Review of a Concern Resolution Record dated [DATE] reflected a family member of Resident #7 was quite concerned about the potential danger facing Resident #7 because she had left the faciity on her own on [DATE]. She was returned by the police after being found at a local convenience store. This was the third incident of this nature in a month. The family member was extremely upset and had not received a satisfactory answer as to why this kept happening. The concern was referred to the social worker (SW) who notified the family on [DATE] that Resident #7 needed to be transferred to the secure unit and Resident #7 ' s family member agreed to the transfer. Observation on [DATE] at 6:55 a.m. revealed the distance from the convenience store to the facility was 0.5 miles. Further observation revealed there was a two lane street that intersected at a stop light with heavy traffic with approximate speed limits of 40 miles per hour (mph). There is also a railroad track that runs behind the facility located about one-half a football field length away. Review of Nurse ' s Notes dated [DATE] reflected Resident #7 was transferred to the Secured Unit on D Hall. There were no updated interventions or approaches related to Resident #7 ' s exit seeking behavior and elopements that occurred on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. There were also no investigation reports for the above incidents that included observations, interviews, witness statements, or new interventions to prohibit further elopement for Resident #7. In an interview on [DATE] at 3:55 PM Licensed Vocational Nurse (LVN) E stated that she worked the 6:00 AM to 2:00 PM shift on [DATE]. She was assigned to Resident #7 ' s hall that day. She stated that she went to lunch late at approximately 1:00 PM. She stated that she had seen Resident # 7 just finish eating in the main dining room at approximately 12:45 PM. She stated that she had given report to the oncoming nurse at 2:00 PM and Resident #7 was brought back to the facility by local police at 2:10 PM. LVN E stated that she was not aware that Resident #7 had left the facility. She stated that Resident #7 had eloped from the facility one other time that she was aware of. It was in [DATE] and she had left the facility through the front door, along with a group of visitors. She stated that she never got past the parking lot with that incident. LVN E stated that she started working at the facility in [DATE] and as not aware at that time that Resident #7 was an exit seeker. She didn't ' t ' know how Resident #7 could have left the facility through the front door on [DATE] because there was always office staff in that area. She stated that Resident #7 must have gotten out the back door but she was not sure at all. She stated that Resident #7 resided on the 200 hall, in the general population at the time of the incident. LVN E stated that Resident #7 was only alert to herself. She was not sure if she knew her full name or where she lived. She had told the police officer that she was trying to get home or someplace like that. She stated that Resident #7 did not have good judgment and would not be able to judge when to cross the road safely, who to take a ride from or what cloths would be appropriate for the weather. She stated that there were many dangers out there for Resident #7. In an interview on [DATE] at 3:55 PM LVN D stated that she worked the 2:00 PM to 10:00 PM shift on [DATE] and had just received shift report from LVN E when Resident #7 was brought to the facility by local police. The local police stated that Resident #7 was found up the road at a gas station. LVN D stated that she assessed Resident #7 and sat her at a table in the dining room across from the Nurse ' s station where staff was giving her fluids. The police officer stated that she was at the gas station asking people for a ride home but she didn't know where home was. She stated that she notified the DON, Administrator and Resident #7 ' s family. She was instructed by the DON to monitor Resident #7 frequently. LVN D stated that the DON instructed her to monitor Resident #7 every 15 minutes but she told the DON that monitoring that frequently was not feasible. She stated the DON instructed her to check on Resident #7 as frequently as possible. She stated that she did not document 15 minute monitoring but only that Resident #7 was being monitored frequently. She stated that when she asked Resident #7 her name, Resident #7 gave the name of her deceased husbands name, not her own. She stated that Resident #7 ' s short term memory was very poor. She stated that Resident #7 would not be able to make good decisions on her own. LVN D stated that she was not aware of Resident #7 having exit seeking behavior or prior elopements. She stated that she was never asked to give or write a statement about the incident by the facility. In an interview on [DATE] at 4:15 PM the Administrator stated that she started working at the facility on [DATE] and was not there when Resident #7 eloped. She stated that she could not locate an investigation into Resident #7 ' s elopement and did not think one had been done. She stated that a complete investigation should have been done and that it would not be safe for Resident #7 to leave the facility on her own. She stated that the DON was no longer working at the facility as of last week due to many reasons. She stated that the Assistant Director of Nurses (ADON) was employed by the facility at that time and may be able to answer some questions. In an interview on [DATE] at 4:55 PM the ADON stated that she was a floor nurse at the time of the incident on [DATE] and had only been the ADON now for about one month. She stated that she didn't work on [DATE] when Resident #7 eloped. She stated that she only heard about the incident by other staff. She stated that she did not know Resident #7 to be a wanderer or exit seeker but that Resident #7 had gotten out of the facility on one occasion that she was aware of but did not get off the premises. She stated she did not know how many times Resident #7 had left the facility unattended. She stated that when she came back to work, Resident #7 had been moved from the general population to the secured unit. In an interview on [DATE] at 4:00 PM the Administrator stated that at other facility's they had implemented a plan for residents that wander and were at risk for elopement called "Happy Feet". She stated that the program had not yet been fully implemented at this facility. She stated that part of the "Happy Feet" program was posting the pictures of the residents at risk for elopement in the employee break room and in the focus room. She stated that staff was in-serviced last night on the "Happy Feet" program and now the Policy and Procedure and pictures of the residents at risk were in a binder at the nurse's station for all of the staff. She further stated that the Elopement Risk Review assessment was to be completed on all newly admitted residents and reassessed quarterly and as needed. She further stated that there was nothing on the assessment that would guide the staff into a decision as to whether the resident was at high risk for elopement or not at high risk. She stated that the former DON was not completing Incident/Accident reports and she thinks that the charge nurses did not have good leadership. The Administrator stated that Incident/Accident reports were forgotten and not followed up on. Review of the facility's undated procedure for a Missing Resident reflected the following: " Reporting Guidelines When Resident is not Located " If the resident was not located during a search of the facility, facility grounds, and the immediate vicinity, and there are circumstances which place the resident ' s health, safety, and/or welfare at risk, the Police and/or other Law Enforcement must be notified immediately. The Texas Department on Ageing and Disability Services must be notified via the Incident Reporting telephone number. Examples include but are not limited to: 2. Extreme weather conditions exposes the resident to the potential of freezing, heat prostration or drowning from flooding; 3. A resident is confused or otherwise is incapable of assessing potential danger. Investigation An investigation will begin immediately and will be documented including: 1. Observations, interviews and record reviews of all residents involved; 2. Interviews of all witnesses, including residents, staff and family members; 3. Document all relevant findings. QA & A Follow-Up 1. Review incident, determine causative factors. 2. Discuss methods of prevention, training needs, systems, policies, etc. 3. What could be done better or differently? Review of the facility's policy and procedure dated ,[DATE] for Reporting Abuse and Neglect reflected the following: Neglect 1. The facility must determine if an injury or harm of a resident was due to facility failure to provide services, treatment or care to a resident. Conduct an Investigation Investigate the facility actions when conducting an investigation and initiate the corporate Incident/Accident Report form. - Observations of the situation (resident(s), the surroundings, etc.), interviews and record reviews of all residents involved; - Interviews of all witnesses, including residents, staff, and family members & obtain written statements; PROCEDURES FOR TELEPHONE REPORTS When reporting an incident by telephone, the following information is needed: facility name, vendor #, resident name(s), time and date of incident, what occurred, condition of resident(s), person(s) involved (other then resident), and action taken by facility authority to date. Within five working days of making oral report, send the written investigation report. OTHER REPORTABLE INCIDENTS Injuries of Unknown Source - No one saw the incident that resulted in the injury or the source of the injury could not be explained by the resident; AND, The injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observe at one particular point in time or the number of the injuries over time. The facility's Administrator, interim DON and ADON were informed on [DATE] at 3:45 PM that a Past IJ had been identified and existed [DATE] through [DATE] for Resident #7. Although, the facility relocated Resident #7 to the Secured Unit on [DATE], which removed the immediacy, the facility remained out of compliance at a Severity level of potential for more than minimal harm at a pattern that is not IJ due to an additional three (3) residents with known wandering behaviors identified and residing in the open area of the facility at risk for elopement. The facility identified three (3) wandering residents in the general population.

Based on observation, interview and record review the facility failed to ensure one of three residents reviewed for harness positioning (Resident #1) received adequate supervision and assistance devices to prevent accidents when: The facility failed to supervise Resident #1 while in the wheelchair and to ensure safe harness positioning for her upper body in accordance with the manufacturer's installation and user's instructions. Resident #1 was found with the harness crisscrossed up around her neck. This placed Resident #1 at risk for entrapment, strangulation, asphyxiation, and death. This deficient practice resulted in an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 07/27/12. While the IJ was removed on 07/27/12, the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm that was not IJ with a Scope of Pattern because the facility did not have time to monitor the Plan of Removal for effectiveness or to train all staff. This deficient practice had the potential to place six residents identified by the facility as having shoulder harnesses at risk of entrapment, strangulation, asphyxiation, or death. The findings include: Review of Resident #1's Face Sheet and Consolidated Physician order [REDACTED]. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] reflected she had severely impaired cognitive skills for daily decision making and "other" behavior symptoms. She had required supervision and setup only for bed mobility and total dependence on two people for transfers. She did not ambulate. Resident #1's Consolidated Physician order [REDACTED]. The order included to check the device every very hour and release it every two hours. Resident #1's Care Plan dated 04/02/12 reflected she was unable to respond to questions and commands or to make her needs known verbally. She was at risk for injury related to uncontrollable, restless movements; her desire to roll on the floor in her room and the halls; and her need for a seatbelt with harness when in the wheelchair for positioning. The care plan's documented approaches included monitoring her while she was rolling in the floor, repositioning her in the wheelchair as needed, and checking the seatbelt and harness devices daily to make sure they were in good condition. Observation on 07/27/12 at 10:00 AM revealed Resident #1 sitting in her room in her wheelchair with a seat belt and shoulder harness. No staff members were in the room when the surveyor and escort, Licensed Vocational Nurse (LVN) A, entered Resident #1's room. Resident #1 did not speak. She randomly kicked out her feet and pushed them against LVN A and the surveyor. In an interview on 07/27/12 at 10:00 AM, LVN A said Resident #1 preferred to be on the ground and got around the facility by rolling. Her arms and legs made random movements. She did not have control over her arms and legs or muscle tone to support herself upright in the wheelchair, but she could roll by rotating her hips. She would not be able to sit upright in the wheelchair without the harness. In an interview on 07/27/12 at 10:45 AM, Resident #2, identified by the facility as interviewable, stated she would visit Resident #1 and play with her or read to her. Yesterday, 07/26/12, Resident #2 found Resident #1 in her room in her wheelchair hanging by her wheelchair's shoulder harness. The buckle that connected the sternum strap was rubbing against her eye. Resident #1's face was red, she was struggling to breathe and a froth-like substance was on her face, neck, pants, and wheelchair. Resident #2 said this was not the first time she had found the resident like this. She ran and got Restorative Aide (RA) B. RA B and LVN D helped reposition the resident. In an interview on 07/27/12 at 2:05 PM, LVN D stated she was not working yesterday, 07/25/12. Resident #2 went into Resident #1's room frequently to visit with her and her roommate. One day last week RA B came to get LVN D. When LVN D entered Resident #1's room Resident #2 was behind Resident #1's wheelchair near her roommate's bed. Resident #1 was sitting low in her wheelchair. She was not struggling or caught in the straps of the shoulder harness. But, she could have gotten tangled if she slumped more "absolutely." RA B and LVN D repositioned the resident higher in the wheelchair but did not ask Resident #2 to leave the room. There had been several times when they had to reposition her to keep her from getting caught in the straps. Resident #1 frequently wriggled to try to get out of the chair to roll on the floor. In an interview on 07/27/12 at 11:30 AM the Regional Nurse Consultant said the residents in the facility who used the shoulder harness while in the wheelchair would not be able to get out of the wheelchair with or without the harness, so it was not being used as a restraint. Resident #1 could not support her upper body and would slide over the left or right sides of the wheelchair without the harness. Resident #1 was only up in the wheelchair during meals where she was supervised. Observation on 07/27/12 at 12:00 noon reflected Resident #1 in her room with no staff in the room. She was sleeping in her wheelchair with the seat belt and shoulder harness applied. The nylon straps of the shoulder harness were crossed like an X over her upper chest and she was sitting so low in the wheelchair that the straps were under her chin, up against her left and right sides of her neck. The sternum strap of the H-shaped shoulder harness was not buckled. The under side of her right upper arm and her upper right inner torso were rubbing against a metal bar that was missing its cushion padding. The surveyor summoned facility staff, and these observations were confirmed by the Administrator, Admissions Coordinator, and Regional Nurse Consultant who released the strap and repositioned the resident higher into the chair. In an interview on 07/27/12 at 12:00 noon, the Administrator and Regional Nurse Consultant stated the straps of Resident #1's shoulder harness were not supposed to be crossed, the resident was positioned too low in the wheelchair, and the cushioned padding to the bar under her arm could not be located in her room. At the request of the surveyor on 07/27/12 at 12:00 noon, the facility found the staff member who applied the shoulder strap harness to Resident #1 and asked him to demonstrate on the resident how he applied the straps in front of the surveyor, Administrator and Regional Nurse Consultant. Certified Nurse Aide (CNA) C demonstrated that he brought the left strap up over the resident across her chest and buckled it into the clamp over her right shoulder; he brought the right strap over the resident across her chest and buckled it into the clamp over her left shoulder. He did not buckle the sternum strap. The resident became agitated. The staff assisted her out of the wheelchair so she could roll on the floor. In an interview on 07/27/12 at 12:00 noon, when asked why he applied Resident #1's harness the way he demonstrated, CNA C said an unidentified CNA told him to cross the straps of the harness or the resident would slip out of the wheelchair. In an interview on 07/27/12 at 12:10 PM, when asked how she applied Resident #1's harness straps, CNA E said she crossed the straps. She stated Resident #1 was the only resident for whom she crossed the straps of the shoulder harness. In an interview on 07/27/12 at 12:13 PM LVN D stated she had seen Resident #1's shoulder straps crossed before. She would correct it when she saw it. Whether or not Resident #1's shoulder straps were crossed depended on the CNA who was assigned to her and how well they knew her. She had not seen the straps of the shoulder harnesses on other residents crossed. In an interview on 07/27/12 at 12:15 PM CNA F said one of Resident #1's straps on her shoulder harness was tighter than the other, so she crossed the tighter one first across the resident's chest and then crossed the looser strap over. She said she only crossed the straps on Resident #1's shoulder harness, not on the other residents' harnesses. In a telephone interview on 07/27/12 at 2:00 PM, LVN G said Resident #1 had to sit upright for an hour after each tube feeding. She had observed that the CNAs crossed the straps on Resident #1's shoulder harness when they placed her in the wheelchair to sit up, but she had not observed Resident #1 tangled in the harness. Review of the facility's Active Employee List dated 07/27/12 reflected CNA C was hired on 06/19/12 and CNA F was hired on 10/18/11. In an interview on 07/27/12 at 1:30 PM the Administrator stated she had just started as the facility's Administrator two days ago, 07/25/12, and was not there when CNA A was trained. She had not observed Resident #1's harness straps crossed. She looked at CNA C's personnel file and determined he received orientation on restraints and a check-off on restraint application, but she could not determine whether the restraint check-off included applying the shoulder harnesses. In an interview on 07/27/12 at 2:15 PM CNA C and F said their orientation did not include training or a return demonstration check-off related to applying the residents' shoulder harnesses. In an observation on 07/27/12 at 2:35 PM the CNA Trainer and Regional Nurse Consultant demonstrated to the surveyor that Resident #1 was in her wheelchair with the shoulder harness and seatbelt correctly applied. There was no more than a three-finger width distance between the straps of the seatbelt and the shoulder harness and the resident. In an interview on 07/27/12 at 2:35 PM the Regional Nurse Consultant stated they had determined the CNAs were crossing Resident #1's harness straps because the straps had gotten loose. The straps were tightened and the resident was able to sit upright and comfortably without risk of entanglement. When asked if Resident #1 should be alone, unsupervised in the wheelchair, the CNA Trainer and Regional Nurse Consultant emphatically stated no, she should not. In an interview on 07/27/12 at 2:50 PM Physical Therapist (PT) H stated he was the person who evaluated and measured Resident #1 to be fitted for her specialized wheelchair, seatbelt and shoulder harness. Resident #1 liked to squirm in the wheelchair and ended up hanging over the sides of the wheelchair. She had no control or muscle tone of her upper torso. Without the harness, there was concern she would hit her head against something beside her wheelchair. With the surveyor, PT H went to look at Resident #1's unoccupied wheelchair, seatbelt and shoulder harness in her room. The Physical Therapist stated the shoulder harness was a standard shoulder harness and was not designed to be crossed. Review of the undated Shoulder Harness Installation and User's Instructions by the manufacturer for the standard shoulder harness reflected the following. - Installation. Seat user in wheelchair and establish correct posture with pelvic support belt. Place harness on user with upper straps between neck and shoulder joint. Standard Harness: Center the sternum strap on the sternum. - Fitting. Position the user in wheelchair and fasten the pelvic support belt securely, then buckle the shoulder harness sternum strap, if used, and adjust sternum width. Adjust the lower straps to prevent the sternum strap from riding up. Then tighten the top straps to position the pads and to properly support the user. - Safety Check. When properly positioned in wheelchair, have user lean forward and side to side to check fit. Check for: (1) Normal operation of buckles and adjustment straps. (2) Comfort - if rubbing neck, relocate upper straps. (3) Position - If too high or too low, adjust lower straps. On 07/27/12 at 4:00 PM the Administrator, Regional Nurse Consultant and Interim Director of Nurses (IDON) were informed that an IJ and SQC existed due to the failure to properly apply the shoulder harness, ensure safe positioning and provide supervision to Resident #1 while in her wheelchair with a seat belt and shoulder harness. On 07/25/12 at 5:25 PM, the Administrator provided the surveyor with a written plan of removal, which reflected the following and was accepted. Problem: Harness was applied incorrectly to (Resident #1). Goal: To make sure that harness is applied per manufacturers' recommendations. Interventions: Staff in-servicing was started today (07/27/12) and will continue until all staff have been in-serviced. Responsible Person: Administration. Date of Completion: In-servicing began on 07/27/12 and will continue until all staff has been in-serviced. Goal: To make sure that all residents have their harnesses applied per manufacturers' recommendations. Interventions: - Staff will be in-serviced on proper application of harness for (Resident #1) as well as all other residents who have a harness. Responsible Person: Administration and Regional Nurse Consultant. Date of Completion: In-service to begin 07/27/12 and will be complete by 07/30/12. - Manufacturer of wheelchair was called regarding wheelchair harness. Responsible Person: Administrator. Date of Completion: 07/27/12. Manufacturer will be coming to facility on Monday, 07/30/12. - Staff will be in-serviced on proper fitting of harnesses. Responsible Person: Administration and Regional Nurse Consultant. Date of Completion: In-service to begin on 07/27/12 and will be complete by 07/30/12. - Staff will be in-serviced on notifying their supervisor immediately if harness looks like it does not fit properly. Responsible Person: Administration and Regional Nurse Consultant. Date of Completion: In-service to begin 07/27/12 and will be complete by 07/30/12. - All new staff hired after 07/27/12 will be given individual in-servicing on how to apply harnesses correctly. Responsible Party: Human Resources and CNA Trainer. Date of Completion: Will begin with next new employee orientation. - (Resident #1's) wheelchair harness has been adjusted to ensure it fits snugly. Responsible Person: Regional Nurse Consultant. - All department heads will monitor all residents with harnesses at least daily to ensure the fit is correct and that it is applied correctly. Responsible Person: Administrator and Regional Nurse Consultant. Date of Completion 07/27/12. - A list of all residents with harnesses will be maintained in the Focus Room to ensure monthly safety checks are completed. Responsible Party: Administrator. - A reminder will be put in the TELS system to remind Maintenance Man to perform safety check. Responsible Person: Maintenance Man. Date of Completion: 07/27/12. - Any time (Resident #1) is up (in) her wheelchair, she will be placed in public area for monitoring. All staff will be in-serviced on this process. Responsible Person: Administration and Regional Nurse Consultant. Date of Completion: In-service will begin today (07/27/12) and will be on-going as new staff is hired. - Charge nurses will be in-serviced on monitoring the CNAs for proper application of harnesses. Responsible Person: Administration and Regional Nurse Consultant. Date of Completion: In-servicing will begin today (07/27/12) and will be ongoing as new staff is hired. - PT has completed an evaluation of all residents who have a harness. Date of Completion: Done. - Will review Care Plans on all residents who wear harness to ensure proper interventions and monitoring are in place. Responsible Party: MDS Nurse. Completion Date: Will be completed by 08/03/12. - Walking round sheets will be updated to include monitoring of proper fit of harness. Responsible Party: Administrator. Date of Completion: 07/27/12. - Interventions put in place will be brought to Monthly QA for monitoring and follow up. Responsible Party: Administrator. Date of Completion: Will occur at next QA meeting. The surveyor confirmed the facility had started to implement the plan of removal. - Observations on 07/27/12 at 5:15 PM, escorted by the IDON, revealed all residents with shoulder harnesses who were up in the wheelchairs (Resident #1, Resident #4 and Resident #5) were positioned correctly in their wheelchairs and had proper placement of the seatbelt and shoulder harness. - Random interviews of direct care staff on 07/27/12 between 5:00 PM and 5:45 PM confirmed understanding of in-services conducted on 07/27/12 (CNA I, CNA L, LVN J, and LVN K). - An interview on 07/27/12 at 5:00 PM with PT H confirmed he had re-examined all wheelchairs with shoulder harnesses. - Resident #1 was observed on 07/27/12 at 4:15 PM in her wheelchair positioned by the nurses' station with the seatbelt and shoulder harness applied correctly. While the IJ was removed on 07/27/12, the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm that was not IJ with a Scope of Pattern because the facility did not have time to monitor the Plan of Removal for effectiveness or to train all staff. Observation and interview on initial tour on 07/27/12 at 10:00 AM with LVN A and again with the IDON on 07/27/12 at 5:15 PM revealed six residents had shoulder harnesses on their wheelchairs.

Based on observation, interview and record review the facility failed to ensure one of one Certified Nurse Aides (CNA) observed applying a shoulder harness (CNA C) demonstrated competency in skills and techniques necessary to care for the needs of one of three residents reviewed for shoulder harness use (Resident #1) as identified through the resident assessment and described in the plan of care. CNA C failed to ensure safe harness positioning for Resident #1's her upper body in accordance with the manufacturer's installation and user's instructions. Resident #1 was found with the harness crisscrossed up around her neck. This placed Resident #1 at risk for entrapment, strangulation, asphyxiation, and death. This deficient practice resulted in an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 07/27/12. While the IJ was removed on 07/27/12, the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm that was not IJ with a Scope of Pattern because the facility did not have time to monitor the Plan of Removal for effectiveness or to train all staff. This deficient practice had the potential to place six residents identified by the facility as having shoulder harnesses at risk of entrapment, strangulation, asphyxiation, or death. The findings include: Review of Resident #1's Face Sheet and Consolidated Physician order [REDACTED]. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] reflected she had severely impaired cognitive skills for daily decision making and "other" behavior symptoms. She had required supervision and setup only for bed mobility and total dependence on two people for transfers. She did not ambulate. Resident #1's Consolidated Physician order [REDACTED]. The order included to check the device every very hour and release it every two hours. Resident #1's Care Plan dated 04/02/12 reflected she was unable to respond to questions and commands or to make her needs known verbally. She was at risk for injury related to uncontrollable, restless movements; her desire to roll on the floor in her room and the halls; and her need for a seatbelt with harness when in the wheelchair for positioning. The care plan's documented approaches included monitoring her while she was rolling in the floor, repositioning her in the wheelchair as needed, and checking the seatbelt and harness devices daily to make sure they were in good condition. Observation on 07/27/12 at 10:00 AM revealed Resident #1 sitting in her room in her wheelchair with a seat belt and shoulder harness. No staff members were in the room when the surveyor and escort, Licensed Vocational Nurse (LVN) A, entered Resident #1's room. Resident #1 did not speak. She randomly kicked out her feet and pushed them against LVN A and the surveyor. In an interview on 07/27/12 at 10:00 AM, LVN A said Resident #1 preferred to be on the ground and got around the facility by rolling. Her arms and legs made random movements. She did not have control over her arms and legs or muscle tone to support herself upright in the wheelchair, but she could roll by rotating her hips. She would not be able to sit upright in the wheelchair without the harness. In an interview on 07/27/12 at 11:30 AM the Regional Nurse Consultant said the residents in the facility who used the shoulder harness while in the wheelchair would not be able to get out of the wheelchair with or without the harness, so it was not being used as a restraint. Resident #1 could not support her upper body and would slide over the left or right sides of the wheelchair without the harness. Resident #1 was only up in the wheelchair during meals where she was supervised. Observation on 07/27/12 at 12:00 noon reflected Resident #1 in her room with no staff in the room. She was sleeping in her wheelchair with the seat belt and shoulder harness applied. The nylon straps of the shoulder harness were crossed like an X over her upper chest and she was sitting so low in the wheelchair that the straps were under her chin, up against her left and right sides of her neck. The sternum strap of the H-shaped shoulder harness was not buckled. The under side of her right upper arm and her upper right inner torso were rubbing against a metal bar that was missing its cushion padding. The surveyor summoned facility staff, and these observations were confirmed by the Administrator, Admissions Coordinator, and Regional Nurse Consultant who released the strap and repositioned the resident higher into the chair. In an interview on 07/27/12 at 12:00 noon, the Administrator and Regional Nurse Consultant stated the straps of Resident #1's shoulder harness were not supposed to be crossed, the resident was positioned too low in the wheelchair, and the cushioned padding to the bar under her arm could not be located in her room. At the request of the surveyor on 07/27/12 at 12:00 noon, the facility found the staff member who applied the shoulder strap harness to Resident #1 and asked him to demonstrate on the resident how he applied the straps in front of the surveyor, Administrator and Regional Nurse Consultant. Certified Nurse Aide (CNA) C demonstrated that he brought the left strap up over the resident across her chest and buckled it into the clamp over her right shoulder; he brought the right strap over the resident across her chest and buckled it into the clamp over her left shoulder. He did not buckle the sternum strap. The resident became agitated. The staff assisted her out of the wheelchair so she could roll on the floor. In an interview on 07/27/12 at 12:00 noon, when asked why he applied Resident #1's harness the way he demonstrated, CNA C said an unidentified CNA told him to cross the straps of the harness or the resident would slip out of the wheelchair. In an interview on 07/27/12 at 12:10 PM, when asked how she applied Resident #1's harness straps, CNA E said she crossed the straps. She stated Resident #1 was the only resident for whom she crossed the straps of the shoulder harness. In an interview on 07/27/12 at 12:13 PM LVN D stated she had seen Resident #1's shoulder straps crossed before. She would correct it when she saw it. Whether or not Resident #1's shoulder straps were crossed depended on the CNA who was assigned to her and how well they knew her. She had not seen the straps of the shoulder harnesses on other residents crossed. In an interview on 07/27/12 at 12:15 PM CNA F said one of Resident #1's straps on her shoulder harness was tighter than the other, so she crossed the tighter one first across the resident's chest and then crossed the looser strap over. She said she only crossed the straps on Resident #1's shoulder harness, not on the other residents' harnesses. In a telephone interview on 07/27/12 at 2:00 PM, LVN G said Resident #1 had to sit upright for an hour after each tube feeding. She had observed that the CNAs crossed the straps on Resident #1's shoulder harness when they placed her in the wheelchair to sit up, but she had not observed Resident #1 tangled in the harness. Review of the facility's Active Employee List dated 07/27/12 reflected CNA C was hired on 06/19/12 and CNA F was hired on 10/18/11. In an interview on 07/27/12 at 1:30 PM the Administrator stated she had just started as the facility's Administrator two days ago, 07/25/12, and was not there when CNA A was trained. She had not observed Resident #1's harness straps crossed. She looked at CNA C's personnel file and determined he received orientation on restraints and a check-off on restraint application, but she could not determine whether the restraint check-off included applying the shoulder harnesses. In an interview on 07/27/12 at 2:15 PM CNA C and F said their orientation did not include training or a return demonstration check-off related to applying the residents' shoulder harnesses. In an observation on 07/27/12 at 2:35 PM the CNA Trainer and Regional Nurse Consultant demonstrated to the surveyor that Resident #1 was in her wheelchair with the shoulder harness and seatbelt correctly applied. There was no more than a three-finger width distance between the straps of the seatbelt and the shoulder harness and the resident. In an interview on 07/27/12 at 2:35 PM the Regional Nurse Consultant stated they had determined the CNAs were crossing Resident #1's harness straps because the straps had gotten loose. The straps were tightened and the resident was able to sit upright and comfortably without risk of entanglement. When asked if Resident #1 should be alone, unsupervised in the wheelchair, the CNA Trainer and Regional Nurse Consultant emphatically stated no, she should not. In an interview on 07/27/12 at 2:50 PM Physical Therapist (PT) H stated he was the person who evaluated and measured Resident #1 to be fitted for her specialized wheelchair, seatbelt and shoulder harness. Resident #1 liked to squirm in the wheelchair and ended up hanging over the sides of the wheelchair. She had no control or muscle tone of her upper torso. Without the harness, there was concern she would hit her head against something beside her wheelchair. With the surveyor, PT H went to look at Resident #1's unoccupied wheelchair, seatbelt and shoulder harness in her room. The Physical Therapist stated the shoulder harness was a standard shoulder harness and was not designed to be crossed. Review of the undated Shoulder Harness Installation and User's Instructions by the manufacturer for the standard shoulder harness reflected the following. - Installation. Seat user in wheelchair and establish correct posture with pelvic support belt. Place harness on user with upper straps between neck and shoulder joint. Standard Harness: Center the sternum strap on the sternum. - Fitting. Position the user in wheelchair and fasten the pelvic support belt securely, then buckle the shoulder harness sternum strap, if used, and adjust sternum width. Adjust the lower straps to prevent the sternum strap from riding up. Then tighten the top straps to position the pads and to properly support the user. - Safety Check. When properly positioned in wheelchair, have user lean forward and side to side to check fit. Check for: (1) Normal operation of buckles and adjustment straps. (2) Comfort - if rubbing neck, relocate upper straps. (3) Position - If too high or too low, adjust lower straps. On 07/27/12 at 4:00 PM the Administrator, Regional Nurse Consultant and Interim Director of Nurses (IDON) were informed that an IJ and SQC existed due to the failure to properly apply the shoulder harness, ensure safe positioning and provide supervision to Resident #1 while in her wheelchair with a seat belt and shoulder harness. On 07/25/12 at 5:25 PM, the Administrator provided the surveyor with a written plan of removal, which reflected the following and was accepted. Problem: Harness was applied incorrectly to (Resident #1). Goal: To make sure that harness is applied per manufacturers' recommendations. Interventions: Staff in-servicing was started today (07/27/12) and will continue until all staff have been in-serviced. Responsible Person: Administration. Date of Completion: In-servicing began on 07/27/12 and will continue until all staff has been in-serviced. Goal: To make sure that all residents have their harnesses applied per manufacturers' recommendations. Interventions: - Staff will be in-serviced on proper application of harness for (Resident #1) as well as all other residents who have a harness. Responsible Person: Administration and Regional Nurse Consultant. Date of Completion: In-service to begin 07/27/12 and will be complete by 07/30/12. - Manufacturer of wheelchair was called regarding wheelchair harness. Responsible Person: Administrator. Date of Completion: 07/27/12. Manufacturer will be coming to facility on Monday, 07/30/12. - Staff will be in-serviced on proper fitting of harnesses. Responsible Person: Administration and Regional Nurse Consultant. Date of Completion: In-service to begin on 07/27/12 and will be complete by 07/30/12. - Staff will be in-serviced on notifying their supervisor immediately if harness looks like it does not fit properly. Responsible Person: Administration and Regional Nurse Consultant. Date of Completion: In-service to begin 07/27/12 and will be complete by 07/30/12. - All new staff hired after 07/27/12 will be given individual in-servicing on how to apply harnesses correctly. Responsible Party: Human Resources and CNA Trainer. Date of Completion: Will begin with next new employee orientation. - (Resident #1's) wheelchair harness has been adjusted to ensure it fits snugly. Responsible Person: Regional Nurse Consultant. - All department heads will monitor all residents with harnesses at least daily to ensure the fit is correct and that it is applied correctly. Responsible Person: Administrator and Regional Nurse Consultant. Date of Completion 07/27/12. - A list of all residents with harnesses will be maintained in the Focus Room to ensure monthly safety checks are completed. Responsible Party: Administrator. - A reminder will be put in the TELS system to remind Maintenance Man to perform safety check. Responsible Person: Maintenance Man. Date of Completion: 07/27/12. - Any time (Resident #1) is up (in) her wheelchair, she will be placed in public area for monitoring. All staff will be in-serviced on this process. Responsible Person: Administration and Regional Nurse Consultant. Date of Completion: In-service will begin today (07/27/12) and will be on-going as new staff is hired. - Charge nurses will be in-serviced on monitoring the CNAs for proper application of harnesses. Responsible Person: Administration and Regional Nurse Consultant. Date of Completion: In-servicing will begin today (07/27/12) and will be ongoing as new staff is hired. - PT has completed an evaluation of all residents who have a harness. Date of Completion: Done. - Will review Care Plans on all residents who wear harness to ensure proper interventions and monitoring are in place. Responsible Party: MDS Nurse. Completion Date: Will be completed by 08/03/12. - Walking round sheets will be updated to include monitoring of proper fit of harness. Responsible Party: Administrator. Date of Completion: 07/27/12. - Interventions put in place will be brought to Monthly QA for monitoring and follow up. Responsible Party: Administrator. Date of Completion: Will occur at next QA meeting. The surveyor confirmed the facility had started to implement the plan of removal. - Observations on 07/27/12 at 5:15 PM, escorted by the IDON, revealed all residents with shoulder harnesses who were up in the wheelchairs (Resident #1, Resident #4 and Resident #5) were positioned correctly in their wheelchairs and had proper placement of the seatbelt and shoulder harness. - Random interviews of direct care staff on 07/27/12 between 5:00 PM and 5:45 PM confirmed understanding of in-services conducted on 07/27/12 (CNA I, CNA L, LVN J, and LVN K). - An interview on 07/27/12 at 5:00 PM with PT H confirmed he had re-examined all wheelchairs with shoulder harnesses. - Resident #1 was observed on 07/27/12 at 4:15 PM in her wheelchair positioned by the nurses' station with the seatbelt and shoulder harness applied correctly. While the IJ was removed on 07/27/12, the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm that was not IJ with a Scope of Pattern because the facility did not have time to monitor the Plan of Removal for effectiveness or to train all staff. Observation and interview on initial tour on 07/27/12 at 10:00 AM with LVN A and again with the IDON on 07/27/12 at 5:15 PM revealed six residents had shoulder harnesses on their wheelchairs.

Based on interview and record review the facility failed to immediately report an allegation of physical abuse to the appropriate State agency for 1 of 6 residents ( Resident #3) sampled for abuse when:. The facility failed to immediately report an allegation of abuse regarding Resident #3 on 12/18/2010 until three days after the alleged incident occurred 12/21/2010. An Immidiate Jeopardy was identified on 1/5/11 at 12:15 p.m.. While the IJ was lowered on 1/5/2011 at 6:02 p.m the facility remained out of complaince at a a scope of a pattern and a severity of potential for more than minimal harm that is not immediate jeopardy because the facility was continuing to in-service staff on abuse/neglect as outlined in their plan of removal. This failure to report has the potential to place the 64 residents residing in the facility at risk for physical harm. The findings include: Review of the admission face sheet dated 10/17/10 for Resident #3 reflected an admission date of [DATE] with the following Diagnoses: [REDACTED]. Review of the clinical record for Resident #3 reflected frequent agitation and aggressive behaviors. Further review reflected care plans, dated 12/10/10, for Resident #3 for wandering behavior, cognitive impairment, impaired communication, depression, anxiety, resistive to care, and inappropriate behaviors such as touching others with episodes of hitting. Review of the facility investigation report dated 12/21/10 reflected an allegation of abuse was reported to Licensed Vocational Nurse (LVN) H on 12/18/10 by Housekeeper (Hskp) B. Hskp B reported she had witnessed RN E slap Resident #3 three times on the arm. LVN H reported the allegation to the Director of Nurses (DON) who notified the Administrator and an investigation was initiated on 12/18/10 at 4:10 PM. Observation on 1/3/11 at 9:00 AM revealed Resident #3 walking the hall in the secure unit. Attempts to interview him were unsuccessful due to advanced dementia and the resident became very agitated; walking away mumbling when questioned about the incident. In an interview on 1/3/11 at 9:20 AM the DON stated she had conducted the investigation into the allegation of abuse and determined after interviewing all but one of the witnesses (Activity Director (AD) F, Assistant AD, and LVN H) the allegation was unsubstantiated. She stated she was not able to interview the complainant, Hskp B, "the only alleged eye witness", until 12/21/10 and at that time Hskp B, when told the allegation was unsubstantiated, stated she had called in the complaint to the state. The DON further stated she had "Only called the incident in to the state in order to tell our side of the story". The DON stated she completed the investigation on the evening of 12/18/10, unsubstantiated the allegation and called RN E and told him to report to work on 12/19/10, which he did. She stated RN E is currently employed at the facility and has worked his regular full time schedule as a staff nurse as well as the weekend RN supervisor since 12/19/10. When asked by the surveyor, the DON stated we are only required to report substantiated allegations to DADS. In an interview on 1/3/11 at 10:35 AM the Administrator stated the allegation of abuse was unsubstantiated as a result of the facility investigation. He further stated the facility is only required to report allegations they substantiate through their investigation. In an interview on 1/4/11 at 9:00 AM RN E stated he was attempting to take Resident #3 back to the secure unit (Hall 400) from the main dining room. When Resident #3 got to the doors of the secure unit he grabbed the door and would not let go. RN E stated he put his hand on Resident #3's arm and "gently pushed down" . RN E further stated it could have been misinterpreted as hitting but "I never hit the man". RN E stated "You have to understand how stressful it has been around here lately. My work load has increased because we have cut staff because of a low census". Observation on 1/4/11 at 9:00 AM, during the interview, revealed RN E to be nervous, making no eye contact and fidgeting throughout the interview. In an interview on 1/4/11 at 9:20 AM AD F stated she was in the main dining room on 12/18/10 because the facility was having a Christmas party for the residents and Resident #3 was attending the party. She further stated Resident #3 became agitated because of the music and people. She observed RN E begin to walk Resident #3 back to Hall 400, the secure unit. She stated Resident #3 was walking toward Hall 400 with RN E without any problems. She further stated she turned to leave the dining room and go toward Hall 100 and never saw RN E and Resident #3 at the door of the secure unit. In an interview on 1/4/11 at 9:30 AM Assistant AD G stated Resident #3 attended a party in the main dining room and became agitated and needed to be taken back to the secure unit. She further stated she offered to take Resident #3 to the secure unit but RN E told her he would take the resident back. She stated RN E took Resident #3 by the arm and started leading him out of the dining room toward Hall 400. Assistant AD G stated she returned to the party in the dining room and never saw RN E and Resident #3 arrive at the doors leading into the secure unit. In an interview on 1/4/11 at 10:50 AM LVN H stated she was sitting at the desk in the secure unit, looked up and out of the window beside the desk and into hall and observed RN E with both arms around Resident #3 in a "bear hug" . She further stated where she was sitting she was unable to see RN E and Resident #3 until they were past the doors leading into the unit and never saw Resident #3 holding onto the door. In an interview on 1/4/11 at 11:40 AM Hskp B stated she was standing in front of the door to the dirty utility room on the secure unit facing the double doors into the secure unit. She further stated the dirty utility room is located 4 or 5 feet inside the double doors leading into the secure unit. She stated she observed RN E attempting to pull Resident #3's hands off of the doors and when Resident #3 would not let go; RN E slapped him three times, open handed, on the forearm attempting to get Resident #3 to let go of the door. She stated Resident #3 did not let go of the door and RN E forcibly pulled his hand off of the door and began to walk Resident #3 in a "bear hug" into the secure unit. Hskp B further stated that RN E seemed "frustrated and frazzled". Hskp B further stated the only people she saw in the area were RN E, Resident #3 and LVN H who was sitting at the desk inside the secure unit. Observation of Hall 400 on 1/4/11 at 12:00 PM revealed the witnesses (AD F, Assistant AD G and LVN H) were not in a position to observe RN E and Resident #3 at the door of the secure unit. Further observation revealed the only potential eye witness to RN E and Resident #3 at the double doors entering the secure unit was Hskp B. Placement on the map of the facility floor plan of RN E, Resident #3 and all witnesses listed in the facility investigation report confirmed Hskp B was the only person in place to witness the events between RN E and Resident #3. Review of the personnel file for RN E reflected a hire date of 6/28/06. Further review reflected an allegation of physical abuse was made against RN E on 9/27/06 and the facility investigation unsubstantiated the allegation however it resulted in RN E being required to attend anger management classes. On 1/5/11 at 12:15 PM an Immediate Jeopardy (IJ) was identified and the facility Administrator and Director of Nurses (DON) were informed of an IJ related to the failure to report allegations of abuse as required by federal, state and local laws. The Plan of Removal for the Immediate Jeopardy as submitted by the facility on 1/5/11 at 6:02 PM was as follows: 'Step 1: The RN that the complaint was on was terminated on January 4, 2011. Step 2: January 4, 2011 The Social Worker was asked to Random interview residents within her work day to ask if they have had anyone miss treat them or staff being mean or abusing them. She will keep documentation of the visits. If anyone says that they were abused then she is to report back to the DON and Administrator for an investigation to begin. Step 3: On January 5, 2011 the facility conducted an in-service on our Abuse and Neglect policies. (See sign-in sheet and material attached). Step 4: On January 5, 2011 as part of the investigation 10% of the facility residents were interviewed and asked, "Do you feel safe at Wind Crest Nursing Home?" all answers were positive or yes. Step 5: On January 5, 2011 as part of the investigation a random selection of employees from all departments were asked, "Have you ever seen anyone abused or seen signs of abuse here at Wind Crest Nursing Home?" All answers were "No". Step 6: Administrator will call the DAD's Liaison, request to conduct an in-service for the staff as soon as their schedule permits. I will place this call on January 6, 2011. Step 7: The Administrator and DON will attend a state approved seminar on "Abuse Reporting" Friday, January 7, 2011 conducted by chaseminars.com starting at 9:00 AM and [MEDICATION NAME] 8 hours. chaseminars.com. Step 8: The Resident Council will review Residents Rights and Abuse at quarterly meetings to see if they had been mistreated or know of anyone else that had been mistreated. This will start January 19, 2011 which is the next scheduled Resident Council Meeting. Step 9: The facility will implement procedures that include these seven components: screening, training, prevention, identification, investigation, protection and reporting/response. I. Screening: The facility business office will screen potential employees for a history of abuse, neglect or mistreating residents as defined by the applicable requirements at 483.13?(1)(ii)(A) and (B). This includes obtaining information from previous employers and/or current employers, and checking the misconduct registry, and criminal background history. II. Training: The facility will train employees, through orientation and in-services on issues related to abuse prohibition practices. The employee training will be conducted and documented by the Human Resources Department prior to employment and the in-services will be conducted by individuals trained to conduct the abuse in-service related to: ? Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents: ? How staff should report their knowledge related to allegations without fear of reprisal: ? How to recognize signs of burnout, frustration and stress that may lead to abuse: and ? What constitutes abuse, neglect and misappropriation of resident property. III. This facility will provide residents, families and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution: and provide feedback regarding the concerns that have been expressed. All residents and responsible party members will receive copies of their "Resident Rights" explaining to them that they can voice grievances and have the facility respond to those grievances at the time of admission. The Social Worker will also review these rights with each resident and family member during Care Plan meeting. Identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. This includes an analysis of: ? Features of the physical environment that may make abuse and/or neglect more likely to occur, such as secluded areas of the facility: ? The deployment of staff on each shift in sufficient numbers to meat the needs of the residents, and assure that the staff assigned has knowledge of the individual residents' care needs: ? The supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their beds: and ? The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other resident's rooms, residents with self-injurious behaviors, residents with communication disorders, those that require heavy nursing care and/or are totally dependent on staff. IV. Identification Have procedures to: Identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse: and to determine the direction of the investigation. V. Investigation Have procedures to: Investigate different types of incidents: and identify the staff member responsible for the initial reporting, investigation of alleged violations and reporting of results to the proper authorities. VI. Protection: Implement procedures to protect residents from harm during an investigation. VII. Report/Response: Implement procedures to report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation: ? Report to the state nurse aide registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service; and ? Analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. The above policies and procedures will be completed and in-serviced to all staff by January 31, 2011. DVD copies of the in-services will be given to employees that miss due to illness or vacation time.' On 1/5/11 at 6:02 PM the plan of removal was accepted and verfied by the surveyor. While the the IJ was lowered the facility remained out of complaince at a a scope of a pattern and a severity of potential for more than minimal harm that is not immediate jeopardy because the facility was continuing to in-service staff on abuse/neglect as outlined in their plan of removal. The facility Administrator provided the census of 64.

Based on interview and record review the facility failed to implement its written polices and procedures that when thay failed to thoroughly investigate an allegation of physical abuse for 1 of 6 residents ( Resident #3) when: The facility unsubstantiated an allegation of abuse involving RN E and Resident #3 before interviewing all eyewitnesses (Housekeeper B). Therefore allowing RN E to return back to work on 12/19/2010 before a thorough investigation was conducted, which allowed RN E to work with other facility residents including Resident #3 until his termination of employment on 1/4/2010. An Immidiate Jeopardy was identified on 1/5/11 at 12:15 p.m.. While the IJ was lowered on 1/5/2011 at 6:02 p.m the facility remained out of complaince at a a scope of a pattern and a severity of potential for more than minimal harm that is not immediate jeopardy because the facility was continuing to in-service staff on abuse/neglect as outlined in their plan of removal. The failure to investigate could place the 64 residents residing in the facility at risk for physical harm. The findings include: Review of the undated facility policy titled 'Reporting Abuse-Physical, Sexual and/or Verbal reflected the following: Policy: All types of abuse/neglect must be reported immediately to the Administrator or the DON if neither are in the facility report to the charge nurse. The charge nurse must immediately call and inform the correct person using the Facility Contact List. The Contact person will immediately begin an investigation and will follow the State Guidelines for reporting. Review of the undated facility policy titled 'Reporting/Investigating Resident Accidents/Incidents' reflected the following: 5. All accidents/incidents involving residents will be thoroughly investigated by management and the findings of such investigation will be submitted to QA and will be part of the investigation report. Review of the admission face sheet dated 10/17/10 for Resident #3 reflected an admission date of [DATE] with the following Diagnoses: [REDACTED]. Review of the clinical record for Resident #3 reflected frequent agitation and aggressive behaviors. Further review reflected care plans, dated 12/10/10, for Resident #3 for wandering behavior, cognitive impairment, impaired communication, depression, anxiety, resistive to care, and inappropriate behaviors such as touching others with episodes of hitting. Review of the facility investigation report dated 12/21/10 reflected an allegation of abuse was reported to Licensed Vocational Nurse (LVN) H on 12/18/10 by Housekeeper (Hskp) B. Hskp B reported she had witnessed RN E slap Resident #3 three times on the arm. LVN H reported the allegation to the Director of Nurses (DON) who notified the Administrator and an investigation was initiated on 12/18/10 at 4:10 PM. Observation on 1/3/11 at 9:00 AM revealed Resident #3 walking the hall in the secure unit. Attempts to interview him were unsuccessful due to advanced dementia and the resident became very agitated; walking away mumbling when questioned about the incident. In an interview on 1/3/11 at 9:20 AM the DON stated she had conducted the investigation into the allegation of abuse and determined after interviewing all but one of the witnesses (Activity Director (AD) F, Assistant AD, and LVN H) the allegation was unsubstantiated. She stated she was not able to interview the complainant, Hskp B, "the only alleged eye witness", until 12/21/2010 three days after the alleged incident. The DON stated at that time Hskp B, when told the allegation was unsubstantiated, stated she had called in the complaint to the state. The DON further stated that she (DON) had "Only called the incident in to the state in order to tell our side of the story". The DON stated she completed the investigation on the evening of 12/18/10, unsubstantiated the allegation and called RN E and told him to report to work on 12/19/10, which he did. She stated RN E is currently employed at the facility and has worked his regular full time schedule as a staff nurse as well as the weekend RN supervisor since 12/19/10. When asked by the surveyor, the DON stated we are only required to report substantiated allegations to DADS. In an interview on 1/3/11 at 10:35 AM the Administrator stated the allegation of abuse was unsubstantiated as a result of the facility investigation. He further stated the facility is only required to report allegations they substantiate through their investigation. In an interview on 1/4/11 at 9:00 AM RN E stated he was attempting to take Resident #3 back to the secure unit (Hall 400) from the main dining room. When Resident #3 got to the doors of the secure unit he grabbed the door and would not let go. RN E stated he put his hand on Resident #3's arm and "gently pushed down" . RN E further stated it could have been misinterpreted as hitting but "I never hit the man". RN E stated "You have to understand how stressful it has been around here lately. My work load has increased because we have cut staff because of a low census". Observation on 1/4/11 at 9:00 AM, during the interview, revealed RN E to be nervous, making no eye contact and fidgeting throughout the interview. In an interview on 1/4/11 at 9:20 AM AD F stated she was in the main dining room on 12/18/10 because the facility was having a Christmas party for the residents and Resident #3 was attending the party. She further stated Resident #3 became agitated because of the music and people. She observed RN E begin to walk Resident #3 back to Hall 400, the secure unit. She stated Resident #3 was walking toward Hall 400 with RN E without any problems. She further stated she turned to leave the dining room and go toward Hall 100 and never saw RN E and Resident #3 at the door of the secure unit. In an interview on 1/4/11 at 9:30 AM Assistant AD G stated Resident #3 attended a party in the main dining room and became agitated and needed to be taken back to the secure unit. She further stated she offered to take Resident #3 to the secure unit but RN E told her he would take the resident back. She stated RN E took Resident #3 by the arm and started leading him out of the dining room toward Hall 400. Assistant AD G stated she returned to the party in the dining room and never saw RN E and Resident #3 arrive at the doors leading into the secure unit. In an interview on 1/4/11 at 10:50 AM LVN H stated she was sitting at the desk in the secure unit, looked up and out of the window beside the desk and into hall and observed RN E with both arms around Resident #3 in a "bear hug" . She further stated where she was sitting she was unable to see RN E and Resident #3 until they were past the doors leading into the unit and never saw Resident #3 holding onto the door. In an interview on 1/4/11 at 11:40 AM Hskp B stated she was standing in front of the door to the dirty utility room on the secure unit facing the double doors into the secure unit. She further stated the dirty utility room is located 4 or 5 feet inside the double doors leading into the secure unit. She stated she observed RN E attempting to pull Resident #3's hands off of the doors and when Resident #3 would not let go; RN E slapped him three times, open handed, on the forearm attempting to get Resident #3 to let go of the door. She stated Resident #3 did not let go of the door and RN E forcibly pulled his hand off of the door and began to walk Resident #3 in a "bear hug" into the secure unit. Hskp B further stated that RN E seemed "frustrated and frazzled". Hskp B further stated the only people she saw in the area were RN E, Resident #3 and LVN H who was sitting at the desk inside the secure unit. Observation of Hall 400 on 1/4/11 at 12:00 PM revealed the witnesses (AD F, Assistant AD G and LVN H) were not in a position to observe RN E and Resident #3 at the door of the secure unit. Further observation revealed the only potential eye witness to RN E and Resident #3 at the double doors entering the secure unit was Hskp B. Placement on the map of the facility floor plan of RN E, Resident #3 and all witnesses listed in the facility investigation report confirmed Hskp B was the only person in place to witness the events between RN E and Resident #3. Review of the personnel file for RN E reflected a hire date of 6/28/06. Further review reflected an allegation of physical abuse was made against RN E on 9/27/06 and the facility investigation unsubstantiated the allegation however it resulted in RN E being required to attend anger management classes. On 1/5/11 at 12:15 PM an Immediate Jeopardy (IJ) was identified and the facility Administrator and Director of Nurses (DON) were informed of an IJ related to the failure to thorougly investigate allegations of abuse. The Plan of Removal for the Immediate Jeopardy as submitted by the facility on 1/5/11 at 6:02 PM was as follows: 'Step 1: The RN that the complaint was on was terminated on January 4, 2011. Step 2: January 4, 2011 The Social Worker was asked to Random interview residents within her work day to ask if they have had anyone miss treat them or staff being mean or abusing them. She will keep documentation of the visits. If anyone says that they were abused then she is to report back to the DON and Administrator for an investigation to begin. Step 3: On January 5, 2011 the facility conducted an in-service on our Abuse and Neglect policies. (See sign-in sheet and material attached). Step 4: On January 5, 2011 as part of the investigation 10% of the facility residents were interviewed and asked, "Do you feel safe at Wind Crest Nursing Home?" all answers were positive or yes. Step 5: On January 5, 2011 as part of the investigation a random selection of employees from all departments were asked, "Have you ever seen anyone abused or seen signs of abuse here at Wind Crest Nursing Home?" All answers were "No". Step 6: Administrator will call the DAD's Liaison, request to conduct an in-service for the staff as soon as their schedule permits. I will place this call on January 6, 2011. Step 7: The Administrator and DON will attend a state approved seminar on "Abuse Reporting" Friday, January 7, 2011 conducted by chaseminars.com starting at 9:00 AM and [MEDICATION NAME] 8 hours. chaseminars.com. Step 8: The Resident Council will review Residents Rights and Abuse at quarterly meetings to see if they had been mistreated or know of anyone else that had been mistreated. This will start January 19, 2011 which is the next scheduled Resident Council Meeting. Step 9: The facility will implement procedures that include these seven components: screening, training, prevention, identification, investigation, protection and reporting/response. I. Screening: The facility business office will screen potential employees for a history of abuse, neglect or mistreating residents as defined by the applicable requirements at 483.13?(1)(ii)(A) and (B). This includes obtaining information from previous employers and/or current employers, and checking the misconduct registry, and criminal background history. II. Training: The facility will train employees, through orientation and in-services on issues related to abuse prohibition practices. The employee training will be conducted and documented by the Human Resources Department prior to employment and the in-services will be conducted by individuals trained to conduct the abuse in-service related to: ? Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents: ? How staff should report their knowledge related to allegations without fear of reprisal: ? How to recognize signs of burnout, frustration and stress that may lead to abuse: and ? What constitutes abuse, neglect and misappropriation of resident property. III. This facility will provide residents, families and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution: and provide feedback regarding the concerns that have been expressed. All residents and responsible party members will receive copies of their "Resident Rights" explaining to them that they can voice grievances and have the facility respond to those grievances at the time of admission. The Social Worker will also review these rights with each resident and family member during Care Plan meeting. Identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. This includes an analysis of: ? Features of the physical environment that may make abuse and/or neglect more likely to occur, such as secluded areas of the facility: ? The deployment of staff on each shift in sufficient numbers to meat the needs of the residents, and assure that the staff assigned has knowledge of the individual residents' care needs: ? The supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their beds: and ? The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other resident's rooms, residents with self-injurious behaviors, residents with communication disorders, those that require heavy nursing care and/or are totally dependent on staff. IV. Identification Have procedures to: Identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse: and to determine the direction of the investigation. V. Investigation Have procedures to: Investigate different types of incidents: and identify the staff member responsible for the initial reporting, investigation of alleged violations and reporting of results to the proper authorities. VI. Protection: Implement procedures to protect residents from harm during an investigation. VII. Report/Response: Implement procedures to report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation: ? Report to the state nurse aide registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service; and ? Analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. The above policies and procedures will be completed and in-serviced to all staff by January 31, 2011. DVD copies of the in-services will be given to employees that miss due to illness or vacation time.' On 1/5/11 at 6:02 PM the plan of removal was verifed and accepted. While the the IJ was lowered the facility remained out of complaince at a a scope of a pattern and a severity of potential for more than minimal harm that is not immediate jeopardy because the facility was continuing to in-service staff on abuse/neglect as outlined in their plan of removal. The facility Administrator provided the census of 64.