Every finding on record at Falcon Ridge Rehabilitation

Based on record review and interview, the facility failed to use the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week, for 1 of 1 facility reviewed for RN coverage. The facility did not have RN coverage on [DATE], [DATE], [DATE], [DATE], and [DATE].This failure could have placed residents at risk of not receiving adequate care or monitoring of staff that required the supervision or decision making of an RN. Record review of the facility's resident roster, dated [DATE], revealed a census of 90 residents. Record review of the facility's nursing time sheets from [DATE] through [DATE] reflected five dates with no RN coverage: [DATE], [DATE], [DATE], [DATE], and [DATE].During an interview on [DATE] at 9:26 a.m., the DON stated the facility did not have RN coverage on the five identified dates. The DON stated she was aware of the regulatory requirement for RN coverage for eight consecutive hours per day. She explained that one of their nurses died in [DATE] and the facility had difficulty obtaining RN coverage despite using agency staff. The DON stated the potential negative outcomes for residents included harm due to delayed assessment, because only an RN could complete a head-to-toe assessment, administer IV medications, perform PICC line changes (a thin flexible tube used to deliver medications or treatments through a vein), and pronounce death. The DON stated she was not aware of any negative outcomes to residents on those dates. During an interview on [DATE] at 9:57 a.m., RN L stated she was aware of the requirement for RN coverage for eight consecutive hours per day. RN L stated the potential negative outcome for residents could be death due to malpractice or negligence if an LVN worked outside the scope of practice. She stated only an RN could complete head to toe assessments, PICC line changes, administer IV medications, and pronounce death. RN L stated she was the weekend RN supervisor, had worked at the facility for about one month, and was not aware of any days without RN coverage.During an interview on [DATE] at 10:07 a.m., LVN J stated she was aware of the requirement for RN coverage for eight consecutive hours per day. LVN J stated the potential negative outcome for residents could be death due to the absence of an RN's critical thinking and consultative skills. She stated she was not aware of any days without RN coverage.During an interview on [DATE] at 3:59 p.m., the ADM stated he was aware of the five dates without RN coverage. The ADM stated RN coverage for eight hours per day was both a regulatory requirement and his expectation. He stated he did not have a clinical background but understood that some tasks, such as pronouncing death, could only be performed by an RN. He stated he was not aware of any negative outcomes to residents due to the lack of RN coverage and noted the facility had Telehealth or on call nurses available if needed. Record review of facility's policy Leadership Policies and Procedures, on staffing, revised [DATE], reflected Policy: The Facility's Leadership will provide a sufficient number of staff to successfully implement patient/resident-focused functions. A. Nursing.3. Except when waived, uses the services of a RN for at least eight (8) consecutive hours per day, seven (7) days per week.

Based on observation, interview, and record review, the facility failed to post its most recent survey in an area accessible to residents, family members, and legal representatives of residents, in 1 of 1 survey binders.The facility failed to ensure the most recent standard survey was readily available for residents and families to review.This failure could leave residents without access to up-to-date information about the facility's compliance with federal and state regulations, limiting their ability to make informed decisions and exercise their rights.During a confidential group interview at an undisclosed date and time, 6 residents confirmed they did not have access to the most recent standard survey results and wanted to review them.An observation on 06/30/2026 at 4:05 PM indicated that the survey results were not posted where residents could have access to the binder . The survey binder was located behind the reception desk and not accessible for residents and family members. An interview on 7/1/2026 at 2:05 PM with the receptionist. She stated a survey binder has been kept behind the desk for as long as she was aware. She stated if someone asked for the survey, she would have to ask the DON or the Administrator where it was. She stated she has never had any staff, family, or residents ask her where the survey results were. She stated she is aware of the policy that a survey binder should be available for residents, family, and Ombudsman to view. She stated the survey results have been behind the Desk as far as she can remember.An interview on 07/01/2026 at 2:19 PM CNA M stated she does not know where the survey results binder is located. She stated she would have to ask the Administrator where the binder was. She stated no one had told her where the survey binder was located and what to do if someone asks for the binder. An interview on 07/01/2026 at 2:55 PM, the ADM stated the survey results binder should be posted for residents, family, and the ombudsman to see. He stated the survey binder has been behind the receptionist desk but should be out where it is available to be looked at. He stated that the last survey was in 2025. Policies: The ADM stated they do not have a policy on where the binder should be in the facility.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 2 of 2 kitchens reviewed for Food and Nutrition Services.The facility failed to ensure dietary staff followed proper handwashing and glove use. These deficient practices could place residents at risk for food borne illness.During an observation on 06/29/2026 at 10:40 a.m., in Kitchen 1, [NAME] E finished a task of pureeing meatloaf. She removed her gloves and she picked up a white dish rag from the preparation counter, and she moved it to the dirty linens pile. [NAME] E failed to wash hands before putting on a new pair of gloves and beginning to puree carrots for the lunch meal. During an interview on 06/30/26 at 1:10 p.m., [NAME] E stated she has been employed at this facility for about 1 year, she has a current Food Handlers Certificate, and she has been trained in Food Service Safety and Sanitation. She stated she has been in-serviced on hand washing and glove use in the kitchen. She said, I have been trained to wash my hands before and after use of gloves in the kitchen. She said she knows to never reuse gloves and if she does not properly sanitize her hands a resident could get sick. [NAME] E said she forgot to wash her hands before putting on a new pair of gloves. During observation on 06/29/2026 at 11:30 a.m., DA G entered Kitchen 2 and she failed to wash her hands or don gloves before serving food from the steam table to the lunch trays.During an observation on 06/29/2026 at 11:32 a.m., DA H entered Kitchen 2 and she failed to wash her hands or don gloves prior to distributing food to the dining plates. During an interview on 06/30/26 at 1:53 p.m., DA G stated she has been employed at this facility since December of 2025 and she has been in-serviced by other staff in hand hygiene and she said, everyone is supposed to practice hand hygiene. She stated she knows that kitchen staff are expected to wash hands whenever moving from one task to another. She stated that staff are to practice proper hand hygiene to prevent transfer of germs to a resident. DA G did not recall that she failed to wash her hands when she entered Kitchen # 2. During an observation and interview on 06/29/2026 at 11:35 a.m., [NAME] F failed to wash her hands when she walked from Kitchen #1's food prep counter to the steam table. Observed [NAME] F lifting her right, ungloved hand to touch her nose and mouth. [NAME] F used her ungloved hands to pick up silverware, to serve food on plates and to put plates on the trays and move trays to the hall cart. [NAME] F stated, kitchen staff must always wash hands when entering the kitchen. She said they must always wear gloves when prepping food and when they have a workstation change. She said, I am supposed to always wash hands between tasks. She said food borne illnesses can happen if kitchen staff did not wash their hands frequently. [NAME] F said she did not recall lifting her hands to her face while in Kitchen # 1 and she did not recall if she had washed her hands or not. During an observation and interview on 06/29/2026 at 12:17 p.m., AD failed to sanitize her hands prior to picking up a food tray at the Kitchen #2 food service area and delivering the lunch tray to a resident in the dining room. During an interview AD stated she is a new employee at the facility, and she had been trained in hand sanitation techniques. AD stated, hand hygiene is important because seniors are susceptible to illness. She stated she did not remember that she was supposed to use sanitizer on her hands when she picked up the lunch tray. During an observation and interview on 06/29/2026 at 12:18 p.m., RN O failed to wash her hands or use hand sanitizer prior to picking up and delivering a lunch tray to a resident in the dining room. RN O stated she has been trained in hand hygiene, and that hygiene is necessary to prevent foodborne illness. RN O was not sure of why she did not use sanitizer on her hands before picking up the lunch trays to deliver them to the residents.During an observation on 6/29/2026 at 12:30 p.m., Maintenance Director entered the kitchen #2 and he failed to wash hands prior to walking through the kitchen. During an interview on 07/01/2026 at 1:39 p.m., Maintenance Director stated, I understand the hand-washing process. He stated he understood that washing hands prevents the spread of germs. He stated hand hygiene is related to the job being performed by the staff member. He stated, he did not wash his hands when he entered kitchen #1 on 6/29/2026 at 12:30 p.m., because he was doing a quick once over and did not need to wash his hands.During an interview on 06/30/26 at 2:29 p.m., DM stated he has been training in hand hygiene. He stated the training included the reason hand hygiene is needed, hand washing technique and, consequences, if hand hygiene was not used by staff. He stated, I am responsible for the staff and their hand hygiene. He stated everyone is supposed to practice proper hand hygiene because residents could get sick if hand hygiene is not used. He stated all staff are required to wash hands when changing tasks, when they enter the kitchen and when they change gloves. All staff are required to wear gloves when they are prepping food or serving food at the steam table. DM stated he was not aware that [NAME] E failed to wash hands prior to donning gloves for the puree and that staff failed to wash hands prior to entering Kitchen # 2.During an interview on 07/01/26 at 2:33 p.m., DON stated she has been employed here since May 22, 2026, and her duties are to oversee nursing services, and she is over infection control for the facility. She stated it is her expectation that staff are to wash hands between any type of contact or when staff are changing rooms. She stated, if staff failed to wash hands there could be widespread infection. She stated it is the policy that kitchen staff should wash hands when preparing food. She stated, they should use gloves when handling raw food and they should wash hand between tasks. She stated kitchen staff should use gloves when dealing with raw food and if food is taken out of a package. She stated the DM is responsible for kitchen staff hand hygiene practices.During an interview on 07/01/2026 at 3:00 p.m., ADM stated, he has been employed at this facility since January 2026, and his duties are to make sure residents are safe and taken care of. ADM stated his expectation is that staff follow guidelines for handwashing and hand hygiene. ADM stated, he believed hand hygiene requirements are included in the food handlers permit training.Record review of Nutrition Policies and Procedures dated 10/15/2025 reflected:Subject Sanitation & Food Safety in Food and Nutrition ServicesPolicy The Certified Dietary Manager will assume responsibility for the food safety and sanitation of the Nutrition Culinary Department.Procedures:1.Infection control and sanitation practices are followed to minimize the risk of contamination of food and prevent food borne illness.4. The DM monitors food safety and sanitation in the Food and Nutrition Department daily. Record review of Nutrition Policies and Procedures, dated 10/15/2025 reflected:Subject: Hand Hygiene/ Hand WashingPolicy: Hand hygiene is the most important component for preventing the spread of infection. Proper washing techniques will be used when hand washing is indicated. Employees keep their hands and exposed portions of arms clean.Procedures:1.Clean hands in a hand-washing sink. Hands may not be cleaned in a sink used for food preparation.2.Wash Hands:A.When hands are visibly soiled.B.Before starting work.C.Before putting on gloves, when changing into a fresh pair of gloves, and immediately after removing gloves. Before handling or eating foodJ. After contact with soiled or contaminated articles.3. Wash hands with soap and water when hands are visibly dirty, contaminated, or soiled. Antimicrobial gels cannot be used in place of proper hand-washing techniques in a food service setting. ( this refers to in the kitchen and food preparation but not to passing of trays.) Record review of Infection Prevention and Control Policies and Procedures dated 05/15/2023 reflected:Subject: Indications for Glove UsePolicy The facility recognizes and implements Standard Precautions. The use of enhanced and transmission-based precautions is implemented as clinically indicated and recommended by health authorities.Gloves are provided as a barrier for protection from . likely to soil the hands. Procedures:Gloves are worn when:3.Handling items or environmental surfaces that are or are likely soiled .4.Hand hygiene is performed prior to donning gloves.

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain personal hygiene for 1 of 20 residents reviewed for ADLs. (Resident # 99).The facility did not provide Resident #99, who required extensive assistance with bathing, with a shower/bath on scheduled days of 6/17, 6/19, 6/22, 6/24, 6/26 and 6/29/26. This failure could affect residents who received activities of daily living help from facility staff by placing them at risk for loss of dignity and self-worth, skin breakdown and discomfort.Record review of Resident #99's face sheet dated 07/01/26 revealed resident was a [AGE] year-old female with an initial admission date 06/17/26.Record review of Resident # 99's health and physical dated 06/17/2026 revealed medical diagnoses of displaced bimalleolar fracture of left lower leg ( is a serious ankle injury in which both the inner tibia and outer fibula are broken, and the bone ends are out of alignment) sequela (a condition which is the consequence of a previous disease or injury), Insomnia (is a common sleep disorder that can make it hard to fall asleep or stay asleep), and hypertension (High blood pressure ). Record review of Resident 99's MDS dated [DATE] revealed Resident # 99 had a BIMS score of 13 indicating cognition was intact, with normal thinking and memory (no cognitive impairment). Section GG - Functional Abilities notated Resident # 99 required substantial/maximal assistance and was dependent, meaning the helper does more than half or all the effort to complete bathing and showering activities. Record review of Resident # 99's care plan dated 6/30/2026 indicated Resident requires assistance of 1 person to complete ADLs. The goal was Resident will complete ADLS with assistance and staff are not to rush the resident and to allow extra time to complete ADLs. Record review of Physician order dated 06/24/2026: Bathing (Bath/Shower/Days/Shift): M W F 2:1 . Record Review of Point of Care History: Shower log from 6/17/2026 through 6/30/2026 revealed that on 06/26/2026 at 4:43 p.m., shower was offered to Resident # 99, and it was refused and no other recorded dates of showers having been offered to Resident # 99 or having been received by Resident # 99. During an observation and attempted interview on 06/29/2026 at 1:00 p.m., Resident # 99 was mobilizing herself using her wheelchair to enter the bathroom in her room. Resident stated she was getting ready for a doctor's appointment, and she did not have time to talk now.During an interview and observation on 06/30/2026 at 9:04 a.m., Resident # 99's left ankle was covered due to a recent ankle surgery. She said it has been difficult maneuvering around and she has been able to get stronger through the help of physical therapy. Her goal is to get back to her home and be back to her normal self and to be independent. At this moment she has limited motion and does not want to push herself and have another injury. She said she has not had a shower due to her ankle injury, and she is not getting wet. She said she is not getting a sponge bath and would like to have those. She would like her hair washed and said her hair is gunky and makes her feel gross.During an interview on 06/30/2026 at 4:03 p.m., LVN I stated the shower schedules were in a binder behind the front desk for 400, 500, and 600 halls. LVN I said she was with Agency and was not sure of showers offered or refused by residents. She said she does not have full access or know where to look in the patient's chart.During an interview on 06/30/2026 at 4:09 p.m., ADON A said she was not aware of the issue with showers not being given or offered for Resident #99. She did report that showers for Resident #99 are scheduled for Monday, Wednesday, and Fridays and immediately wanted to go check on patient due to not having heard a report from the patient either on the shower issue. ADON A said neither Resident # 99 nor staff reported any issues, and she would look in the daily charting for the resident on her laptop. She reported that she was not sure if agency were not giving or offering Resident # 99 her scheduled showers. She said agency may not know where to log if a shower was given or refused. She was able to pull up the shower log data ranging from 06/17/26- 6/30/26 in her laptop and there was 1 recorded shower as refused, and no other showers were recorded or refused. ADON said if patient is not showered or bathed it can cause breakdown of skin and it is a dignity issue for the resident. She said agency staff or nursing staff would be educated again on showers, bathing, or bed bath and educated on where and how to log offered, given or refused in the kiosk or laptop.During a follow up interview on 06/30/2026 at 4:43 p.m., ADON A said she spoke to Resident #99 and patient said to her she had not received a shower since being admitted to facility and patient reported 1 staff went to her room [ROOM NUMBER] day and offered to shower her and patient accepted but that the 1 staff never came back again. ADON A said she wrapped up her leg and was currently in the shower in her room and patient did not refuse.During an interview on 07/01/2026 at 10:39 a.m., Resident # 99 stated she is doing good; she received her shower on 06/30/2026 in the evening and she got a good shower and feels very clean and said her hair is fluffy and she slept better than she has in a while. She was smiling from ear to ear. She reported a staff woman came to her and said you should have told me you had not been receiving yours showers instead of telling the other lady . She said there were 2 ladies that transferred her to the shower chair and one staff lady that helped to shower her in areas she could not reach and helped to wash her hair and said she took her time and did not make her rush, she was also happy the staff helping her was a woman and not a man. During an interview on 07/01/2026 at 11:28 a.m., CNA C said she is full-time with the facility and her normal shift is 6 AM- 2 PM . The shower list is odd room numbers are scheduled to receive showers Monday, Wednesday, and Friday and even room numbers are scheduled for Tuesday, Thursday and Saturday. Patients that are scheduled for showers, bed bath, sponge bath usually know their days and if the patient refuses for any reason, then the CNA on that scheduled shower day and time are to record in the patient chart in the kiosk. She said there are multiple kiosks down all the halls and between the patient's room(s). She said if a resident refuses a shower staff are to report that to the nurse, and the nurse will also ask resident unless the resident is leaving for an appointment or with family and that is noted in their chart as not given for one of those reasons. She said if showers are not recorded properly there is a risk that patients could have skin issues like breakdown and patients can become embarrassed and not want to go out for activities or be social with other patients and want to stay in their rooms, so showers are important to every patient. During an interview on 07/01/26 at 2:33 p.m. DON stated she has been employed at this facility since 05/22/2026 and her duties include overseeing nursing services. She stated she was a resource for the nursing staff regarding clinical insights. Two requests were made to DON for copies of the facility's shower policy, and the policy was not provided during this survey. DON stated, they have a premade assignment of shower days for each resident. She stated that residents' records are updated to try and accommodate residents' preferences for shower times and days. DON stated ADONs are responsible for making sure the residents are showered according to the care plan. She stated the care staff, CNAs, perform the showers for the residents. DON stated her expectation is that residents will be bathed per the schedule on the care plan. She stated the residents could have body irritation, skin breakdown or overall uncomfortableness if they do not receive shower. During an interview on 07/01/2026 at 3:00 p.m., ADM stated he has been employed at this facility since January 2026. ADM stated his duties include overseeing operations of the building and making sure residents are safe and taken care of. ADM stated residents have a right to have self-determination. ADM stated that he expects staff to follow the shower schedule and that CNAs are responsible for showering the residents. ADM stated some residents refuse showers. ADM stated, I am not aware if there is a written policy regarding showers. ADM answered the question presented, what could happen to a resident if they do not get a shower? He stated, I expect them to follow the care plan.Record Review of MDS for Resident #99 dated 06/21/2026 reflected:Activities of Daily Living, Optimal FunctionActivities of daily living, refer to tasks related to personal care including grooming, dressing, oral hygiene, transfer, bed mobility, eating, bathing and communication system. Policy:The Facility provides care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. The Facility provides necessary care to all residents that are unable to care out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene.Procedures:1.Facility staff recognize and assess an inability to perform ADLs or a risk for decline in any ability to perform ADLs by reviewing the most current comprehensive or most recent [NAME] assessment. 2.Facility staff monitor conditions which may cause an unavoidable decline in the resident's ability to perform ADLs.3.Facility staff develop and implement interventions in accordance with the residents' assessed needs, goals for care, preferences and recognized standards of practice that address the identified limitations in ability to perform ADLs.4.Facility staff review Physician's orders for therapy and restorative, if applicable.

Based on observations, interviews, and record reviews, the facility failed to ensure the residents received services with reasonable accommodation for each resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 7 of 12 residents (Residents #3, #63, #76, #18, #04, #12, and #54) reviewed for call light accessibility. The facility failed to ensure the call light system was accessible to Residents #3, #63, #76, #18, #04, #12, and #54.This failure could place residents at risk of not being able to call for staff assistance to meet care needs or at risk of injury or pain.Findings included: Record Review of Resident #3's face sheet dated 07/01/2026 reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included cerebrovascular disease (condition that affects blood flow to the brain), diabetes, legal blindness, aphasia (language disorder), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (paralysis on one side of the body after a stroke), epilepsy (seizure disorder), acute respiratory failure with hypoxia (insufficient oxygen levels), and chronic respiratory failure with hypercapnia (elevated levels of carbon dioxide in the blood), history of falling, and contracture (stiff joints of right hand). Record Review of Resident #3's Quarterly MDS dated [DATE] and 06/17/2026 reflected Resident #3 was non-verbal, vision was severely impaired, and no BIMS score was listed because resident was rarely/never understood. She was dependent on all tasks and activities. She had a feeding tube and received oxygen therapy. Record review of Resident #3's care plan dated 06/22/2026 reflected the resident was at high risk for falling and had impaired vision related to legal blindness. Interventions included: Keep call light within reach at all times. Record Review of Resident #63's face sheet dated 07/01/2026 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included dementia, hemiplegia and hemiparesis (paralysis on one side of the body), aphasia (language disorder), chronic kidney disease, dysphagia following cerebral infarction (difficulty swallowing after a stroke), epilepsy (seizure disorder), and multiple bone and muscle contractures to multiple sites throughout the body (elbows, left shoulder, upper arms, hands, and knees). Record Review of Resident #63's Quarterly MDS dated [DATE] reflected Resident #63's hearing was highly impaired, she was non-verbal, and no BIMS score was listed because resident was rarely/never understood. She was dependent on all tasks and activities. She had a feeding tube. Record review of Resident #63's care plan revised on 06/29/2026 reflected the resident was at risk for falling related to impaired mobility and hemiplegia. Interventions included: Keep call light within reach at all times. Record Review of Resident #76's face sheet dated 07/01/2026 reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (stroke) pressure ulcer of right buttock, chronic pain, non-pressure chronic ulcer of other part of left lower leg, chronic embolism and thrombosis of unspecified deep veins of lower extremity, bilateral, (blood clots in both legs), and hemiplegia (paralysis on one side of the body). Record Review of Resident #76's admission MDS dated [DATE] reflected Resident #76's BIMS score was 07, indicating a severe cognitive impairment. She was on continuous oxygen therapy and was prescribed opioids (narcotic pain medication). She was dependent on all tasks and activities, except for eating and oral hygiene she required maximal assistance with. Record review of Resident #76's care plan dated 06/30/2026 reflected the resident was at risk for falling related to impaired mobility and limited in ability to transfer self-related to stroke. Interventions included: Keep call light within reach at all times. Record review of Resident #18's Face sheet dated 07/01/2026 indicated that the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included type two diabetes (high blood sugar) with diabetic neuropathy (acute pain), protein malnutrition (losing muscle mass and fat), chronic kidney disease stage three (kidney damage), acute pain, and cognitive communication deficit (memory, processing speed).Record review of Resident #18's Quarterly MDS dated [DATE] reflected a BIMS of 6, indicating severe cognitive impairment. He was dependent on all tasks.Record review of Resident #18's care Plan dated 5/22/2026 reflected Resident #18 had impaired mobility. Interventions included: Keep call light within reach at all times.Record review of Resident #4's Face sheet reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included anemia (lacks enough healthy red blood cells), major depressive disorder with psychotic symptoms, hyperlipidemia (high levels of lipids and fats), and high blood pressure.Record review of Resident #4's quarterly MDS dated [DATE] revealed resident had a BIMS score of a 09 which revealed moderate cognitive impairment. He was dependent on all tasks.Record review of Resident #4's Care plan revised on 5/06/2026 reflected Resident #4 was at risk for falling related to impaired mobility. Interventions included: keep call light within reach at all times.Record review of Resident #12's face sheet reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: Heart disease (heart's ability to pump blood ), acid reflux disease (stomach acid flows backward into the esophagus), and muscle weakness.Record review of Resident #12's Quarterly MDS dated [DATE] reflected Resident #12's BIMS was a 7 which indicated severe cognitive impairment. He was dependent on all task and activities.Record review of Resident #12's Care plan revised on 4/08/2026 reflected Resident #12 was at risk for falling related to impaired mobility. Interventions included: Keep call light within reach at all times.Record review of Resident #54's Face sheet reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included the following: shortness of breath, localized swelling, mass and lump, and dementia (progressive decline in mental and cognitive abilities).Record review of Resident #54's Quarterly MDS dated [DATE] reflected that Resident #54 did not have a BIMS because of the dementia diagnoses .Record review of Resident #54's care plan, revised on 5/15/2026, reflected that Resident #54 has as evidenced by poor decision-making and dementia. During an observation and interview on 6/29/2026 at 10:49 AM with Resident #54, his call light was behind the bed, out of reach. He stated he does not know how long the call light had been behind the bed. He stated that he did not realize the call light was on the floor. He stated he does not use the call light often. He stated he has not had any falls due to staff not coming to help him.During an observation on 06/29/2026 at 12:08 p.m. and 2:39 pm. , Resident #3 was asleep in bed with oxygen nasal cannula in place and feeding tube. Resident #3's call light was observed hanging off the side of the bed tucked between the bed rails and the bed frame and out of reach. Resident #3 was noted to be non-verbal and not interviewed. During an observation on 06/29/2026 at 12:11 p.m. and 2:40 p.m., Resident #63 was asleep in bed. She had bilateral contractures of both hands with a towel in her left hand. Resident #63's call light was observed hanging off the back of her bed, touching the floor, and out of reach. Resident #63 was noted to be non-verbal and not interviewed.An observation and interview on 6/29/2026 at 12:25 PM with Resident #12 revealed his call light was in his bedside table drawer. He was not really able to answer questions. Resident #12 family member stays in the same room with him. The family member stated that he is blind and does not know how to use the call light because he cannot see the buttons on the call light. The family member stated that if he needs any help, she will use a call light for him. An observation and interview on 6/30/2026 at 9:19 AM with Resident #4 revealed he was in his wheelchair and the call light was behind the bed, close to the floor. He was not able to reach the call light in his wheelchair or if he was in the bed. He stated he has not had any injuries from staff not checking on him because he could not use the call light.An observation and interview on 6/30/2026 at 9:23 AM with Resident #18 revealed his call light was behind the bed and not close to the resident. He stated he does not use the call light. He stated falls or injuries from not being able to use the call light .During an observation on 06/29/2026 at 2:17 p.m. and 06/30/2026 at 9:26 a.m., Resident #76's call light was observed underneath the bed and out of reach. The resident was asleep in bed with oxygen nasal cannula in place. During an observation and interview on 06/30/2026 at 9:34 a.m., CNA D searched Resident #76's bed for the call light, located it underneath the bed, and placed it in the resident's hand. CNA D stated the call light was not within reach and all residents' call lights should always be accessible so residents could call for help. She stated she had been trained in call light placement and that staff were responsible for checking call lights during rounding at least every two hours. She stated a call light out of reach could result in falls or unmet needs.During an observation and interview on 06/30/2026 at 9:38 a.m., Resident #76 stated she used her call light but was unaware it had been underneath the bed. She complained of pain, grimaced, and was unable to continue the interview due to distress. She was being assessed by LVN K.During an interview on 06/30/2026 at 9:41 a.m., LVN K stated all call lights should always be within reach. She stated a call light out of reach could prevent residents from alerting staff, resulting in unmet needs or delayed care. She stated Resident #76 could not have reached the call light where it was lying behind the bed. She stated the resident became anxious and pulled at covers, and the call light may have fallen. She stated that she was not sure why the residents call light was not close to the residents. She stated staff were trained to check call lights anytime they entered a room and during rounding at least every two hours.During an interview on 06/30/2026 at 10:06 a.m., ADON B stated it was her expectation that all call lights be within reach. She stated a call light out of reach could cause delayed care or treatment. She stated staff had been trained in call light placement and she was developing an in service training . She stated staff were responsible for checking call lights during rounding at least every two hours.During a telephone interview on 06/30/2026 at 11:39 a.m., Resident #3's family member stated she did not think the resident used her call light or knew where it was due to blindness and paralysis. She stated she had a camera in the resident's room and received alerts when staff entered.During an interview on 07/01/2026 at 2:22 p.m., the DON stated it was her expectation that all call lights be readily available and within reach. She stated residents unable to reach their call lights could not call for help or express needs, and could fall or be injured attempting to reach the call light. She stated staff had been trained in call light placement and were responsible for checking call lights before exiting a room and during rounds at least every two hours.During an interview on 07/01/2026 at 2:55 PM, ADM stated that call lights should be kept within reach of the resident at all times. He stated that staff are expected to make rounds at least every two hours and ensure that the call light is within reach of the resident. He stated he was unaware of any negative outcome if this was not done. He only stated that staff are expected to check on residents to ensure their call lights are within reach.Record review of the facility policy titled Patients and Residents revised on 12/20/2024 reflected:Call bells, lights, and drainage bags are not to be attached to the bed rails. The call-light is to be easily accessible to the patient.

Based on observation, interview, and record review, the facility failed to ensure each resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three resident reviewed for accidents. CNA A failed to get assistance while providing care for Resident #1 who was a 2 -person assist. CNA A and the MDS Nurse failed to lock Resident #1's bed and Geri chair (a specialized, highly padded recliner on wheels) while transferring Resident #1 via mechanical lift from the bed to the Geri chair. This failure could place residents at risk for falls, injury and hospitalization.Findings included:Review of Resident #1's face sheet, dated 06/16/2026, reflected a [AGE] year-old male, admitted [DATE] and readmitted on [DATE], with diagnoses that included Quadriplegia (the partial or total paralysis of all four limbs (both arms and both legs) and the torso), Unspecified intracranial injury with loss of consciousness (a medical term used to classify a traumatic brain injury (TBI) where there is a confirmed loss of consciousness, but the specific location or exact type of brain damage has not been completely determined), Generalized anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry about everyday topics like health, money, and work), Contracture of muscle (a chronic shortening or tightening of muscles, tendons, or skin that restricts normal joint movement); Contracture of muscle, left upper arm; Contracture of muscle, right upper arm.Record review of Resident #1's care plan, dated 06/03/2026, reflected Resident #1 was at risk for falling related to immobility and muscle weakness, TBI. It also reflected Resident #1 had contractures to bilateral hands and elbows, ADL Functional Status/Rehabilitation Potential required total assistance with all ADLs, Hoyer transfer X 2 person, had acute (something characterized by sharpness, sudden onset, or high intensity) and chronic pain R/T quadriplegia, cancer, pressure ulcers, intracranial injury, impaired mobility.Record review of Resident #1's quarterly MDS assessment, dated 04/14/2026, reflected a BIMS score of 10 indicating moderate cognitive impairment. Section GG-Functional Abilities reflected Resident #1's mobility device was a wheelchair and upper and lower extremities impairment on both sides. Section GG also reflected, Resident #1, roll left and right (The ability to roll from lying on back to left and right side, and return to lying on back on the bed.), sit to lying position (The ability to move from sitting on side of bed to lying flat on the bed) and Chair/bed-to-chair transfer (The ability to transfer to and from a bed to a chair (or wheelchair) were coded as 1 indicating Resident #1 was Dependent - Helper does ALL of the effort. Residents do none of the effort to complete the activity, or, the assistance of 2 or more helpers was required for the resident to complete the activity.During an observation on 06/16/2026 at 09:53 a.m. through 10:17 a.m., CNA A was noted coming from Resident #1's room and stated she had gotten Resident #1 dressed and ready for the day and she was going to get assistance for a mechanical lift transfer. CNA A left the room and returned with MDS Nurse. Surveyor asked to look at Resident #1's buttocks area for wounds, CNA A asked MDS Nurse to wait outside while she provided care. CNA A was observed using the draw sheet to pull Resident #1 to the center of his bed, CNA A rolled Resident #1 onto his right side all by herself without assistance, pulled his pants with one hand while the other hand was on Resident #1's hip area. Resident #1 was in a side lying position, both arms contracted and up to his face. Resident #1 did not participate or assist in stabilizing himself while on his right side. When done, CNA A asked the MDS Nurse to help transfer Resident #1 from his bed to his Geri chair. While CNA A was getting the sling connected to the mechanical lift, she unlocked Resident #1's bed to move the bed and did not lock the bed back. CNA A was controlling the mechanical lift while the MDS Nurse was standing at the back of Resident #1's Geri chair. It was observed Resident #1's bed started to move once Resident #1 was being lifted and when CNA A was lowering him into the chair, the geri chair started to move. The MDS Nurse was focused on stabilizing the chair from moving, Resident #1's right foot slipped between the footrest and the sideboard of the chair. During an interview on 06/16/2026 at 11:26 a.m., CNA A stated she worked at the facility PRN. CNA A stated usually she asked other staff and the nurses to know how much assistance a resident needed. CNA A stated there was a place to look in the residents charting to know how much care to provide but she did not know how to look and she did not ask for help on how to look at the POC before providing care. CNA A stated Resident #1 may require 2 people with ADLs, because he had gained weight. CNA A stated Resident #1 was at risk of rolling out of the bed, falling and getting hurt when she provided care by herself. CNA A stated it was not safe for one person to provide care for Resident #1. CNA A stated two staff were required for mechanical lift transfers. She stated safety measures were to make sure there were two staff, lock the bed and chair, one person was operating the lift while the other person was guarding the resident into the bed or chair to prevent injury. CNA A stated during the transfer of Resident #1 from bed to his geri chair, his chair was not locked, she expected the MDS nurse to lock the geri chair since she was standing behind the chair. CNA A stated the second person was supposed to angle the resident but Resident #1's leg was not angled correctly that is why it fell. CNA A stated Resident #1's leg could have hurt badly. CNA A stated not locking the bed or chair placed the resident at risk for falls and, dropping from the lift. During an interview on 06/16/2026 at 11:45 a.m., the MDS Nurse stated Resident #1 needed maximal assistance with ADLs. The MDS Nurse stated she was not familiar with how much assistance Resident #1 needed but for residents who were dependent, they needed 2-persons assist because they were totally dependent. The MDS Nurse stated the risk of turning Resident #1 with one person, from side to side in the bed, were falls, for safety reasons we need 2-persons. The MDS nurse stated CNAs could ask the nurses and other CNAs to know how much assistance was needed to provide car for a resident. The MDS Nurse stated, usually it was two people for mechanical transfers, one person maneuvering the lift while the other person positioned the resident. The MDS nurse stated staff were to ensure the bed and the chair were locked before transferring the resident. The MDS Nurse stated they were told not to lock the chair because it was difficult to maneuver the chair while locked, that was why she did not lock Resident #1's chair. The MDS Nurse stated the bed was supposed to be locked so it did not move during the transfer and that she attempted to lock the bed but did not know that it did not lock. The MDS Nurse stated, when CNA A was controlling the mechanical lift, she was supposed to position Resident #1 and made sure he got on the chair safely. The MDS Nurse stated Resident #1 could have had an injury to his leg. During an interview on 06/16/2026 at 2:10 pm, the ADON stated the CNA A knew how much help to provide to a resident by asking the nurses, there was a sheet at the nurse's station, walking rounds and POC charting for CNAs. The ADON stated Resident #1 required 2-persons assist because he was quadriplegic, stiff and it was difficult for staff to perform care all by themselves. The ADON stated, if Resident #1 was being rolled from side to side, one staff should do the rolling or turning while the other staff was there to ensure safety, one person rolling Resident #1 from side to side could cause him to fall. The ADON stated 2 staff were required for mechanical lift transfers. She stated safety measures were to make sure to have the second person, right size of sling, everything positioned correctly, and bed locked. The ADON stated the geri/wheelchair was not supposed to be locked because when you were transferring the resident and the chair was not positioned correctly, it was easy to reposition the chair. The ADON stated you could maneuver the Resident and the chair at the same time, by tilting the chair back or moving it to the side. The ADON stated, if the staff felt comfortable locking the chair, they could. The ADON stated, if the chair was not locked while placing the resident in the chair, the chair could move, the resident could fall and the risk was on the resident and the staff because that was a moving chair with the staff standing behind it. During an interview on 06/16/2026 at 2:36 pm, the DON stated Resident #1 required 2-person assist with bed mobility because he was a quadriplegic and was not able to help or participate in his care when rolling from side to side. The DON stated 2 staff were needed for mechanical lift transfer. The DON stated the only thing that should be locked at all times was the mechanical lift, and only thing that was not locked during a t transfer was the wheelchair. The DON stated one person stood behind the chair and the wheelchair could be moved but the mechanical lift cannot be moved during the transfer. The DON stated the bed should be locked. The DON stated the person behind the wheelchair is holding the chair maneuvering the wheelchair as well as the patient. She stated, sometimes the patient moves while in the lift, they flex and can be moved, if you have a locked wheelchair, you could be struggling to get the patient in the chair. The DON stated when you start to bring down the sling with the patient, patients get startled and push back, spring forward, you have the ability to also move the chair as well as guide the sling. The DON stated she would let the wheelchair move for the safety of the residents. She stated to lock the mechanical lift so that it stayed in the area of where they are and lock the mechanical lift for safety. During an interview on 06/16/2026 at 3:53 pm, the DOR/PT stated she would sometimes do training for nursing staff as needed for residents receiving skilled nursing services. The DOR/PT stated mechanical lift transfers were always 2-persons assist. The DOR/PT stated some safety measures were to have 2 people, make sure the sling is placed appropriately, the bed is locked, the chair is positioned properly, the chair is locked. The DOR/PT stated, if staff needed to position the chair correctly then make sure the patient was safe, unlock the chair, move the chair to the preferred position, and then lock the chair before bringing the resident back down. She stated if the chair was unlocked, the chair might tilt and the patient would fall back. She stated, for me as Therapy staff, my first goal was always resident safety. She stated the Therapy Department was third party, so they had different policies from the facility. Record review of the facility's policy titled, Activities of Daily Living, Optimal Function, dated 05/05/2023, reflected, DEFINITION:Activities of daily living (ADLs), refer to tasks related to personal care including, grooming, dressing, oral hygiene, transfer, bed mobility, eating, bathing and communication system.POLICY:The Facility provides care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. The Facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene.PROCEDURES:Facility staff recognize and assess an inability to perform ADLs, or a risk for decline in any ability to perform ADLs by reviewing the most current comprehensive or most recent quarterly assessment;Facility staff develop and implement interventions in accordance with the resident's assessed needs, goals for care, preferences and recognized standards of practice that address the identified limitations in ability to perform ADLs. Record review of the facility's policy titled, Mechanical Lifts, General Guidelines dated 05/05/2023, reflected: Policy:The Facility may employee the use of mechanical lifts to assist with transfers to ensure the safety of patients, residents, and staff.SCOPE:Mechanical lifting equipment includes any permanently mounted or portable/floor-based lifts that may be either powered or manual, used to transfer or move patients/residents.PROCEDURE:Prior to staff using any mechanical lift device, competence must be documented in the safe and appropriate use of the equipment per policy and manufacturer guidelines specific to the device.Mechanical lifts may be used for the enhanced safety of patients, residents and staff in situations including but not limited to:A Lifting from floor.B. Bed to chair transfer.C. Lateral transfer.D. Toileting and bathing.E. Repositioning.F. Sit or laying - to stand. 3. Prior to initiating use of mechanical lift for a patient or resident: A. Evaluate patient/resident ability to assist with transfer.B. Validate patient/resident weight is within operating parameters for the mechanical lift and associated equipment.C. Determine how many caregivers are necessary to safely lift the patient or resident. In most cases and for safety, a minimum of 2 caregivers is recommended.D. Evaluate patient/resident for:1) Medical stability, when appropriate.2) Ability to follow instructions: awake, alert.3) Readiness for transfer.E. Evaluate for appropriate sling size, when used.1) Slings too large may allow the person to slip out of the sling.2) Slings too small may allow a person to fall out of the sling.3) If between sizes, choose a smaller size for a snugger fit.F. Choose the correct sling based on manufacturer recommendations and the following criteria:1) Type of transfer task.2) Medical condition.3) Size and weight.4) Pressure sensitivity.

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices during a mechanical lift transfer for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to ensure Resident #1 was transferred per mechanical lift by two people. CNA A transferred Resident #1 from his bed to his motorized wheelchair without the assistance of another person. This failure could place the residents at risk of not receiving the care and services to meet their needs and puts them at risk for injury. Findings included: Review of an undated face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included cerebral palsy (a neurological condition that affects movement and posture, caused by abnormal brain development or damage to the brain, often occurring before or during birth.), hemiplegia, affecting the right dominant side (Hemiplegia is a symptom that involves one-sided paralysis. Hemiplegia affects either the right or left side of your body.), and , borderline intellectual functioning (refers to cognitive abilities that fall between average intellectual functioning and intellectual disability, typically characterized by IQ scores ranging from 71 to 84.). Record review of Resident #1's Minimum Data Set, Significant change in status assessment, dated 11/01/25, reflected a previous BIMS score of 15, which indicated no cognitive impairment. Record review of Resident #1's Quarterly Minimum Data Set Assessment, dated 09/05/25, reflected a BIMS score of 15, which indicated no cognitive impairment. Section GG Functional Limitation in Range of Motion reflected an impairment in bilateral (both left and right side) upper and lower extremities. Section GG further reflected Resident #1 used a an electric scooter for mobility and required the assistance of 2 or more helpers to complete activities of daily living, including chair/bed-to-chair transfers. Record review of Resident #1's Care Plan, dated 10/23/25, reflected the following:*Problem: ADLs Functional Status/Rehabilitation Potential - Resident #1 prefers to be out of bed daily by 9:00 AM. Resident #1 requires assistance with activities of daily living related to cerebral palsy, limited mobility, and debility.*Goal: Resident to be out of bed daily by 9:00 AM. He will maintain a sense of dignity by being clean, dry, and odor-free and well-groomed. *Approach: Resident #1 to be transferred from bed-to-chair and chair-to-bed with the assistance of two people and a mechanical lift. An interview on 10/23/25 at 3:19 PM with Resident # 1 revealed in the morning of 10/19/25, CNA A used the mechanical lift by himself to transfer him from his bed to his motorized wheelchair. Resident #1 stated this made him feel unsafe. He stated he knew what the rules were, and that staff were supposed to do mechanical lift transfers with two people assisting. Resident #1 stated he had not fallen from the mechanical lift, nor had he been injured during the one-person mechanical lift transfer on 10/19/25. Resident #1 revealed after breakfast on 10/19/25 he had gone outside, and as he was moving along the sidewalk he fell to the left side onto the pavement and on his face. Resident #1 stated and demonstrated to this writer how the strap of his blue mechanical lift vest had gotten tangled in the left wheel of his motorized scooter. Resident #1 stated he had just returned from an orthopedic appointment, and the doctor told him he no longer needed to wear a left arm sling. He stated he had injured his left shoulder when he slid out of his motorized scooter in the morning of 10/19/25. An observation on 10/23/25 at 3:19 PM of Resident #1 revealed he was clean and well-groomed and was seated in his motorized scooter with his blue mechanical lift vest in the seat underneath him. The straps of the vest were tucked in. An interview on 10/23/25 at 3:49 PM with Resident #1's RP revealed the facility had left a message for her on 10/19/25 around 8:30 AM. She stated they informed her Resident #1 had gone outside after his breakfast and had fallen from his scooter. She further stated if you talk with Resident #1, he will tell you that a strap had gotten caught in the wheel of his power scooter wheel, and that was what made it tip over and he had slid out of it an onto the ground. The RP stated she had not been aware of Resident #1 being transferred in the mechanical lift in the morning of 10/19/25 by one staff member. Review of a progress note dated 10/19/25 at 9:15 AM reflected LVN A was informed Resident #1 had fallen outside the building at approximately 8:15 AM. Upon arrival to the scene, LVN A observed Resident #1 lying face down on the ground with his scooter next to him with his right arm positioned next to his right side and his left arm was pinned across his chest. A small amount of blood was noted on the right hand. Resident #1 sustained skin tears on tip of his right hand and facial area. He was alert and oriented times 4. EMS was called; advised not to move resident until EMS arrival due to possible fracture. The ADM, the DON, and the ADON were notified via text and phone calls. The RP was notified and LVN A spoke to the RP. Resident #1 was sent to the hospital on [DATE] at approximately 9:00 AM. Review of a progress note dated 10/19/25 at 12:49 PM reflected Resident #1 returned from the hospital at 12:30 PM via EMS transport. His diagnosis was a left shoulder fracture, and pain medication was Hydrocodone 5/325mg 1 tablet by mouth every 4 hours as needed for pain. The ADM, the DON, and the RP were notified of his return to the facility. An interview on 10/23/25 at 4:37 PM with ADON A who stated she had done one-on-one training with all staff members on mechanical lift transfers. ADON A further stated monitoring included going in behind the staff and watching at least one mechanical lift transfer per day. She stated that sometimes therapy can assist with training. ADON A stated CNA A had been involved in assisting Resident #1 up on 10/19/25. She stated CNA A had been a good worker, was very respectful, and they had just conducted training with him a couple weeks ago. Review of a Wheelchair Safety Checklist dated 10/20/25 reflected the wheelchair was in good working condition and was safe to operate. Review of Safety Skills Assessment for Power Wheelchair/Scooter dated 10/21/25 reflected the power scooter had no seatbelt, Resident #1 was able to turn the device on/off independently, occasionally cuts corners too close, and going onto the narrow sidewalk may be questionable. In summary, Resident #1 was safe to use the power scooter. An interview on 10/23/25 at 5:40 PM the DON stated she had come in on Sunday, 10/19/25, after being notified of the incident of Resident #1 sliding out of his motorized scooter outside. The DON stated Resident #1 frequently strolled around outside in his motorized scooter. The DON further stated CNA A had suddenly not shown up for his scheduled shifts and to date had not answered the facility's phone calls. The DON stated CNA A's last shift worked was on Sunday, 10/19/25 on the 6am - 2pm shift. He further stated CNA A had been a no-call/no-show on Monday 10/20/25, and today 10/23/25.The DON stated she and the ADON's were responsible for ensuring and monitoring staff were conducting mechanical lift transfers with two person assist, and when staff were not transferring residents with two person assist in the mechanical lift it puts the residents at risk for falls and injuries. An interview on 10/23/25 at 5:55 PM the ADM stated Resident #1 had a history of making his own decisions, and Resident #1 knew his rights . He stated Resident #1 had a BIMS score of 15. The ADM further stated Resident #1 had been re-assessed for motorized scooter safety on 10/20/25 by OT and Speech Therapy after the incident, and it was determined Resident #1 was safe to continue to use the motorized scooter for mobility. The ADM further stated Resident #1 was given a driving exam in the therapy room and outside the facility. The ADM stated Resident #1 frequently strolled around outside in his motorized scooter. The ADM further stated CNA A had suddenly not been showing up for his scheduled shifts and was not answering their phone calls. The ADM stated CNA A's last shift worked was on Sunday, 10/19/25 on the 6am - 2pm shift. He further stated CNA A had been a no-call/no-show on Monday 10/20/25, and today 10/23/25. The ADM stated the DON/nursing was responsible for ensuring and monitoring staff were conducting mechanical lift transfers with two person assist, and when staff were not transferring residents with two person assist in the mechanical lift it puts the residents at risk for a fall and injury. Review of an in-service dated 10/04/2025 reflected CNA A had signed the in-service and received training titled, All mechanical lifts must be performed with two staff members present at all times. Review of an in-service for the policy & procedures and competency check-off dated 10/07/2025 for use of mechanical lifts reflected CNA A had passed the competency check off. The in-service additionally reflected, 1. Identifies patient/resident and introduces self & co-worker to patient/resident (and family, if appropriate). Review of a Power Wheelchair (PW) or Scooter Safety Skills Assessment Supplement, dated 10/20/25, reflected Resident #1 was safe to use PW or Scooter by OTR A and SLP A. Review of facility Policy & Procedure on Use of a Mechanical Lift, dated 07/01/23, which reflected, 1. Identifies patient/resident and introduces self & co-worker to patient/resident (and family, if appropriate).

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals are stored in locked compartments and only authorized persons have access to the keys for 1 of 3 medication carts (MC #1) reviewed for drug storage and labeling.The facility failed to ensure MC #1, was locked, medications secured, and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.Findings included: During an observation on 12/11/2025 at 8:24a.m., MC #1, was on 100-hall and unlocked. RN A was not on the hall while the medication cart was unlocked. MC #1 contained residents' prescription drugs, over the counter medications, and narcotics in a locked box in the medication cart. During an interview with RN A on 12/11/2025 at 10:02a.m., she said she had been trained on medication storage. She said the policy was staff must lock the medication carts any time the medication cart was out of the staff member's sight. She said if staff stepped away or turned their back the staff member was supposed to lock the medication cart. She said the person who was assigned to the medication cart at that time was responsible for ensuring it was locked. She said if left unlocked and unattended another nurse can get into the medication cart, or a resident and family member could get into the cart and take medications. She said everyone monitored to ensure that the medication carts were locked. She said staff monitored the medication carts through observation. She said she left the medication cart unlocked because a resident's lips were turning blue in the dining room and she ran to get her blood pressure cuff and forgot to lock the medication cart. During an interview with the ADON on 12/11/2025 at 1:19p.m., she said she had been trained on medication storage. She said the policy was if the medication cart was out of sight of staff it should be locked. She said the person who was on the medication cart was responsible for ensuring the medication cart was locked. She said all staff monitored to ensure staff were locking the medication cart. She said staff monitored by doing observations. She said if the medication cart was left unlocked and unattended anyone could get into the medication cart and access the medications. She also said the medication could get into the wrong hands and cause a drug diversion. She said all managers monitor to ensure the medication carts were locked. She said the managers monitored day to day by observations. She said that RN A had a situation in the dining room and forgot to lock the medication cart when she got her blood pressure cuff. During an interview with the ADM on 12/10/2025 at 1:30p.m., she said she had been trained on medication storage. She said the policy on the medication cart was that the medication cart should be locked any time staff walk away from the cart. She said the person on the cart was responsible for locking the cart. She said if the medication cart was left unlocked and unattended someone could get into the medication cart and steal medications, or a resident can get into the cart and have an adverse reaction. She said all the managers monitored to ensure staff were locking the carts. She said the managers monitored through observation. She said RN A did not lock the medication cart due to having an emergency and forgot because she was rushing back to the resident. Record review of Medication Labeling and Storage Policy dated 4/2019, revealed The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use.

Based on interview, observation, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 residents (Resident #1) reviewed for quality of care. The facility failed to give Resident #1 his Biofreeze Gel 4% scheduled medication during the standard time frame for 13 days and did not get his Biofreeze Gel at all on 06/19/2025. These failures placed residents at risk of pain, and a decreased quality of life. Findings included: Record review of Resident #1's face sheet, dated 06/23/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: pain in joint, muscle wasting, and type 2 diabetes mellitus with diabetic neuropathy (nerve damage due to diabetes). Record review of Resident #1's Quarterly MDS assessment, dated 04/29/2025, reflected the resident had a BIMS score of 15, which indicated intact cognitive response. Resident #1 required partial/moderate assistance in the areas of toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear. The MDS revealed that the resident had frequent pain, the resident had scheduled and PRN pain medication. Record review of Resident #1's care plan, dated 05/08/2025, reflected Resident #1 was care planned for pain: resident has complaints of chronic pain related to bilateral lower extremity amputee. The approach was monitor and record any complaints of pain: location, frequency, effect on function, intensity, alleviating factors, aggravating factors. Record review of Resident #1's Biofreeze order dated 4/28/2025 revealed the Biofreeze was ordered twice a day at 8:00am and 8:00pm. Apply to bilateral hands with reminder not to touch face, sensitive skin areas, until completely dry. Record review of Resident #1's Medication Administration Record (MAR) for Biofreeze Gel 4% revealed the topical gel was scheduled twice a day at 8:00am and 8:00pm. The MAR revealed that staff gave the resident the cream at the following dates and times. Scheduled Date Scheduled Time Charted Date - Time (GIVEN) 06/10/2025 8:00 AM 06/10/2025 - 10:50 AM 8:00 PM NOT GIVEN 06/11/2025 8:00 AM 06/11/2025 - 10:34 AM 8:00 PM 06/11/2025 - 09:28 PM 06/12/2025 8:00 AM 06/12/2025 - 12:44 PM 8:00 PM 06/12/2025 - 10:36 PM 06/13/2025 8:00 AM 06/13/2025 - 10:35 AM 8:00 PM 06/14/2025 - 12:13 AM 06/14/2025 8:00 AM NOT GIVEN 8:00 PM 06/14/2025 - 10:15 PM 06/15/2025 8:00 AM 06/15/2025 - 10:04 AM 8:00 PM 06/16/2025 - 12:06 AM 06/16/2025 8:00 AM 06/16/2025 - 11:56 AM 8:00 PM NOT GIVEN 06/17/2025 8:00 AM 06/17/2025 - 12:21 PM 8:00 PM NOT GIVEN 06/18/2025 8:00 AM 06/18/2025 - 11:12 AM 8:00 PM 06/18/2025 - 11:24 PM 06/19/2025 8:00 AM NOT GIVEN 8:00 PM NOT GIVEN 06/20/2025 8:00 AM 06/20/2025 - 11:48 AM 8:00 PM 06/20/2025 - 09:08 PM 06/21/2025 8:00 AM 06/21/2025 - 02:20 PM 8:00 PM 06/21/2025 - 09:03 PM 06/22/2025 8:00 AM 06/22/2025 - 09:45 AM 8:00 PM NOT GIVEN 06/23/2025 8:00 AM 0 6/23/2025 - 9:49 AM During an interview with Resident #1 on 06/23/2025 at 10:10 a.m., revealed that Resident #1 would tell the CNAs that he needed his pain medication. He said the aides would never tell the nurse that he needed the pain medication. He stated that he had not gotten his Biofreeze medication for his hands. He said he was going to the nurses' station to ask for the medication. He said he was supposed to get the Biofreeze medication twice a day. He said the staff do not always give him the Biofreeze medication. During an observation of Resident #1 on 06/23/2025 at 10:16 a.m., revealed he was asking the nurse for his Biofreeze medication. During an interview with the NP on 06/23/2025 at 10:52 a.m., revealed that staff was to give scheduled medication within an hour of the scheduled time. She stated that Resident #1's Biofreeze is a scheduled medication and not PRN. She said the negative of him not getting it depends on his pain level. She said she was not sure why staff are giving it to him late. During an interview with the DON on 06/23/2025 at 1:00 p.m., revealed that the times on the EMar for medication was the time that staff charted/gave to the resident. She also said that the time that the medicaiton was entered was the time that it was given. She said that medication was supposed to be given an hour before or an hour after. She said that she had been working with the pharmacy to change the times for giving the medication on Resident #1's hall. She said that medication pass started at 8:00 am on Resident #1's hall. She said that Resident #1 would tell the nurse that he would come to the desk to get the Biofreeze. She said that staff should have been documenting about him not taking when offered. She siad that he was not refusing the medication. She said there would be no negative outcome of not giving Resident #1 his Biofreeze. She said that she was not sure why Resident #1 had been given his medication late everyday for the past 14 days she said she was going to check into it. During an interview with LVN A on 06/23/2025 at 1:15 p.m., revealed she went to Resident #1's room at 8:05 a.m. to give him the Biofreeze gel. She said he told her to let him get up and that he was going up to the nurses' station to get his pain medications and Biofreeze. She said she took the medication back down to Resident #1's room again at 9:49 a.m. She said Resident #1 told her again he was coming. She said Resident #1 did not refuse, he said not right now. She said she did not want to put refused because Resident #1 would take the medication later. She said that if she puts refuse then Resident #1 cannot get the medication. She said by Resident #1 not taking the medication at the time she would take it to him it did put him out of the range for medication administration. She said the policy stated one hour before or one hour after. She said Resident #1 was ordered the Biofreeze twice a day at 8:00 am and 8:00 pm not when Resident #1 wanted to take the medication. She said the times in the administration record is the times that he was getting the medication. She said staff do not follow the doctor order on the Biofreeze. She said she was not sure if she had talked to the doctor or NP regarding the Biofreeze. She said that when the doctor was notified the doctor told her to just give him the Biofreeze. She said that she did not have the doctor write an order stating Resident #1 could have the Biofreeze when he wanted. She said staff was to let the doctor know if when a resident did not want their medication. When asked what could happen if he did not get his cream on time or at all and she responded that he did not go without the Biofreeze. During an interview with the ADM on 06/23/2025 at 2:29 p.m., revealed he had been trained on medication administration. He said the policy was for scheduled medications, ordered at a specific time should be given within the parameters. He said the parameters for medications was one hour before and one hour after. He said the parameters did apply to scheduled creams. He said that the negative outcome depended on the type of medication. He said some medications was not as severe as other. He did say that pain did affect the resident's quality of life. He said Resident #1 would tell the nurse he did not want the medication at the time ordered. He said he would try to get the Biofreeze order changed to as needed. Record review of the Nursing Policies and Procedures Medication Management Program revised May 05, 2023, revealed medications are administered no more than one hour before to one hour after the medication pass time.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one of six residents (Resident #36) reviewed for comprehensive care plans. The facility failed to ensure Resident #36's care plan addressed that the resident received hospice service. This deficient practice could result in a loss of quality of life due to residents receiving improper care. Findings include: Record review of Resident #36's face sheet, dated 3/19/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36 had diagnoses which included COPD (a lung disease which makes breathing difficult), chronic congestive heart failure (the heart is not able to pump enough blood to meet the body's needs), anxiety, pneumonia and type 2 diabetes. Record review of Resident #36's Hospice Informed Consent/Election of Hospice Benefit form, dated 12/31/2024, signed by the POA revealed Resident #36 would be receiving hospice service from [hospice agency] starting on 1/1/2025. Record review of Resident #36's physician orders, dated 1/1/2025, revealed a physician order of Admit to [hospice agency] with admitting diagnosis as COPD. Record review of Resident #36's care plan, dated 1/29/2025, revealed no care plan for hospice service. In an interview on 3/20/2025 at 1:36 PM, the ADON stated hospice service should be care planned because the care plan let staff know how to care for a resident. She stated the risk of a care plan not being up to date could result in residents not getting proper care . In an interview on 3/20/2025 at 1:42 PM, the DON stated if a resident was on hospice, it was considered a change in status. The DON stated she had to update the face sheet, make sure there was an order in place for hospice service, and update the care plan. She stated she and the ADON met every Friday to go over residents, to update their care plans as needed, Record review of the facility's Care plan policy & procedures, dated 5/5/2023, revealed the facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident .the facility will initiate person-centered care plans when the resident's clinical status or change of condition occurs.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food in the dry storage area was kept off the floor. This failure could affect residents by placing them at risk for accumulation of insects and/or rodents causing food-borne illness. Findings included: In an observation on 3-18-2025, at 8:45 AM, in the facility's dry food storage area, one loaf of bagged bread was observed to be on the floor. In an interview with the Dietary Manager on 3-20-2025 at 11:00 AM, it was revealed the Dietary Manager had worked at the facility for one month. The Dietary Manager said that it is all the kitchen staff's responsibility to ensure food in the dry storage area is kept off the floor to prevent cross contamination to the residents. The Dietary Manger stated his expectation was for food to be kept 6 inches off the floor and if food falls on the floor for it to be thrown away in the trash. In an interview with the Dietician on 3-20-2025 at 11:34 AM, it was revealed that the Dietary Manager was responsible to ensure food, in the dry storage area, is kept off the floor. The Dietician stated her expectation for food in the dry storage area was for food to be kept off the floor. The Dietician stated if food falls on the floor, she expected the food to be thrown away. The Dietician stated the potential risk to residents, when food was on the floor, was for cross contamination and food borne illness. In an interview with the Administrator on 3-20-2025 at 2:00 PM, it was conveyed that the facility followed a policy and procedure regarding food kept in the dry storage area of the kitchen. The Administrator said he expected food in the dry storage area to be kept off the floor to prevent rodents from getting into the food. The Administrator stated he expected food to be thrown that fell on the floor. The Administrator said the potential risk to residents, when food is not kept off the floor was that it could create pest control issues. Record review of the facility's Nutrition Policies and Procedures Policy dated 2020 and revised 6-20-2023 stated General Food Storage Guidelines . Dry Storage Guidelines - (focus shall be to keep non-refrigerated foods, disposable dishware, and napkins in a clean dry area, which is free of contaminants.) 1. Store foods at least 6 of the floor .

Based on observation, interview, and record review, it was revealed that 1 of 2 trash dumpsters, reviewed for proper trash containment, was not maintained in a sanitary condition to prevent the harborage of feeding pest. The facility failed to ensure an outside trash dumpster was properly sealed with the lid closed. This failure could place residents at risk of contracting disease by attracting pest and disease carrying rodents. Findings included: During an observation on 3-18-2025 at 9:00 AM, a large trash receptacle, containing trash, was in the back parking lot with the lid open. This trash dumpster was observed to not be in use. In an interview with the Dietary Manager on 8-18-2025 at 9:10 AM, it was conveyed the entire kitchen staff were responsible for keeping the lid closed on the trash dumpster when not in use. The Dietary Manager started that he expected staff to keep the lid closed on the dumpster as there was a risk of debris blowing outside the facility around residents. In an interview with the Dietician on 3-20-2025 at 11:34 AM, it was stated that her expectation was for the garbage dumpster to have its lid closed when not in use. The Dietician said she was not sure who was responsible for ensuring the lid stays closed. The Dietician said the risk to residents for not keeping the trash dumpster lid closed was the accumulation of rodents and insects. In an interview with the Administrator on 8-20-2025 at 2:10 PM, it was revealed that the kitchen staff are responsible to ensure the outside garbage dumpster's lid stayed closed. The Administrator said the risk to residents, leaving a trash dumpster lid open, was the potential for rodents to accumulate. Record review of the facility's policy dated 2020 and revised on 6-20-2023 titled: Nutrition Policies and Procedures stated: Subject: Cleaning Trash Cans Policy: Trash cans are kept covered. They will be maintained in a clean, sanitary conditions .

Based on observation, interview, and record review, the facility failed to protect the resident's right to reside and receive services in the facility with reasonable accommodation of needs and preferences for 1 of 8 residents (Resident #1) reviewed for accommodation of needs. The facility failed to ensure Resident #1 could access his call button on 12/18/24. This failure placed residents at risk of not being able to call for help if they need it. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included history of traumatic brain injury, muscle wasting and atrophy (loss of muscle mass and tissue), cognitive communication deficit, and contracture of muscle in both upper arms. Review of the annual MDS assessment for Resident #1 dated 12/09/24 reflected a BIMS score of 14, indicating intact cognitions. It reflected he was completely dependent on staff for transfers from bed to chair. Review of the care plan for Resident #1 dated 10/25/24 reflected the following: Category: Falls [Resident #1] is at risk for falling R/T impaired mobility, TBI, medications. Resident will remain free from major injury until next review. Scoop mattress place due to fall. Keep bed in lowest position with brakes locked. Keep call light and reach at all times. Observation and interview on 12/18/24 at 11:03 AM revealed Resident #1 calling out from his room Hey! Hey! Upon entering his room, he stopped calling out. He was lying in bed, and both hands and arms had severe contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to restricted joint mobility). His elbows were bent and hands resting on both shoulders. His call button was not visible on the bed. The call button, which was a flat pad as opposed a small button, was hanging towards the floor at the head of the bed. The cord was wrapped around the mobility bars at the head of the bed several times. Resident #1 stated he could not move his arms to reach the call pad, but it would not matter, because it did not work. A test of the call pad revealed the light outside Resident #1's room did not go on. During an interview on 12/18/24 at 11:11 AM, LVN A stated she did not know why the call button was not in reach and did not know that it was not working. LVN A stated it she was the nurse in charge of Resident #1, but it was not her who wrapped the cord around the mobility rails. LVN A stated she was trying to untangle the call pad from the mobility rails, but it was difficult and was taking some time. She stated the call pad should have always been placed in reach of Resident #1's hands. She stated Resident #1 was able to use the call pad and regularly used it. She stated there was no definite way that she ensured the call system was working and that aides placed the call buttons within reach of residents when they left resident rooms. Observation on 12/18/24 at 11:15 AM revealed an alarm emitting from a telephone/call system switchboard at the nurse's station closest to Resident #1's room. A display on the telephone/call system switchboard had the words Cord Out [Resident #1's room]. During an interview on 12/18/24 at 01:30 PM, CNA B stated the call button not being accessible to Resident #1 was her fault, because she liked to get it way out of the way when she repositioned him, which she did once an hour. She stated he used the call pad frequently, but he also hollered out her name often to get her attention. She stated she wrapped the cord around the mobility rails to get it out of the way, and then while she was helping him, someone called out to her that one of her other residents was trying to get out of bed, so she ran out, intending to come back and finish setting Resident #1 up with all his accommodations but forgot. CNA B stated she and Resident #1 had a good relationship, and she felt very bad that she did not put the call pad back within reach. During an interview on 12/18/24 at 03:28 PM, the DON stated it was her expectation that call buttons would be given to the residents when staff left the rooms. She stated a potential negative outcome was that a resident could fall trying to get up when no one came to help them. She stated another potential negative outcome might be pain not being addressed. During an interview on 12/18/24 at 03:53 PM, the ADM stated call buttons should have been within reach at all times especially for residents with reach issues and mobility issues such as Resident #1. The Adm stated a potential negative outcome was needing incontinent care and having skin breakdown. Review of facility policy dated 05/05/23 and titled Call Lights, Responding To reflected the following: Policy: the staff will respond to call lights or other requests for assistance to meet the patient's/resident's needs. Procedures: 6. When leaving the patient or resident room, ensure the call light is placed within the patient's/resident's reach.

Based on observation, interview, and record review, the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 of 8 residents reviewed for prevention of pressure ulcer. The facility failed to ensure Resident #2 received weekly skin assessments in accordance with his care plan. This failure placed residents at risk of pressure ulcers going untreated. Findings: Review of the undated face sheet for Resident #2 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included spastic quadriplegic cerebral palsy (a form of cerebral palsy that affects both arms and legs and often the torso and face), unspecified contracture of muscle, and muscle wasting and atrophy (loss of muscle mass and strength). Review of the admission MDS assessment for Resident #2 dated 10/07/24 reflected a BIMS score of 12, indicating moderately impaired cognition. It reflected he was frequently incontinent of bladder. There were no skin issues identified in the MDS. Review of the care plan for Resident #2 dated 10/15/24 reflected the following: Category: Pressure Ulcer/Injury [Resident #2] is at risk for Pressure Injury related to: impaired mobility, incontinence. Resident's skin will remain free from major injury until next review. Encourage fluids to maintain hydration. Licensed Nurse to complete skin assessment weekly. Registered Dietician to assess nutritional status and make recommendations. Reposition resident as needed per tolerance. Review of weekly skin check assessments for Resident #2 from 10/07/24 to 12/18/24 reflected one conducted on 10/10/24 and no subsequent assessments. Review of the most recent shower sheet for Resident #2 dated 12/11/24 reflected he received a bed bath and had no new skin problems. Review of nursing progress notes for Resident #2 dated 12/17/24 at 02:36 PM and documented by the TXN reflected the following: Noted circular rash with crusts on the edges to chest, notified NP, received verbal order from Np to apply antifungal ointment to affected area Q shift. RP notified. Observation and interview on 12/18/24 at 11:52 AM revealed Resident #2 in a customized manual wheelchair (a highly personalized mobility device designed to meet the specific needs, preferences, and lifestyle of the user) talking with the DON. He introduced himself and stated he loved it here and everyone treated him well. He stated he was not in any pain and had no skin problems to his knowledge. During an interview on 12/18/24 at 03:01 PM, the TXN stated she was responsible for the skin breakdown prevention program at the facility. She stated individual charge nurses were responsible for weekly skin assessments. She stated she had just learned the weekly skin assessments were not conducted for Resident #2, and the assessments should have been conducted. She stated she was not sure of the system in place to monitor to ensure that skin assessments were done. She stated she assessed Resident #2's skin yesterday and did catch a rash on his chest which now had treatment in place. She stated they tracked the shower sheets very closely and had recent shower sheets for Resident #2 that showed no new skin issues. She stated the weekly skin assessments were important because they were conducted by a licensed nurse, unlike the shower sheets which were conducted by CNAs. The TXN stated she had done the skin assessment on Resident #2 the day prior as part of her program to oversee incontinent care. She stated she had been observing the CNAs perform incontinent care on Resident #2, noticed a rash, and did a complete skin assessment. She stated the rash was the only problem she noted. She stated a potential negative outcome of not doing the skin assessments over two months was they could fail to find skin problems on time, and they could develop to something more serious. During an interview on 12/18/24 3:28 pm, the DON stated the nursing team was heavily involved with Resident #2. She stated the staff were trained on the policy and procedure, and the skin assessments should have been conducted weekly after the first one 10/10/24. She stated they also relied on shower sheets, which were entered into the EMR and tracked by licensed nurses. She stated potential negative outcomes of not doing skin checks were tissue breakdown and unknown skin tears or bruising. During an interview on 12/18/24 at 03:53 PM, the ADM stated skin assessments should have happened at least weekly. He stated his team were freaking out about Resident #2's skin assessments not being done and wondering how it could have fallen through the cracks. The ADM stated a potential negative outcome of skin assessments not being done was skin breakdown. Review of facility policy dated 06/01/15 and titled licensed nurse skin checks reflected the following: all patients/residents will have a thorough weekly skin evaluation performed by a licensed nurse. Weekly, the licensed nurse performs a head-to-toe check of the patient's/resident's skin, paying particular attention to: a. The surfaces of the skin that come in contact with the bed and chair; b. Bony prominences (heel, tailbone, shoulder blades, elbows, back of the head, etc.); c. The surfaces of the skin that come in contact with our orthotic device, tube, brace or positioning device, d. Skin folds.

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, personal and oral hygiene for two (Resident #7 and Resident #8) of three residents reviewed for ADLs. The facility failed to provide showers to Residents #7 and #8 in compliance with their shower schedules. This deficient practice could place residents at risk of a decline in hygiene, at risk of skin breakdown, level of satisfaction with life, and feelings of self-worth. Findings include: 1. Record review of Resident #7's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #7 had diagnoses which included unspecified dementia (impairment of brain functions), pain in shoulders, fractured sixth cervical vertebra, hyperkalemia (high potassium) and lack of coordination. Record review of Resident #7's admission MDS assessment, dated 09/30/24, reflected a BIMS score of 15, which indicated he was cognitively intact. Section GG (Functional Abilities and Goals) reflected he required substantial/maximal assistance with showering. Record review of Resident #7's care plan, dated 10/08/24, reflected he had an ADL self-care performance deficit related to a need for assistance with ADLs with an intervention of one person assistance with bathing. Record review of Resident #7's showering schedule, provided by the facility, revealed he was scheduled to receive showers every Tuesday, Thursday, and Saturday. Indicating twenty-two showers were scheduled for 9/20/24-11/11/24. Record review of Resident #7's showering tasks in his EMR , from 09/20/24 -11/11/24, reflected he received six showers on the dates 10/03/24,10/05/24, 10/08/24, 10/16/24,11/02/24 and 11/05/24. An observation and interview on 11/10/24 at 9:19 AM revealed Resident #7 laying in his bed. Resident #7 was noted to appear disheveled with stains on his shirt, unbrushed hair, and dirty fingernails. Resident #7 stated he did not get his showers. He stated he could not remember when the last shower he received happened because it had been a while. Resident #7 stated it did not feel good to be dirty, but he stopped asking for showers because they always said they will come back later, and it never happened. 2. Record review of Resident #8's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident # 8 had diagnoses which included unspecified dementia (impairment of brain functions), chronic pain, lack of coordination and need for personal assistance with personal care. Record review of Resident #8's quarterly MDS assessment, dated 10/04/24, reflected a BIMS score of 15, which indicated she was cognitively intact. Section GG (Functional Abilities and Goals) reflected she required substantial/maximal assistance with showering. Record review of Resident #8's care plan, dated 10/06/24, reflected she had an ADL self-care performance deficit related to a need for assistance with ADLs with an intervention of one person assistance with bathing. Record review of Resident #8's showering schedule, provided by the facility, revealed she was scheduled to receive showers every Monday, Wednesday, and Friday. Indicating twenty showers were scheduled for 8/15/24-09/30/24. Record review of Resident #8's showering tasks in her EMR, from 08/15/24 -9/30/24, reflected she received ten showers on the dates 08/19/24,08/23/24, 08/26/24(documented twice on same day by two different staff), 08/30/24,09/02/24,09/04/24,09/18/24, 09/23/24, 09/25 and 09/27/24. . An observation and interview on 11/10/24 at 9:55 AM revealed Resident #8 in her room in bed . She stated it seems to her like she got a shower about twice a week. Resident #8 stated it would be nice to have had three showers a week; she felt better after having a shower. She stated she thought she was supposed to get three a week, but they were so busy it did not seem like they had time. During an interview on 11/10/24 at 1:50 pm, CNA A stated she gave showers on the days she worked. She stated she was a shower aide, and she got her assigned showers done. She stated she did not know about the CNA's assigned to the halls, whether they got all theirs done, but they also gave some of the showers. During an interview on 11/10/24 at 2:22 pm, CNA B stated there usually was time to get the showers she was assigned done. She stated if something happened and she could not get one done, she let the nurse know and told the next shift. During an interview on 11/10/24 at 2:50 PM, LVN C stated she did not check whether showers were given or not. She stated the CNAs were supposed to bring their shower sheets and she would look at those . During an interview on 11/10/24 at 3:23 PM, LVN D stated she did not know when each shower was given, but the shower aides were good about letting the nurses know if a shower was not given. During an interview on 11/14/24 at 3:12 PM, the Administrator stated they had recognized there was a problem with the shower system when they began auditing them on 11/10/24 after the request for shower records. He stated it appeared some staff were using the POC system in the EHR and others were documenting on paper shower sheets. They combined the showers on the documents provided. They will be implementing a new system to track showers and oversight will be provided. He stated residents were to be receiving showers on their scheduled shower days as intended. Record review of the facility's Nursing Policy and Procedures, undated, reflected the following: Subject: Activities of Daily Living, Optimal Function Definition: Activity of Daily Living (ADL) refer to tasks related to personal care including, grooming, dressing, oral hygiene, transfer, bed mobility, eating, bathing and communication system. Policy: The Facility provides care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. The Facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene. Record review of the facility's Admission Policy, section titled Agreement For Care, undated reflected the following: 6. Provide assistance in daily living and restorative nursing care in accordance with Resident's care plan, where appropriate. Resident reserves the right to refuse said treatment. If said treatment is refused, Resident and/or Representative will hold Facility harmless from any injury as a result thereof.

Based on observations, interviews, and record reviews, the facility failed to provide based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 1 of 1 activity programs and two (Resident #1 and Resident #2) of four residents reviewed for activities. 1. The facility failed to provide an activity program designed to meet the interests and needs of Residents #1 and #2. 2. The facility failed to notify all residents of canceled and postponed activity programs. This deficient practice placed all residents at risk for a diminished quality of life, isolation, lack of stimulation, and a decline in mental status. Findings included: Review of Resident #1's face sheet revealed he was a male resident admitted on [DATE] and had diagnoses including unspecified dementia, unspecified depression, unspecified anxiety disorder, unspecified altered mental status, and cognitive communication deficit. Review of Resident #1's quarterly MDS, dated [DATE], revealed he had a BIMS score of 14, which indicated he was cognitively intact. Resident #1 had no assessment reflecting the activity program. Review of Resident #1's care plan, dated 07/31/24, revealed he needed 1:1 visits in an effort to meet his emotional, intellectual, physical, and social needs. Activities and all staff were required to notify him of any changes to the activities calendar and encourage participation in 1:1 visits that are outdoors or outdoor themed. The care plan reflected staff will provide sensory stimulation activities, and will socialize with him during 1:1 visits. Review of Resident #2's face sheet revealed she was a female resident readmitted on [DATE] and had diagnoses including unspecified vascular dementia and cognitive communication deficit. Review of Resident #2's comprehensive MDS, dated [DATE], revealed she had a BIMS score of 10, which indicated she was moderately cognitively impaired. Resident #2 indicated it was very important for her to do her favorite activities. Review of Resident #2's care plan, dated 04/10/24, revealed no notes related to activities. Review of the facility's Activity Calendar for September 2024 revealed residents were provided with the following activity program for 09/10/24: Table Talk at 9:00 a.m., Price is Right Show at 10:00 a.m., Exercise and Music at 11:00 a.m., Bingo Time at 2:00 p.m., and Room Visits at 3:00 p.m. An observation of the nursing station near 400-600 hall on 09/10/24 at 10:13 a.m. revealed there was no Price is Right Show activity taking place. The activity program calendar for September 2024 was posted in the living area across from the nursing station. During an interview on 09/10/24 at 10:24 a.m., Resident #1 stated the facility activity program was poor. Resident #1 explained that residents were lucky if Bingo time was held twice a month. He said residents mostly watched tv, and most activity programs were watching tv shows and movies, which was boring to him. Resident #1 stated he often felt bored. Resident #1 also stated the AD did not follow the activity program calendar. Resident #1 stated he told the AD and nursing staff that he was bored and they did nothing. An observation of the nursing station near 100-300 hall and 400-600 hall on 09/10/24 at 11:07 a.m. revealed there was no Exercise and Music activity taking place. An observation of the nursing station near 100-300 hall on 09/10/24 at 11:29 a.m. revealed there was no Exercise and Music activity taking place. A male resident rolled his wheelchair towards LVN A, who was standing at the medication cart next to the nursing station, and told her that he was bored. During an interview on 09/10/24 at 11:38 a.m., AD stated the Price is Right Show activity program at 10:00 a.m. was on the tv at the nursing station near 100-300 hall. AD explained the Price is Right Show activity program was not on the tv at the nursing station near 400-600 hall because residents who resided on that side of the facility building often misplaced the tv remote due to their cognitive status. AD stated she had nursing staff to monitor the location of the tv remote at the nursing station near 400-600 hall to ensure it was not misplaced. AD stated nursing staff were aware to put on Price is Right tv show during activity time. AD stated she did not know why she did not inform nursing staff to turn on the show for 400-600 hall residents and that she should have informed the nursing staff. AD stated Exercise and Music activity did not take place at 11:00 a.m. because her volunteer informed her on 09/10/24 at 11:30 a.m. that they had to cancel. AD stated she did not contact the volunteer before 11:00 a.m., did not know why she did not contact them, and that she should have contacted them to know if they were assisting with hosting the activity or not. AD stated she did not continue to host the Exercise and Music activity because the volunteer usually helped her with the activity. AD stated she postponed the Exercise and Music activity to be held at 2:00 p.m. AD explained she would have Bingo time and Exercise and Music activities occur at the same time at 2:00 p.m. AD stated she usually notified residents whenever an activity was postponed or canceled by posting a notice or verbally telling them. AD stated she verbally notified some residents who were sitting in the living area near nursing station near 100-300 hall. AD stated she had not notified or posted a notice of the Exercise and Music activity postponement for residents on 400-600 hall and residents who were in their rooms on 100-300 hall. AD stated she was responsible for arranging and organizing activities. AD stated she asked eight residents monthly about the quality of the activities and did not receive any concerns. AD stated residents could feel as though they are not getting attention if they did not have activities to participate in. AD stated residents who have an actual need for a schedule or daily routine could feel unsettled if they were not notified of canceled or postponed activities. During an interview on 09/10/24 at 12:18 p.m., CE B revealed residents expressed to them that they were not losing interest emotionally, but they felt bored. CE B stated residents needed more activities for stimulation. CE B stated the AD was doing stimulating and engaging activities all the time at the beginning of the [AGE] year and no longer did for unknown reasons. CE B stated most of the activities listed on the activity calendar were tv-related. During an interview on 09/10/24 at 12:54 p.m., Resident #2 stated there was not many activities she could attend because she was bed bound due to her recent fall. Resident #2 stated she mostly watched tv. Resident #2 stated the AD did not visit her in her room and did not try to engage her in activities in her room. Resident #2 stated she told the AD and nursing staff she was bored and they did nothing. Resident #2 stated she felt bored because there were a lack of activities and she had to find ways of entertaining herself. Resident #2 stated AD did not tell her about the canceled/postponed activities on 09/10/24. During an interview on 09/10/24 at 2:11 p.m., ADM stated he never received any complaints or concerns about activities from residents and staff. ADM stated he did not know the activities calendar was not being followed, residents felt bored, and most activities were tv shows and movies. Review of the Resident Satisfaction Monthly Interviews for Activities, 07/01/24-09/10/24, revealed residents reported wanting more outside activities, wanting more crafts, did not read the activity calendar, were not interested in the activities, and not participating in activities. Review of the facility's Activity/Recreation Programming policy and procedure, dated 2022, revealed the following: 2. The patients, residents, or representative expressed needs, interests, hobbies and cultural preferences are included in the development of programs. Input from the individuals is received and discussed at Resident Council/group meetings, event planning meetings, or QAPI satisfaction interviews. 3. The care team assists the activity staff in the development of a person-centered activity care plan that considers the patient or resident needs, interests, hobbies, cultural preferences, attention span and level of function/ability in an effort to support the domains of wellness (security, autonomy, growth, connectedness, identity, joy and meaning). 4. Activity/Recreation programs are designed based on patient and resident leisure interests, hobbies, cultural preferences and implemented to address the needs (physical, cognitive, creative, social, spiritual, independent, empowerment, and sensory stimulation). The programs will be geared to maintain functional ADL s, provide social interaction while protecting from over stimulation. Individuals with dementia will have programs designed that are personal and customized based on previous lifestyle (occupation, family, and hobbies), preferences and comforts. 5. Those who cannot participate in a group setting are provided one on one/individual programming. Inability to participate or persons who refuse to participate in activities, who are in transmission-based precautions for medical reasons, who are on physician ordered bed rest or those who were not able to attend due to no more than the number of residents where 6-foot distancing among residents has been maximized. One to one programming can occur in person, via telephone or live video chat on approved facility devices. 6. Programming includes large groups, small groups, one to one visit and independent opportunities. 7. Programs take place mornings and afternoons, 7 days/week, and include holidays and evenings. 8. Programs take place in various areas, including but not limited to activity rooms, lounge areas, dining rooms, in house TV channels, virtually through live video feeds/conferencing on facility owned devices, phone conferencing, hallways, resident rooms, outdoor courtyards, patios, etc. 10. Documentation at least quarterly is conducted to note patient/resident progress, response and outcome. 11. Intervention strategies are developed as needed to address unsatisfactory outcomes. 12. The opportunity may be provided for regular off premise community outings/trips. 13. Programs are developed to include community resources, volunteers and involvement within, as well as outside the Facility. 14. Subacute patients/residents with an extended length of stay (14 days or more) are provided with a variety of specialized programs that enhance functional life activities and quality of life. If it is determined that the patient/resident will be discharged within the next three months, activity/recreation programming for subacute patients/residents will reflect discharge planning and preparation, i.e. group or individual intervention discussing leisure and activity/recreational plans once discharged , ability to adapt to new disability or limitation (when applicable), and community outings.

Based on record review and interview, the facility failed to develop a base line care plan that included the instructions needed to provide effective and person-centered care of the resident, for one Resident (Resident #2) of four residents reviewed for base line care plans. The facility failed to timely and accurately assess resident's care plan needs. 1. Resident #2's baseline care plan problem start dates and approach dates for Residents #2's were dated 22 days and 21 days, respectively, prior to her admission to the facility. 2. Resident #2's care plan failed to address her preferred language, incontinent care, delirium, cognitive loss/dementia, activity preferences, and communication needs. 3. The care plan failed to address that Resident #2's functional abilities and goals reflected the use of the mobility device walker, and not a wheelchair. These failures could affect all residents by placing them at risk for not receiving care and services to meet their needs. Findings included: Review of the undated face sheet for Resident #2 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of wedge compression fracture of first lumbar vertebra, need for assistance with personal care, unsteadiness on feet, abnormalities of gait and mobility, repeated falls, chronic pain syndrome, and cognitive communication deficit. Review of the admission MDS assessment for Resident #2 dated 07/05/24 reflected a BIMS score of 0, indicating severe cognitive impairment. MDS revealed the following information: Resident #1's preferred language was Spanish. Section B hearing, speech, and vision revealed unclear speech slurred or mumbled words. Resident #1 makes herself understood, is usually understood, has difficulty communicating some words or finishing thoughts, but is able if prompted or given time. Acute onset mental status change reflected behavior usually present that does not fluctuate - disorganized thinking and altered level of consciousness. Section F - preferences for customary routine and activities reflected Resident #1 had preferences for her routine and activities. Section GG - Functional Abilities and Goals reflected mobility device - walker. Bowel incontinence reflected Resident #1 was frequently incontinent. Section V Care Area Assessment triggered the following care areas: Delirium Cognitive loss/dementia Communication Urinary Incontinence and indwelling catheter and Mood State Review of the baseline care plan, category problem, for Resident #2 dated 06/05/24 reflected the following: resident was a new admission, admitted from a local hospital status post fall. The resident's baseline care plan would be developed within 48 hours. Edited 07/27/24. Review of Resident #2's approach to problem start dated: 06/05/24 reflected dehydration risk - provide adequate fluids, determine likes/dislikes; created 06/06/24. Review of Resident #2's approach to problem start dated: 06/05/24 reflected no elopement risk; created 06/06/24. Review of Resident #2's approach to problem start dated: 06/05/24 reflected minimize falls, encourage use of call light, orient to room, and safety devices; created 06/06/24. Review of Resident #2's approach to problem start dated: 06/05/24 reflected pain management monitor pain, verbal/descriptor, location: back treatment - see physicians orders; created 06/06/24. Review of Resident #2's approach to problem start dated: 06/05/24 reflected ambulation device: wheelchair; created 06/06/24. Review of Resident #2's approach to problem start dated: 06/05/24 reflected activity preference - activity preferences were left blank; created 06/06/24. Review of Resident #2's approach to problem start dated: 06/05/24 reflected continent of bowel and bladder; created 06/06/24. Review of facility fall incident detail report dated 06/25/24 - 08/25/24 reflected: 07/05/24 location - patient's room, type of incident - fall witnessed, secondary injury - no apparent injury, physician notified - no, transfer to hospital/emergency - no, care planned - no 08/20/24 location - TV room, type of incident - found on floor, secondary injury - no apparent injury, physician notified - no, transfer to hospital/emergency - no, care planned - yes 08/22/24 location - patient's room, type of incident - found on floor, secondary injury - no apparent injury, physician notified - no, transfer to hospital/emergency - no, care planned - yes Review of Resident #2's care plan revealed no revised care plan for the resident's falls on 08/20/24 and 08/22/24. In an interview on 08/25/24 at 2:56 pm, Resident #2's family member was asked if it was alright to speak with Resident #2. The family member replied, do you speak Spanish? In an attempted interview on 08/25/24 at 4:17 pm with HHSC contractor interpreter via phone with Resident #2 revealed resident was not interviewable. Observation on 08/25/24 at 4:17 PM revealed a fall mat was not next to Resident #2's bed. An interview on 08/25/24 at 4:54 pm with the Administrator revealed Resident #2's care plan was not up to date. The care plan was in place to document and to know the resident's specific needs. It was the outline of all the facility's needs to do to care for the resident. The Administrator stated that they were short staffed and did not currently have an MDS coordinator, the MDS coordinator would be the person in charge of making sure assessments were accurate and the care plan was dated correctly. Review of the facility's care plan process, person-centered care, dated 2023, reflected the facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care for the resident that meet professional standards and quality of care. Person centered care means the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. Person centered care includes trying to understand what each person is communicating, verbally and nonverbally, identifying what is important to each resident with regard to daily routines and activities, and understanding the resident's life before coming to reside in the nursing home. Procedures; Develop and implement the baseline person centered care plan within 48 hours of residence admission. The baseline person centered care plan will include the minimum health care information necessary to properly care for the resident including, but not limited to initial goals based on admission orders, resident goals, position orders, dietary orders, therapy services, social services and PASARR recommendation, if applicable the baseline person centered care plan summary includes immediate resident needs. The person-centered care plan includes date, problem, resident goals at admission and desired outcomes, time frames for achievement, interventions, discipline specific services and frequency.

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. 1. The facility failed to ensure Resident #1's care plan, which called for floor mats to be on the floor at her bedside, was followed. No fall mat was observed beside Resident #1's bed. 2. The facility failed to prevent Resident #1 from sustaining a fall in her room and fracturing her left wrist. This deficient practice could affect residents by contributing to falls with injury, hospitalization , and death. The findings were: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing, metabolic encephalopathy (a problem in the brain), anxiety disorder due to known physiological condition, dementia, mild, with agitation, anorexia, fracture of the lower end of right radius (part of two joints: the elbow and the wrist), initial encounter for closed fracture, and repeated falls. Review of the admission MDS assessment for Resident #1 dated 05/19/24 reflected: BIMS score of 3, indicating severe cognitive impairment. Section GG - Functional Abilities and Goals reflected impairment on both sides - lower extremity (hip, knee, ankle, foot). Mobility Devices - wheelchair. Any Falls Since Admission/Entry or Reentry or Prior Assessment, whichever is more recent - No Recent Surgery Requiring Active SNF (skilled nursing facility) Care - yes, repair fractures of the pelvis, hip, leg, knee, or ankle Review of Resident #1's care plan reflected the following: Problem start date: 03/07/24 category pain - Resident #1was at risk for pain related to fall with fracture, impairment mobility. Problem state date: 03/07/24 edited 08/16/24 category falls - Resident #1 is at risk for falling related to impaired mobility, vascular dementia, and history of falls. Approach - low bed with floor mat on both sides dated 03/21/24. Review of facility's fall incident detail reports for Resident #1 dated 06/25/24 - 08/25/24 reflected: 07/07/24 location - patient's room, type of incident - found on floor, secondary injury - abrasion skin tear, location of injury - back of right elbow, physician notified - no, transfer to hospital/emergency - no, care planned - no 07/12/24 location - patient's room, type of incident - witnessed fall, secondary injury - skin tear, location of injury - lower left arm, left upper leg, and right lower leg, physician notified - no, transfer to hospital/emergency - yes, care planned - no 08/16/24 location - patient's room, type of incident - found on floor, secondary injury - fracture, location of injury - left wrist, physician notified - no, transfer to hospital/emergency - yes, care planned - yes Review of Resident #1's progress note dated entered by LVN A dated 08/16/24 reflected resident's roommate notified this nurse that her roommate was on the floor. Upon entering resident room, resident observed on floor in her supine position by the roommate bed. Resident stated 'I came back from the bathroom, and I was trying to transfer from chair to bed and fell on the floor'. Wheelchair was next to the bed lock. Call light was within reach. Head to toe assessment done, noted small laceration on left hip and left wrist swollen. Assisted resident to the bed. Range of motion done to all extremities. Resident complained of pain on left wrist. Administered as needed pain medication. Notified hospice nurse and neuro check initiated. Attempted interview on 08/25/24 at 4:05 pm with Resident #1 revealed she was not interviewable. An interview on 08/25/24 at 4:15 pm with LVN A revealed she was notified by resident's roommate that Resident #1 fell . Resident #1 said she went to the restroom then tried to transfer from the wheelchair to the bed and fell . LVN A revealed Resident #1's wheelchair was not locked. LVN A revealed there was no floor mat on the floor, and they needed a floor mat. She revealed Resident #1 fell by her bed and a floor mat would have helped her during her fall. LVN revealed she did not see any floor mat; Resident #1 had never had a floor mat in her room. Observation on 08/25/25 at 4:15 pm revealed LVN A looked all around and in the closets, and in Resident #1's room, but did not locate a mat. An interview on 08/25/24 at 4:07 pm with LVN B revealed she often took care of Resident #1 and Resident #1 was next to the bed when she fell . She revealed Resident #1 had fall interventions, but she did not see the fall mat in the room when Resident #1 fell and could not recall the last time she saw the fall mat. She revealed it was a problem that that intervention was not there because Resident #1 tried to get up, and she was not in the right mind to know her limitations. LVN B thought the fall mat was a great thing when Resident #1 was in the bed because she had a history of falls and a history of injury, so it was important for interventions to be in place. An interview on 08/25/24 at 4:45 pm with the Administrator revealed Resident #1 was care planned for a mat beside her bed. The care plan was in place to document and to know the resident's specific needs. It was the outline of all the facility needed to do to care for the resident. Review of the facility's Fall Management policy dated 2023 reflected the facility will identify each patient/resident who is at risk for falls and will plan care and implement interventions to manage falls. Qualified staff will complete the fall risk evaluation to determine if patient/resident is a fall risk. The fall management program includes education for staff and creative, functional strategies while recognizing patient/rights and highest practicable level of function. The care plan reflects individualized interventions that are reassessed and revised as needed.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen reviewed for sanitation. The facility failed to discard of food products that were past the use by date or in accordance with facility policy in the double door refrigerator, walk-in refrigerator, walk-in freezer, and dry storage area. The facility failed to label and date food products in the walk-in freezer and walk-in refrigerator. The facility failed to close food product bags in the walk-in freezer to prevent exposure to air. The facility failed to prevent mold growth on bottled products in the walk-in refrigerator. The facility failed to clean the industrial can opener. The facility failed to remove dented cans from the dry storage area to prevent service to residents. These failures could place residents at risk of cross contamination, loss of nutritional value, weight loss, and foodborne illness. Findings included: Observation on [DATE] at 9:05 AM of the facility's only walk in freezer revealed an open bag of chicken strips that were not labeled or dated and exposed to air, a box of chicken nuggets that were exposed to air, an open box of carrot slices that were exposed to air, a sealed bag of tater tots that were not dated, a sealed bag of popcorn shrimp that were not labeled or dated, and a sealable plastic bag of pork chops dated [DATE] that had visible freezer burn. Observation on [DATE] at 9:10 AM of the facility's only walk in refrigerator revealed a one-gallon container of cole slaw dressing dated [DATE] with an expiration date of [DATE], a one-gallon container of mayonnaise dated ,d+[DATE] with a best by date of [DATE] and visible mold growth on the lid and container, a one-gallon container of sweet pickle relish dated ,d+[DATE] with no best by date and visible mold growth near the lid, a four pound four ounce container of picante sauce with no date and visible mold growth around the lid, a one gallon container of yellow salad mustard dated ,d+[DATE] with no best by date and dried mustard and visible mold growth on the container, 2 five pound containers of sour cream dated [DATE] with a use by date of [DATE], plastic sealable bag containing sliced turkey breast with a use by date of [DATE], a plastic sealable bag containing sliced turkey breast dated ,d+[DATE] and use by date of [DATE]. Observation on [DATE] at 9:37 AM of a container of peaches out on a table in the kitchen. The container was dated [DATE] and showed a use by date of [DATE]. Observation on [DATE] at 9:38 AM of the facility's double door refrigerator revealed a one gallon container of ranch dressing that had no date or use by date on it, 4 plastic containers of tea that was not labeled or dated , 1 plastic container of labeled tea dated [DATE] and a use by date of [DATE], 46 ounce container of prune juice dated ,d+[DATE] with a use by date of [DATE], 4 individually bagged peanut butter and jelly sandwiches dated [DATE] and use by date of [DATE], and an individually bagged sliced turkey breast sandwich dated ,d+[DATE] with a use by date of [DATE]. Observation on [DATE] at 9:45 AM of the facility's dry storage area revealed 4 forty-six ounce containers of prune juice dated [DATE] with a use by date of [DATE], 4 forty six ounce containers of cranberry cocktail juice dated [DATE] with a use by date of [DATE], box dated [DATE] with 23 twelve ounce cans of evaporated milk that all had a best by date of [DATE], two 6.61 pound cans of mandarin oranges dated [DATE] with dents in them near the top seal, and a metal rack with four shelves labeled [DATE] with a use by date of [DATE] that contained 2 packages of hot dog buns, 10 packages of hamburger buns, and one and half loaves of bread. Observation on [DATE] at 10:02 AM of the facility's only industrial can opener revealed dried and moist substances around and behind the cutting blade. Interview on [DATE] at 10:05 AM, the RDC stated the industrial can opener should be cleaned after every use and failure to do so could lead to cross contamination and food borne illness. The RDC stated that all food in the freezer should be labeled when received and opened. The RDC stated all bags containing food products in the freezer should have been sealed to prevent exposure to air and that failure to do so could result in loss of nutritional value and taste. The RDC stated failure by staff to remove food products that were past their best by dates could result in residents becoming sick due to food borne illnesses. The RDC stated products from dented cans should never been served to residents due to uncertainty if air was allowed into the product which could result in food borne illnesses. The RDC stated the containers in the walk-in refrigerator were not properly dated because they had no year listed and further advised that they should have been removed immediately if any mold growth was observed. Interview on [DATE] at 3:45 PM, the DOC stated she had been in the facility since September of 2023. The DOC stated all products should have receive date, open date, and expiration / best by dates if opened. The DOC stated the dates should always include the month, day, and year because failure to list all three could lead to uncertainty. The DOC stated cooked foods that are refrigerated should be dated to expire three days after date in. The DOC stated the can opener should be cleaned after every use or daily at a minimum. The DOC stated failure to properly seal bags of food products in the freezer could lead to freezer burn and loss of nutritional value. The DOC stated that service of out-of-date food products could lead to food borne illness and weight loss due to issues of palatability. The DOC stated dates of products should be checked daily and all expired / out of date products should be discarded. The DOC stated she was made aware of the condiment containers and showed a picture that the RDC captured of them. The DOC stated it was primarily her responsibility to check them, but she could not see the condiments very well due to their height on the shelf and her being short. The DOC stated the mold growth on the containers likely resulted from the refrigerator getting above a minimum temperature of 41 degrees Fahrenheit approximately three weeks ago. The DOC stated all items except for the containers of condiments were discarded due to the elevated temperature in the refrigerator before repair. The DOC stated products from dented cans were not to be served to residents because it could result in food borne illnesses. Interview on [DATE] at 5:03 PM, the ADM stated she had been advised of the kitchen observations, which she stated could result in food borne illnesses. Review of in-service summary and attendance dated [DATE] revealed, Subject: Labeling & FIFO (first in first out) conducted by the DOC revealed, 5 DATES NEEDED WHEN LABELING *Received date *Open date *Expiration / use by * Pull Date, ALWAYS REMEMBER FIFO METHOD, rotate the oldest item to the front and newest to the back. All Labeling and item names should be visible at all times. In-service was attended by seven culinary staff members including the DOC. Review of the facility's Nutrition Policies and Procedures dated [DATE], SUBJECT: FOOD SAFETY IN RECEIVING AND STORAGE, POLICY: Food will be received and stored by methods to minimize contamination and bacterial growth. PROCEDURES: Receiving Guidelines 5. Inspect food when it is delivered to the facility and prior to storage for signs of contamination. Food packages shall be in good condition to protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants. Refrigerated Storage Guidelines 12. Refrigerated, ready to eat Time/Temperature Control for Safety FOODS (TCS) are properly covered, labeled, dated with a use-by date, and refrigerated immediately. [NAME] them clearly to indicate the date by which the food shall be consumed or discarded. The day of preparation or day original container is opened shall be considered day 1. Follow USDA guidelines for food storage. 13. In the case of commercially processed food, the date marked by the facility may not exceed a manufacturer's use-by date. 14. Refrigerated condiments and salad dressings are properly covered, labeled, and clearly marked to indicate a use by date two months from the date opened. SUBJECT: SAFE FOOD HANDLING, POLICY: Food acquisition, storage, and distribution will comply with accepted food handling practices. Proper food handling is essential in preventing foodborne illness. Review of Infection Prevention and Control Policies and Procedures dated [DATE], did not reveal any documentation that directly related to food borne illness.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 (Resident #19, Resident #32, Resident #76) of 19 residents reviewed for ADL care. The facility failed to provide fingernail care for Resident #19, Resident #32, and Resident #76. This failure could lead to a reduction in quality of life and could contribute to health-related issues from lack of hygiene. Findings included: Review of Resident #19's Face Sheet dated 1/25/24, reflected a [AGE] year of age male, who was admitted to the facility on [DATE]. Resident #19 was diagnosed with Cerebral Palsy (group of disorders that affect a person's ability to move and maintain balance and posture), Hemiplegia-right dominant side (paralysis that affects only one side of the body), Congestive Heart Failure (serious condition in which the heart doesn't pump blood as efficiently as it should), and Onychogryphosis (nail disorder resulting from slow nail plate growth). Review of Resident #19's MDS Optional State assessment dated [DATE], revealed that he had a BIMS score of 15 indicating cognition is intact. Review of Resident #19's Consolidated Care Plan indicated last care conference date of 11/29/2023 revealed that he requires assistance with ADL's r/t cerebral palsy, limited mobility, debility, which was last reviewed on 09/25/2023. Review of Resident #19's Orders dated 01/25/24 revealed a treatment order on 10/25/2023 for Nail Check to be completed once a day on Wednesday Second 07:00 PM - 07:00 AM. Review of Resident #19's Progress Notes dated 01/25/2024 from 11/02/2023 - 01/23/2024 reflected no documented attempts or refusals for nail care. Review of Resident #32's Face Sheet dated 1/25/24, reflected a [AGE] year of age female, who was admitted to the facility on [DATE]. Resident #32 was diagnosed with Parkinsonism (refers to brain conditions that cause slowed movements, rigidity (stiffness) and tremors), Neurocognitive Disorder with Lewy Bodies (type of progressive dementia that leads to a decline in thinking, reasoning, and independent function), and Contracture of Left and Right Hand (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Review of Resident #32's MDS Optional State assessment dated [DATE], revealed that she had a BIMS score of 0 indicating severe cognitive impairment. MDS reflected that Resident #32 required extensive assistance with ADL's. Review of Resident #32's Care Plan indicated last care conference date of 11/15/2023 revealed Problem: Resident requires assistance with ADL's secondary to cognitive and physical decline with Goal: Will maintain a sense of dignity by being clean, dry, odor free and exhibit a well-groomed appearance over next 90 days which was edited on 01/22/2024. Review of Resident #32's Orders dated 01/25/24 revealed an open-ended treatment order on 07/09/2021 for Nail Check to be completed once a day on Monday Second 07:00 PM - 07:00 AM. Review of Resident #76's Face Sheet dated 1/25/24, reflected a [AGE] year of age male, who was admitted to the facility on [DATE]. Resident #76 was diagnosed with Quadriplegia (form of paralysis that affects all four limbs, plus the torso), Encephalopathy (damage or disease that affects the brain) and need for assistance with personal care. Review of Resident #76's MDS Optional State assessment dated [DATE], revealed that he had a BIMS score of 14 indicating cognition is intact. MDS reflected that Resident #76 required extensive assistance with ADL's. Review of Resident #76's Care Plan indicated last care conference date of 12/20/2023 revealed Problem: requires assistance with ADL's with Goal: Will maintain a sense of dignity by being clean, dry, odor free and well-groomed over next 90 days which was edited on 01/17/2024. Review of Resident #76's undated Orders revealed an open-ended treatment order on 12/05/2023 for Contractures in both arms (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Resident #76 did not show to have any orders in reference to nail care. Observation on 01/24/2024 at 10:49 AM of Resident #32, who was in her room in bed. Resident #32 was observed to have long fingernails on her left and right hands with black and brown material under some. Resident #32 was observed to have contractors to both her left and right hand. Resident #32 was not interviewable but did allow her palms to be checked, which did not have any abrasions. Observation on 01/24/2024 at 11:01 AM, Resident #76 was seated in his wheelchair in a common area of the facility. Resident #76 was observed to have long fingernails on both his right and left hands with black material under some. Resident #76 was also observed to have contractures to both his right and left hand. Observation and interview on 01/24/2024 at 12:00 PM, Resident #19 was observed in his motorized wheelchair. Resident #19 was observed to have long fingernails on both his left and right hand, which also displayed a brown tint and had a black substance under some. Resident #19 was observed to have limited use of his left and right hand, which were partially contracted. Resident #19 stated he did not want his fingernails as long as they were. Resident #19 stated, there is no point in telling staff he wanted his nails cut. Resident #19 stated that staff would not do anything and would say that they do not have time right now. Observation and interview on 01/25/2024 at 3:18 PM, Resident #76 was observed to still have long fingernails on both hands with debris present. Resident #76 stated that he did not want his fingernails as long as they were and last had them cut approximately one month ago. Resident #76 allowed his palms on both hands to be checked and did not have any abrasions. Interview on 01/25/2024 at 3:30 PM, CNA I stated that basic nail care could be performed by a Nurse or CNA. CNA I stated that if the resident is diabetic or required more than basic nail care she would notify a nurse. CNA I stated that all staff are supposed to pay attention to nail care but that the primary responsibility falls on staff that are providing the residents with their shower. CNA I stated that as a part of the shower process they are supposed to check for fingernail length and cleanliness. CNA I looked at the fingernails of Resident # 32 and stated that they were too long and needed to be cut. CNA I stated that long nails, especially in residents with contractures, could result in skin breakdown, which she checked Resident #32 for. CNA I looked at the fingernails of Resident #76 and stated they were too long given the contracted state of his hands. Resident #76 advised CNA I that he did not want his fingernails as long as there were. CNA I looked at the fingernails of Resident #19 and stated that his nails were too long given the contracted state of both hands. CNA I asked Resident #19 why he did not say anything, and he informed her that he told other staff, but they did nothing about it. Interview on 01/25/2024 at 3:38 PM, CNA J stated that nail care can be provided by CNAs, but they must notify a Nurse if they are a diabetic. CNA J stated that residents with long nails, especially those with contractures, could lead to skin breakdown, infection, and self-inflicted abrasions. CNA J looked at the fingernails or Resident #32 and stated they were not in line with her training and should be cut. CNA J looked at the fingernails of Resident #76 and stated they were not in line with her training and should be cut. CNA J looked at the fingernails of Resident #19 and stated they were not in line with her training and should be cut. Interview on 01/25/2024 at 3:46 PM, LVN D stated that nail care checks should be done by everyone but stated that nails are primarily checked during shower times, which are to occur three times a week. LVN D looked at the fingernails of Resident #32 and stated their length was unacceptable and needed to be cut to prevent skin breakdown. LVN D looked at the fingernails of Resident #19 and she stated they were too long unless he wanted them that length and appeared to have a fungal issue. Resident #19 informed LVN D that he wanted them cut and did not want them the length there were. LVN D looked at the fingernails of Resident #76 and stated they were too long unless he wanted them that length. Resident #76 told LVN D that he did not want them long and requested they be cut. LVN D stated that the hallway we currently were in was not her hallway and that she regularly checks her resident's fingernail lengths. Interview on 01/25/2024 at 4:40 PM, the DON stated that nail checks are to be performed by staff during shower time. The DON stated that failure to maintain nail care could result in presence of bacteria, which could become an infection issue. Interview on 01/25/2024 at 5:03 PM, the ADMINISTRATOR stated that ADL nail care should be conducted during resident showers. The ADMINISTRATOR stated that failure to trim fingernails could result in abrasions or possible infection depending on the circumstances. Review of facility's Nursing Policies and Procedures dated 05/05/2023 revealed, SUBJECT: ACTIVITIES OF DAILY LIVING, OPTIMAL FUNCTION; DEFINITION: Activities of daily living (ADLs), refer to task related to personal care including, grooming, dressing, oral hygiene, transfer, bed mobility, eating, bathing, and communication system. PROCDURES: 3. Facility staff develop and implement interventions in accordance with the resident's assessed needs, goals for care, preferences and recognized standards of practice that address the identified limitations in ability to perform ADLs.

Based on observation, interview, and record review, the facility failed to ensure the residents had the right to be free from abuse for one (Resident #2) out of three residents reviewed for abuse, in that: The facility failed to prevent a physical altercation between Resident #1 and Resident #2 that led to Resident #2 sustaining an abrasion to his left ear, redness to the back of the left side of his head and neck, causing him to have a headache and experience dizziness. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 10/31/23 at 3:00 PM. While the IJ was removed on 11/01/23 at 2:30 PM, the facility remained at a level of actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk pain, injury, hospitalization , intimidation, and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including vascular dementia (a condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain) with behavioral disturbances, cerebral infarction (stroke), altered mental status, and violent behaviors. Review of Resident #1's quarterly MDS assessment, dated 09/25/23, reflected a BIMS score of 8, indicating a moderately impaired cognition. Review of Resident #1's quarterly care plan, revised 10/16/23, reflected he had behavioral symptoms of hitting other residents with an intervention of keeping distance between himself and other residents when he became physically abusive. Review of a progress note in Resident #1's EMR, dated 04/03/23 and documented by LVN A, reflected the following: During dinner, [Resident #1] became upset, stood up, and attempted to charge another resident. Staff immediately interfered and instructed [Resident #1] to sit back down. CN asked why he (Resident #1) attempted to do that and he replied, she is always getting to close to me. Attempted to explain to [Resident #1] this particular resident is not aware of what she is doing, therefore he is not allowed to do that to her or any other resident in this building. [Resident #1] became angry with CN and ambulated down 100 hall and sat in hallway. Review of a progress note in Resident #1's EMR, dated 08/10/23 and documented by LVN B, reflected the following: Peer to peer disagreement in the dining room. [Resident #1] had a verbal altercation with [Resident #2] over changing the channel on the TV in the dining room area. [Resident #1] rose from the chair and lunged at [Resident #2]. Nurse (LVN B) immediately ran in-between the two individuals to diffuse the situation. Review of a progress note in Resident #1's EMR, dated 08/22/23 and documented by RN C, reflected the following: With SW present, conversation with [Resident #1] regarding behaviors with [Resident #2] in the dining room where they had to be separated due to [Resident #1] threatening to hit [Resident #2]. Explained to [Resident #1] that there will be consequences if he at any point follows through with that threat and encouraged [Resident #1] to remove himself moving forward if [Resident #2] makes him feel the way he did this morning to prevent from any further threats. There was no progress note regarding an additional incident between Resident #1 and #2 on the morning of 08/22/23, as documented in the above progress note. Review of Resident #1's Psychologist's assessment, dated 08/18/23, reflected the following: A/O x2. Affect reserved and flattened in context of defected mood (despite his denial of such). Psychologist received a request from SW that [Resident #1] be seen ASAP as there had been reports of controlling and manipulative behavior. Review of Resident #1's Psychologist's assessment, dated 08/25/23, reflected the following: A/O x2. Psychologist received a request from the SW that [Resident #1] be seen ASAP as there had been reports of angry, threatening behavior. Affect became labile and defensive when asked about a recent incident where [Resident #1] threatened to break the jaw of [Resident #2]. Aggression: Physical, verbal, threatened to break the jaw of [Resident #2] Overall Treatment Progress: Slight, two separate sessions required on 08/25/23 due to inappropriate, controlling, coercive and threatening behaviors towards other residents. Review of a progress note in Resident #1's EMR, dated 10/13/23 and documented by the SW, reflected the following: [Resident #1] was in an altercation with [Resident #2] in the dining room during lunch time . Review of a progress note in Resident #1's EMR, dated 10/18/23 and documented by the SW, reflected the following: [Resident #1] left for (behavioral health hospital) . Review of Resident #2's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), unspecified dementia without behavioral disturbance, depression, and age-related physical debility. Review of Resident #2's quarterly MDS assessment, dated 10/13/23, reflected a BIMS score of 14, indicating he was cognitively intact. Review of Resident #2's quarterly care plan, revised 10/11/23, reflected he received antidepressant medication related to behavioral issues such as sadness and tearfulness with an intervention of approaching him in a calm manner and remaining positive when providing care. Review of an investigation report for the incident between Resident #1 and #2, dated 10/13/23 and completed by the DON, reflected the following: [Resident #1] was seen hitting [Resident #2] in the head in the dining room with a closed fist. Upon assessment of [Resident #2]'s head there was redness to the area behind the left side of the back of his head with a small open rea to his ear that was bleeding slightly. Review of a progress note in Resident #2's EMR, dated 10/13/23 and documented by LVN D, reflected the following: [Resident #2] was involved in an altercation with [Resident #1]. [Resident #2] is noted to have an abrasion on his left ear with redness to the left side of his neck and head. He c/o light headache and being dizzy. [Resident #2] is being sent to the ER for evaluation and treatment. Review of a progress note in Resident #2's EMR, dated 10/16/23 and documented by the SW, reflected the following: Spoke with [Resident #2] regarding anxiety and if [Resident #2] would be agreeable for psych services to see him. [Resident #2] stated not at this time, that he believed the anxious feelings would go away on their own . [Resident #2] expressed gratitude that steps were being taken to keep [Resident #1] away, and that he was starting to feel better. Observation and interview on 10/31/23 at 2:51 PM revealed Resident #2 in his bed watching television. He stated he was no longer experiencing head pain or dizziness after the incident with Resident #1. He stated it had only lasted a few days. He stated Resident #1 was a psychopath and had been antagonizing him for months. He stated on 10/13/23, Resident #1 was arguing with him about what the television and out of now where he started punching him in the back of the head. He stated he was so bad that he filed a police report. He stated he was now afraid of him and was told he would not be coming back to the facility. He stated if he did come back to the facility, he was going to have a real problem. During an interview on 10/31/23 at 8:36 AM, the DON stated she did not witness the altercation on 10/13/23 but was there to assess Resident #1 and #2. She stated she was notified Resident #1 punched Resident #2 in the back of the head. She stated they immediately moved Resident #1 to a different hallway and after Resident #2 had given his statement to the police, he was sent to the ER for further evaluation. She stated he came back the same day with no findings. She stated Resident #1 was currently at a behavioral health hospital and their plan was to find alternate placement for him. The DON stated her main concern was that Resident #1 had no remorse or saw a problem with what he did to Resident #2. The DON stated she had only been at the facility since September (2023) and had never been made aware of any prior physical/verbal aggression from Resident #1. She stated there had been nothing in his care plan regarding behaviors and if she had known he had a history, there would have been interventions in place. During an interview on 10/31/23 at 11:46 AM, the SW stated he did not see the altercation between Resident #1 and #2 on 10/13/23 but had been walking down the hall when he heard yelling in the dining room area. He stated the aides had told him Resident #1 had put his hands on Resident #1. He stated Resident #2 requested he call the police and during his interview with the police told them Resident #1 had punched him with a closed fist to his head at least three times. He stated when he interviewed Resident #1, he admitted that was what he had done, but could not give an explanation as to why. The SW stated Resident #1 had a history of verbal aggression but not physical. He stated he did not remember any incident regarding him charging at a resident in April. He stated he did remember the incident from August when Resident #1 lunged at Resident #2 but stated he had not physically touched Resident #2. He stated he followed up with Resident #2 a few days after the incident. He stated Resident #2 told him he was feeling anxious from the incident but felt better knowing that Resident #1 had been moved to a different hall. During an interview on 10/31/23 at 12:03 PM, LVN A stated she worked regularly with Resident #1 and #2. She stated Resident #1 had always been very verbally aggressive, but not exactly aggressive. She stated he would do things to intimidate residents, like run up behind them in their wheelchairs and scream. There were a few vulnerable residents that are unable to speak that she watched out for when Resident #1 was around. She stated there was an incident in April when a resident he did not like, for whatever reason, got close to him in the dining room and he got up and charged at her. She stated she intervened immediately after she saw the look in his eye. She stated she had always been fearful that Resident #1 could be physically aggressive. She stated he was always loud and cursing, got frustrated easily, and he was unpredictable. LVN A stated Resident #1 had always been annoyed by Resident #2, and it normally revolved around what channel the television was on. She stated Resident #2 was scared after the incident with Resident #1. She stated Resident #2 was more withdrawn for a few days. During an interview on 10/31/23 at 12:33 PM, CNA E stated she witnessed the incident between Resident #1 and #2 on 10/13/23. She stated Resident #2 told Resident #1 to put the TV on, they bickered back and forth, yes - no - yes - no, until Resident #1 out of nowhere went behind Resident #2 and punched him three times in the back of the head while Resident #2 just covered his head with his arms attempting to protect himself. She stated it was always Resident #1 who was the aggressor and he was always yelling about something. She stated she had always been fearful that Resident #1 would be physically aggressive with the residents. On 10/31/23 at 2:55 PM and 11/01/23 at 12:02 PM, attempts were made to contact Resident #1's Psychologist via telephone. A returned phone call was not received prior to exit. Review of the facility's undated Abuse and Neglect Policy, reflected the following: . 3. The facility's Leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect or exploitation or mistreatment and will implement immediate action to safeguard residents. . 3. Abuse if the willful infliction of injury, intimidation, confinement, or punishment that results in physical harm, pain, or mental anguish. The ADM and DON were notified on 10/31/23 at 3:00 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 11/01/23 at 12:00 PM: On 10/31/23 an abbreviated survey was initiated at (facility). On 10/31/23 the surveyor provided an Immediate Jeopardy Template (IJ) notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: F600 - The facility failed to keep the residents free from abuse. Resident #1 no longer at facility. Upon resident return to facility, resident will be reevaluated by psychiatry services. Behaviors will be monitored on Resident #1 and documented in clinical record using behavior monitoring forms. Should aggressive behaviors continue, resident #1 will be placed on 1:1 supervision until alternate placement arrangements can be made Residents residing in the facility had the potential to be affected by the alleged deficient practice. Action: Head to toe completed on Resident #2 with no negative outcomes. Staff Responsible: Director of Nursing/Designee Date Initiated: 11/1/23 Date Completed: 11/1/23 Action: Psychosocial evaluation will be completed on Resident #2. Identified psychosocial needs will be addressed at the time of the evaluation and referrals made as indicated. Staff responsible: Social Services Director Date Initiated: 11/1/23 Date Completed: 11/1/23 Action: Interviews will be completed with residents residing in the facility with Resident #1 prior to his discharge to identify any negative psychosocial effects and referrals will be made as indicated. Staff Responsible: Social Services Director/Designee Date Initiated: 11/1/23 Date Completed: 11/1/23 Action: The Administrator and Director of Nursing will be re-educated on Abuse and Neglect policy and Behavior Management including: Need to update care plan interventions with any new interventions that are implemented in an attempt to prevent any further behaviors and maintain a safe environment. Staff Responsible: Clinical Consultant Date Initiated: 11/1/23 Date Completed: 11/1/23 Action: The Licensed Clinical Team and Social Services Director will be reeducated on need to update care plan interventions with any new interventions that are implemented in an attempt to prevent further behaviors and maintain a safe environment. Staff Responsible: Director of Nursing/Designee Date Intiated:11/1/23 Date Completed: 11/1/23 Action: Facility staff will be reeducated on the Abuse and Neglect Policy including prevention and reporting of behaviors and maintenance of a safe environment. Facility staff not receiving this reeducation prior to this date will receive prior to next scheduled shift. This education will be presented in New Hire and agency staff orientation Staff Responsible: Director of Nursing/Designee Date Intiated:11/1/23 Date Completed: 11/1/23 Action: Incident reports and grievance reports will be reviewed Monday - Friday in morning meeting to identify resident to resident behaviors and to determine interventions have been implemented, safe environment has been maintained, allegations reported per abuse policy, and care plan has been updated. Staff Responsible: Administrator/Designee Date Intiated:11/1/23 Date Completed: ongoing, Monday - Friday Action: A review of behavior documentation, such as nurse notes, incident reports, 24 hours reports will be completed Monday through Friday during clinical review to determine if any resident had any unwanted behaviors towards other residents and to ensure interventions were in place to prevent further occurrences, and safe environment. Staff Responsible: Director of Nursing/Designee Date Intiated:11/1/23 Date Completed: ongoing, Monday - Friday Action: Three Random Residents will be interviewed validating residents feel safe and have no care concerns daily for one week, then weekly for three months validating residents feel safe and have no care concerns. Interviews will be documented on an interview sheet and maintained by the Administrator. Staff Responsible: Nursing Management Date Initiated: 11/1/23 Date Completed: 2/1/24 Action: The results of this monitoring will be presented to the Quality Assurance/Performance Improvement Committee for review and recommendation. Any identified concerns will be addressed at the time of discovery. Staff Responsible: Administrator/Designee Date Initiated: 11/1/23 Date Completed: 2/1/24 Ad Hoc QAPI will be held on 11/1/23. The Medical Director was notified of the Immediate Jeopardy on 10/31/23. The Surveyor monitored the POR on 11/01/23 as followed: During interviews on 11/01/23 from 1:17 PM - 2:22 PM with the AD, MRC, SW, one CNA, and two LVNs revealed they all stated they were in-serviced prior to their shifts on abuse and neglect, types of abuse, the protocol for handling situations of verbal and physical altercations between residents. All staff members were able to relay different types of abuse such as physical, mental, verbal, and sexual. They all stated their ADM was their Abuse and Neglect Coordinator and all suspicions of abuse or neglect should be reported to her immediately. All staff members stated that if they witnessed a verbal or physical altercation between residents that they would separate them immediately, make sure they were safe, would immediately notify their charge nurse and ADM, would check on them every 15 minutes, and would not let them be in the same area alone until they were sure the hostility had been defused. The AD and SW, whom had access to care plans, stated they would update resident behaviors in their care plan immediately. The SW stated after any resident-to-resident altercation he would arrange a care plan with the resident's RP and would notify the psychologist for a psychiatric evaluation. During an interview on 11/01/23 at 1:51 PM, the DON stated all staff had been in-serviced prior to their shifts and the in-servicing would continue until all staff had been in-serviced. She stated all residents had been interviewed utilizing a safe survey questionnaire and no concerns had arisen. She stated she would be responsible for ensuring care plans were updated after any behaviors between residents. Review of an Ad Hoc QAPI Meeting Agenda Summary, dated 11/01/23, reflected the MD, NP, ADM, DON, and CSD were in attendance. Review of an in-service conducted by the CSD, dated 11/01/23, reflected the ADM and DON were in-serviced on the abuse and neglect policy, behavior management, care plans being updated with any new interventions that were implemented to prevent further behaviors to maintain a safe environment. Review of an in-serviced conducted by the DON, dated 11/01/23, reflected the licensed clinical team was in-serviced on the following: 1. Updating care plan interventions with behaviors. 2. The care plan interventions need to be updated at time of incident and/or time behavior was identified. 3. This will prevent further behaviors and maintain a safe environment. Review of an in-serviced conducted by the DON, dated 11/01/23, reflected all staff were in-serviced before their shifts on abuse and neglect and who to notify when behaviors were witnessed. While the IJ was removed on 11/01/23 at 2:30 PM, the facility remained at a level of actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure that each resident received, and the facility provided at least three meals daily, at regular times comparable to normal mealtimes in the community for five (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) out of five residents reviewed for timely meals, in that: The facility failed to serve breakfast to Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5 until over an hour after the scheduled mealtime on 07/27/23. This caused Resident #3 to feel neglected, cry uncontrollably, and caused psychosocial harm. This failure placed residents at risk of unplanned weight loss, altered nutritional status, decreased feelings of self-worth, and a diminished quality of life. Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including type II diabetes, abnormal weight loss, dysphagia (difficulty in swallowing), and muscle wasting and atrophy (wasting away). Review of Resident #1's annual MDS assessment, dated 05/01/23, reflected a BIMS of 15, indicating no cognitive impairment. Review of Resident #1's quarterly care plan, dated 05/19/23, reflected she was at risk for malnutrition related to multiple sclerosis (a disease that affects the central nervous system) with an intervention of monitoring intakes of meals, fluids, supplements, and snacks. During an observation and interview on 07/27/23 at 9:18 AM, revealed Resident #1 in her room with her head down with her empty bedside table in front of her. She stated she was waiting on her breakfast and was so hungry. She stated meals were always late and it made her feel like she was forgotten about. Review of Resident #2's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including adult failure to thrive, anxiety, abnormal weight loss, non-pressure chronic ulcer of buttock, and non-pressure chronic ulcer of other part of right foot. Review of Resident #2's quarterly MDS assessment, dated 05/19/23, reflected a BIMS of 15, indicating no cognitive impairment. Review of Resident #2's quarterly care plan, dated 06/02/23, reflected she was at risk for malnutrition/dehydration related to schizoaffective disorder with an intervention of honoring food preferences of foods and fluids. During an observation and interview on 07/27/23 at 9:21 AM, revealed Resident #2 immediately looking at her empty bedside table and yelled, I'm starving! She stated meals were always late - she would not receive lunch until around 2:00 PM and dinner at 7:00 PM. She stated it made her feel lousy and disgusting, and often made her not even want to eat. Review of Resident #3's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including type II diabetes, dysphagia, muscle wasting and atrophy, history of TIA (stroke), and anxiety disorder. Review of Resident #3's quarterly MDS assessment, dated 04/16/23, reflected a BIMS of 14, indicating no cognitive impairment. Review of Resident #3's quarterly care plan, dated 07/24/23, reflected she was at risk of malnutrition and/or dehydration related to bipolar disorder with an intervention of honoring her food preferences of foods and fluids. During an observation and interview on 07/27/23 at 9:26 AM, reflected Resident #3 knitting and she stated she was doing anything she could to keep her mind off how hungry she was. She stated no one should have to wait until after 9:00 AM to eat breakfast. She immediately started shaking, crying, and yelled, It makes me feel like shit! Like I do not count, like I am not a human being, but a dog! She stated all meals were late and dinner was rarely served before 7:00 PM. She stated it made her so depressed she never left her room anymore. Review of Resident #4's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including pressure ulcer of left and right heel, dysphagia, anxiety disorder, and age-related cognitive decline. Review of Resident #4's quarterly MDS assessment, dated 05/27/23, reflected a BIMS of 13, indicating no cognitive impairment. Review of Resident #4's quarterly care plan, dated 06/02/23, reflected she was at risk for malnutrition and/or dehydration related to multiple sclerosis with an intervention of honoring food preferences of foods and fluids. Review of Resident #5's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including type II diabetes, anxiety disorder, weakness, and muscle wasting and atrophy. Review of Resident #5's quarterly MDS assessment, dated 07/12/23, reflected a BIMS of 15, indicating no cognitive impairment. Review of Resident #5's quarterly care plan, dated 07/24/23, reflected she was at risk for malnutrition and/or dehydration related to Parkinson's disease (degenerative disorder of the central nervous system) with an intervention of honoring food preferences. During an observation and interview on 07/27/23 at 9:34 AM, revealed Residents #4 and #5 sitting a table in the dining room. There were no food or drinks on the table. They stated they had not eaten breakfast yet. They stated they were starving, but it was nothing new, as meals were regularly late, and the staff did not seem to care about it or about them being hungry. They stated it made them feel unimportant. During an observation and interview on 07/27/23 at 9:42 AM, revealed CNA A delivering a meal tray to Resident #5. She stated meals were served late most of the time. She stated she was not sure why, but she assumed kitchen must be short-staffed. During an interview on 07/27/23 at 10:38 AM, the DON stated she would say 9/10 meals were served late. She stated it was more typical for lunch and dinner to be late. She stated breakfast being served after 9:00 AM was unacceptable. She stated there were a multitude of negative outcomes that could come from late meals such as dropping blood sugars, weight loss, and loss of dignity. She stated she had been made aware that Resident #3 had recently had a change in her behavior and had become more tearful than usual and had claimed to aides that she felt like a dog when her meals had been delivered late. She stated tearfulness and her outbursts were not normal for her. Observation on 07/27/23 at 12:45 PM revealed no meal trays had been delivered to the dining room or 100 and 200 halls. Observation on 07/27/23 at 1:15 PM revealed no meal trays had been delivered to the dining room. Residents #4 and #5 were observed sitting at an empty table. During an interview on 07/27/23 at 3:08 PM, the ADM stated the scheduled mealtimes were 7:30 AM, 12:30 PM, and 5:30 PM. She stated meals were not always served right on time, but rarely were considered late. She stated she would consider a meal being late if it was over an hour after the scheduled mealtime. She stated if there were residents who did not receive their breakfast until after 9:30 AM, that would be unacceptable. She stated a negative outcome could be weight loss or a decline in self-worth. Review of the facility's Meal Service in the Dining Room policy, revised 06/20/23, reflected the following: .6. Serve meals at the times specified/posted. Review of the facility's Meal Delivery policy, revised 06/20/23, reflected the following: . 2. Make effort to deliver the trays at the same time each day so patients/residents and nursing staff can anticipate the approximate time of arrival. . 4. Schedule staff mealtimes around the patient/resident mealtime so that an adequate amount of nursing staff and interdisciplinary staff are present and available to assist patients or residents. This will ensure that the food is delivered to the patient/resident at the proper temperature .

Based on observation, interview and record reviewed the facility failed to ensure residents were free from involuntary seclusion for 4 of 4 [MEDICAL TREATMENT] residents reviewed for involuntary seclusion. (R#1, R#2, R#3 and R #4) when: The facility failed to ensure R#1, R#2, R#3 and R#4, were not involuntarily secluded on the quarantine hall, from 06/24/20 to11/23/20, after testing negative for COVID-19 and showing no signs and symptoms of COVID-19. R#1 suffered a decline in lower body strength and a need for increased assistance with ADLs. R#2 was prescribed an antidepressant for recurring depression in September 2020 after being isolated on the quarantine hall since 06/24/20. These failures place residents at risk for depression, decrease of ADLs, decreased quality of life, and failure to thrive. Findings Included: R#1 Record review of R#1's EMR reflected a 76-yr. old male with an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a 'General Order Nursing Order' for R#1 dated 06/24/20 reflected the following: Start Date:06/24/20. Description- Quarantine. Reason-[MEDICAL TREATMENT]; Duration-Open ended. Ordered by DON. Review of an MDS for R#1 dated 10.16.20 reflected a BIMS score of 14, indicating his cognition was intact. Further review reflected he needed assistance of 2 for bed mobility and transfers. Mobility on the unit reflected extensive assistance of 1 person, method of mobility was a wheelchair. Record review of a care plan for R#1 dated 03/13/20 and edited 10/16/20 revealed the following: Resident is at risk for alteration in Psychosocial Well-being related to restriction on visitation and group activities due to the Covid-19 prevention and response plan. Goals: Will not experience any isolation and will have no impact on interpersonal relationships throughout the review period. Approach: Encourage alternative communication with family and visitors via phone and video chats, letters and cards. Provide in room activities- music, tv, puzzles, etc. The Care Plan showed an edited date of 10/16/20 but there were no changes made in the goals or approaches. There was no documentation to support R#1 was placed on the quarantine hall on 06/24/20. In an interview on 11/20/20 at 12:00 p.m., the MDS nurse stated she had been in the position for less than 2 weeks. She said the MDS generates care plans and the DON reviews them. In an interview on 11/20/20 at 12:15 p.m., the DON stated the previous MDS nurse was no longer employed and she was unaware there were no changes in the goals for R#1 when the care plan was edited on 11/18/20 or there was no care plan for being on the quarantine hall since 06/24/20. During a phone interview on 11/19/20 at 2:27 p.m., R#1 stated he had been on the quarantine hall for several months but couldn't say exactly how long. He said he was moved there because he goes to [MEDICAL TREATMENT] 3 days a week. R#1 was asked how he had been doing since he moved to the hall. He paused and said, mentally he thought he was ok because he got along good with his roommate (who is a [MEDICAL TREATMENT] patient as well) and that helps keep me going. He said if he could move to another hall with his roommate, see his family, and play bingo again that would make him very happy, but he was afraid to move without his roommate. R#1 said he misses his children very much and wants to see them in person. He has seen his daughters a couple of times through the glass on the door when one of them brings something by for him, but it is not the same. R#1 stated emphatically, I want to know when I can see my kids. My roommate and I both want to see our kids.R#1 said physically he is losing strength in his lower body and wanted to get back to the gym (meaning the facility gym). He said he just stays in bed in his room when he is not in [MEDICAL TREATMENT] and it is making him weaker. (The interview with R#1 was conducted over the phone while the resident was in his room and facilitated by the administrator.) During a telephone interview on 11/23/20 at 11:15 a.m., R#1's family member stated her father had been a resident at the facility since 2017 and on the quarantine hall since 06/2020. She was told he was moved there because he was a [MEDICAL TREATMENT] resident and was more at risk for Covid. She said prior to Covid and his move to the quarantine hall she saw her father every other day. Since he has been on the quarantine hall she has seen him through the door a few times, but otherwise visits are via Facetime. The family member said she knows her father very well and she can see it in his face that he is depressed. She said he tries to put up a good front so she and her siblings won't worry about him. She said her father desperately wants a hug and he says he is lonely. She was asked if any other means of visitation had been offered to her or her siblings and she said no, but if it had that would have been such a welcomed relief. R#1's daughter stated she was angry and sad she had not been able to see her father. The daughter said she was also worried about R#1 because he had gotten to the point where he couldn't stand anymore and was complaining of losing his strength. She said he stays in bed when he is in his room and the only time he leaves his room is for [MEDICAL TREATMENT]. In an interview on 11/19/20 at 2:50 p.m., the Director of Therapy (DOT) stated if a resident wants to use the equipment in the therapy room they may, but it must be done under supervision. He said whenever there is an outbreak of Covid then no one can use the gym. The DOT was asked if he knew R#1 and he said he did because he had received a recent request from the resident for physical therapy services. The DOT was asked which equipment R#1 could use if he had access to the gym and he said the parallel bars, but he would have to be evaluated first to use any other equipment. The DOT said he had completed his evaluation of R#1 for therapy services and had just received approval from the payor source for the therapy services. However, the resident could not receive any services because he was on the quarantine hall and recently had been exposed to Covid on 11/18/20 by a charge nurse from the hall. Review of a request for Physical therapy services form dated 11/18/20 reflected the request was initiated by R#1. The section of the form to be completed by the patient/resident reflected the following: Symptoms began on 11/09/20. Briefly describe your symptoms. Decline in lower extremity strength not allowing patient to assist with ADLs. How did your symptoms start? Answer-Too much time in bed. How does this interfere with your ADLs? Moderately-51%-75% of the time. The section of the request form completed by the Provider (facility) DOT reflected the following: Patient type-established with new episode Nature of Condition: Chronic-greater than 3 months Nature of treatment-Rehabilitative Review of the Approval of Request for Services from Optum (a third-party payor source) was addressed to R#1 and reflected services were approved effective 11/19/20 and through 05/19/21. R#2 Record review of R#2's EMR reflected a 76-yr. old male with an original admission date of [DATE] and [DIAGNOSES REDACTED]. Muscle weakness and wasting. Review of a 'General Order Nursing Order' for R#2 dated 06/24/20 reflected the following: Start Date:06/24/20. Description- Quarantine. Reason-[MEDICAL TREATMENT]; Duration-Open ended. Ordered by DON. Review of a physician order [REDACTED]. daily for R#2. Review of MEDICATION ORDERS FOR [REDACTED]. Review of a readmission MDS for R#2 dated 10/13/20 for a hospital stay 10/09/20 reflected the following: BIMS score of 9 indicating moderate cognitive impairment, Extensive assistance of 2 person for bed mobility and transfers, assistance of 1 person for wheelchair mobility, incontinent of bowel and bladder. Active [DIAGNOSES REDACTED]. During an interview on 11/23/20 at 10:08 a.m., R#2's family member stated he has not been able to visit R#2 since 06/2020. The family member said as declined in his ability to communicate on the phone and he is concerned. The family member added it makes it very difficult because his father is his best friend. The family member said about 10 days ago (11/10/20) he (the family member) was told by facility staff he could have open window visits with R#2 on Mondays and Wednesdays from 2-4 p.m. The family member said he told the ADM he (the family member) couldn't visit on those days because those were R#2's [MEDICAL TREATMENT] treatment days. The family member said the ADM told him she would have to get approval from her corporate office to change the visitation days. The ADM was supposed to get back with him but had not. The family member said someone called him on 11/18/20 to tell him R#2 had been exposed to Covid. The family member stated he had not been offered any other type of visitation other than open window and Facetime with R#2. During an interview on 11/20/20 at 2:10 p.m., the DON stated she was not aware R#2 returned from the hospital on [DATE] with physician orders [REDACTED]. She stated new orders are reviewed in the morning meeting and if there is a new [MEDICAL CONDITION] medication she informs the Social Worker. The DON stated R#2 should have been referred for psychiatric services and monitored for depression. During an interview on 11/20/20 at 12:50 p.m, the SW stated she had held the position since 09/2019. She said, in general, when a resident has a new order for [MEDICAL CONDITION] medications the DON will let her know verbally, but there is no set system. The SW said if she is notified of a new [MEDICAL CONDITION] medication she would make notes in the resident's chart and make a referral for psychiatric services. The SW confirmed there were no notes for R#2 regarding [MEDICATION NAME] or a referral for depression, which meant she was probably out that day and missed the morning meeting. R#3 Review of R#3's EMR reflected a 70-yr old female with original admission date of [DATE] and [DIAGNOSES REDACTED]. Review of R# 3's care plan last updated 08/22/20 reflected she was at risk for alteration in psychosocial well-being due to restriction of visitation and activities. Approaches included: Encourage to participate in activities, staff will assist in outdoor activities weather permitting, and invite to current events. There was care plan for depression or placement on the quarantine hall. Review of a 'General Order Nursing Order' for R#3 dated 06/24/20 reflected the following: Start Date:06/24/20. Description- Quarantine. Reason-[MEDICAL TREATMENT]; Duration-Open ended. Ordered by DON. In an interview on 11/23/20 at 11:45 a.m., R#3 said she would like to visit her 2 nieces, daughter and friend. R#3 said she has only been able to visit them through Facetime or window visits. She feels sad about not being able to visit with her family and misses the activities she had when she is not on quarantine. She really enjoys bingo and misses playing with her friends. R#3 said she would like to get off quarantine hall if she could. (Attempts to contact R#3's Responsible Party went unanswered.) R#4 Review of R#4's EMR revealed a 67-yr old female with an original admission date of [DATE] and [DIAGNOSES REDACTED]. Unclear speech and difficulty communicating and traumatic leg amputation. Review of a care plan for R#4 updated 11/18/20 reflected exposure to Covid-19. Approaches will update family with any changes of condition; At risk for alteration in psychosocial well-being due to restriction of visitation and activities. Approaches included: Provide individual activities when needed, encourage alternative visitation-Facetime and window visits. Review of a 'General Order Nursing Order' for R#4 dated 06/24/20 reflected the following: Start Date:06/24/20. Description- Quarantine. Reason-[MEDICAL TREATMENT]; Duration-Open ended. Ordered by DON. During a phone interview on 11/23/20 at 12:45 p.m., A family member stated R#2 had been on the quarantine hall for a long time and he was told she had to be there because of needing [MEDICAL TREATMENT] treatments. The family member added he received a phone call from the facility on 11/19/20 to inform him R #4 had been exposed to Covid. The family member stated prior to Covid he saw R#4 once a week, but now when he tries to talk with R#$ on the phone she is tearful and more forgetful. The family member stated he feels like she is depressed. The family member stated he had not been offered plexiglass or essential care giver visitation since R#4 has been on the quarantine hall. The family member said he would love to see R#4 in person and more often. During an interview on 11/20/20 at 1:15 p.m., with the DON and ADM, the ADM stated the criteria for residents residing on the quarantine hall was new admissions, re-admissions, residents with emergency room visits which exceed 24 hours, residents returning from a leave of absence and residents receiving [MEDICAL TREATMENT] services. The ADM stated residents receiving [MEDICAL TREATMENT] services were just too much at risk for exposure when they are at [MEDICAL TREATMENT] centers and that was the reasoning for keeping them on the quarantine hall. The ADM provided the policy/criteria for residents requiring quarantine which was undated. The DON stated all the [MEDICAL TREATMENT] residents on the quarantine hall have tested negative since being placed there which showed their system worked. The DON and ADM were unable to provide an explanation as to how cohorting the [MEDICAL TREATMENT] residents, with histories of testing negative for Covid, with residents of unknown status kept them safer. The DON confirmed all the residents, including the 4 [MEDICAL TREATMENT] residents, on the quarantine hall were exposed to a charge nurse designated to the hall who tested positive for Covid on 11/18/20. Both the DON and ADM stated there had been no negative outcomes for the 4 [MEDICAL TREATMENT] residents who have been quarantined since 06/24/2020. The ADM was asked when visitation reopened for residents in the general population and she stated 09/22/20. The ADM was asked if the [MEDICAL TREATMENT] residents on the quarantined hall were given the opportunity for plexiglass, outdoor, or essential care giver visitations and she said no because they are on the quarantine hall due their increased risk of exposure. During an interview on 11/20/20 at 3:30 p.m. the ADM provided a policy for Quarantine Units/halls dated 08/01/20 and said the previous policy provided was the wrong one. The policy included the following: Procedures: #3. The facility will house all residents who leave the facility for overnight for physician appointments, emergency room visits, [MEDICAL TREATMENT] appointments, leave of absences, or any other reason on the quarantine unit/hall for a minimum of 14 days. #4. The facility may choose to house residents who leave the facility for any reason on the quarantine unit/hall based on assessment of the risk of transmission after the resident leaves the facility. Review of an undated facility Leadership Policies and Procedures- Section XI: Resident Rights provided by the ADM on 11/23/20 at 10:00 a.m. reflected the following: Section-Limited Personal Visitation: #4 a) The facility will demonstrate the following in order to receive a facility visitation designation: It has separate areas, units, wings, halls, or buildings designated for Covid-19 positive, Covid-19 negative or unknown Covid-19 status. In a follow-up interview on 11/23/20 at 10:30, the ADM stated she should have done what she originally wanted to do, which was keep the [MEDICAL TREATMENT] residents with a negative testing history and no signs and symptoms of Covid-19 on the general population halls rather than quarantine them. After the ADM's statement the COVID-19 Rule regarding the definition of unknown COVID-19 status was discussed, to which she nodded her head in agreement. A review of COVID-19 Emergency Rule 40 TAC §19.2802(a)(8), revealed the State definition of unknown COVID-19 status to be A person who is a new admission, readmission, has spent one or more nights away from the facility, has had known exposure or close contact with a person who is COVID-19 positive, or who is exhibiting symptoms of COVID-19 while awaiting test results.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being in accordance with the comprehensive assessment and plan of care for 1 of 5 residents reviewed for wound care. (Resident #1) Staff Nurses and the Wound Care Nurse (WCN)/Director of Nurses (DON) failed to perform venous stasis wound care from 10/28/16 to 11/10/16 resulting in wounds on Resident #1's feet becoming infected and admission to the hospital. This facility failure placed 5 residents with pressure sores/stasis ulcers at risk for the development of new pressure sores, stasis ulcers, infection and worsening of current sores. Finding Include: Review of Resident #1's Face Sheet reflected a [AGE] year old female re-admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. (There was no mention of wounds in the diagnoses.) Review of Residents #1's clinical record reflected that she was a previous resident of the facility and had been sent out to an acute care hospital on [DATE] due to worsening wounds. Before being transferred out of the facility, Resident #1 was being treated for [REDACTED]. Resident #1 had only been at the acute care hospital 22 days before readmission. Review of Resident #1's transfer orders (back to the facility) on 10/28/16 revealed the following: Transfer to SNF (Skilled Nursing Facility) Wound care per wound care orders. Review of a Discharge Planning Order dated 10/28/16 for Resident #1 revealed the following: Wound Care Orders: B (Bilateral) feet: daily. Paint areas of eschar with [MEDICATION NAME] BID (two times a day). Dry dressing to L (left) heel, xeroform and heel pad to R (right) heel, change daily. During an interview on 11/12/16 at 11:30 AM, the Director of Nurses (DON) stated that the Physician Assistant (PA) went to see Resident #1 and found the wound. There were dressings on the heels and she had on boots, but the dressing did not have a date on it. The DON stated, Resident #1 has a history of venous stasis ulcers and arrived here 10/28/16. We're not sure if anyone changed the dressings, there was no date on it. She was sent out to the hospital. I came in Friday (11/11/16) and did an audit, got the nurses together and started education. The nurses are doing there own wound care now. During an interview on 11/12/16 at 2:45 PM, the PA stated she had looked at Resident #1's labs and her white count was up so she decided to take a look at her heel wounds. She stated that they looked infected and had an odor so she called the Primary Care Physician (PCP) and was told to send Resident #1 to the hospital. When asked if the resident looked septic (infection in the blood), she stated, No, she didn't have any signs or symptoms of being septic, she was not unstable. When asked by the surveyor if she was aware that Resident #1's wounds had not been treated or dressings changed since she had been admitted , she stated, No. The PA stated that she was in the facility Monday through Friday, 8:00 AM to 5:00 PM but staff could call the on-call number after hours. During an interview on 11/12/16 at 3:00 PM, Licensed Vocational Nurse (LVN)/Assistant Director of Nurses (ADON) C stated that she had gone in with the PA when Resident #1's wounds were identified. She stated that the PA called the PCP and decided to send her out to the hospital. LVN C stated, After Resident #1 was sent out, we performed a skin assessment audit and everyone else was ok. When asked by the surveyor who would have been responsible for taking care of Resident #1's wound care, she stated The wound care nurse would have taken care of the wounds and there wasn't one (wound care nurse). That's possibly where the communication broke down. During an interview on 11/12/16 at 11:00 AM, LVN D stated, We used to have a wound care nurse and did not have to do our own wound care. I signed an inservice yesterday (11/11/16) evening stating that now we do have to do the wound care treatments. During a telephone interview on 11/12/16 at 2:20 PM, Registered Nurse (RN) B stated that she had been asked to come in for a couple of hours on 11/01/16 to perform skin assessments. Resident #1 had boots on bilaterally and Kerlix was wrapped around her leg and heels. I unwrapped the wounds and they were covered with white eschar with weeping (fluid). There was no orders for wound care and it was late, around 8:30 PM, so I wrote a note to the DON/WCN and slid it under the door to followup with the PA the next day (11/02/16). RN B stated, The resident did not have any pain, there was no odor and it did not look infected. I rewrapped the wound with clean Kerlix. The surveyor asked the RN if she followed up with the DON to make sure she got the note, RN B stated, No, and I did not work Resident #1's hall after that. The surveyor asked, was the wrap dated, she stated, No. During an interview on 11/12/16 at 2:30 PM, the DON stated that she did not remember a note being placed under her door from RN B regarding Resident #1's wounds. The DON stated, Yes, I would have expected her to call someone for orders. During observation of Resident #1 at the hospital on [DATE] at 4:30 PM Resident #1 responded minimally to questions asked by the surveyor by nodding her head. During an interview on 11/12/16 at 5:30 PM, the hospital Podiatrist stated that Resident #1 was receiving IV antibiotics for [MEDICAL CONDITION] and heel and foot wounds. During an interview on 11/12/16 at 6:00 PM, the PCP stated that she had not been notified by the facility that Resident #1 had not received wound care treatment since her admission on 10/28/16. The PCP stated that she goes to the facility every other week and not seen Resident #1 since she had returned. When asked by the surveyor if harm had come to the resident by not receiving treatment, the PCP stated that she would have to speak with the other physicians and check on the wound cultures that would be back the next day. During an interview on 11/13/16 at 10:00 AM, the Director of Nurses (DON) stated that LVN F did the initial admission on Resident #1 and would have done the orders. LVN F missed the wound care orders when putting them in the computer. LVN A performed the physical assessment. During an interview on 11/13/16 at 11:40 AM, LVN D stated that Resident #1 had boots on and her ointment that was ordered was put everywhere but where the dressing covered. LVN D stated The DON replaced RN G (wound care nurse) and I was under the impression she was doing them (wounds). The computer was not prompting me to do wound care in the TAR (Treatment Administration Report) for us (nurses) to do it for two weeks. The wound care orders were never transferred to the TAR. During an interview on 11/13/16 at 11:50 AM, LVN F stated that she had missed the page that had the wound care orders on it. She stated that she gives a copy of the orders to the PA in case she wants to discontinue any of the orders and she approves them. LVN F stated the process includes the DON and/or ADON do a 24 hour chart check to make sure everything is correct. The PA also looks at the packet, (admit information from the acute care hospital), assesses the patient and does a H & P (History and Physical) for us in the first 72 hours. During an interview on 11/13/16 at 12:00 PM, the DON stated that it was possible during the two week transition the nurses didn't know to do their own wound care. The DON stated, I told some of them verbally, but don't have any papers to back it up. During an interview on 11/13/16 at 12:25 PM, the DON stated that she did not check the packet. She stated that she normally does the Long Term Care side and ADON (LVN C) does the medicare or rehabilitation side where Resident #1 resided. During an interview on 11/13/16 at 1:00 PM, LVN C/ADON stated that she had been out on personal leave when Resident #1 was admitted and was not in house to look at the packet. During an interview on 11/13/16 at 1:15 PM, LVN E stated that the facility always had a wound care nurse, and he had not been told he had to perform wound care on his residents until Friday (11/11/16). During an interview on 11/13/16 at 2:00 PM, the Administrator stated that the now acting DON was originally hired to take the place of the Wound Care Nurse, The DON/WCN was hired on 9/30/16 and accepted the position of DON on 10/27/16 after the other DON left on 10/26/16. When asked by the surveyor, so you did not have a WCN or anyone performing wound care from 10/27/16? The Administrator stated, We fixed that on Friday (11/11/16). Review of a facility note dated 11/11/16 revealed the following: Going forward from today, 11/11/16, I understand that I am responsible for wound care for my assigned patients and I will date, initial and time each dressing, and document appropriately in the chart. (The note was signed by 5 nurses). During an interview on 11/17/16 at 1:30 PM, LVN A stated that when she assessed Resident #1 upon admission that she did see that there were wounds on the resident's heels, but did not remove the dressings because there was no order for wound care. LVN A stated that she told the Wound Care Nurse/DON the next day (10/29/16) and was told that she (DON/WCN) would look at them during rounds and get with the physician for orders. She (LVN A) stated that RN B had told her she had looked at the wounds and since there had not been an order she had left a note under the DON/WCN's door to follow-up with the physician the next day. Prior to Resident #1's discharge LVN A stated that she had not been told she was responsible for her resident's wound care. She stated that she did not find out until 11/14/16 when the DON approached her to sign a memo stating she would be responsible for her own wound care. LVN A stated, I was the only nurse that documented she had wounds. Review of the Weekly Pressure Ulcer Record reflected the facility failed to document any wound measurements on Resident #1 from 10/28/16 to 11/10/16. Review of the Admission History for Resident #1 to the hospital on [DATE] revealed the following: Chief Complaint: Left heel wound. Patient is a [AGE] year old female with extensive past medical history currently resident at nursing facility was sent to hospital today on account of worsening left foot primarily heel wound. Heel was noted to start getting swollen and there was drainage that was starting to come out of the area. Patient denies foot pain. Assessment & Plan: 1. Left heel wound: We'll start patient on IV antibiotics. Wound care. Podiatry consult in the morning. Based on patients' clinical condition at time of admission I expect her to be admitted to the hospital for at least two midnights for treatment of [REDACTED]. Review of the initial skin assessment conducted at the hospital on [DATE] at 6:08 PM by the Hospital Podiatrist reflected the following: Lower Extremity Physical Exam: Derma: warm bilateral [MEDICAL CONDITION]: present bilateral [DIAGNOSES REDACTED] (Redness): present left Wound Evaluation: Wound #1 Location left posterior medial heel [DIAGNOSES REDACTED] Minimal per wound [MEDICAL CONDITION]: present Drainage: Moderate, serosanguinous (bloody fluid) Malodor: present (Odor was present) Pain to palpation: minimal Pre-debridement measurement: 55 mm x 50 mm Post debridement measurement: 50 mm x 40 mm Wound #2 Location: right posterior medial heel [DIAGNOSES REDACTED]: absent Drainage: Moderate serous (yellowish fluid) Malodor: present Pre-debridement measurement 40 mm x 40 mm Post debridement measurement: same Wound #3 Location: right lateral 5th MPJ (Metatarsophalangeal joint - joint on fifth toe) Drainage: moderate serous Malodor: present Pre-debridement measurement: 20 mm x 20 mm Post debridement measurement: same Wound #4 Location: right lateral 5th metatarsal (toe) base Drainage: moderate serous Malodor: present Pre-debridement measurement: 15 mm x 10 mm Post debridement measurement: same Plan: Applied dry dressings to the feet. Continue with IV abx (antibiotics), will monitor for resolution of the [MEDICAL CONDITION]. Wound Care Policies and Procedures revised 06/01/2015 reflected the following elements: Subject: Wound Evaluations Policy: Evaluation of wounds will be performed on admission, weekly, and on discover. Procedures: Evaluation is the formal process in which wound characteristics, underlying conditions and contributory medical history are identified/quantified. Evaluation should result in treatment approaches including elimination or compensation for causative factors and a prognosis for healing. 1. Objective evaluation components include: A. Location B. Measurements C. Appearance D. Drainage E. Odor F. Presence of undermining/tunneling G. Healing H. Stage and date of onset if a pressure ulcer I. Pain J. [MEDICAL CONDITION] 2. Refer to wound documentation for specific parameters for evaluation and documentation. 3. Evaluation results are communicated to the members of the care team through documentation, care plan meetings, and care planning. Five residents were reviewed for wound care.

Based on observation, interview and record review, the facility failed to follow their written policies and procedures that prohibit neglect for 1 of 5 residents reviewed for wound care. (Resident #1) Staff Nurses and the Wound Care Nurse (WCN)/Director of Nurses (DON) failed to perform wound care to venous stasis ulcers for Resident #1 from 10/28/16 to 11/10/16 resulting in hospitalization due to infection. This facility failure placed 5 residents with pressure sores/stasis ulcers at risk for the development of new pressure sores, stasis ulcers, infection and worsening of current sores. Finding Include: Review of the facility revised 11/01/16 Policy and Procedures for Abuse, Neglect and Misappropriation of Property revealed the following elements: Policy: 1. The facility's Leadership prohibits neglect. Procedures: Component III: Prevention 4. Adequate supervision of staff is maintained in order to identify and prevent inappropriate behaviors, such as: C. Ignoring the patients'/residents' needs, requests, etc. Component IV: Identification: 2. Neglect is the failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish, or mental illness. Review of Resident #1's Face Sheet reflected a [AGE] year old female re-admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. (There was no mention of wounds in the diagnoses.) Review of Residents #1's clinical record reflected that she was a previous resident of the facility and had been sent out to an acute care hospital on [DATE] due to worsening wounds. Before being transferred out of the facility, Resident #1 was being treated for [REDACTED]. Resident #1 had only been at the acute care hospital 22 days before readmission to the facility. Review of Resident #1's transfer orders (back to the facility) on 10/28/16 revealed the following: Transfer to SNF (Skilled Nursing Facility) Wound care per wound care orders. Review of a Discharge Planning Order dated 10/28/16 for Resident #1 revealed the following: Wound Care Orders: B (Bilateral) feet: daily. Paint areas of eschar with [MEDICATION NAME] BID (two times a day). Dry dressing to L (left) heel, xeroform and heel pad to R (right) heel, change daily. During an interview on 11/12/16 at 11:30 AM, the Director of Nurses (DON) stated that the Physician Assistant (PA) went to see Resident #1 and found the wound. There were dressings on the heels and she had on boots, but the dressing did not have a date on it. The DON stated, Resident #1 has a history of venous stasis ulcers and arrived here 10/28/16. We're not sure if anyone changed the dressings, there was no date on it. She was sent out to the hospital. I came in Friday (11/11/16) and did an audit, got the nurses together and started education. The nurses are doing there own wound care now. During an interview on 11/12/16 at 2:45 PM, the PA stated she had looked at Resident #1's labs and her white count was up so she decided to take a look at her heel wounds. She stated that they looked infected and had an odor so she called the Primary Care Physician (PCP) and was told to send Resident #1 to the hospital. When asked if the resident looked septic (infection in the blood), she stated, No, she didn't have any signs or symptoms of being septic, she was not unstable. When asked by the surveyor if she was aware that Resident #1's wounds had not been treated or dressing changed since she had been admitted , she stated, No. The PA stated that she was in the facility Monday through Friday, 8:00 AM to 5:00 PM but staff could call the on-call number after hours. During an interview on 11/12/16 at 3:00 PM, Licensed Vocational Nurse (LVN)/Assistant Director of Nurses (ADON) C stated that she had gone in with the PA when Resident #1's wounds were identified. She stated that the PA called the PCP and decided to send her out to the hospital. LVN C stated, After Resident #1 was sent out, we performed a skin assessment audit and everyone else was ok. When asked by the surveyor who would have been responsible for taking care of Resident #1's wound care, she stated The wound care nurse would have taken care of the wounds and there wasn't one (wound care nurse). That's possibly where the communication broke down. During an interview on 11/12/16 at 11:00 AM, LVN D stated, We used to have a wound care nurse and did not have to do our own wound care. I signed an inservice yesterday (11/11/16) evening stating that now we do have to do the wound care treatments. During a telephone interview on 11/12/16 at 2:20 PM, Registered Nurse (RN) B stated that she had been asked to come in for a couple of hours on 11/01/16 to perform skin assessments. Resident #1 had boots on bilaterally and Kerlix was wrapped around her leg and heels. I unwrapped the wounds and they were covered with white eschar with weeping (fluid). There was no orders for wound care and it was late, around 8:30 PM, so I wrote a note to the DON/WCN and slid it under the door to followup with the PA the next day (11/02/16). RN B stated, The resident did not have any pain, there was no odor and it did not look infected. I rewrapped the wound with clean Kerlix. When asked by the surveyor if she followed up with the DON to make sure she got the note, RN B stated, No, and I did not work Resident #1's hall after that. The surveyor asked, was the wrap dated, she stated, No. During an interview on 11/12/16 at 2:30 PM, the DON stated that she did not remember a note being placed under her door from RN B regarding Resident #1's wounds. The DON stated, Yes, I would have expected her to call someone for orders. During observation of Resident #1 at the hospital on [DATE] at 4:30 PM Resident #1 responded minimally to questions asked by the surveyor by nodding her head. During an interview on 11/12/16 at 5:30 PM, the hospital Podiatrist stated that Resident #1 was receiving IV antibiotics for [MEDICAL CONDITION] and heel and foot wounds. During an interview on 11/12/16 at 6:00 PM, the PCP stated that she had not been notified by the facility that Resident #1 had not received wound care treatment since her admission on 10/28/16. The PCP stated that she goes to the facility every other week and not seen Resident #1 since she had returned. When asked by the surveyor if harm had come to the resident by not receiving treatment, the PCP stated that she would have to speak with the other physicians and check on the wound cultures that would be back the next day. During an interview on 11/13/16 at 10:00 AM, the Director of Nurses (DON) stated that LVN F did the initial admission on Resident #1 and would have done the orders. LVN F missed the wound care orders when putting them in the computer. LVN A performed the physical assessment. During an interview on 11/13/16 at 11:40 AM, LVN D stated that Resident #1 had boots on and her ointment that was ordered was put everywhere but where the dressing covered. LVN D stated The DON replaced RN G (wound care nurse) and I was under the impression she was doing them (wounds). The computer was not prompting me to do wound care in the TAR (Treatment Administration Report) for us (nurses) to do it for two weeks. Review of Resident #1's TAR history dated 10/28/16 to 11/10/16 reflected no orders for wound care. During an interview on 11/13/16 at 11:50 AM, LVN F stated that she had missed the page that had the wound care orders on it. She stated that she gives a copy of the orders to the PA in case she wants to discontinue any of the orders and she approves them. LVN F stated the process includes the DON and/or ADON do a 24 hour chart check to make sure everything is correct. The PA also looks at the packet, (admission information from the acute care hospital), assesses the patient and does a H & P (History and Physical) for us in the first 72 hours. During an interview on 11/13/16 at 12:00 PM, the DON stated that it was possible during the two week transition the nurses didn't know to do their own wound care. The DON stated, I told some of them verbally, but don't have any papers to back it up. During an interview on 11/13/16 at 12:25 PM, the DON stated that she did not check the packet. She stated that she normally does the Long Term Care side and ADON (LVN C) does the medicare or rehabilitation side where Resident #1 resided. During an interview on 11/13/16 at 1:00 PM, LVN C/ADON stated that she had been out on personal leave when Resident #1 was admitted and was not in house to look at the packet. During an interview on 11/13/16 at 1:15 PM, LVN E stated that the facility always had a wound care nurse, and he had not been told he had to perform wound care on his residents until Friday (11/11/16). During an interview on 11/13/16 at 2:00 PM, the Administrator stated that the now acting DON was originally hired to take the place of the Wound Care Nurse, The DON/WCN was hired on 9/30/16 and accepted the position of DON on 10/27/16 after the other DON left on 10/26/16. When asked by the surveyor, so you did not have a WCN or anyone performing wound care from 10/27/16? The Administrator stated, We fixed that on Friday (11/11/16). Review of a facility note dated 11/11/16 revealed the following: Going forward from today, 11/11/16, I understand that I am responsible for wound care for my assigned patients and I will date, initial and time each dressing, and document appropriately in the chart. (The note was signed by 5 nurses). During an interview on 11/17/16 at 1:30 PM, LVN A stated that when she assessed Resident #1 upon admission that she did see there were wounds on the resident's heels, but did not remove the dressings because there was no order for wound care. LVN A stated that she told the Wound Care Nurse/DON the next day (10/29/16) and was told that she (DON/WCN) would look at them during rounds and get with the physician for orders. She (LVN A) stated that RN B had told her she had looked at the wounds and since there had not been an order she had left a note under the DON/WCN's door to follow-up with the physician the next day. Prior to Resident #1's discharge LVN A stated that she had not been told she was responsible for her resident's wound care. She stated that she did not find out until 11/14/16 when the DON approached her to sign a memo stating she would be responsible for her own wound care. LVN A stated, I was the only nurse that documented she had wounds. Review of the Weekly Pressure Ulcer Record reflected the facility failed to document any wound measurements on Resident #1 from 10/28/16 to 11/10/16. Review of the hospital Admission History for Resident #1 dated 11/10/16 revealed the following: Chief Complaint: Left heel wound. Patient is a [AGE] year old female with extensive past medical history currently resident at nursing facility was sent to hospital today on account of worsening left foot primarily heel wound. Heel was noted to start getting swollen and there was drainage that was starting to come out of the area. Patient denies foot pain. Assessment & Plan: 1. Left heel wound: We'll start patient on IV antibiotics. Wound care. Podiatry consult in the morning. Based on patients' clinical condition at time of admission I expect her to be admitted to the hospital for at least two midnights for treatment of [REDACTED]. Review of the initial skin assessment conducted at the hospital on [DATE] at 6:08 PM by the Hospital Podiatrist reflected the following: Lower Extremity Physical Exam: Derma: warm bilateral [MEDICAL CONDITION]: present bilateral [DIAGNOSES REDACTED] (Redness): present left Wound Evaluation: Wound #1 Location left posterior medial heel [DIAGNOSES REDACTED] Minimal per wound [MEDICAL CONDITION]: present Drainage: Moderate, serosanguinous (bloody fluid) Malodor: present (Odor was present) Pain to palpation: minimal Pre-debridement measurement: 55 mm x 50 mm Post debridement measurement: 50 mm x 40 mm Wound #2 Location: right posterior medial heel [DIAGNOSES REDACTED]: absent Drainage: Moderate serous (yellowish fluid) Malodor: present Pre-debridement measurement 40 mm x 40 mm Post debridement measurement: same Wound #3 Location: right lateral 5th MPJ (Metatarsophalangeal joint - joint on fifth toe) Drainage: moderate serous Malodor: present Pre-debridement measurement: 20 mm x 20 mm Post debridement measurement: same Wound #4 Location: right lateral 5th metatarsal (toe) base Drainage: moderate serous Malodor: present Pre-debridement measurement: 15 mm x 10 mm Post debridement measurement: same Plan: Applied dry dressings to the feet. Continue with IV abx (antibiotics), will monitor for resolution of the [MEDICAL CONDITION]. Five residents were reviewed for wound care.

Based on observation, interview, and record review the facility failed to implement policies and procedures that prohibit neglect for 1 of 5 residents (Resident #1) reviewed for wound care. Staff Nurses and the Wound Care Nurse (WCN)/Director of Nurses (DON) neglected to perform wound care to venous stasis ulcers for Resident #1 from 10/28/16 to 11/10/16 resulting in hospitalization due to infection. This facility failure placed 5 residents with pressure sores/stasis ulcers at risk for the development of new pressure sores, stasis ulcers, infection and worsening of current sores. Finding Include: Review of Resident #1's Face Sheet reflected a [AGE] year old female re-admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. (There was no mention of wounds in the diagnoses.) Review of Residents #1's clinical record reflected that she was a previous resident of the facility and had been sent out to an acute care hospital on [DATE] due to worsening wounds. Before being transferred out of the facility, Resident #1 was being treated for [REDACTED]. Resident #1 had only been at the acute care hospital 22 days before readmission to the facility. Review of Resident #1's transfer orders (back to the facility) on 10/28/16 revealed the following: Transfer to SNF (Skilled Nursing Facility) Wound care per wound care orders. Review of a Discharge Planning Order dated 10/28/16 for Resident #1 revealed the following: Wound Care Orders: B (Bilateral) feet: daily. Paint areas of eschar with [MEDICATION NAME] BID (two times a day). Dry dressing to L (left) heel, xeroform and heel pad to R (right) heel, change daily. During an interview on 11/12/16 at 11:30 AM, the Director of Nurses (DON) stated that the Physician Assistant (PA) went to see Resident #1 and found the wound. There were dressings on the heels and she had on boots, but the dressing did not have a date on it. The DON stated, Resident #1 has a history of venous stasis ulcers and arrived here 10/28/16. We're not sure if anyone changed the dressings, there was no date on it. She was sent out to the hospital. I came in Friday (11/11/16) and did an audit, got the nurses together and started education. The nurses are doing there own wound care now. During an interview on 11/12/16 at 2:45 PM, the PA stated she had looked at Resident #1's labs and her white count was up so she decided to take a look at her heel wounds. She stated that they looked infected and had an odor so she called the Primary Care Physician (PCP) and was told to send Resident #1 to the hospital. When asked if the resident looked septic (infection in the blood), she stated, No, she didn't have any signs or symptoms of being septic, she was not unstable. When asked by the surveyor if she was aware that Resident #1's wounds had not been treated or dressing changed since she had been admitted , she stated, No. The PA stated that she was in the facility Monday through Friday, 8:00 AM to 5:00 PM but staff could call the on-call number after hours. During an interview on 11/12/16 at 3:00 PM, Licensed Vocational Nurse (LVN)/Assistant Director of Nurses (ADON) C stated that she had gone in with the PA when Resident #1's wounds were identified. She stated that the PA called the PCP and decided to send her out to the hospital. LVN C stated, After Resident #1 was sent out, we performed a skin assessment audit and everyone else was ok. When asked by the surveyor who would have been responsible for taking care of Resident #1's wound care, she stated The wound care nurse would have taken care of the wounds and there wasn't one (wound care nurse). That's possibly where the communication broke down. During an interview on 11/12/16 at 11:00 AM, LVN D stated, We used to have a wound care nurse and did not have to do our own wound care. I signed an inservice yesterday (11/11/16) evening stating that now we do have to do the wound care treatments. During a telephone interview on 11/12/16 at 2:20 PM, Registered Nurse (RN) B stated that she had been asked to come in for a couple of hours on 11/01/16 to perform skin assessments. Resident #1 had boots on bilaterally and Kerlix was wrapped around her leg and heels. I unwrapped the wounds and they were covered with white eschar with weeping (fluid). There was no orders for wound care and it was late, around 8:30 PM, so I wrote a note to the DON/WCN and slid it under the door to followup with the PA the next day (11/02/16). RN B stated, The resident did not have any pain, there was no odor and it did not look infected. I rewrapped the wound with clean Kerlix. When asked by the surveyor if she followed up with the DON to make sure she got the note, RN B stated, No, and I did not work Resident #1's hall after that. The surveyor asked, was the wrap dated, she stated, No. During an interview on 11/12/16 at 2:30 PM, the DON stated that she did not remember a note being placed under her door from RN B regarding Resident #1's wounds. The DON stated, Yes, I would have expected her to call someone for orders. During observation of Resident #1 at the hospital on [DATE] at 4:30 PM Resident #1 responded minimally to questions asked by the surveyor by nodding her head. During an interview on 11/12/16 at 5:30 PM, the hospital Podiatrist stated that Resident #1 was receiving IV antibiotics for [MEDICAL CONDITION] and heel and foot wounds. During an interview on 11/12/16 at 6:00 PM, the PCP stated that she had not been notified by the facility that Resident #1 had not received wound care treatment since her admission on 10/28/16. The PCP stated that she goes to the facility every other week and not seen Resident #1 since she had returned. When asked by the surveyor if harm had come to the resident by not receiving treatment, the PCP stated that she would have to speak with the other physicians and check on the wound cultures that would be back the next day. During an interview on 11/13/16 at 10:00 AM, the Director of Nurses (DON) stated that LVN F did the initial admission on Resident #1 and would have done the orders. LVN F missed the wound care orders when putting them in the computer. LVN A performed the physical assessment. During an interview on 11/13/16 at 11:40 AM, LVN D stated that Resident #1 had boots on and her ointment that was ordered was put everywhere but where the dressing covered. LVN D stated The DON replaced RN G (wound care nurse) and I was under the impression she was doing them (wounds). The computer was not prompting me to do wound care in the TAR (Treatment Administration Report) for us (nurses) to do it for two weeks. Review of Resident #1's TAR history dated 10/28/16 to 11/10/16 reflected no orders for wound care. During an interview on 11/13/16 at 11:50 AM, LVN F stated that she had missed the page that had the wound care orders on it. She stated that she gives a copy of the orders to the PA in case she wants to discontinue any of the orders and she approves them. LVN F stated the process includes the DON and/or ADON do a 24 hour chart check to make sure everything is correct. The PA also looks at the packet, (admission information from the acute care hospital), assesses the patient and does a H & P (History and Physical) for us in the first 72 hours. During an interview on 11/13/16 at 12:00 PM, the DON stated that it was possible during the two week transition the nurses didn't know to do their own wound care. The DON stated, I told some of them verbally, but don't have any papers to back it up. During an interview on 11/13/16 at 12:25 PM, the DON stated that she did not check the packet. She stated that she normally does the Long Term Care side and ADON (LVN C) does the medicare or rehabilitation side where Resident #1 resided. During an interview on 11/13/16 at 1:00 PM, LVN C/ADON stated that she had been out on personal leave when Resident #1 was admitted and was not in house to look at the packet. During an interview on 11/13/16 at 1:15 PM, LVN E stated that the facility always had a wound care nurse, and he had not been told he had to perform wound care on his residents until Friday (11/11/16). During an interview on 11/13/16 at 2:00 PM, the Administrator stated that the now acting DON was originally hired to take the place of the Wound Care Nurse, The DON/WCN was hired on 9/30/16 and accepted the position of DON on 10/27/16 after the other DON left on 10/26/16. When asked by the surveyor, so you did not have a WCN or anyone performing wound care from 10/27/16? The Administrator stated, We fixed that on Friday (11/11/16). Review of a facility note dated 11/11/16 revealed the following: Going forward from today, 11/11/16, I understand that I am responsible for wound care for my assigned patients and I will date, initial and time each dressing, and document appropriately in the chart. (The note was signed by 5 nurses). During an interview on 11/17/16 at 1:30 PM, LVN A stated that when she assessed Resident #1 upon admission that she did see there were wounds on the resident's heels, but did not remove the dressings because there was no order for wound care. LVN A stated that she told the Wound Care Nurse/DON the next day (10/29/16) and was told that she (DON/WCN) would look at them during rounds and get with the physician for orders. She (LVN A) stated that RN B had told her she had looked at the wounds and since there had not been an order she had left a note under the DON/WCN's door to follow-up with the physician the next day. Prior to Resident #1's discharge LVN A stated that she had not been told she was responsible for her resident's wound care. She stated that she did not find out until 11/14/16 when the DON approached her to sign a memo stating she would be responsible for her own wound care. LVN A stated, I was the only nurse that documented she had wounds. Review of the Weekly Pressure Ulcer Record reflected the facility failed to document any wound measurements on Resident #1 from 10/28/16 to 11/10/16. Review of the hospital Admission History for Resident #1 dated 11/10/16 revealed the following: Chief Complaint: Left heel wound. Patient is a [AGE] year old female with extensive past medical history currently resident at nursing facility was sent to hospital today on account of worsening left foot primarily heel wound. Heel was noted to start getting swollen and there was drainage that was starting to come out of the area. Patient denies foot pain. Assessment & Plan: 1. Left heel wound: We'll start patient on IV antibiotics. Wound care. Podiatry consult in the morning. Based on patients' clinical condition at time of admission I expect her to be admitted to the hospital for at least two midnights for treatment of [REDACTED]. Review of the initial skin assessment conducted at the hospital on [DATE] at 6:08 PM by the Hospital Podiatrist reflected the following: Lower Extremity Physical Exam: Derma: warm bilateral [MEDICAL CONDITION]: present bilateral [DIAGNOSES REDACTED] (Redness): present left Wound Evaluation: Wound #1 Location left posterior medial heel [DIAGNOSES REDACTED] Minimal per wound [MEDICAL CONDITION]: present Drainage: Moderate, serosanguinous (bloody fluid) Malodor: present (Odor was present) Pain to palpation: minimal Pre-debridement measurement: 55 mm x 50 mm Post debridement measurement: 50 mm x 40 mm Wound #2 Location: right posterior medial heel [DIAGNOSES REDACTED]: absent Drainage: Moderate serous (yellowish fluid) Malodor: present Pre-debridement measurement 40 mm x 40 mm Post debridement measurement: same Wound #3 Location: right lateral 5th MPJ (Metatarsophalangeal joint - joint on fifth toe) Drainage: moderate serous Malodor: present Pre-debridement measurement: 20 mm x 20 mm Post debridement measurement: same Wound #4 Location: right lateral 5th metatarsal (toe) base Drainage: moderate serous Malodor: present Pre-debridement measurement: 15 mm x 10 mm Post debridement measurement: same Plan: Applied dry dressings to the feet. Continue with IV abx (antibiotics), will monitor for resolution of the [MEDICAL CONDITION]. Review of the facility revised 11/01/16 Policy and Procedures for Abuse, Neglect and Misappropriation of Property revealed the following elements: Policy: 1. The facility's Leadership prohibits neglect. Procedures: Component III: Prevention 4. Adequate supervision of staff is maintained in order to identify and prevent inappropriate behaviors, such as: C. Ignoring the patients'/residents' needs, requests, etc. Component IV: Identification: 2. Neglect is the failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish, or mental illness. Five residents were reviewed for wound care.

Based on interview and record review, the facility failed to ensure services provided met professional standards of quality for 1 of 5 residents reviewed for wound care. (Resident #1) Staff Nurses and the Wound Care Nurse (WCN)/Director of Nurses (DON) failed to perform wound care to venous stasis ulcers for Resident #1 from 10/28/16 to 11/10/16 resulting in hospitalization due to infection. This facility failure placed 5 residents with pressure sores/stasis ulcers at risk for the development of new pressure sores, stasis ulcers, infection and worsening of current sores. Finding Include: Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.11 Standards of Nursing Practice (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (D) Accurately and completely report and document; (i) the client's status including signs and symptoms; (ii) nursing care rendered; (ii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s) and (vi) contacts with other health care team members concerning significant events regarding clients's status; (G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices; (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications; Review of Resident #1's Face Sheet reflected a [AGE] year old female re-admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. (There was no mention of wounds in the diagnoses.) Review of Residents #1's clinical record reflected that she was a previous resident of the facility and had been sent out to an acute care hospital on [DATE] due to worsening wounds. Before being transferred out of the facility, Resident #1 was being treated for [REDACTED]. Resident #1 had only been at the acute care hospital 22 days before readmission to the facility. Review of Resident #1's transfer orders (back to the facility) on 10/28/16 revealed the following: Transfer to SNF (Skilled Nursing Facility) Wound care per wound care orders. Review of a Discharge Planning Order dated 10/28/16 for Resident #1 revealed the following: Wound Care Orders: B (Bilateral) feet: daily. Paint areas of eschar with [MEDICATION NAME] BID (two times a day). Dry dressing to L (left) heel, xeroform and heel pad to R (right) heel, change daily. During an interview on 11/12/16 at 11:30 AM, the Director of Nurses (DON) stated that the Physician Assistant (PA) went to see Resident #1 and found the wound. There were dressings on the heels and she had on boots, but the dressing did not have a date on it. The DON stated, Resident #1 has a history of venous stasis ulcers and arrived here 10/28/16. We're not sure if anyone changed the dressings, there was no date on it. She was sent out to the hospital. I came in Friday (11/11/16) and did an audit, got the nurses together and started education. The nurses are doing there own wound care now. During an interview on 11/12/16 at 2:45 PM, the PA stated she had looked at Resident #1's labs and her white count was up so she decided to take a look at her heel wounds. She stated that they looked infected and had an odor so she called the Primary Care Physician (PCP) and was told to send Resident #1 to the hospital. When asked if the resident looked septic (infection in the blood), she stated, No, she didn't have any signs or symptoms of being septic, she was not unstable. When asked by the surveyor if she was aware that Resident #1's wounds had not been treated or dressing changed since she had been admitted , she stated, No. The PA stated that she was in the facility Monday through Friday, 8:00 AM to 5:00 PM but staff could call the on-call number after hours. During an interview on 11/12/16 at 3:00 PM, Licensed Vocational Nurse (LVN)/Assistant Director of Nurses (ADON) C stated that she had gone in with the PA when Resident #1's wounds were identified. She stated that the PA called the PCP and decided to send her out to the hospital. LVN C stated, After Resident #1 was sent out, we performed a skin assessment audit and everyone else was ok. When asked by the surveyor who would have been responsible for taking care of Resident #1's wound care, she stated The wound care nurse would have taken care of the wounds and there wasn't one (wound care nurse). That's possibly where the communication broke down. During an interview on 11/12/16 at 11:00 AM, LVN D stated, We used to have a wound care nurse and did not have to do our own wound care. I signed an inservice yesterday (11/11/16) evening stating that now we do have to do the wound care treatments. During a telephone interview on 11/12/16 at 2:20 PM, Registered Nurse (RN) B stated that she had been asked to come in for a couple of hours on 11/01/16 to perform skin assessments. Resident #1 had boots on bilaterally and Kerlix was wrapped around her leg and heels. I unwrapped the wounds and they were covered with white eschar with weeping (fluid). There was no orders for wound care and it was late, around 8:30 PM, so I wrote a note to the DON/WCN and slid it under the door to followup with the PA the next day (11/02/16). RN B stated, The resident did not have any pain, there was no odor and it did not look infected. I rewrapped the wound with clean Kerlix. When asked by the surveyor if she followed up with the DON to make sure she got the note, RN B stated, No, and I did not work Resident #1's hall after that. The surveyor asked, was the wrap dated, she stated, No. During an interview on 11/12/16 at 2:30 PM, the DON stated that she did not remember a note being placed under her door from RN B regarding Resident #1's wounds. The DON stated, Yes, I would have expected her to call someone for orders. During observation of Resident #1 at the hospital on [DATE] at 4:30 PM Resident #1 responded minimally to questions asked by the surveyor by nodding her head. During an interview on 11/12/16 at 5:30 PM, the hospital Podiatrist stated that Resident #1 was receiving IV antibiotics for [MEDICAL CONDITION] and heel and foot wounds. During an interview on 11/12/16 at 6:00 PM, the PCP stated that she had not been notified by the facility that Resident #1 had not received wound care treatment since her admission on 10/28/16. The PCP stated that she goes to the facility every other week and not seen Resident #1 since she had returned. When asked by the surveyor if harm had come to the resident by not receiving treatment, the PCP stated that she would have to speak with the other physicians and check on the wound cultures that would be back the next day. During an interview on 11/13/16 at 10:00 AM, the Director of Nurses (DON) stated that LVN F did the initial admission on Resident #1 and would have done the orders. LVN F missed the wound care orders when putting them in the computer. LVN A performed the physical assessment. During an interview on 11/13/16 at 11:40 AM, LVN D stated that Resident #1 had boots on and her ointment that was ordered was put everywhere but where the dressing covered. LVN D stated The DON replaced RN G (wound care nurse) and I was under the impression she was doing them (wounds). The computer was not prompting me to do wound care in the TAR (Treatment Administration Report) for us (nurses) to do it for two weeks. Review of Resident #1's TAR history dated 10/28/16 to 11/10/16 reflected no orders for wound care. During an interview on 11/13/16 at 11:50 AM, LVN F stated that she had missed the page that had the wound care orders on it. She stated that she gives a copy of the orders to the PA in case she wants to discontinue any of the orders and she approves them. LVN F stated the process includes the DON and/or ADON do a 24 hour chart check to make sure everything is correct. The PA also looks at the packet, (admission information from the acute care hospital), assesses the patient and does an H & P (History and Physical) for us in the first 72 hours. During an interview on 11/13/16 at 12:00 PM, the DON stated that it was possible during the two week transition the nurses didn't know to do their own wound care. The DON stated, I told some of them verbally, but don't have any papers to back it up. During an interview on 11/13/16 at 12:25 PM, the DON stated that she did not check the packet. She stated that she normally does the Long Term Care side and ADON (LVN C) does the medicare or rehabilitation side where Resident #1 resided. During an interview on 11/13/16 at 1:00 PM, LVN C/ADON stated that she had been out on personal leave when Resident #1 was admitted and was not in house to look at the packet. During an interview on 11/13/16 at 1:15 PM, LVN E stated that the facility always had a wound care nurse, and he had not been told he had to perform wound care on his residents until Friday (11/11/16). During an interview on 11/13/16 at 2:00 PM, the Administrator stated that the now acting DON was originally hired to take the place of the Wound Care Nurse, The DON/WCN was hired on 9/30/16 and accepted the position of DON on 10/27/16 after the other DON left on 10/26/16. When asked by the surveyor, so you did not have a WCN or anyone performing wound care from 10/27/16? The Administrator stated, We fixed that on Friday (11/11/16). Review of a facility note dated 11/11/16 revealed the following: Going forward from today, 11/11/16, I understand that I am responsible for wound care for my assigned patients and I will date, initial and time each dressing, and document appropriately in the chart. (The note was signed by 5 nurses). During an interview on 11/17/16 at 1:30 PM, LVN A stated that when she assessed Resident #1 upon admission that she did see there were wounds on the resident's heels, but did not remove the dressings because there was no order for wound care. LVN A stated that she told the Wound Care Nurse/DON the next day (10/29/16) and was told that she (DON/WCN) would look at them during rounds and get with the physician for orders. She (LVN A) stated that RN B had told her she had looked at the wounds and since there had not been an order she had left a note under the DON/WCN's door to follow-up with the physician the next day. Prior to Resident #1's discharge LVN A stated that she had not been told she was responsible for her resident's wound care. She stated that she did not find out until 11/14/16 when the DON approached her to sign a memo stating she would be responsible for her own wound care. LVN A stated, I was the only nurse that documented she had wounds. Review of the Weekly Pressure Ulcer Record reflected the facility failed to document any wound measurements on Resident #1 from 10/28/16 to 11/10/16. Review of the hospital Admission History for Resident #1 dated 11/10/16 revealed the following: Chief Complaint: Left heel wound. Patient is a [AGE] year old female with extensive past medical history currently resident at nursing facility was sent to hospital today on account of worsening left foot primarily heel wound. Heel was noted to start getting swollen and there was drainage that was starting to come out of the area. Patient denies foot pain. Assessment & Plan: 1. Left heel wound: We'll start patient on IV antibiotics. Wound care. Podiatry consult in the morning. Based on patients' clinical condition at time of admission I expect her to be admitted to the hospital for at least two midnights for treatment of [REDACTED]. Review of the initial skin assessment conducted at the hospital on [DATE] at 6:08 PM by the Hospital Podiatrist reflected the following: Lower Extremity Physical Exam: Derma: warm bilateral [MEDICAL CONDITION]: present bilateral [DIAGNOSES REDACTED] (Redness): present left Wound Evaluation: Wound #1 Location left posterior medial heel [DIAGNOSES REDACTED] Minimal per wound [MEDICAL CONDITION]: present Drainage: Moderate, serosanguinous (bloody fluid) Malodor: present (Odor was present) Pain to palpation: minimal Pre-debridement measurement: 55 mm x 50 mm Post debridement measurement: 50 mm x 40 mm Wound #2 Location: right posterior medial heel [DIAGNOSES REDACTED]: absent Drainage: Moderate serous (yellowish fluid) Malodor: present Pre-debridement measurement 40 mm x 40 mm Post debridement measurement: same Wound #3 Location: right lateral 5th MPJ (Metatarsophalangeal joint - joint on fifth toe) Drainage: moderate serous Malodor: present Pre-debridement measurement: 20 mm x 20 mm Post debridement measurement: same Wound #4 Location: right lateral 5th metatarsal (toe) base Drainage: moderate serous Malodor: present Pre-debridement measurement: 15 mm x 10 mm Post debridement measurement: same Plan: Applied dry dressings to the feet. Continue with IV abx (antibiotics), will monitor for resolution of the [MEDICAL CONDITION]. Review of the facility revised 11/01/16 Policy and Procedures for Abuse, Neglect and Misappropriation of Property revealed the following elements: Policy: 1. The facility's Leadership prohibits neglect. Procedures: Component III: Prevention 4. Adequate supervision of staff is maintained in order to identify and prevent inappropriate behaviors, such as: C. Ignoring the patients'/residents' needs, requests, etc. Component IV: Identification: 2. Neglect is the failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish, or mental illness. Five residents were reviewed for wound care.

Based on observation, interview, and record review, the facility failed to implement policies and procedures that prohibit neglect for one of two residents reviewed for [MEDICAL TREATMENT] (Resident #1). Resident #1, who had a history of [REDACTED]. Resident #1 requested to go to [MEDICAL TREATMENT], complained of not feeling well, difficulty in breathing, had a decrease in BP, and requested to go to the hospital three times over two days, including different shifts. Resident #1 was not sent to the hospital per her request, and died in the facility on [DATE] at 2:44 a.m. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm and with a scope identified as isolated. This deficient practice resulted in the death of one resident, and could place one resident on [MEDICAL TREATMENT], at risk for not having their requests honored, and of receiving goods and services necessary to avoid physical harm, mental anguish and death. The Findings Include: Review of Resident #1 ' s face sheet reflected she was [AGE] years old, admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #1 was her own responsible party. Review of Resident #1 ' s admission MDS dated [DATE] reflected a BIMS of 12, indicating she was cognitively intact, had no refusals of care and required limited assistance or supervision for ADLs. Resident #1 used a walker and wheelchair, and was usually continent of bowel and bladder. Resident #1 received [MEDICAL TREATMENT] prior to being admitted , as well as when a resident at the facility. Review of Resident #1 ' s Care Plan dated [DATE] reflected she has a history of chest pain related to recurrent [MEDICAL CONDITION], with the following approaches included: monitor and record any complaints of pain; monitor blood pressure closely for [MEDICAL CONDITION]. Further review of Resident #1 ' s Care Plan reflected she required [MEDICAL TREATMENT], with the following approaches included: supply lunch on [MEDICAL TREATMENT] days; monitor shunt for thrills/bruit daily, monitor for bleeding and weakness. Resident #1 was a DNR. In an interview on [DATE] at 1:30 p.m., LVN A stated she was the night shift (7:00 p.m. to 7:00 a.m.) nurse on [DATE]. LVN A stated the day shift nurse, LVN B, reported Resident #1 had missed [MEDICAL TREATMENT] on [DATE], was stable, but had vomited one time during the day. LVN A stated Resident #1 requested to go to the hospital to receive [MEDICAL TREATMENT] and she did not feel well. LVN A stated she called the NP to inform her of Resident #1 ' s status and request to go to the hospital. The NP gave orders for chest xray, [MEDICATION NAME] (antianxiety), increase [MEDICATION NAME] (diuretic), and hold blood pressure medications. LVN A stated the NP said Resident #1 can go to the hospital, but it is not an emergency transport, and to continue to monitor her vital signs every four hours. LVN A stated Resident #1 ' s blood pressure at that time was ,[DATE], and parameters for the facility are ,[DATE]. LVN A stated she was taking Resident #1 ' s vital signs around 2:00 a.m. when Resident #1 became unresponsive. She called for the CNAs to call 911 because she did not know Resident #1 ' s code status. The CNAs came to the room, so LVN A left the room to call 911. LVN A stated Resident #1 was still breathing when she left the room, and was still breathing when she went back to the room. (EMS arrived and began CPR.) When asked what the facility ' s policy was for sending residents to the hospital, LVN A stated, Policy is, we treat here at the facility, then send out to the hospital if needed. LVN A stated she also called the ADON and the DON to report Resident #1 ' s request to go to the hospital, and was told to continue to monitor. In a follow-up interview on [DATE] at 11:55 a.m., LVN A stated the last time she spoke with the NP on [DATE] was at 10:00 p.m. when she reported Resident #1 ' s blood pressure of ,[DATE], and received the orders to hold her blood pressure medications, get a chest xray and take vital signs every four hours. The next time she went to take Resident #1 ' s vital signs around 2:00 a.m. on [DATE], was when she went unresponsive. In an interview on [DATE] at 3:35 p.m., LVN B stated she worked on [DATE], when Resident #1 told her she felt like she was having a [MEDICAL CONDITION], and was having difficulty breathing. Resident #1 had standing orders for oxygen, so she started oxygen. LVN B received orders for [MEDICATION NAME] (used to prevent or relieve sudden chest pain). LVN B stated Resident #1 had breakfast, then started feeling bad again, so she sent her to the hospital. Resident #1 returned before the end of her shift on [DATE]. LVN B stated Resident #1 was to receive [MEDICAL TREATMENT] on [DATE], and was not sure if she had [MEDICAL TREATMENT] at the hospital. On [DATE], Resident #1 did not want to go to [MEDICAL TREATMENT], but LVN B told her how important it was, so Resident #1 agreed to go. On [DATE], Resident #1 was scheduled to go to [MEDICAL TREATMENT], and is usually picked up by 10:30 a.m. LVN B stated she noticed Resident #1 was still at the facility at 11:00 a.m., so she called the transport company. The transport company stated they did not have Resident #1 on their list, but agreed to pick her up later that day. LVN B stated Resident #1 did not want to go by the time the transport company arrived because she would only be dialyzed for a short time. LVN B stated Resident #1 had some [MEDICAL CONDITION], but her vital signs were stable on [DATE]. LVN B stated Resident #1 was asking to go to the hospital for [MEDICAL TREATMENT], but her vital signs were stable and she continued to monitor. In an interview on [DATE] at 4:55 p.m., the Administrator stated the facility had contracts with two different transport companies to take residents to appointments. The Administrator stated they recently found out that one of the companies was not available on Saturday or Sunday. When asked what the back-up transportation plan was, she stated they would call the other transport company, but was working on a plan to share a van with another building. The Administrator also stated the facility should have made other arrangements for Resident #1 to go to [MEDICAL TREATMENT] on [DATE] when the transport company was late. In a telephone interview on [DATE] at 3:05 p.m., the NP stated she was on-call for the weekend beginning 12:01 a.m., [DATE] to 6:00 a.m., [DATE]. The NP stated Resident #1 was not her patient, but worked with the medical group that provided services to the facility. The NP stated LVN A called her twice that weekend regarding Resident #1. The first call was before lunch, and LVN A reported Resident #1 missed [MEDICAL TREATMENT] the day before ([DATE]), was not feeling well and wanted to go to the hospital. LVN A reported vital signs were stable. The NP stated she recommended to continue to monitor Resident #1, but if she was insisting to go to the hospital, it would not be an emergency, but the resident could go. The NP stated the second call from LVN A was later in the evening when she reported Resident #1 was short of breath, blood pressure had dropped and was anxious. The NP gave orders to double Resident #1 ' s [MEDICATION NAME] (diuretic), chest xray, administer [MEDICATION NAME] (antianxiety), and to hold her blood pressure medications. The NP did not remember if LVN A reported another request from Resident #1 to go to the hospital, but added the facility did not need an order to call EMS. In an interview on [DATE] at 5:30 p.m., the DON stated she received a call on [DATE] at 8:00 p.m. from LVN A, reporting that Resident #1 wanted to go to the hospital. The DON asked what the NP had recommended, and told LVN A to continue to monitor Resident #1. The DON stated she called the facility back later that evening to check how things were going, as she was the nurse on call. The DON stated she spoke with LVN A, and told her to continue to monitor Resident #1, and if there were changes to send her out. The DON stated she expects the nursing staff to notify her and the doctor if sending a resident to the hospital, but does not know if the facility had a policy of when to send a resident to the hospital. The DON stated it is a resident right to go to the hospital. In a telephone interview on [DATE] at 6:15 p.m., the MD stated he had not treated Resident #1 at this facility, but had treated her in the past. The MD stated he was the physician on call when Resident #1 passed away on [DATE], and he responded to the facility ' s request to pronounce her death. The MD stated many things can go wrong when someone misses [MEDICAL TREATMENT], the most severe would be an increase in potassium which can lead to cardiac problems. The MD stated one of the signs and symptoms of cardiac problems would be shortness of breath and difficulty breathing. The MD also stated if a resident asks to go to the hospital, the facility should send them. Review of Progress Notes for Resident #1: [DATE], 7:35 a.m.: Resident complaining of having feeling of [MEDICAL CONDITION] .on assessment noted vital signs ,[DATE] (BP) .[MEDICATION NAME] administered three times, every five minutes. Resident stated she is feeling better .will continue to monitor. [DATE], 8:30 a.m.: Resident called and stated that she is not feeling good and [MEDICAL CONDITION] symptoms still noted. Paged NP, new order to send resident to hospital . [DATE], 3:00 p.m., Resident returned to facility .stated she is feeling much better . [DATE], 9:45 a.m.: Resident complaining of being nauseated and not feeling well, did not want to go to [MEDICAL TREATMENT], asking to be sent to the hospital. Advised her it was very important that she attends [MEDICAL TREATMENT] today as she already missed her [MEDICAL TREATMENT] on [DATE]. She agreed to go .vital signs stable, ,[DATE] (BP), pulse 80, respirations 20, oxygen saturation 90%. [DATE], 11:00 a.m.: Called (contracted transport company) after realizing Resident had not been picked up for [MEDICAL TREATMENT]. The gentleman stated he did not see her on their schedule .what was the earliest they could pick her up and he stated in two hours. Called [MEDICAL TREATMENT] and notified them Resident was going to be running late if they could still see her. They stated they can take her but she will get dialyzed for two hours only. Resident stated it would not help. Notified ADON, Resident is upset with transportation .informed her we will do our best to take care of the problem .all vitals stable at this moment . [DATE], 1:30 a.m., (time of documentation, referring to earlier in her shift on [DATE]): Resident has reported she has missed [MEDICAL TREATMENT] and has expressed her desire to be taken to the hospital to be dialyzed. I told resident I will pass the message to the incoming shift .stable with vital signs within parameters; no labored breathing . [DATE], 9:30 a.m.: Resident called and stated she needed me to send her to (hospital) so she can receive [MEDICAL TREATMENT] .Assessed, all vitals seem stable, ,[DATE] (BP), pulse 80, respirations 18, oxygen saturation 96% on room air Resident stated she felt like she couldn ' t breathe well, administered oxygen at two liters via nasal canula, oxygen sats increased to 98%. Lung sounds a little course but clear. [DATE], 1:37 a.m., (time of documentation, referring to between 8:00 p.m. and 10:00 p.m. on [DATE]): Resident has expressed her intention to be taken to the hospital due to not feeling well. Resident has complained of breathing difficulty. No labored breathing noted; oxygen saturation is 94% with oxygen via nasal canula at 2/liters; regular heart sound and rhythm XXX,[DATE] (BP), heart rate 52, respirations 18 .DON, ADON and MD (NP) are notified; all advised to continue to monitor .resident is alert, oriented x3, stable and watching television in her room during assessment. [DATE], 1:51 a.m., (time of documentation, referring to 10:00 p.m. on [DATE]): New order on [DATE]: [MEDICATION NAME] 1 mg every 12 hours as needed; chest xray STAT; [MEDICATION NAME] 40 mg for two days; hold [MEDICATION NAME] for heart rate <60; hold losartan for 2 days; take vital signs every four hours for 24 hours. [DATE], 2:20 a.m.: At 10:30 p.m., Resident was reassessed after receiving [MEDICATION NAME] 1 mg at 10:00 p.m .resting in bed . [DATE], 3:41 a.m.: Resident assessed at 1:30 a.m., alert, oriented x3. Vital signs are within parameters .no labored breathing, has regular heart sounds and rhythm . [DATE], 11:40 a.m.: (time of documentation, referring to 2:00 a.m. on [DATE]): This nurse was at resident ' s bedside at 0200 to check her vital signs. Resident #1 woke up and stated Ok. During vital sign check resident became unresponsive. Nurse called 911 and explained that she has become unresponsive. EMS came and performed CPR .Another nurse came and stated that Resident #1 is a DNR .Physical copy of DNR was provided to EMS and they stopped CPR .MD arrived and pronounced member dead . Review of the chest xray, ordered by the NP, dated [DATE] at 10:15 p.m.: Impression: Mild left lung infiltrate. Review of the Discharge Note for Resident #1, dated [DATE], completed by the MD: Reason for this visit: coded and expired. History/Physical information relating to this visit: I was contacted on call by NP at 3:10 a.m. that this patient had coded and expired .regarding the need to speak to a medical attending .to pronounce the patient dead .NP on call was contacted and reportedly an order for [REDACTED]. Assessment and plan: 1) Dependence on HD due to [MEDICAL CONDITION]: with lack of [MEDICAL TREATMENT] attendance contributing to demise. 2) Recurrent [MEDICAL CONDITION]: Likely ultimate cause of death, with [MEDICAL CONDITION] contributing. Additional text: Patient pronounce dead as of [DATE] at 4:15 a.m. Review of the facility ' s Policy and Procedures for Abuse, Neglect and Misappropriation of Property, revised [DATE]: Policy: 1) The facility ' s Leadership prohibits neglect, Procedures: Prevention: 4) Adequate supervision of staff is maintained in order to identify and prevent inappropriate behaviors, such as: .C) Ignoring the patients ' /residents ' needs, requests, etc. Identification: 2) Neglect is the failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish, or mental illness. Review of the facility ' s Statement of Resident Rights: You, the resident, do not give up any rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights It is against the law for any nursing facility employee to threaten, coerce .for exercising your rights. You have a right to: 1) All care necessary for you to have the highest possible level of health. IJ components: The facility Administrator, DON and Regional Director of Clinical Services were notified on [DATE] at 5:45 p.m. that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on [DATE] at 7:00 p.m. The final Plan of Removal was accepted by the investigator on [DATE] at 3:00 p.m. Neglect related to Failure to honor Resident Rights: I. Failure to honor resident's right to be sent to hospital after she asked to go. II. All Facility staff will be re-educated by Director of Nursing/ designee regarding resident ' s rights to be free from neglect. This education will start on [DATE] at 7:15PM. No facility staff will be allowed to work after 10:00pm on [DATE] until they receive the required education. This information will be provided in new hire orientation and all new hires will receive this education before allowed to work. III. A. 100% audit of alert and oriented residents will be completed by social worker and activity director on [DATE] to ensure no resident is currently at risk for neglect. Additionally, responsible parties of non-interviewable residents will be contacted by the Guardian Angel Program committee to identify any concerns with resident rights or neglect. Any identified issue will be addressed immediately. These responsible parties will be contacted by [DATE], at 5:00pm. Two call attempts will be made for unreachable responsible parties. Additionally, all residents will be assessed during rounds for by nurse managers for signs and symptoms of neglect by 1:45pm on [DATE]. B. 10% of facility resident ' s medical records will be audited for neglect. Nurse Managers will audit 10 medical records per week for 4 weeks to monitor for missed care or services. IV. Resident Rights will be discussed at the next scheduled Resident Council which will be [DATE] and Family Council Meeting which will be [DATE] by Administrator/designee. A copy of the Resident ' s Rights will be emailed to any responsible party whose email is on file. A copy of the Resident ' s Rights will be mailed to all responsible parties via United States Post Office ' s certified mail. V. Director of Nursing/designee will monitor residents with a change of condition through the twenty-four hour report and/or the grievance process for any concerns related to missing care of services. The process will begin on [DATE]; will be done daily for the next 30 days, five times a week thereafter in morning clinical meeting. Nurse Managers will monitor on the weekends during the 30 day period. Any areas of concern will be addressed at the time of discovery. I. Director of Nursing/designee will report progress to Quality Assurance Performance Improvement Committee monthly times 3 months and until compliance has been achieved. The next Quality Assurance Performance Improvement Committee will be no later than [DATE]. Any areas of concern will be addressed at the time of discovery. The survey team monitored the current plan of removal as follows: Observations on [DATE] between 10:00 a.m. and 3:00 p.m. revealed staff receiving in-services and training on resident rights, abuse/neglect, resident assessment and change of condition and resident code status. Interviews with one RN, three LVNs, one MA and three CNAs on [DATE] between 10:00 a.m. and 5:00 p.m. revealed staff received in-service training for assessment and recognizing a resident's change of condition, their code status, abuse/neglect and resident rights. Charge Nurses were in-serviced on the importance of nursing judgment and decision making at the bedside. Review of the facility ' s audit checklist reflected the facility had implemented the resident medical record review audits to identify potential neglect and/or unidentified change of condition. On [DATE] at 5:20 p.m., the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope as isolated, due to the facility requiring time to train all staff and monitor their Plan of Removal. Review of the facility's form CMS 672 reflected one other resident who received [MEDICAL TREATMENT].

Based on observation, interview, and record review, the facility failed to ensure residents have the right to exercise his or her rights as a resident of the facility, for one of seven residents reviewed for resident rights (Resident #1). Resident #1 missed her regularly scheduled [MEDICAL TREATMENT] appointment on [DATE], due to the contracted transportation company failure to pick her up on time. Resident #1 requested to go to the hospital three times over two days, including different shifts. Resident #1 was not sent to the hospital per her request, and died in the facility on [DATE] at 2:44 a.m. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm and with a scope identified as isolated. This deficient practice resulted in the death of one resident, and could place one resident, who is their own responsible party, at risk for not having their requests honored, and of receiving goods and services necessary to avoid physical harm, mental anguish and death. The Findings Include: Review of Resident #1 ' s face sheet reflected she was [AGE] years old, admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #1 was her own responsible party. Review of Resident #1 ' s admission MDS dated [DATE] reflected a BIMS of 12, indicating she was cognitively intact, had no refusals of care and required limited assistance or supervision for ADLs. Resident #1 used a walker and wheelchair, and was usually continent of bowel and bladder. Resident #1 received [MEDICAL TREATMENT] prior to being admitted , as well as when a resident at the facility. Review of Resident #1 ' s Care Plan dated [DATE] reflected she has a history of chest pain related to recurrent [MEDICAL CONDITION], with the following approaches included: monitor and record any complaints of pain; monitor blood pressure closely for [MEDICAL CONDITION]. Further review of Resident #1 ' s Care Plan reflected she required [MEDICAL TREATMENT], with the following approaches included: supply lunch on [MEDICAL TREATMENT] days; monitor shunt for thrills/bruit daily, monitor for bleeding and weakness. Resident #1 was a DNR. In an interview on [DATE] at 1:30 p.m., LVN A stated she was the night shift (7:00 p.m. to 7:00 a.m.) nurse on [DATE]. LVN A stated the day shift nurse, LVN B, reported Resident #1 had missed [MEDICAL TREATMENT] on [DATE], was stable, but had vomited one time during the day. LVN A stated Resident #1 requested to go to the hospital to receive [MEDICAL TREATMENT] and she did not feel well. LVN A stated she called the NP to inform her of Resident #1 ' s status and request to go to the hospital. The NP gave orders for chest xray, [MEDICATION NAME] (antianxiety), increase [MEDICATION NAME] (diuretic), and hold blood pressure medications. LVN A stated the NP said Resident #1 can go to the hospital, but it is not an emergency transport, and to continue to monitor her vital signs every four hours. LVN A stated Resident #1 ' s blood pressure at that time was ,[DATE], and parameters for the facility are ,[DATE]. LVN A stated she was taking Resident #1 ' s vital signs around 2:00 a.m. when Resident #1 became unresponsive. She called for the CNAs to call 911 because she did not know Resident #1 ' s code status. The CNAs came to the room, so LVN A left the room to call 911. LVN A stated Resident #1 was still breathing when she left the room, and was still breathing when she went back to the room. (EMS arrived and began CPR.) When asked what the facility ' s policy was for sending residents to the hospital, LVN A stated, Policy is, we treat here at the facility, then send out to the hospital if needed. LVN A stated she also called the ADON and the DON to report Resident #1 ' s request to go to the hospital, and was told to continue to monitor. In a follow-up interview on [DATE] at 11:55 a.m., LVN A stated the last time she spoke with the NP on [DATE], was at 10:00 p.m. when she reported Resident #1 ' s blood pressure of ,[DATE], and received the orders to hold her blood pressure medications, get a chest xray and take vital signs every four hours. The next time she went to take Resident #1 ' s vital signs around 2:00 a.m. on [DATE], was when she went unresponsive. In an interview on [DATE] at 3:35 p.m., LVN B stated she worked on [DATE], when Resident #1 told her she felt like she was having a [MEDICAL CONDITION], and was having difficulty breathing. Resident #1 had standing orders for oxygen, so she started oxygen. LVN B received orders for [MEDICATION NAME] (used to prevent or relieve sudden chest pain). LVN B stated Resident #1 had breakfast, then started feeling bad again, so she sent her to the hospital. Resident #1 returned before the end of her shift on [DATE]. LVN B stated Resident #1 was to receive [MEDICAL TREATMENT] on [DATE], and was not sure if she had [MEDICAL TREATMENT] at the hospital. On [DATE], Resident #1 did not want to go to [MEDICAL TREATMENT], but LVN B told her how important it was, so Resident #1 agreed to go. On [DATE], Resident #1 was scheduled to go to [MEDICAL TREATMENT], and is usually picked up by 10:30 a.m. LVN B stated she noticed Resident #1 was still at the facility at 11:00 a.m., so she called the transport company. The transport company stated they did not have Resident #1 on their list, but agreed to pick her up later that day. LVN B stated Resident #1 did not want to go by the time the transport company arrived because she would only be dialyzed for a short time. LVN B stated Resident #1 had some [MEDICAL CONDITION], but her vital signs were stable on [DATE]. LVN B stated Resident #1 was asking to go to the hospital for [MEDICAL TREATMENT], but her vital signs were stable and she continued to monitor. In a telephone interview on [DATE] at 3:05 p.m., the NP stated she was on-call for the weekend beginning 12:01 a.m., [DATE] to 6:00 a.m., [DATE]. The NP stated Resident #1 was not her patient, but worked with the medical group that provided services to the facility. The NP stated LVN A called her twice that weekend regarding Resident #1. The first call was before lunch, and LVN A reported Resident #1 missed [MEDICAL TREATMENT] the day before ([DATE]), was not feeling well and wanted to go to the hospital. LVN A reported vital signs were stable. The NP stated she recommended to continue to monitor Resident #1, but if she was insisting to go to the hospital, it would not be an emergency, but the resident could go. The NP stated the second call from LVN A was later in the evening when she reported Resident #1 was short of breath, blood pressure had dropped and was anxious. The NP gave orders to double Resident #1 ' s [MEDICATION NAME] (diuretic), chest xray, administer [MEDICATION NAME] (antianxiety), and to hold her blood pressure medications. The NP did not remember if LVN A reported another request from Resident #1 to go to the hospital, but added the facility did not need an order to call EMS. In an interview on [DATE] at 5:30 p.m., the DON stated she received a call on [DATE] at 8:00 p.m. from LVN A, reporting that Resident #1 wanted to go to the hospital. The DON asked what the NP had recommended, and told LVN A to continue to monitor Resident #1. The DON stated she called the facility back later that evening to check how things were going, as she was the nurse on call. The DON stated she spoke with LVN A, and told her to continue to monitor Resident #1, and if there were changes to send her out. The DON stated she expects the nursing staff to notify her and the doctor if sending a resident to the hospital, but does not know if the facility had a policy of when to send a resident to the hospital. The DON stated it is a resident right to go to the hospital. In a telephone interview on [DATE] at 6:15 p.m., the MD stated he had not treated Resident #1 at this facility, but had treated her in the past. The MD stated he was the physician on call when Resident #1 passed away on [DATE], and he responded to the facility ' s request to pronounce her death. The MD stated many things can go wrong when someone misses [MEDICAL TREATMENT], the most severe would be an increase in potassium which can lead to cardiac problems. The MD stated one of the signs and symptoms of cardiac problems would be shortness of breath and difficulty breathing. The MD also stated if a resident asks to go to the hospital, the facility should send them. Review of Progress Notes for Resident #1: [DATE], 7:35 a.m.: Resident complaining of having feeling of [MEDICAL CONDITION] .on assessment noted vital signs ,[DATE] (BP) .[MEDICATION NAME] administered three times, every five minutes. Resident stated she is feeling better .will continue to monitor. [DATE], 8:30 a.m.: Resident called and stated that she is not feeling good and [MEDICAL CONDITION] symptoms still noted. Paged NP, new order to send resident to hospital . [DATE], 3:00 p.m., Resident returned to facility .stated she is feeling much better . [DATE], 9:45 a.m.: Resident complaining of being nauseated and not feeling well, did not want to go to [MEDICAL TREATMENT], asking to be sent to the hospital. Advised her it was very important that she attends [MEDICAL TREATMENT] today as she already missed her [MEDICAL TREATMENT] on [DATE]. She agreed to go .vital signs stable, ,[DATE] (BP), pulse 80, respirations 20, oxygen saturation 90%. [DATE], 11:00 a.m.: Called (contracted transport company) after realizing Resident had not been picked up for [MEDICAL TREATMENT]. The gentleman stated he did not see her on their schedule .what was the earliest they could pick her up and he stated in two hours. Called [MEDICAL TREATMENT] and notified them Resident was going to be running late if they could still see her. They stated they can take her but she will get dialyzed for two hours only. Resident stated it would not help. Notified ADON, Resident is upset with transportation .informed her we will do our best to take care of the problem .all vitals stable at this moment . [DATE], 1:30 a.m., (time of documentation, referring to earlier in her shift on [DATE]): Resident has reported she has missed [MEDICAL TREATMENT] and has expressed her desire to be taken to the hospital to be dialyzed. I told resident I will pass the message to the incoming shift .stable with vital signs within parameters; no labored breathing . [DATE], 9:30 a.m.: Resident called and stated she needed me to send her to (hospital) so she can receive [MEDICAL TREATMENT] .Assessed, all vitals seem stable, ,[DATE] (BP), pulse 80, respirations 18, oxygen saturation 96% on room air Resident stated she felt like she couldn ' t breathe well, administered oxygen at two liters via nasal canula, oxygen sats increased to 98%. Lung sounds a little course but clear. [DATE], 1:37 a.m., (time of documentation, referring to between 8:00 p.m. and 10:00 p.m. on [DATE]): Resident has expressed her intention to be taken to the hospital due to not feeling well. Resident has complained of breathing difficulty. No labored breathing noted; oxygen saturation is 94% with oxygen via nasal canula at 2/liters; regular heart sound and rhythm XXX,[DATE] (BP), heart rate 52, respirations 18 .DON, ADON and MD (NP) are notified; all advised to continue to monitor .resident is alert, oriented x3, stable and watching television in her room during assessment. [DATE], 1:51 a.m., (time of documentation, referring to 10:00 p.m. on [DATE]): New order on [DATE]: [MEDICATION NAME] 1 mg every 12 hours as needed; chest xray STAT; [MEDICATION NAME] 40 mg for two days; hold [MEDICATION NAME] for heart rate <60; hold losartan for 2 days; take vital signs every four hours for 24 hours. [DATE], 2:20 a.m.: At 10:30 p.m., Resident was reassessed after receiving [MEDICATION NAME] 1 mg at 10:00 p.m .resting in bed . [DATE], 3:41 a.m.: Resident assessed at 1:30 a.m., alert, oriented x3. Vital signs are within parameters .no labored breathing, has regular heart sounds and rhythm . [DATE], 11:40 a.m.: (time of documentation, referring to 2:00 a.m. on [DATE]): This nurse was at resident ' s bedside at 0200 to check her vital signs. Resident #1 woke up and stated Ok. During vital sign check resident became unresponsive. Nurse called 911 and explained that she has become unresponsive. EMS cam and performed CPR .Another nurse came and stated that Resident #1 is a DNR .Physical copy of DNR was provided to EMS and they stopped CPR .MD arrived and pronounced member dead . Review of the Discharge Note for Resident #1, dated [DATE], completed by the MD: Reason for this visit: coded and expired. History/Physical information relating to this visit: I was contacted on call by NP at 3:10 a.m. that this patient had coded and expired .regarding the need to speak to a medical attending .to pronounce the patient dead .NP on call was contacted and reportedly an order for [REDACTED]. Assessment and plan: 1) Dependence on DH due to [MEDICAL CONDITION]: with lack of [MEDICAL TREATMENT] attendance contributing to demise. 2) Recurrent [MEDICAL CONDITION]: Likely ultimate cause of death, with [MEDICAL CONDITION] contributing. Additional text: Patient pronounce dead as of [DATE] at 4:15 a.m. Review of the facility ' s Statement of Resident Rights: You, the resident, do not give up any rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights It is against the law for any nursing facility employee to threaten, coerce .for exercising your rights. You have a right to: 1) All care necessary for you to have the highest possible level of health. IJ components: The facility Administrator, DON and Regional Director of Clinical Services were notified on [DATE] at 5:45 p.m. that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on [DATE] at 7:00 p.m. The final Plan of Removal was accepted by the investigator on [DATE] at 3:00 p.m. Neglect related to Failure to honor Resident Rights: I. Failure to honor resident's right to be sent to hospital after she asked to go. II. All Facility staff will be re-educated by Director of Nursing/ designee regarding resident ' s rights to be free from neglect. This education will start on [DATE] at 7:15PM. No facility staff will be allowed to work after 10:00pm on [DATE] until they receive the required education. This information will be provided in new hire orientation and all new hires will receive this education before allowed to work. III. A. 100% audit of alert and oriented residents will be completed by social worker and activity director on [DATE] to ensure no resident is currently at risk for neglect. Additionally, responsible parties of non-interviewable residents will be contacted by the Guardian Angel Program committee to identify any concerns with resident rights or neglect. Any identified issue will be addressed immediately. These responsible parties will be contacted by [DATE], at 5:00pm. Two call attempts will be made for unreachable responsible parties. Additionally, all residents will be assessed during rounds for by nurse managers for signs and symptoms of neglect by 1:45pm on [DATE]. B. 10% of facility resident ' s medical records will be audited for neglect. Nurse Managers will audit 10 medical records per week for 4 weeks to monitor for missed care or services. IV. Resident Rights will be discussed at the next scheduled Resident Council which will be [DATE] and Family Council Meeting which will be [DATE] by Administrator/designee. A copy of the Resident ' s Rights will be emailed to any responsible party whose email is on file. A copy of the Resident ' s Rights will be mailed to all responsible parties via United States Post Office ' s certified mail. V. Director of Nursing/designee will monitor residents with a change of condition through the twenty-four hour report and/or the grievance process for any concerns related to missing care of services. The process will begin on [DATE]; will be done daily for the next 30 days, five times a week thereafter in morning clinical meeting. Nurse Managers will monitor on the weekends during the 30 day period. Any areas of concern will be addressed at the time of discovery. I. Director of Nursing/designee will report progress to Quality Assurance Performance Improvement Committee monthly times 3 months and until compliance has been achieved. The next Quality Assurance Performance Improvement Committee will be no later than [DATE]. Any areas of concern will be addressed at the time of discovery. The survey team monitored the current plan of removal as follows: Observations on [DATE] between 10:00 a.m. and 3:00 p.m. revealed staff receiving in-services and training on resident rights, abuse/neglect, resident assessment and change of condition and resident code status. Interviews with one RN, three LVNs, one MA and three CNAs on [DATE] between 10:00 a.m. and 5:00 p.m. revealed staff received in-service training for assessment and recognizing a resident's change of condition, their code status, abuse/neglect and resident rights. Charge Nurses were in-serviced on the importance of nursing judgment and decision making at the bedside. Review of the facility ' s audit checklist reflected the facility had implemented the resident medical record review audits to identify potential neglect and/or unidentified change of condition. On [DATE] at 5:20 p.m., the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope as isolated, due to the facility requiring time to train all staff and monitor their Plan of Removal. The Administrator provided a list of one resident who was their own responsible party.

Based on observation, interview, and record review, the facility failed to implement policies and procedures that prohibit neglect for one of two residents reviewed for [MEDICAL TREATMENT] (Resident #1). Resident #1, who had a history of [REDACTED]. Resident #1 requested to go to [MEDICAL TREATMENT], complained of not feeling well, difficulty in breathing, had a decrease in BP, and requested to go to the hospital three times over two days, including different shifts. Resident #1 was not sent to the hospital per her request, and died in the facility on [DATE] at 2:44 a.m. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm and with a scope identified as isolated. This deficient practice resulted in the death of one resident, and could place one resident on [MEDICAL TREATMENT], at risk for not having their requests honored, and of receiving goods and services necessary to avoid physical harm, mental anguish and death. The Findings Include: Review of the facility ' s Policy and Procedures for Abuse, Neglect and Misappropriation of Property, revised [DATE]: Policy: 1) The facility ' s Leadership prohibits neglect, Procedures: Prevention: 4) Adequate supervision of staff is maintained in order to identify and prevent inappropriate behaviors, such as: .C) Ignoring the patients ' /residents ' needs, requests, etc. Identification: 2) Neglect is the failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish, or mental illness. Review of the facility ' s Statement of Resident Rights: You, the resident, do not give up any rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights It is against the law for any nursing facility employee to threaten, coerce .for exercising your rights. You have a right to: 1) All care necessary for you to have the highest possible level of health. Review of Resident #1 ' s face sheet reflected she was [AGE] years old, admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #1 was her own responsible party. Review of Resident #1 ' s admission MDS dated [DATE] reflected a BIMS of 12, indicating she was cognitively intact, had no refusals of care and required limited assistance or supervision for ADLs. Resident #1 used a walker and wheelchair, and was usually continent of bowel and bladder. Resident #1 received [MEDICAL TREATMENT] prior to being admitted , as well as when a resident at the facility. Review of Resident #1 ' s Care Plan dated [DATE] reflected she has a history of chest pain related to recurrent [MEDICAL CONDITION], with the following approaches included: monitor and record any complaints of pain; monitor blood pressure closely for [MEDICAL CONDITION]. Further review of Resident #1 ' s Care Plan reflected she required [MEDICAL TREATMENT], with the following approaches included: supply lunch on [MEDICAL TREATMENT] days; monitor shunt for thrills/bruit daily, monitor for bleeding and weakness. Resident #1 was a DNR. In an interview on [DATE] at 1:30 p.m., LVN A stated she was the night shift (7:00 p.m. to 7:00 a.m.) nurse on [DATE]. LVN A stated the day shift nurse, LVN B, reported Resident #1 had missed [MEDICAL TREATMENT] on [DATE], was stable, but had vomited one time during the day. LVN A stated Resident #1 requested to go to the hospital to receive [MEDICAL TREATMENT] and she did not feel well. LVN A stated she called the NP to inform her of Resident #1 ' s status and request to go to the hospital. The NP gave orders for chest xray, [MEDICATION NAME] (antianxiety), increase [MEDICATION NAME] (diuretic), and hold blood pressure medications. LVN A stated the NP said Resident #1 can go to the hospital, but it is not an emergency transport, and to continue to monitor her vital signs every four hours. LVN A stated Resident #1 ' s blood pressure at that time was ,[DATE], and parameters for the facility are ,[DATE]. LVN A stated she was taking Resident #1 ' s vital signs around 2:00 a.m. when Resident #1 became unresponsive. She called for the CNAs to call 911 because she did not know Resident #1 ' s code status. The CNAs came to the room, so LVN A left the room to call 911. LVN A stated Resident #1 was still breathing when she left the room, and was still breathing when she went back to the room. (EMS arrived and began CPR.) When asked what the facility ' s policy was for sending residents to the hospital, LVN A stated, Policy is, we treat here at the facility, then send out to the hospital if needed. LVN A stated she also called the ADON and the DON to report Resident #1 ' s request to go to the hospital, and was told to continue to monitor. In a follow-up interview on [DATE] at 11:55 a.m., LVN A stated the last time she spoke with the NP on [DATE] was at 10:00 p.m. when she reported Resident #1 ' s blood pressure of ,[DATE], and received the orders to hold her blood pressure medications, get a chest xray and take vital signs every four hours. The next time she went to take Resident #1 ' s vital signs around 2:00 a.m. on [DATE], was when she went unresponsive. In an interview on [DATE] at 3:35 p.m., LVN B stated she worked on [DATE], when Resident #1 told her she felt like she was having a [MEDICAL CONDITION], and was having difficulty breathing. Resident #1 had standing orders for oxygen, so she started oxygen. LVN B received orders for [MEDICATION NAME] (used to prevent or relieve sudden chest pain). LVN B stated Resident #1 had breakfast, then started feeling bad again, so she sent her to the hospital. Resident #1 returned before the end of her shift on [DATE]. LVN B stated Resident #1 was to receive [MEDICAL TREATMENT] on [DATE], and was not sure if she had [MEDICAL TREATMENT] at the hospital. On [DATE], Resident #1 did not want to go to [MEDICAL TREATMENT], but LVN B told her how important it was, so Resident #1 agreed to go. On [DATE], Resident #1 was scheduled to go to [MEDICAL TREATMENT], and is usually picked up by 10:30 a.m. LVN B stated she noticed Resident #1 was still at the facility at 11:00 a.m., so she called the transport company. The transport company stated they did not have Resident #1 on their list, but agreed to pick her up later that day. LVN B stated Resident #1 did not want to go by the time the transport company arrived because she would only be dialyzed for a short time. LVN B stated Resident #1 had some [MEDICAL CONDITION], but her vital signs were stable on [DATE]. LVN B stated Resident #1 was asking to go to the hospital for [MEDICAL TREATMENT], but her vital signs were stable and she continued to monitor. In an interview on [DATE] at 4:55 p.m., the Administrator stated the facility had contracts with two different transport companies to take residents to appointments. The Administrator stated they recently found out that one of the companies was not available on Saturday or Sunday. When asked what the back-up transportation plan was, she stated they would call the other transport company, but was working on a plan to share a van with another building. The Administrator also stated the facility should have made other arrangements for Resident #1 to go to [MEDICAL TREATMENT] on [DATE] when the transport company was late. In a telephone interview on [DATE] at 3:05 p.m., the NP stated she was on-call for the weekend beginning 12:01 a.m., [DATE] to 6:00 a.m., [DATE]. The NP stated Resident #1 was not her patient, but worked with the medical group that provided services to the facility. The NP stated LVN A called her twice that weekend regarding Resident #1. The first call was before lunch, and LVN A reported Resident #1 missed [MEDICAL TREATMENT] the day before ([DATE]), was not feeling well and wanted to go to the hospital. LVN A reported vital signs were stable. The NP stated she recommended to continue to monitor Resident #1, but if she was insisting to go to the hospital, it would not be an emergency, but the resident could go. The NP stated the second call from LVN A was later in the evening when she reported Resident #1 was short of breath, blood pressure had dropped and was anxious. The NP gave orders to double Resident #1 ' s [MEDICATION NAME] (diuretic), chest xray, administer [MEDICATION NAME] (antianxiety), and to hold her blood pressure medications. The NP did not remember if LVN A reported another request from Resident #1 to go to the hospital, but added the facility did not need an order to call EMS. In an interview on [DATE] at 5:30 p.m., the DON stated she received a call on [DATE] at 8:00 p.m. from LVN A, reporting that Resident #1 wanted to go to the hospital. The DON asked what the NP had recommended, and told LVN A to continue to monitor Resident #1. The DON stated she called the facility back later that evening to check how things were going, as she was the nurse on call. The DON stated she spoke with LVN A, and told her to continue to monitor Resident #1, and if there were changes to send her out. The DON stated she expects the nursing staff to notify her and the doctor if sending a resident to the hospital, but does not know if the facility had a policy of when to send a resident to the hospital. The DON stated it is a resident right to go to the hospital. In a telephone interview on [DATE] at 6:15 p.m., the MD stated he had not treated Resident #1 at this facility, but had treated her in the past. The MD stated he was the physician on call when Resident #1 passed away on [DATE], and he responded to the facility ' s request to pronounce her death. The MD stated many things can go wrong when someone misses [MEDICAL TREATMENT], the most severe would be an increase in potassium which can lead to cardiac problems. The MD stated one of the signs and symptoms of cardiac problems would be shortness of breath and difficulty breathing. The MD also stated if a resident asks to go to the hospital, the facility should send them. Review of Progress Notes for Resident #1: [DATE], 7:35 a.m.: Resident complaining of having feeling of [MEDICAL CONDITION] .on assessment noted vital signs ,[DATE] (BP) .[MEDICATION NAME] administered three times, every five minutes. Resident stated she is feeling better .will continue to monitor. [DATE], 8:30 a.m.: Resident called and stated that she is not feeling good and [MEDICAL CONDITION] symptoms still noted. Paged NP, new order to send resident to hospital . [DATE], 3:00 p.m., Resident returned to facility .stated she is feeling much better . [DATE], 9:45 a.m.: Resident complaining of being nauseated and not feeling well, did not want to go to [MEDICAL TREATMENT], asking to be sent to the hospital. Advised her it was very important that she attends [MEDICAL TREATMENT] today as she already missed her [MEDICAL TREATMENT] on [DATE]. She agreed to go .vital signs stable, ,[DATE] (BP), pulse 80, respirations 20, oxygen saturation 90%. [DATE], 11:00 a.m.: Called (contracted transport company) after realizing Resident had not been picked up for [MEDICAL TREATMENT]. The gentleman stated he did not see her on their schedule .what was the earliest they could pick her up and he stated in two hours. Called [MEDICAL TREATMENT] and notified them Resident was going to be running late if they could still see her. They stated they can take her but she will get dialyzed for two hours only. Resident stated it would not help. Notified ADON, Resident is upset with transportation .informed her we will do our best to take care of the problem .all vitals stable at this moment . [DATE], 1:30 a.m., (time of documentation, referring to earlier in her shift on [DATE]): Resident has reported she has missed [MEDICAL TREATMENT] and has expressed her desire to be taken to the hospital to be dialyzed. I told resident I will pass the message to the incoming shift .stable with vital signs within parameters; no labored breathing . [DATE], 9:30 a.m.: Resident called and stated she needed me to send her to (hospital) so she can receive [MEDICAL TREATMENT] .Assessed, all vitals seem stable, ,[DATE] (BP), pulse 80, respirations 18, oxygen saturation 96% on room air Resident stated she felt like she couldn ' t breathe well, administered oxygen at two liters via nasal canula, oxygen sats increased to 98%. Lung sounds a little course but clear. [DATE], 1:37 a.m., (time of documentation, referring to between 8:00 p.m. and 10:00 p.m. on [DATE]): Resident has expressed her intention to be taken to the hospital due to not feeling well. Resident has complained of breathing difficulty. No labored breathing noted; oxygen saturation is 94% with oxygen via nasal canula at 2/liters; regular heart sound and rhythm XXX,[DATE] (BP), heart rate 52, respirations 18 .DON, ADON and MD (NP) are notified; all advised to continue to monitor .resident is alert, oriented x3, stable and watching television in her room during assessment. [DATE], 1:51 a.m., (time of documentation, referring to 10:00 p.m. on [DATE]): New order on [DATE]: [MEDICATION NAME] 1 mg every 12 hours as needed; chest xray STAT; [MEDICATION NAME] 40 mg for two days; hold [MEDICATION NAME] for heart rate <60; hold losartan for 2 days; take vital signs every four hours for 24 hours. [DATE], 2:20 a.m.: At 10:30 p.m., Resident was reassessed after receiving [MEDICATION NAME] 1 mg at 10:00 p.m .resting in bed . [DATE], 3:41 a.m.: Resident assessed at 1:30 a.m., alert, oriented x3. Vital signs are within parameters .no labored breathing, has regular heart sounds and rhythm . [DATE], 11:40 a.m.: (time of documentation, referring to 2:00 a.m. on [DATE]): This nurse was at resident ' s bedside at 0200 to check her vital signs. Resident #1 woke up and stated Ok. During vital sign check resident became unresponsive. Nurse called 911 and explained that she has become unresponsive. EMS cam and performed CPR .Another nurse came and stated that Resident #1 is a DNR .Physical copy of DNR was provided to EMS and they stopped CPR .MD arrived and pronounced member dead . Review of the chest xray, ordered by the NP, dated [DATE] at 10:15 p.m.: Impression: Mild left lung infiltrate. Review of the Discharge Note for Resident #1, dated [DATE], completed by the MD: Reason for this visit: coded and expired. History/Physical information relating to this visit: I was contacted on call by NP at 3:10 a.m. that this patient had coded and expired .regarding the need to speak to a medical attending .to pronounce the patient dead .NP on call was contacted and reportedly an order for [REDACTED]. Assessment and plan: 1) Dependence on DH due to [MEDICAL CONDITION]: with lack of [MEDICAL TREATMENT] attendance contributing to demise. 2) Recurrent [MEDICAL CONDITION]: Likely ultimate cause of death, with [MEDICAL CONDITION] contributing. Additional text: Patient pronounce dead as of [DATE] at 4:15 a.m. IJ components: The facility Administrator, DON and Regional Director of Clinical Services were notified on [DATE] at 5:45 p.m. that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on [DATE] at 7:00 p.m. The final Plan of Removal was accepted by the investigator on [DATE] at 3:00 p.m. Neglect related to Failure to honor Resident Rights: I. Failure to honor resident's right to be sent to hospital after she asked to go. II. All Facility staff will be re-educated by Director of Nursing/ designee regarding resident ' s rights to be free from neglect. This education will start on [DATE] at 7:15PM. No facility staff will be allowed to work after 10:00pm on [DATE] until they receive the required education. This information will be provided in new hire orientation and all new hires will receive this education before allowed to work. III. A. 100% audit of alert and oriented residents will be completed by social worker and activity director on [DATE] to ensure no resident is currently at risk for neglect. Additionally, responsible parties of non-interviewable residents will be contacted by the Guardian Angel Program committee to identify any concerns with resident rights or neglect. Any identified issue will be addressed immediately. These responsible parties will be contacted by [DATE], at 5:00pm. Two call attempts will be made for unreachable responsible parties. Additionally, all residents will be assessed during rounds for by nurse managers for signs and symptoms of neglect by 1:45pm on [DATE]. B. 10% of facility resident ' s medical records will be audited for neglect. Nurse Managers will audit 10 medical records per week for 4 weeks to monitor for missed care or services. IV. Resident Rights will be discussed at the next scheduled Resident Council which will be [DATE] and Family Council Meeting which will be [DATE] by Administrator/designee. A copy of the Resident ' s Rights will be emailed to any responsible party whose email is on file. A copy of the Resident ' s Rights will be mailed to all responsible parties via United States Post Office ' s certified mail. V. Director of Nursing/designee will monitor residents with a change of condition through the twenty-four hour report and/or the grievance process for any concerns related to missing care of services. The process will begin on [DATE]; will be done daily for the next 30 days, five times a week thereafter in morning clinical meeting. Nurse Managers will monitor on the weekends during the 30 day period. Any areas of concern will be addressed at the time of discovery. I. Director of Nursing/designee will report progress to Quality Assurance Performance Improvement Committee monthly times 3 months and until compliance has been achieved. The next Quality Assurance Performance Improvement Committee will be no later than [DATE]. Any areas of concern will be addressed at the time of discovery. The survey team monitored the current plan of removal as follows: Observations on [DATE] between 10:00 a.m. and 3:00 p.m. revealed staff receiving in-services and training on resident rights, abuse/neglect, resident assessment and change of condition and resident code status. Interviews with one RN, three LVNs, one MA and three CNAs on [DATE] between 10:00 a.m. and 5:00 p.m. revealed staff received in-service training for assessment and recognizing a resident's change of condition, their code status, abuse/neglect and resident rights. Charge Nurses were in-serviced on the importance of nursing judgment and decision making at the bedside. Review of the facility ' s audit checklist reflected the facility had implemented the resident medical record review audits to identify potential neglect and/or unidentified change of condition. On [DATE] at 5:20 p.m., the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope as isolated, due to the facility requiring time to train all staff and monitor their Plan of Removal. Review of the facility's form CMS 672 reflected one other resident who received [MEDICAL TREATMENT].