Every finding on record at Five Points of Pflugerville

Based on interview, and record review, the facility failed to ensure the resident's right to be free from misappropriation of resident property for one of five residents (Resident #1) reviewed for misappropriation.The facility failed to prevent a diversion of Resident #1's blister packet of 30 pills of the medication Gabapentin Oral Capsule, 100 MG for Peripheral Neuropathy. Resident #1's medication was taken from the facility by RN A on 07/03/2026 and was confiscated by the local PD during a routine traffic stop.This failure could place residents at risk for decreased quality of life, unrelieved pain, and misappropriation of property.Findings included:Record review of Resident #1's face sheet, printed 07/22/2026, reflected a [AGE] year-old female admitted to the facility 06/01/2021 and readmitted [DATE]. Her diagnoses included Polyneuropathy (a medical condition where many peripheral nerves throughout the body are damaged at the same time, commonly causing numbness, tingling, and weakness starting in the hands and feet), prediabetes (a health condition where blood sugar levels are higher than normal, but not high enough to be type 2 diabetes), Moderate intellectual Disability (a neurodevelopmental condition, noticeable developmental delays, and significant limits in daily adaptive skills). Record review of Resident #1's quarterly MDS assessment, dated 06/27/2026, Section C (Cognitive Patterns) reflected a BIMS score of 11 indicating moderately impaired cognition. Section I (Active Diagnoses) reflected Polyneuropathy, Moderate intellectual Disability, Generalized muscle weakness. Section J (-Pain) reflected Resident #1 received scheduled pain medication regimen.Record review of Resident #1's comprehensive care plan, revised 04/26/2026, reflected Resident #1 was at risk for increased episodes.of pain r/t Peripheral Neuropathy, impaired cognitive function and impaired thought processes r/t Dementia (term for a decline in mental abilities severe enough to interfere with daily life), impaired memory, intellectual disability, ADL Self Care Performance Deficit r/t morbid obesity(a serious health issue defined by a body mass index (BMI) of 40 or higher), and intellectual disability.Record review of Resident #1's medication administration record for July 2026, reflected Gabapentin Oral Capsule 100 MG be given 1 capsule by mouth three times a day, for Peripheral Neuropathy related to POLYNEUROPATHY.Record review of Resident #1's physician order, reflected an order, dated 05/28/2026, indicated: Gabapentin Oral Capsule 100 MG (Gabapentin) Give 1 capsule by mouth three times a day for Peripheral Neuropathy (damage to the nerves outside your brain and spinal cord, which often causes numbness, tingling, and pain mostly in the hands and feet. It happens when these signal-carrying pathways are hurt, stopping your body and brain from talking to each other right) related to POLYNEUROPATHY, UNSPECIFIED.Record review of the Provider Investigation Report, dated 07/08/2026, reflected: Investigation Summary: Blister pack of Gabapentin seized by the police. [RN A] reported on 7/6/26 she was stopped by the police for a routine traffic stop on 7/3/26. The officer had probable cause to search her vehicle and during the search, a blister pack of Gabapentin was found that belongs to [Resident #2] in her purse. [RN A] states she is not sure how the blister pack got into her purse. [RN A] had sole possession of the medication cart during her shift. [RN A] initially stated the blister back belonged to [Resident #2] but in her statement she admitted which resident it actually belonged to. [RN A] also stated she was not sure where she was stopped due to being new to area but then informed us it was in [xxx] which help the facility identify the resident and police department to retrieve the medication. The facility had to do a drug test [RN A] 3x due to contaminated urine samples she provided. On the third attempt the results were positive for THC. Sergeant [XXX] with [local]PD stated that Gabapentin mixed with alcohol gives you a high. Investigation findings: Confirmed.During a telephone interview on 07/22/2026 at 2:53 pm, the Administrator stated RN A reported the incident on Monday 07/06/2026 and the incident happened on Friday 07/03/2026, she was off on the weekend. The Administrator stated RN A reported the incident to the ADON and the ADON reported the incident to the DON and the Administrator. The Administrator stated he got some information from RN A regarding the PD involved, statement, drug test and terminated RN A same day. The Administrator stated he contacted the local PD, met with the Sergeant and was able to retrieve the medications belonging to Resident #1 (Gabapentin Oral Capsule 100 MG, 30 pills on a blister packet). The Administrator stated the Sergeant stated Gabapentin with alcohol caused the same effect/high as THC (tetrahydrocannabinol) was the main active chemical in cannabis that made people feel high, changed mood, and increased appetite). The Administrator stated the Sergeant stated the Traffic Officer had probable cause to search RN A's car and, from the search, there were medications in the car not belonging to RN A, so the medications were confiscated (to officially take private property away from someone by legal authority, usually as a punishment, rule enforcement, or for public safety). The Administrator stated the Sergeant stated that due to medications not being a control substance, RN A was allowed to leave. The Administrator stated the facility initiated an audit on all residents ordered Gabapentin, pain assessments were completed, in-services completed on keeping all personal belongings in their lockers, drug destruction, pain assessment and monitoring, ensuring medications were not left on the table or at the nurses station, abuse and neglect, he ensured all the lockers in the breakroom were fixed and had keys, staff not to have personal belongings at the nurse's station. The Administrator stated the facility referred RN A's nursing license to the state board of nursing.During a telephone interview on 07/22/2026 at 03:06 pm, the DON stated she was notified about the incident on 07/06/2026 by the ADON. The DON stated she immediately notified the Administrator and HR. The DON stated RN A was drug tested and it was positive for marijuana. The DON stated that RN A was in possession of a resident's medication outside of the facility so that was an immediate termination. The DON stated she audited all residents with orders for Gabapentin to ensure medications were available and they were. She stated a pain assessment was completed on all residents who took Gabapentin, the lockers in the breakroom were checked and fixed to ensure they locked properly, staff were in-serviced on keeping all personal belongings in their lockers, drug destruction, pain assessment and monitoring, ensuring medications were not left on the table or at the nurses' station, abuse and neglect. The DON stated RN A worked on 300 hall (memory care unit) and was the only staff with access to the medication cart and passing out medication to the residents. The DON stated RN A stated a resident probably put the medication in her bag, and residents should not have access to medications.During an observation on 07/23/2026 at 12:03 pm, cart audit with the DON verifying Residents who were prescribed Gabapentin had medications available on the 300 and 400 halls. Medications were available as physician ordered. During an interview on o7/23/2026 at about 12:20 pm, Resident #1 stated she was fine and denied pain. Resident #1 stated she usually got her medications and did not have concerns. Resident #1 was well groomed, no foul odor not, no distress noted.During a telephone interview on 07/24/2026 at 09:18 am, RN A stated she had worked at the facility for about a month and had been working the 300 and 400 halls. RN A stated on 07/03/2026 she worked on the 300 hall (memory care unit) and she took her bag with her at the nurse's station because the facility's lockers did not have keys and was far away from the memory care unit. RN A stated her work bag was at the nurse's station and at about 1:30 pm she could not find her work bag. RN A stated she later found her work bag with a resident, she took her bag, looked in it to make sure her blood pressure cuff, stethoscope and water cup were in the bag and then she took her bag to her car. RN A stated she did not see Resident #1's Gabapentin in her bag because she did not look in her bag thoroughly. RN A stated her shift was over by 2:00 pm and she left the facility. RN A stated later that day, she got pulled over by a Traffic Officer, he had probable cause to search her car, during the search he found medications belonging to Resident #1 in her bag and took it. RN A stated she did not know how Resident #1's medication got in her bag, she was not given a ticket/citation or arrested by the Officer. RN A stated she was the only one who had access to the 300 hall (memory care unit) medication cart. RN A stated staff were not supposed to have resident's medications in their possession outside of work, that would be considered stealing, but she did not steal Resident #1's medications. RN A stated she did not notify the facility's administration of the incident until 07/06/2026 on her next scheduled day to work because the incident happened after hours on 07/03/2026. RN A stated she reported the incident to the ADON who reported it to the DON and the Administrator. RN A stated she was asked to write a statement, was drug tested, but did not know the result of the drug test because she did not read it, and terminated from the facility the same day, date??.During a telephone interview on 07/24/2026 at 03:04 pm, the Traffic Officer stated he pulled [RN A] over during a routine traffic stop and had a probable cause to search her vehicle. The Traffic Officer stated during the search he found medication belonging to [Resident #1] in RN A's bag. He stated RN A said she did not know how Resident #1's medication got in her bag and sometimes the residents put things in her bag. He stated RN A had no good explanation for having Resident #1's medication in her possession while outside of the facility so he took the medication because it was not in RN A's name. The Traffic Officer stated RN A was not given a ticket or arrested because the medications were non-narcotics.Record review of the facility's investigation folder regarding the incident (date of the incident) reflected the following:--Administrator contacted the local PD for the release of Resident #1's medication, and it was given to the Administrator on 07/06/2026.--Blister packet of retrieved medication containing 30 pills of Gabapentin Oral Capsule 100 MG Give 1 capsule by mouth three times a day for Peripheral Neuropathy related to POLYNEUROPATHY, UNSPECIFIED belonging to Resident #1 filled on 06/03/2026.--An AD Hoc QAPI was held on 07/06/2026--RN A and ADON's statements--All residents in the facility on Gabapentin pain assessments--Weekly monitoring as of 7/6/2026--Staff were in-serviced on 07/06/2026 Ensure to check Gabapentin on cart 2-3 times a week initiated 7/6/2026, Ensure nursing staff to count controlled medications with the incoming nurse/ma logging individual controlled dose at the time of medication administration, Pain management, abuse and neglect, --RN A was drug tested x3 due to contaminated samples and was positive for marijuanaStaff was terminated and referred to BON on 7/7/2026Record review of facility's policy titled, Abuse and Neglect, revised 05/09/2017, reflected: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart.The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility.8.Exploitation: Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion.9.Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.Record review of facility's policy titled, Medication Storage in the Facility, dated 2025, reflected: Policy Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations orthose of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Procedure1.[Pharmacy] dispenses medications in containers that meet legal requirements, including requirements of goodmanufacturing practices where applicable. Medications are kept and stored in these containers. Transfer ofmedications from one container to another is done only by a pharmacist.2. Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications (e.g.medication aides) are allowed unsupervised access to medications. Medication rooms, carts, and medicationsupplies are locked or attended to by persons with authorized access.

Based on observation, interview, and record review, the facility failed to provide the maintenance for comfortable sound levels for 4 of 8 residents (Resident #40, Resident #52, Resident #62, Resident #67) reviewed for homelike environment.The facility failed to ensure that Resident #40, Resident #52, Resident #62, and Resident #67 resided in an environment free from excessive noise levels. This failure placed residents at risk for becoming agitated and disturbed. Findings included: A record review of Resident #40's face sheet dated 3/23/2025 reflected a [AGE] year-old male readmitted on [DATE] with diagnoses of Alzheimer's disease (neurological condition), hyperlipidemia (high cholesterol), hypertension (high blood pressure), type 2 diabetes (uncontrolled blood sugar), dementia (neurological condition), heart disease and peripheral vascular disease (decreased circulation).A record review of Resident #40's MDS assessment dated [DATE] reflected a BIMS score of 7, which indicated severely impaired cognition.A record review of Resident #40's care plan last reviewed on 3/11/2026 reflected that discharge from the facility was not feasible as evidenced by impaired cognition related to Alzheimer's dementia. Interventions included, respect resident's right to view nursing facility as his/her home.A record review of Resident #62's face sheet dated 5/14/2026 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of Parkinson's disease (neurological disorder), type 2 diabetes (uncontrolled blood sugar), heart failure, age-related debility, and mixed hyperlipidemia (high cholesterol).A record review of Resident #62's MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated no cognitive impairment. A record review of Resident #62's care plan last reviewed on 3/11/2026 reflected that he had impaired cognitive function or impaired thought processes. Interventions included that staff were to provide the resident with a homelike environment.A record review of Resident #67's face sheet dated 5/14/2026 reflected a [AGE] year-old female readmitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (lung disease), major depressive disorder (depression), hypothyroidism (underactive thyroid), type 2 diabetes (uncontrolled blood sugar), hyperlipidemia (high cholesterol), bipolar disorder (mental disorder), and insomnia (inability to sleep).A record review of Resident #67's MDS assessment dated [DATE] reflected a BIMS score of 11, which indicated moderately impaired cognition.A record review of Resident #67's care plan last reviewed on 3/03/2026 reflected that discharge from the facility was not feasible. Interventions included that staff were to respect the resident's right to view the nursing home as her home.During an interview on 5/12/2026 at 2:30 PM, Resident #52 stated that a very loud buzzing sound went off when staff did not shut the door in 400-hall properly. Resident #52 stated the noise woke him up sometimes. An observation of the 400-hall on 5/13/2026 at 10:42 AM revealed a door alarm was sounding loudly.During an observation and interview on 5/13/2026 at 10:42 AM, CNA H stated that when exiting the door, you have to make sure it's really closed. CNA H stated that if the door was not closed all the way, the alarm would go off. Observed a doorway in 400-hall that led to a small hallway with an exterior door. CNA H demonstrated how the door did not shut completely if allowed to shut on its own. Observed force was required to close the door so that it latched shut completely.An observation on 5/13/2026 at 10:59 AM revealed the SW walked into the 400-hall from outside. The alarm then started sounding off loudly.During an interview and observation on 5/13/2026 at 11:01 AM, CNA I stated that when the door was opened, it had a problem. Observed the alarm went off again. Observed that the door was already latched, however, the door alarm sounded off anyway. Observed CNA I type in a code to stop the alarm from sounding. An observation on 5/13/2026 at 11:05 AM revealed the door alarm on 400-hall was sounding off loudly. Observed the exterior door to be ajar. During an observation and interview on 5/13/2026 at 11:06 AM, revealed the door alarm on the 400-hall was observed sounding off. FM O stated, Whoever it was didn't close the door. and said that was why the alarm was sounding off.During an observation and interview on 5/14/2026 at 10:37 AM, Resident #40 was observed lying in bed. Resident #40 stated the noise when the alarm sounded off bothered him. During an observation and interview on 5/14/2026 at 10:40 AM, Resident #52 was observed sitting in his wheelchair. Resident #52 stated that the door alarm woke him up every night. Resident #52 stated that he had complained to staff about the noise, but the aides just told him there was a sign on the door that reminded staff to shut the door completely.During an observation and interview on 5/14/2026 at 10:48 AM, Resident #67 was observed sitting in her room. Resident #67 stated the alarm had been going off since she had been there and it bothered her but she had not complained to staff because they always turned it off eventually. Resident #67 stated it sometimes woke her up.During an observation and interview on 5/14/2026 at 10:51 AM, Resident #62 was observed lying in bed. Resident #62 stated it does bother him when the alarm in the 400-hall sounded off. During an interview translated by an HHSC translator on 5/14/2026 at 12:14 PM, the Maintenance Director stated that he was aware of the alarm that sounded in the 400-hall and you have to pull it shut. The Maintenance Director stated that an air bubble between the two doors caused a suction and he added a part about two months ago to help it shut. The Maintenance Director stated he added that part due to a resident complaints. The Maintenance Director stated that he put a sign on the door to remind staff to pull the door shut after using it and that it was happening a lot less now.During an interview on 5/14/2026 at 12:44 PM, the DON stated there was no policy on homelike environment. The DON stated, We try as much as possible to make sure everything is quiet. The DON stated she had heard the alarm sounding off on the 400-hall but she did not know what caused it to sound. The DON stated she did not think it was related to the door latching shut. The DON stated a loud sound could make residents scared or startled. During an interview on 5/14/2026 at 2:30 PM, LVN C stated yes that residents had complained about the alarm on 400-hall. LVN C stated that Resident #67 and Resident #52 had complained to him about the sound and, if you don't close the door enough, it sounds off. LVN C stated that after the alarm sounded off, he needed to wait 10 seconds. LVN C stated, If you just open it and walk through, it's not going to close. LVN C stated he had brought it up with the Maintenance Director, but he told him that he could not do anything. LVN C stated, It would bother me, too.During an interview on 5/14/2026 at 4:55 PM, the Administrator stated, We try to keep it as homelike as possible. The Administrator stated that volume levels varied throughout the facility, but we try to keep it a level where we're not disturbing them as much as possible. The Administrator stated that he was aware that the alarm on the 400-hall bothered residents, and that was why a sign was posted by the door reminding staff to pull it shut. The Administrator stated that staff were in-served on the door alarm, and that he would try to find it. The Administrator stated that the alarm could interrupt residents' rest or agitate them.A record review of the facility's undated policy titled Resident Rights reflected the following: The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy.A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals) for 3 of 14 residents (Resident #8, Resident #35 and Resident #61) to meet the needs of the resident, in that:The facility failed to administer Resident # 8's pain medication on time for 34 administrations. The facility failed to administer Resident #35's Parkinson's medication on time as schedule for 34 administrations. The facility failed to ensure LVN E did not document Resident #61's medications in the MAR as being administered before resident took his medications.These failures placed Residents at risk for uncontrolled pain, tremors, decrease quality of life and hospitalization.3. Record review of Resident# 61's undated admission face sheet reflected a 68-year male was who was admitted to the facility on [DATE]. His diagnoses included epilepsy unspecified not intractable without status epilepticus (seizure disorder that is recurrent but generally controlled or responsive to treatment, without prolonged medical emergencies), hypothyroidism unspecified (underactive thyroid), benign prostatic hyperplasia (BPH) without lower urinary tract symptoms (enlarged prostate gland that is not pressing on the urethra or bladder to cause urination issues), Alzheimer's disease with early onset (a rare form of dementia affecting people under 65). Record review of Resident #61's comprehensive MDS assessment dated [DATE] reflected BIMS score of 05 indicating severe cognitive impairment. The MDS reflected Resident #25 had a seizure disorder or epilepsy. Record review of Resident # 61's care plan reflected: The resident has Seizure Disorder-Date Initiated: 02/22/2026. Goal included- The resident will remain free from injury related to seizure activity through review date -Date Initiated: 02/22/2026. Revised on: 03/09/2026. Interventions included- Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness. He had a care plan Initiated: 02/22/2026 indicating The resident has potential fluid deficit r/t poor intake and impaired cognition A goal included The resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor.- Initiated: 02/22/2026 and revised on: 03/09/2026. Interventions included- Administer medications as ordered. Monitor/document for side effects and effectiveness.Encourage Fluids during med pass and with each care intervention. He had a care plan Initiated: 02/22/2026 indicating The resident has impaired cognitive function/dementia or impaired thought processes Goal included- The resident will maintain current level of cognitive function through the review date.-Date Initiated: 02/22/2026. Intervention included- Administer meds as ordered -Date Initiated: 02/22/2026. The resident has an anticonvulsant ordered r/t for pain and seizures.-Date Initiated: 03/09/2026. Goal included- The resident will not experience any adverse effects from the medication.-Date Initiated: 03/09/2026. Intervention included-Give medications as ordered. Monitor/document for effectiveness and side effects.Inform the physician for any adverse effects and behavioral symptom increase/changes.- Date Initiated: 03/09/2026 Record review of Resident #61's order summary report reflected: -Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG. Give 1 tablet by mouth one time a day for benign prostatic hyperplasia. Start date: 02/20/2026 -Finasteride Oral Tablet 5 MG (Finasteride) Give 1 tablet by mouth one time a day for BPH. Start date: 02/21/202 - Sertraline HCl Oral Tablet 50 MG (Sertraline HCl). Give 1 tablet by mouth one time a day related to depression, unspecified. Start date: 02/21/2026 - Gabapentin Oral Tablet 400 MG (Gabapentin). Give 2tablet by mouth two times a day for Neuropathic pain. Start date: 02/19/2026 - Levetiracetam Oral Tablet 1000 MG (Levetiracetam). Give 1.5 tablet by mouth two times a day for Seizures. Start date: 02/20/2026 An observation of the medications administration on 05/15/2026 approximately at 7:56 a.m. revealed LVN E prepared Resident #61's five medications one by one and placing them into a medication cup. Approximately at 7:59 a.m., LVN E documented that all five medications were given in Resident 61's MAR. Further observation revealed LVN E sanitized her hands after closing the laptop's screen and locking the med cart. She went to the resident's room with the medications and Resident #61 took his medications approximately at 8:02 a.m. LVN E sanitized her hands after she left the resident #61's room and moved the medication cart to the next door. In an interview on 5/13/2026 at 2:00 p.m. with LVN E, she stated that she has been working in the facility for about one month. She stated that there are five rights of administering medications: right patient, right drug, right time, right dose, and right route. She stated that she should not chart Resident #61's five medications as given before he took them because he could refuse to take all these medications or some of them. She stated that she would not be able to uncharted them in the MAR as not given or refused, and she would not be able to document the reason for not giving his medications or the reason for refusal. LVN E stated that the resident's physician must be notified about any refused medications and depending on the medication, the physician then would decide if the medication orders needed to be changed or if new orders needed to be given. In an interview on 05/13/2026 at 4:40 p.m. with the DON, she stated she has been working in the facility for 5 years. She stated that before administering medications, the nurse must verify 5 rights of administering medications: right resident, right medication, right reason, right dose, right time. DON stated the last thing after administering the medications is to document it by checking the medications in the resident's MAR. She stated documenting the medications in the MAR, as given before resident takes them, is not acceptable because resident can refuse medications, but it is already charted as given. In an interview on 05/14/2026 at 7:24 a.m. with ADON, she stated she had been working in the facility for 10 years. She stated that there are seven rights of administering medications: right patient, right medication, right time, right dose, right route, right frequency, right documentation. She stated it is expected that nurses and med aides document the medications that are administered in MAR after residents take their medications. She stated that it is a med error if the medication is signed off in the MAR as given before it is administered to a resident. She stated that any not given or refused medications must be reported to the physician along with the reason for not giving the medication or the reason for the refusal so the physician can evaluate and modify the medication treatment regimen if needed. In an interview on 05/14/2026 at 5:26 p.m. with ADM, he stated medications could not be clicked in MAR as administered because residents can refuse medications. Record review of a document provided by the facility titled Medication Administration and General Guidelines dated 2025 reflected: Adheres to the 6 Rights of Medication Administration: 1) Right Dose 2) Right Route 3) Right Resident 4) Right Medication 5) Right Time 6) Right Documentation Observes the resident take the medications Documents the administration of each medication on the MAR & Controlled Medications on the Control Sheet The findings included: Findings included: 1.Review of Resident #8's face sheet dated 05/15/2026 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis unspecified (a chronic, autoimmune disease of the central nervous system. The immune system mistakenly attacks myelin—the protective sheath covering nerve fiber disrupting electrical signals between the brain and the body), , Muscle Wasting and Atrophy, and Muscle Weakness. Review of Resident #8's quarterly MDS assessment dated [DATE] reflected a BIMS score of 05 indicating severe cognitive impairment. Section J-Health Conditions reflected Resident #8 received scheduled and PRN pain medication, pain was always present and Resident #8 frequently experienced pain. Section J also reflected Resident #8's pain frequently interfered with therapy and day-to-day activities with numeric rating of 6 on the scale 0-10 with 10 being the highest pain. Review of Resident #8's care plan revised 10/09/2025 reflected the following: *Resident #8 had Multiple Sclerosis with interventions to give medications as ordered, Monitor/document for side effects and effectiveness Pain management as needed, See MD orders. Provide alternative comfort measures PRN. Resident #8 was on pain medication r/t Multipe Sclerosis(a chronic autoimmune disease of the central nervous system) ith intervention to administer medication as ordered. Review of Resident #8's physician order reflected: Pregabalin Oral Capsule 50 MG (Pregabalin) Give 1 capsule by mouth three times a day for PAIN start date 10/01/2025. Review of Resident #8's MAR for the months of April and MAY 2026 reflected: Pregabalin Oral Capsule 50 MG (Pregabalin) Give 1 capsule by mouth three times a day for PAIN scheduled at 07:00 am, 1:00 pm and 07:00 pm Review of Resident #8's medication administration audits reflected Resident 8's pain medications were given at the following times: Scheduled 07:00 am doses were administered at: *04/01/26 at 09:40 am *04/06/26 at 09:12 am *04/11/26 at 08:39 am *04/17/26 at 11:35 am *05/12/26 at 11:09 am Scheduled 07:00 pm doses were administered at: *04/01/26 at 09:05 pm *04/02/26 at 09:06 pm *04/04/26 at 08:19 pm *04/06/26 at 9:39 pm *04/07/26 at 8:38 pm *04/08/26 at 8:59 pm *04/09/26 at 9:24 pm *04/10/26 at 9:57 pm *04/11/26 at 9:28 pm *04/12/26 at 9:53 pm *04/13/26 at 9:23 pm *04/14/26 at 8:05 pm *04/16/26 at 10:35 pm *04/17/26 at 10:07 pm *04/18/26 at 9:26 pm *04/19/26 at 9:20 pm *04/20/26 at 8:23 pm *04/21/26 at 9:42 pm *04/22/26 at 9:48 pm *04/25/26 at 8:10 pm *04/26/26 at 8:08 pm *04/27/26 at 9:48 pm *04/29/26 at 9:28 pm *05/04/26 at 9:19 pm *05/06/26 at 9:57 pm *05/07/26 at 8:06 pm *05/08/26 at 9:49 pm *05/09/26 at 9:12 pm *05/12/26 at 10:31 pm During an interview on 05/14/2026 at 3:09 PM with Resident #8 she said she was not getting her pain medications on time. She said getting her pain medications late affected her physically because she was in pain. Resident #8 said that getting her medications late affected her emotionally because she cried because she was in pain from not getting her medications. During an interview on 05/15/2026 at 11:26 AM the NP said Resident #8's had pain because she had Multiple Sclerosis (a chronic, unpredictable autoimmune disease of the central nervous system (brain, spinal cord, and optic nerves). The NP said Resident #8 did not have very good use of her legs and because Resident #8 stayed in bed a lot she had pain in her bilateral lower extremities (both legs and feet simultaneously). The NP said Resident #8 had chronic pain and Resident's scheduled pain medications should be administered timely. The NP said Resident #8 did not tell her she was not getting her pain medications on time. The NP said if Resident #8 received two dose of her scheduled pain medication close together it would not hurt her but she would be a little sleepier. 2.Review of Resident #35's face sheet date 05/15/2026 reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Parkinson's Disease without dyskinesia without mention of fluctuations (Parkinson's is a progressive neurological disorder that primarily affects movement. It occurs when brain cells that produce dopamine—the chemical responsible for coordinating smooth, purposeful muscle control—die or stop working. Dyskinesia is a category of movement disorders characterized by involuntary, erratic, and uncontrollable muscle movements). Review of Resident #35's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 14 indicating no cognitive impairment. Review of Resident #35's care plan revised 04/13/2026 reflected Resident #35 had Parkinson with interventions to give medications as ordered by the physician. Monitor/document side effects and effectiveness, Monitor/document ability to perform ADLS. Report any improvement or decline to MD, Monitor/document/report to MD PRN s/sx of Parkinsons complications: Poor balance, Constipation, Poor coordination, Insomnia, Dysphagia, Tremors, Gait disturbance, Incontinence, Muscle cramps or rigidity, Decline in range of motion Skin Review of Resident #35's physician orders reflected: Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa) Give 2 tablet by mouth three times a day for Parkinson's disease dated 11/28/2025. Review of Resident #35's MAR for the months of April and MAY 2026 reflected: Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa) Give 2 tablet by mouth three times a day for Parkinson's disease scheduled at 07:00 am, 1:00 pm and 07:00 pm Review of Resident #35's medication administration audits reflected Resident 8's pain medications were given late, more than an hour pass the schedule times on the following dates: Scheduled 07:00 am doses were administered at: *04/11/2026 given at 08:04 am *04/29/2026 given at 09:24 am *05/12/2026 given at 09:50 am Scheduled 7:00 pm doses were administered at: * 04/02/2026 at 09:01 pm *04/04/2026 at 08:20 pm *04/06/2026 at 09:28 pm *04/07/2026 at 08:30 pm *04/08/2026 at 08:32 pm *04/10/2026 at 09:57 pm *04/11/2026 at 09:19 pm *04/12/2026 at 09:34 pm *04/13/2026 at 09:13 pm *04/14/2026 at 08:06 pm *04/16/2026 at 08:40 pm *04/17/2026 at 09:48 pm *04/18/2026 at 09:27 pm *04/19/2026 at 08:25 pm *04/20/2026 at 08:24 pm *04/21/2026 at 09:51 pm *04/22/2026 at 09:49 pm *04/25/2026 at 08:10 pm *04/26/2026 at 08:08 pm *04/27/2026 at 09:47 pm *04/28/2026 at 08:44 pm *04/29/2026 at 08:46 pm *04/30/2026 at 08:05 pm *05/01/2026 at 09:40 pm *05/03/2026 at 09:18 pm *05/04/2026 at 08:25 pm *05/05/2026 at 08:13 pm *05/06/2026 at 09:51 pm *05/09/2026 at 9:13 pm *05/11/2026 at 8:39 pm *05/12/2026 at 10:25 pm During an interview on 05/14/2026 at 3:15 PM with Resident #35 she said her tremors from her Parkinson's got bad if she did not get her Parkinson's medication as scheduled. She said when she had tremors, it wore her out physically. Resident #35 said emotionally it made her upset because she knew her tremors would be worse. Resident #35 said she was on everyone else's schedule when getting her medications. During an interview on 05/14/2026 at 2:29 PM with RN A she said when she passed medications the scheduled time frame to give medications was one hour before the medication was scheduled and one hour after the medication was scheduled. RN A said if the medication was given after one hour the time the medication was scheduled, it was a medication error. During an interview on 05/14/2026 at 3:22 PM with LVN S she said they have an hour window before and an hour window after the time medication was scheduled to administer the medication to the resident. LVN S said she could not give medication after an hour it was scheduled to be given, because it would be too late and she would have to contact the provider. LVN S said it would be a medication error if she provided medication too late and did not let the provider know. LVN S said she knew Resident #35 and had given her medications at night. She said Resident #35 did not refuse medication and Resident #35 had never told LVN S she wanted her medication later. During an interview on 05/14/2026 at 3:30 PM with the NP she said medications had a time frame to be administered - one hour before the medication was scheduled and one hour after the medication was scheduled. The NP said if Resident #35 was not getting her Parkinson's medication as scheduled it could cause Resident #35 to have more tremors and dyskinesia (a category of movement disorders characterized by involuntary, erratic, and uncontrollable muscle movements). The NP said it was better that Resident #35 got her Parkinson's medication on a routine schedule. The NP said it was better for her to receive the Parkinson's medication spaced out and not too close together. She said if a resident missed a scheduled dose of medication or received a scheduled medication very late the nursing staff should notify the NP. The NP said if residents requested their medication to be given at a different time than prescribed, she would want to be notified so she could make a change to the dosing time. The NP said if there was a problem and the nurses were unable to issue medication on time the facility was supposed to notify the provider medications were administered late. The NP said she would think that contacting her when medications were administered late would be protocol. The NP said in the last two weeks she had not had any notifications that residents' medications were administered late. The NP said it was a valid concern that Resident #35 was not getting her Parkinson's medication on time. During an interview on 05/14/2026 at 3:50 PM the DON said if there was an assigned time to give a medication, there was a window of one hour before the medication was scheduled and one hour after the medication was scheduled to administer the medication. The DON said that scheduled medications were not administered late every single day. She said medications might be administered late if a staff member was running late. She said she was aware that on 04/29/2026 a lot of scheduled medications were administered late. The DON said it was a hectic day and everyone on the floor tried to catch up to administer the medications on time. She said she knew it was a problem. The DON said no residents had a negative outcome from the late medication administration. The DON said staff checked on the residents to make sure the residents were okay. She said she did not document in the residents' progress notes that residents received late medications and did not document that residents were monitored for any adverse effects. The DON said she walked around and checked on residents and asked the staff to check on the residents. The DON did not remember if she called the MD or the NP to tell them that a lot of residents received scheduled medications late on 04/29/2026. The DON said she apologized to a couple of residents who said they did not get their medications on time. The DON said if a resident was refusing to take medication from the MA should let the nurse know. The DON said staff were supposed to call her if a resident did not want to take their medication. The DON said if they were successful in administering the medication two or three hours later, the nurse could enter a progress note stating that the resident received the medication late. The DON said Resident #35's Parkinson's medication should be given on time. The DON said if it was not given on time, Resident #35 could have more tremors. The DON said she did not remember if she called the MD or the NP to tell them medications were administered late on 04/29/2026. The DON said it was policy to call the MD or the NP if residents received their scheduled medications late. During an interview on 05/14/2026 5:30 pm with the ADM he said he was not aware that on 04/29/2026 a lot of residents received their medications late. The ADM said it was his expectation that when scheduled medications were administered two hours late, the MD or NP should be notified. His expectation was for them to monitor the residents and contact the physician. The DON said that if Parkinson's medication were administered late residents with a diagnosis of Parkinson's could have increased tremors. The ADM said increased tremors would affect resident therapy because the resident could not function if the resident was shaking. The ADM said not taking the Parkinson's medication could affect the resident psychosocially because residents might not want to be around other people if it was out of the norm for them to have tremors. He said residents wanted to feel like themselves as long as they could and not want to shake. The ADM said all late medications from 04/29/2026 should have been documented, the late medications reported to the MD or NP, and residents monitored. During an interview on 05/14/2026 at 6:15 PM the PTA said she was Resident #35's physical therapist. The PTA said Resident #35 had not told her that she had not received her Parkinson's medications on time. The PTA said if residents with a diagnosis of Parkinson's did not get their medications on time it could affect their tremors, could make them more unstable, and possibly make them confused. The PTA said Resident #35 was not confused. The PTA said there was a relationship between taking Parkinson's medications on time and improvement in therapy. She said taking the Parkinson's medication could help with symptoms and when a resident wanted to do a task, they might initiate the task faster. The PTA said it was pretty important to take the Parkinson's medication on time. During an interview on 05/15/2026 12:32 PM with the DON she said the facility had a liberalized time for medications that meant there was a bigger window to administer the medications. The DON said Sinemet (a brand-name prescription medication used primarily to treat Parkinson's disease) should not be liberalized. The DON said the MD controlled the liberalized timing. The DON said in nursing, if you give the same medication 30 minutes apart that was double dosing. The DON said nursing judgment was not to give medications at the same time. She said if some medications were given too close together, there would be side effects. The DON said she had not seen a side effect in residents because they were administered their medications too closely. The DON said the facility policy was to document medication administration immediately after the medication was given. The DON said residents should get their pain medications timely and if they did not get their pain medications timely, there might be potential for a resident to have pain. The DON said she could not remember if Resident #8 had chronic pain. She said Resident #8 was lying in bed because Resident #8 did not want to get up. The DON said that because Resident #8 had Multiple Sclerosis there was potential for pain. An attempt was made to contact MA T on 05/14/2026 at 3:27 PM and with no answer and mailbox full, unable to leave a message. An attempt was made to contact MH T on 05/15/2026 at 9:55 AM with no answer and mailbox full, unable to leave a message. During an interview on 05/15/2026 at 1:32 PM with the RNC she said when medication times are liberalized, they cannot be administered beyond the liberalized time frame. The RNC said if a nurse called the doctor and told the doctor that a resident wanted her AM and PM medication given together and the doctor said it was okay to do so, it would be documented in the resident's progress note. The facility documented when there was a resident change of condition. The facility used an SBAR (a structured communication tool—used by nurses to quickly and accurately report changes in a resident's condition to physicians or during handoffs) and the facility expected their nurses to use SBAR to explain what happened to the resident. After an SBAR, the doctor would provide orders accordingly. If a resident wanted to take their AM and PM medication dose at the same time, it would not be care planned. If the doctor said it was safe for a resident to have the AM and PM dose at the same time, it would be put into the resident's orders. Combining AM and PM medication would be safe depending on the medication. Carbidopa-Levodopa (Parkinson's medication) was used to control tremors, rigidity, and muscle spasms in patients with Parkinson's. Parkinson's medication was time sensitive and extended release. The RNC expected nurses and MAs to give medication as ordered. The RNC did not expect missed doses to happen often and did not want a resident to miss a dose of medication. It was not a current practice to give medicine an hour apart from one another. The RNC said if she had a blood pressure medication at 10:00 AM, she would not give another blood pressure medication at 11:00 AM. The RNC said she expected the MAs to follow orders and if the resident order was to give blood pressure medication, the MA needed to give that medication. The RNC said the MA might need to check the blood pressure medication before given the next dose. The RNC said a MA should let the nurse know before she gave a resident another medication too close together. The MA would communicate with the nurse, and the nurse would communicate with the doctor and then document that she contacted the doctor and got whatever was necessary. If a medication was liberalized the medication needed to be given within the liberalized time frame, if the medication was not liberalized the time frame was one hour before or one hour after the scheduled medication time. Observation on 05/15/2026 at 3:12 PM of Resident #8 Resident smiling good affect, wheeling herself in her wheelchair back to her room from dining room. During and interview on 05/12/2026 at 3:12 PM of Resident #8 she stated she was doing good and iust had ice cream and panda express for lunch. Review of facility's policy titled Medication Administration and General Guidelines dated 2025 reflected: Policy Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication, monograph of all medications is available in LinkRx (pharmacy management software) otherwise authorized personnel should refer to Drug Reference material provided by facility. Procedure- 10. Medications are administered within one hour of the scheduled time, unless the physician specifies a specific time then the med must be given 30 minutes prior to 30 minutes after the specified time (unless facility policy directs otherwise). Before or after meal orders are administered precisely as ordered. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the facility. 12. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (e.g. resident not in facility at scheduled dose time, initial dose of antibiotic), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. The physician must be notified when a dose of medication has not been given. If an electronic medical record is being utilized than the caregiver administering the medication will enter the correct documentation that will then be electronically date/time stamped with their initials. Checklist for completing proper steps in the administration of medications . Adheres to the 6 Rights of Medication Administration: 1) Right Dose 2) Right Route 3) Right Resident 4) Right Medication 5) Right Time 6) Right Documentation Documents the administration of each medication on the MAR & Controlled Medications on the Control Sheet

Based on observation, interview, record review, the facility failed to ensure storage of medications used in the facility were in accordance with currently accepted professional principles and included the appropriate expiration dates to preserve their integrity for the stored medications, and to store medications properly to prevent deterioration for one medications (400-hall Nurse and Medication aide cart) carts out of four reviewed for medications storage for three (Resident #s 57, #62 and # 100) of 8 residents review in that:1. The facility failed to ensure an expired OTC medication belonging to Resident #57 was removed from the 400-hall nurse's cart after it was opened and used.2. The facility failed to label Resident #62's insulin pen with the opened date after it was opened and being used on the 400-hall nurse's cart.3. The facility failed to discard Resident # 100 's insulin pen after it had been opened for 14 days passed the recommended discard day on the 400-hall nurse's cart.These failures could place residents at risk for missed medications and/or not receiving the therapeutic effect of medications.Findings included:1. Review of Resident #57's face sheet date 05/13/2026 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Heart failure unspecified (occurs when the heart muscle doesn't pump blood as effectively as it should), Chronic Atrial Fibrillation (a sustained, long-term irregular heart rhythm where the top chambers (atria) quiver instead of beating effectively), Essential (Primary) Hypertension (high blood pressure with no identifiable medical cause).Review of Resident #57's admission MDS assessment dated [DATE] reflected a BIMS score of 14 indicating intact cognition. Review of Resident #57's care plan initiated 04/14/2026 reflected Resident #57 was at risk for adverse medication effect and for behavior monitoring, potential/actual impairment to skin integrity, an ADL Self Care Performance Deficit r/t activity intolerance, limited mobility, and pain.Review of Resident #57's physician order reflected:Magnesium Oxide Oral Tablet 400 MG (Magnesium Oxide) Give 1 tablet by mouth two times a day for ANTACIDS, MINERALS &ELECTROLYTES With meals dated 4/13/2026Review of Resident #57's MAR for the month of April 2026 reflected Resident #57 was administered Magnesium Oxide Oral Tablet 400 MG (Magnesium Oxide) Give 1 tablet by mouth two times a day for ANTACIDS, MINERALS & ELECTROLYTES With meals from 04/14/2026 to 04/30/2026Review of Resident #57's MAR for the month of May 2026 reflected Resident #57 was administered Magnesium Oxide Oral Tablet 400 MG (Magnesium Oxide) Give 1 tablet by mouth two times a day for ANTACIDS, MINERALS & ELECTROLYTES With meals from 05/01/2026 to 05/12/20262. Review of Resident #62's face sheet date 05/13/2026 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus with other Circulatory complications (damage in large and small blood vessels caused by chronic hyperglycemia) .Review of Resident #62's admission MDS assessment dated [DATE] reflected a BIMS score of 15 indicating intact cognition. Review of Resident #62's care plan initiated 02/16/2026 reflected Resident #62 had Diabetes Mellitus, was at risk for adverse medication effects, and on behavior monitoring. Resident #62 had an ADL Self Care Performance DeficitReview of Resident #62's physician order reflected:NovoLOG Injection Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale:if 0 - 150 = 0 unit;151 - 200 = 2 units ;201 - 250 = 3 units;251 - 300 = 4units;301 - 350 = 5 units;351 - 400 = 6 units BS >400 Give 6 units and notify hospice, subcutaneously before meals and at bedtime for diabetesDated 02/18/2026 Review of Resident #57's MAR for the months of April and May 2026 reflected Resident #62 was administered Novolog insulin almost every day. 3. Review of Resident #100's face sheet date 05/13/2026 reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Type 2 Diabetes Mellitus without complication (indicates high blood sugar due to insulin resistance or insufficient insulin production, but without systemic damage to the eyes, nerves, kidneys, or circulatory system), repeated falls, need for assistance with personal care. Review of Resident #100's admission MDS assessment dated [DATE] reflected a BIMS score of 15 indicating no cognitive impairment. MDS also reflected Resident #100 had Diabetes Mellitus. Review of Resident #100's care plan initiated 05/12/2026 reflected Resident # 100 required enhance barrier precautions and was full code.Review of Resident #100's physician order reflected:Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro)Inject as per sliding scale:if 71 - 149 = no insulin;150 - 199 = 1 unit ;200 - 249 = 2 unit;250 - 299 = 3 units ;300 - 349 = 4 units;350 - 399 = 5 units,subcutaneously before meals and at bedtime for DM2 Greater then 399 give 6 units and notify provider. Dated 05/11/2026During an observation and interview on 05/13/2026 at 8:28 am with LVN E, while reviewing the 400-hall medication cart, it was observed Resident #57 had a bottle of Magnesium 400mg extra strength with an expiration date of November 2025. It was also observed Resident #62 had an insulin pen of Novolog 100 unit/ML without opened date. It was again observed that Resident #100 had insulin Lispro 100 unit/ML pen with opened date of 03/31/2026 with sticker indicating discard 28 days after opening. LVN E stated the potency of medication would decrease when the medication expired. LVN E stated they (the nurses) were not supposed to have expired medication on the medication cart, and all of the nurses were responsible for removing expired medications from the medication cart. LVN E stated when an insulin was opened, the nurse who opened the insulin was responsible for putting the opened date on the pen to know how long it had been used to be thrown out.During an interview on 05/13/2026 at 9:10 am, the ADON stated the charge nurses were responsible for taking out the medications from the cart when they expired. The ADON stated they were not supposed to take expired medications. The ADON stated Resident #57 brought the magnesium 400mg from home when he was admitted to the facility about 2 weeks ago, and he stated he was taking it at home. The ADON stated the nurses were supposed to check the magnesium when Resident #57 brought it. The ADON stated insulins should be dated when opened, and they were good for about 20 days when they were opened. The ADON stated Resident #100 came with her insulin pen from home when she was admitted to the facility, the nurses needed to give her insulin, and the pharmacy had not yet sent Resident #100's insulin. The ADON stated insulins needed to be dated to follow the potency of the medication. The ADON stated Resident #100 should have started a new insulin pen because the opened date of 3/31/2026 was passed the date.During an interview on 05/14/2026 at 12:27 pm, the DON stated expired medication should be taken off the medication cart as soon as possible. The DON stated it was not ok for residents to take expired medication, and she did not know if the potency or the effectiveness of an expired medication would stay the same or decrease because she was not a pharmacist. The DON stated the nurses working on the medication carts were responsible for removing expired medications from the medication carts. The DON stated she audited the mediation carts week before and she did not see the medications and the undated insulin pens on the cart. The DON stated short acting insulins were good for 28 days when they were opened and long-acting insulins were good for about 27 days. The DON stated that the pharmacy recommended to discard insulins after 28 days. The DON later stated because insulins were liquids, when expired, it decreased the potency of the medication, 4 units would work as if it were 3 units.Review of Insulin Storage Guideline, undated, presented by the facility reflected: Lispro-Humalog, Admelog-Expiration date after opening or removing from the refrigerator -28 daysAspart---Novolog--- Expiration date after opening or removing from the refrigerator -28 days.Review of facility's policy titled Medication Storage in the Facility dated 2025 reflected: PolicyMedications and biologicals are stored safely, securely, and properly following manufacturers' recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to the procedures for medication destruction, and reordered from the pharmacy, if a current order exits.

Based on observation, interview, and record review, the facility failed to follow the menu for three of three days reviewed for menu adherence. The facility failed to serve the lunch menu as planned on 5/12/2026 and on 5/13/2026.CK M failed to use a large enough scoop for oatmeal during breakfast on 5/14/2026 and failed to serve orange juice to Resident #95.These failures placed residents at risk for decreased intake, weight loss, and nutritional inadequacy.Findings included:A record review of the facility's menu for 5/12/2026 reflected the following items were to be served for lunch: pork shank with teriyaki glaze, steamed rice, pacific blend vegetables, egg roll, watermelon wedge, and iced tea. During an interview on 5/12/2026 at 10:53 AM, DS K stated that what was on the menu that day was not ordered, so she had to substitute everything. DS K stated, everything was missing. DS K stated that CK L was a cook in the facility and CK L had been placing the orders. DS K stated that they used to have a substitution log, but they had not had one in the last few weeks since the Dietary Manager had been gone. DS K stated that he had been out since April 14th (2026).An observation of meal service on 5/12/2026 at 11:50 AM revealed that beans, rice, and enchiladas were being served for lunch. There were no vegetables, egg roll, or watermelon. A record review of Resident #95's meal ticket dated 5/13/2026 reflected that she was to receive 4 ounces of orange juice.An observation on 5/13/2026 at 8:07 AM revealed that Resident #95 did not have orange juice on her breakfast tray. During an interview on 5/13/2026 at 11:59 AM, CK L stated that the Dietary Manager had been out for three weeks. CK L said that he took inventory, sent it to the Dietary Manager, and the Dietary placed food orders. CK L said if they were out of a menu item, he went to the Administrator to see if we can go get it or we'll substitute. CK L stated that he did keep a log of items that were substituted. A record review of the facility's menu for 5/13/2026 reflected the following items were to be served for lunch: chicken fajitas, charro beans, guacamole & lettuce salad, warm tortilla, picante sauce, apple enchiladas. An observation of a sample meal tray on 5/13/2026 at 12:43 PM revealed lunch consisted of one taco on a flour tortilla, chickpeas, and a salad with lettuce, tomato and cheese. There was no picante sauce, guacamole or apple enchilada.During an interview on 5/14/2026 at 9:59 AM, CK M stated that they did not have pinto beans for the charro beans the day prior (5/13/2026). CK M stated they had a substitution log, but it did not tell the cooks what to use in place of the missing item. CK M stated that he did not fill out the substitution log the day prior (5/13/2026). CK M stated that CK L was the acting manager and he told him to use garbanzo beans (chickpeas). CK M said they were out of pinto beans and guacamole on 5/13/2026. CK M stated I was just trained how to cook when asked what kind of training he had received on portion sizes. When asked how he know which scoop to use for which dish, CK M stated, The guide tells the color and the size. CK M stated, Puree has the same scoops every time and the main meal has the same scoops every time. CK M stated that the Dietary Supervisor had trained him on that. CK M stated that for the oatmeal that morning, he had used the beige (ivory) scoop. CK M stated that they had orange juice and if a resident did not receive it that morning, we messed up. A record review of the facility's menu for 5/14/2026 reflected that a half cup serving of hot cereal was to be served for breakfast. During an observation and interview on 5/14/2026 at 10:51 AM, Resident #62 was observed lying in bed. Resident #62 stated that he liked the oatmeal but, I wish they were larger because I get hungry sometimes. Resident #62 clarified that he wished the portion sizes were larger. During an observation and interview on 5/14/2026 at 10:40 AM, Resident #52 was observed sitting in his wheelchair. Resident #52 stated he received a quarter cup of oatmeal that morning and it was not enough. Resident #52 stated he was not happy with the garbanzo bean substitution for charro beans the day prior (5/13/2026). Resident #52 stated that he was sometimes still hungry after meals. During an interview on 5/14/2026 at 11:46 AM, Resident #95 stated that she would love to have orange juice and she guesses it's because they're out that she did not receive it. Resident #95 stated that the beans served the day prior (5/13/2026) were hard and they weren't the right beans because they were not charro beans. Resident #95 stated she did not receive guacamole the day prior (5/13/2026) as noted on her meal ticket. Resident #95 stated We're all adults and we need more food than what we're given. Resident #95 said yeah, she did not feel she received enough to eat. Resident #95 stated she had complained to staff about not receiving orange juice. Resident #95 stated that the food was either too hard, too cold, undercooked, overcooked, or not enough and I'm still hungry. Resident #95 said it's not what's on the ticket.An observation of the kitchen on 5/14/2026 at 12:04 PM revealed the ivory scoop was 2/5 of a cup.During an interview on 5/14/2026 at 11:10 AM, the RD stated that portion sizes were written on recipes and substitutions should be written on the substitution log for the RD to review at their next visit. She said, It has to be an equivalent. When asked how not following the menu could impact residents, the RD stated residents could get more carbohydrates, it could be a problem with diabetes, and it could be insufficient nutrition.During an interview on 5/14/2026 at 12:44 PM, the DON stated the dietitian monitored the kitchen to ensure they served the correct portion sizes. The DON stated that the dietitian visited the facility twice a month. The DON stated that the Administrator was covering for the Dietary Manager since he was out on medical leave. The DON stated that she had noticed some issues with portion sizes in the last few months, and so she talked with the dietitian. The DON stated that the dietitian went and checked the scoop sizes last month. When asked how the incorrect serving sizes could affect residents, the DON stated, They might have weight loss.During an interview on 5/14/2026 at 4:55 PM, the Administrator stated that the facility had set [NAME], and if something needed to be substituted, we have a substitution log. The Administrator stated that he was not sure whether the substation log had been completed recently. The Administrator stated that the Dietary Manager had been out for a little over a month and he was the acting manager. The Administrator stated that the Regional Dietary Manager came in about three weeks ago and said that everything was good with the scoop sizes. When asked how residents could be impacted if they received less food than the menu called for, the Administrator stated there was potential for weight loss.A request was made for policies on menu substitutions, following menus, and portion sizes on 5/14/2026 at 9:23 AM but were not provided prior to exit.

Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive and at a safe and appetizing temperature for residents who consumed foods orally from the only kitchen in the facility in that: The facility failed to provide palatable food that was attractive or appetizing to residents' who complained the food did not look or taste good and that it was frequently cold from 1 of 1 kitchen.The test tray of the lunch meal on 05/13/2026 was lukewarm, unappetizing in appearance (no condiments provided, and no beans observed in charro beans) the chicken fajita tasted heavily salted, and the tray lacked meal items described on the menu without a substitution (guacamole 5/13/26). These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life.The findings include: Resident #52Review of Resident #52's face sheet dated 05/14/26 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included type 2 diabetes (chronic condition characterized by insulin resistance and high blood sugar levels) and major depressive disorder. Review of Resident 52's quarterly MDS assessment dated [DATE] reflected a BIMS score of 10 indicating moderate cognitive impairment. Review of Resident 52's diet order dated 12/11/25 reflected a regular texture, regular consistency diet. During an interview on 05/12/26 at 02:30 PM with Resident #52 he stated that he had meal concerns because it was always the same thing he complained the food was cold and the oatmeal was too runny. He stated he has expressed his concerns to staff at the facility specifically concerning the cold food. He stated the facility had not done anything to improve the cold meals because they were still cold. Resident #49Review of Resident 49's face sheet dated 05/14/26 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included sepsis (reaction to an infection that causes immune system to harm healthy tissue and organs) and type 2 diabetes (chronic condition characterized by insulin resistance and high blood sugar levels). Review of Resident 49's quarterly MDS assessment dated [DATE] reflected a BIMS score of 12 indicating moderate cognitive impairment. Review of Resident 49's diet order dated 03/20/26 reflected a mechanical soft texture, regular consistency for diet. During an interview on 05/14/26 at 08:10 AM Resident #49 stated his issue was with the breakfast oatmeal frequently being too watery. During a confidential group interview on 05/13/26 at 02:30 PM, 10 of 14 confidential residents described the following concerns:* Breakfast is cold and it's the same thing every morning.* listed (meal ticket) condiments are not there (on the tray) and the dessert does not match what the ticket says they stated this bothered them because they frequently do not know what they are going to be eating.* The food is too salty and sometimes no seasoning at all. The residents stated that their concerns have been given to the SW related to the food palatability. Residents also stated they do not receive enough food, they stated they will sometimes get seconds and other times they wont. Resident #37Review of Resident #37's face sheet dated 05/17/26 reflected an [AGE] year-old female admitted on [DATE] with diagnosis that included type 2 diabetes (metabolic disorder when the body becomes resistant to insulin or when the pancreas fails to produce enough insulin) with diabetic chronic kidney disease, anemia (deficiency in healthy red blood cells or hemoglobin), and gout (form of arthritis characterized by sudden sever pain, swelling, and tenderness in one or more joints). Review of Resident #37's quarterly MDS assessment dated [DATE] reflected a BIMS score of 7 indicating moderate cognitive impairment. Review of Resident #37's diet order dated 07/23/25 reflected she was on a regular texture, regular consistency diet, fortified food with breakfast, lunch, and dinner related to protein calorie malnutrition. During an interview and observation on 05/14/26 at 10:46 AM with Resident #37, she stated she had the chicken fajita taco meal served on 05/13/26. She stated that the meat was salty and she had to mix the salad with it and make it less salty to consume the meal. She stated she was not provided with condiments and did not have dressing or salsa for her taco. Resident #37 also complained that the meal was not sufficient, she stated one taco was not enough for a meal and that it did not fill her up. She stated she was not provided with an apple enchilada but was given a cookie that she said she did not eat and pointed to a cookie on her bedside table that she still had. Resident #37 described the iced tea as terrible and said, it was not sugary and no sugar was provided. Resident #37 stated that she has made multiple complaints to staff about the food but they go unheard and unresolved because there are ongoing dietary issues. She stated she has also started to avoid breakfast because she would be provided with cornflakes (cereal) but not enough milk, she described the food as being consistently not enough. Resident #95Review of Resident #95's face sheet dated 05/17/26 reflected a [AGE] year-old female admitted on [DATE] with diagnosis that included type 2 diabetes mellitus (metabolic disorder when the body becomes resistant to insulin or when the pancreas fails to produce enough insulin) with diabetic neuropathy (nerve damage), anemia (deficiency in healthy red blood cells or hemoglobin), and hypertension (high blood pressure). Review of Resident #95's admission MDS assessment dated [DATE] reflected a BIMS score of 12 indicating moderate cognitive impairment. Review of Resident #95's diet order dated 03/23/26 reflected she was on a regular texture, regular consistency, reduced concentrated sweets. During an interview on 05/14/26 at 11:46 AM with Resident #95, she stated she had the fajita taco meal served on 05/13/26. She stated she did not like the charro beans and added, they were hard; they weren't the right kind of beans, they weren't charro beans. She stated the potion was not enough and she had to ask for seconds, we're all adults and we need more food than we are given she felt she never had enough to eat. Resident #95 stated her meal did not include the guacamole that he meal ticket and menu stated she would get. Resident #95 wanted to add that the palatability of the food was often an issue and said, the food is too hard, too cold, undercooked, overcooked, or not enough to eat and I'm still hungry- it's a joke and its not what is on the ticket. Review of the kitchen menu for 05/13/26 reflected the following was to be served:3oz chicken fajitas, 1/2 cup of charro beans, 1/2 cup of guacamole and lettuce salad, 1 warm tortilla, 2 tablespoons of picante sauce, 1 apple enchilada, and 8 fl oz of ices tea. An observation on 05/13/26 at 12:50 PM of the meal test tray the following items were observed on the tray: A cup of iced water, a cup of iced tea, one single soft taco (flour tortilla) with chicken fajita (no toppings observed), a side salad which consisted of a mixture of lettuce, white cheese, and tomatoes (no guacamole observed as stated on the menu; no substitution provided), a small bowl of charro beans (which were observed made with garbanzo beans), and on the side a cookie. Based on the initial observation the meal was not appealing as the plate lacked toppings and various items such as condiments like the picante sauce listed on the menu, no salad dressing, the guacamole which was not provided, no salt or pepper, no sugar for the tea, and there was no apple enchilada. The temperature of the tortilla was cold and the chicken fajita was lukewarm; the tray was not placed on the meal cart as instructed to dietary staff by surveyors and instead came straight from the kitchen when requested. The observation of this meal tray was prepared immediately upon obtaining the tray directly from the kitchen which still reflected cold to lukewarm unappetizing temperatures The charro beans were tasted and had an odd flavor as the wrong beans were used to create the dish; the beans used for the charro beans were chickpeas which have a more [NAME] and slightly dry or grainy flavor. The tea was pleasant and tasted like a typical unsweet tea; however, no sugar was provided to sweeten it as desired. The cookie was sweet and pleasant; it was soft in the center and not an unpleasant substitution for the apple enchilada not observed on the tray. During an interview and observation on 05/14/26 at 01:55 PM with CK M he stated it was the expectation from dietary that the food served to the residents was cooked well, not spoiled or old, and that all residents enjoyed what they were eating. CK M stated that he did not personally know of any of the grievances the residents had because that was not communicated to him by management or the facility and he has not seen any grievances on paper. CK M stated he had cooked the meal provided 05/13/26 with the chicken fajita taco but stated he did not taste it to check its quality. He stated he had not tasted the food he made here and provided to the residents, he stated that in the past the chefs have told him to try the food before its served but he said it was not something he did. CK M stated condiments are not available outside of the kitchen on the dining room tables or the stations in the dining room for other staff to pass out and that residents rely on the dietary staff while preparing the meal trays to place the condiments on the tray before it goes out (an observation made at this time reflected no salt pepper shakers at the tables or at the stations in the main dining room). CK M stated he was not aware of any potential negative outcome to unpalatable food, he stated if a resident was not happy with their meal they are able to request something else through nursing staff who would relay the massage to him and he would be able to provide something from the always available menu of alternatives. During an interview on 05/14/26 at 02:09 PM with the SW she stated she was the grievance official for the facility. She stated she gets grievances about the food here all the time and said it's the biggest grievance residents have. She stated the specific complaints made about the food services was related to portion size and said some residents for example will say I only got 5 fries, the taste they say they don't like it - they will say they don't like the food texture, or complain that the food is always cold. She stated she does come out to look at the trays during meal services and will assist with passing out meal trays on the hall her office was located at. She said during those times her observations of the meal trays were that they rarely had condiments which was one of the residents grievances no condiments, not seeing ketchup with fries etc The SW state she has brought these resident concerns to the dietary manager (DM) multiple times but had not escalated the concern to the Administrator. She stated it had not been escalated because she figured the DM would be able to handle those concerns. She stated that if residents were not happy with their meals that they could request a substitution, however, if they were consistently unhappy about the meals they received it had the potential to result in weight loss for the residents. During an interview on 05/14/26 at 04:42 PM with the Administrator he stated he was also the current acting Dietary Manager due to the Dietary Manager being on leave for approximately the last month. He stated it was his expectation that the food taste good saying, it should start with your eyes, should look good and taste good. The Administrator stated he had not received any recent grievances concerning food quality or taste. The Administrator stated he has tasted the facility food but could not say exactly when the last time he tried the food. He stated he had seen condiments being provided. He stated the meal on 05/13/26 that he was not aware the chickpeas were substituted for pinto beans in the charro beans made; he stated that was not a good substitution. The Administrator stated that a potential negative outcome to residents not enjoying the food and eating had the potential to result in weight loss adding, you have to eat to survive. At this time the Administrator stated again there was no policy on food palatability. Record review was completed of facility grievances for the last 12 months (date range) which reflected the following recent grievances:A grievance dated 11/05/25 reflected a dietary concern reported to the SW, resident complained the kitchen still not giving condiments with meals. Resident stated she gets frustrated when she cannot get the appropriate condiments with her meals. Resident stated the kitchen had addressed this in the past but she had not received anything but ketchup in a small container occasionally.A grievance dated 02/17/26 reflected a dietary concern reported to the SW, resident complained that she does not like the food.A grievance dated 04/06/26 reflected a dietary concern reported to the SW, resident complained about food not being edible. Resident stated the meat was very hard and she already has issues with chewing. Record review of Resident Council minutes (confidential resident meeting) for the last 12 months (date range) reflected the following recent dates with food concerns reported:*01/13/26- are meals at a satisfactory temperature reflected no*02/10/26- are meals at a satisfactory temperature reflected no*04/07/26- are meals at a satisfactory temperature reflected no*05/11/26- are meals at a satisfactory temperature reflected no often additional resident comments under meal service concerns reflected, doesn't appeal; no milk, no coffee, no sugar/creamer The facility food palatability policy was requested on 05/13/26 at 04:22 PM; the facility stated there was no policy related to food palatability available.

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 one of one kitchens reviewed for sanitation.The facility failed to ensure all food items were dated with an open date on 5/14/2026.The facility failed to ensure all food items were properly covered, labeled and dated on 5/12/2026 and on 5/14/2026.CK N failed to ensure that the temperature of fried chicken was checked before serving lunch on 5/12/2026. CK N failed to ensure that the pureed enchiladas were at least 135 when serving lunch on 5/12/2026.The facility failed to ensure that the thermometer was sanitized between testing each food item. These failures placed resides at risk for foodborne illness.Findings included: An observation of the kitchen's dry storage room on 5/12/2026 at 10:03 AM revealed a container filled with a white granular substance that was open to air. The container was not labeled or dated. An observation of the kitchen on 5/12/2026 at 11:07 AM revealed there was an undated container filled with dried, circular, loop-shaped cereal without a label.During an observation and interview on 5/12/2026 at 11:44 AM, CK N was observed taking food temperatures on the service line. CK N stated no that she had not been documenting the temperatures because the Dietary Manager had been out and he was the one who printed the logs. CK N stated that she thought the food on the service line needed to be at 165 . Observed CK N measure the temperature of the beans, rice, pureed rice, pureed vegetables, and pureed enchiladas. CK N used a paper towel to wipe the thermometer in between food items and she did not sanitize the probe. Observed that the temperature of the pureed enchiladas was 130 and the item was not removed from the service line.An observation of the dry storage room on 5/12/2026 at 11:57 AM revealed the storage bin with the white granular substance was still open. The bin was not in use.An observation of the service line on 5/12/2026 at 11:58 PM revealed there was fried chicken on the serving line that was not there before. The temperature of this item was not checked.During an interview on 5/12/2026 at 12:09 PM, CK N stated no she did not measure the temperature of the fried chicken before serving it. CK N then checked it, and it was 161 . CK N stated I guess that the Dietary Manger trained her on service line temperatures. CK N stated that she used to work as a line cook, she started working in the facility in September of 2025, and it's completely different here. stated that she did not know the difference between cooking temperatures and serving temperatures. During an interview on 5/14/2026 at 9:59 AM, CK M stated that he thought CK L trained him on taking temperature and yes the thermometer should be sanitized in between temping each food item. CK M stated that whoever opened a container should write the date it was opened on it.During an interview on 5/14/2026 at 10:14 AM, CK M stated he did not know why the bins in the dry storage were not labeled but said they should be. CK M stated that they contained rice, cornmeal, and sugar.An observation on 5/14/2026 at 10:14 AM revealed a sign posted in the dry room storage that reflected, please date and label everything in pantry.An observation of the kitchen on 5/14/2026 at 10:16 AM revealed there was an opened container of sweet & sour sauce dated 12/10/2025 and an opened container of roasted salsa verde dated 3/25/2026. During an interview on 5/14/2026 at 10:16 AM, CK M stated that the dates on the sweet & sour sauce and salsa verde were received dates and not opened dates. During an interview on 5/14/2026 at 11:10 AM, the RD stated that the expectation was that staff labeled items with an open date and stored them in a sealed container. The RD stated she believed the facility's policy was 140 for serving temperatures and that staff needed to sanitize the thermometer between each food item. When asked how failing to label or date items could affect residents, the RD stated they could be fed something they're allergic to or it could cause illness if they ate something that had gone bad. The RD stated that contamination of the thermometer could occur if it were not sanitized.During an interview on 5/14/2026 at 4:55 PM, the Administrator stated that staff should check food temperatures before serving and that minimum serving temperature needed to be 135 . The Administrator stated that all items needed a received date, an open date and a use-by date. The Administrator stated that it could cause foodborne illness if sanitation polices were not followed.A record review of the facility's policy titled Food Storage and Supplies dated 2012 reflected the following: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects.Dry bulk foods (e.g. flour, sugar) are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled. record review of the TAC chapter 553 reflected the following: ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. (D) TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked to a temperature and for a time specified underSS 3-401.11 - 3-401.13 and received hot shall be at a temperature of 57 C (135 F) or above.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents (Resident #2, Resident #3, Resident #74) reviewed for infection prevention.1. The facility failed to ensure Treatment Nurse labeled Resident #74's wound dressing on 05/12/2026.2. The facility failed to ensure CNA J properly performed perineal care for Resident #2 with foley catheter on 05/12/2026.3. The facility failed to ensure Resident #2's catheter drainage bag was positioned correctly and not laying on the floor on 05/13/2026.4. The facility failed to ensure RN A disinfected the blood pressure cuff before and after obtaining Resident # 3's BP reading during medication administration on 05/13/2026. These failures could place residents at risk for cross contamination and the spread of infection.The findings included: 1. Record review of Resident #74's quarterly MDS dated [DATE] reflected no BIMS score due to MDS not yet being completed. MDS addressed Resident #74's diagnoses as listed above. Resident #74's cognitive skills for daily decision-making assessment reflected: Severely impaired - never/rarely made decisionsRecord review of Resident #74's undated face sheet reflected a 65-year female was admitted to the facility on [DATE]. Her diagnoses included Parkinson's disease without dyskinesia, without mention of fluctuations (refers to the early or stable phases of the disease where patients maintain predictable symptom control without involuntary movements or off/on medication swings), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (cognitive decline that impacts daily life, but lacks co-occurring behavioral, psychiatric, or mood issues), unspecified abnormalities of gait and mobility (walking or movement difficulties e.g., shuffling, limping, imbalance where the precise underlying cause is not yet identified or documented), need for assistance with personal care (need for help with activities of daily living).Record review of Resident #74's undated care plan reflected: The resident has a stage 3 pressure ulcer Left ischium (the lower and back part of the hip bone). -Date Initiated: 11/18/2025. Goal included- The resident's Pressure ulcer will show signs of healing and remain free from infection through review date. -Date Initiated: 11/18/2025. Interventions included- Notify nurse immediately of any new areas of skin breakdown: Open area, Redness, Blisters, Bruises, discoloration noted during bath or daily care.-Date Initiated: 11/18/2025.Resident #74 has a potential for pressure ulcer development r/t decreased mobility, incontinence.-Date Initiated: 11/25/2024. Goal included- will have intact skin, free of redness, blisters or discoloration through review date.-Date Initiated: 11/25/2024.Interventions included- Needs assistance to turn/reposition as needed/requested. - Date Initiated: 11/25/2024. Follow facility policies/protocols for the prevention/treatment of skin breakdown.-Date Initiated: 11/25/2024. Incontinent care after each episode and apply moisture barrier. -Date Initiated: 11/25/2024. Inform the resident/family/caregivers of any new area of skin breakdown.-Date Initiated: 11/25/2024. Notify nurse immediately of any new areas of skin breakdown: Open area,Redness, Blisters, Bruises, discoloration noted during bath or daily care.-Date Initiated: 11/25/2024. Weekly skin check by licensed nurse. Notify MD if skin breakdown occurs- Date Initiated: 12/02/2024. Resident is on enhanced barrier precautions.-Date Initiated: 10/14/2025. Goal included- There will not be anytransmission of infection from or to the resident.-Date Initiated: 10/14/2025. Interventions included- Gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity- Date Initiated: 10/14/2025. Perform hand sanitation before entering the room and prior to leaving the room.-Date Initiated: 10/14/2025. Posting at the resident's room entrance indicating the resident is on enhanced barrier precautions.-Date Initiated: 10/14/2025 has Parkinson's -Date Initiated: 12/07/2024 Goal included- will remain free of further s/sx, discomfort or complications related to Parkinson's disease through review date. -Date Initiated: 11/20/2025. Interventions included- Give medications as ordered by the physician. Monitor/document side effects and effectiveness.-Date Initiated: 12/07/2024. Monitor/document/report to MD PRN any s/sx of aspiration or dysphagia: choking, fever, coughing. Refer to ST for any dysphagia problems.-Date Initiated: 12/07/2024. Monitor/document/report to MD PRN s/sx of Parkinsons complications: Poor balance, constipation, poor coordination, insomnia, dysphagia, tremors, gait disturbance, incontinence, muscle cramps or rigidity, decline in ROM, skin breakdown, mood changes, decline in cognitive function.-Date Initiated: 12/07/2024.Record review of Resident #74's order summary report reflected:-Skin tear to Left knee: Cleanse wound with wound cleanser/NS, pat dry, apply 2% mupirocin to wound bed, cover with dry dressing. As needed for wound healing: Start date: 04/30/2026.-Skin tear to Left knee: Cleanse wound with wound cleanser/NS, pat dry, apply mupirocin 2% to woundbed, cover with dry dressing. one time a day for wound healing: Start date: 05/01/2026.-Stage 4 pressure wound on left ischium (lower, posterior bone of the pelvis): clean with wound cleanser/NS, pat dry, skin prep peri wound, apply collagen and calcium alginate (highly absorptive, non-woven wound dressings made from brown seaweed) with silver to wound bed, cover with super absorbent gelling dressing as needed for wound healing: Start date: 05/13/2026.-Stage 4 pressure wound on left ischium: clean with wound cleanser/NS, pat dry, skin prep peri wound, apply collagen and Calcium alginate (highly absorptive, non-woven wound dressings made from brown seaweed) with silver to wound bed, cover with super absorbent gelling dressing one time a day for wound healing: Start date: 05/13/2026.-Wound and Skin Healing Support. Route: Intravenous (IV). Infusion Bag: 250 mL Normal Saline (0.9% NaCl) minimum volume. Administration: Slow IV Drip. Rate: Infuse at 250 mL/hour until complete. one time only for wound healing for 7 days IV Additives to be mixed in fluid bag: Vitamin C 5g, B Complex 1ml, Zinc10mg, Biotin 5mg, Magnesium Chloride 1g, Aminoblend 5ml.-Start date: 05/20/2026-Decubi-Vite Oral Capsule (Multiple Vitamins with minerals) Give 1 capsule by mouth one time a day for wound healing.Start date: 10/16/2025.During an observation of Resident #74's wound care on 05/12/2026 approximately at 1:50 p.m. revealed the Treatment nurse removed Resident #74's wound dressing from her left ischium which was not dated and initialed, had a brown spot approximately 3 cm in diameter. No foul odor was noted. Treatment nurse provided wound care to resident's ischium area and applied a new dressing; Treatment nurse did not put the date, time and her initials on the new dressing. Further observation approximately at 2:00 p.m. revealed the Treatment nurse removed Resident #74's wound dressing from resident's left knee; the wound dressing had no date and initials. Treatment nurse provided wound care to resident's left knee area and applied a new dressing; she did not put the date, time and her initials on the new dressing. 2. Record review of Resident #2's face sheet, dated 05/14/26, reflected a [AGE] year-old female originally admitted to the facility on [DATE]. Her diagnoses included acute chronic systolic congestive heart failure (longstanding weak heart muscle experiences a sudden, severe worsening of symptoms), obstructive and reflux uropathy, unspecified refers to a condition where (urine flow is blocked and/or abnormally flows backward toward the kidneys, causing back-pressure and kidney swelling), need help with personal care (need assistance with activities of daily living such as such as bathing, dressing, eating, mobility, and toileting), type 2 diabetes mellitus without complications (a condition where the body does not use insulin properly, leading to high blood sugar), chronic kidney disease, unspecified (long-term kidney damage or reduced function lasting over 3 months that has not been staged (1-5) or specifically diagnosed by a provider regarding its underlying cause).Record review of Resident #2's quarterly MDS dated [DATE] reflected BIMS score of 13 indicating the resident was cognitively intact. Resident #2's assessment reflected she has indwelling catheter, including suprapubic catheter and nephrostomy tube. Resident #2 needs Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.Record review of Resident #2's care plan reflected: Resident is on enhanced barrier precautions.-Date Initiated: 05/01/2026.Goal included- There will not be any transmission of infection from or to the resident.-Date Initiated: 05/01/2026.Interventions included- Gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity- Date Initiated: 05/01/2026. Perform hand sanitation before entering the room and prior to leaving the room.-Date Initiated: 05/01/2026. Posting at the resident's room entrance indicating the resident is on enhanced barrier precautions.-Date Initiated: 05/01/2026. Resident #2 has bladder and bowel incontinence. - Date Initiated: 12/31/2025.Goal included- Resident #2 will remain free from skin breakdown due to incontinence and brief use through the review date. -Date Initiated: 12/31/2025. ' Resident #2 is risk for septicemia will be minimized/prevented via prompt recognition and treatment of symptoms of UTI through the review date. -Date Initiated: 12/31/2025.Interventions included- Incontinent care at least q2h and apply moisture barrier after each incontinent episode. - Date Initiated: 12/31/2025. Monitor/document for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.-Date Initiated: 12/31/2025. Report to charge nurse any foul-smelling urine or if the urine is any color other than yellow.-Date Initiated:12/31/2025.Record review of Resident #2's order summary report reflected:- Monitor foley catheter Q shift for leakage, blockage, sediment buildup, or low output every shift. -Start date: 04/30/2026- Urine output every shift. -Start date: 04/30/2026-Lactulose Oral Solution 10 GM/15ML (Lactulose). Give 15 ml by mouth three times a day for CKD (chronic kidney disease unspecified)-Start date: 05/01/2026.An observation of peri care on 05/12/2026 at 2:15 p.m. revealed CNA J wiped over Resident #2's left side of labia majora by using one wipe going from top to bottom; not separating the labia majora. CNA J performed the same peri care technique on the right side of resident's labia majora; one wipe going from top to bottom and not separating the labia majora. Further observation revealed CNA J moved to clean the foley catheter by holding the catheter approximately 1.5 inches below the urinary meatus and wiping the catheter downward. CNA J lowered Resident #2's bed after completely providing peri care and left Resident # 2's Foley bag touching the floor.An observation on 05/13/2026 at 8:21 a.m. revealed Resident #2's catheter drainage bag was lying on the left side of Resident #2's bed. 3. Review of Resident #3's face sheet, dated 05/13/26, reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included anoxic brain damage, not elsewhere classified (non-traumatic brain injury from oxygen loss), dysphagia following other cerebrovascular disease (swallowing impairment caused by vascular brain injuries other than acute stroke, such as chronic ischemic disease or vascular dementia), tracheostomy status (indicates that a patient has an opening in their windpipe (trachea) to assist with breathing or clear airway blockages), gastrostomy status (clinical condition of having a surgically created opening (stoma) into the stomach).Review of Resident #3's quarterly MDS assessment dated [DATE], reflected no BIMS due to MDS not yet being completed. MDS addressed Resident #3's. Resident #3's cognitive skills for daily decision-making assessment reflected: Severely impaired - never/rarely made decisions. Resident #3's MDS assessment reflected no speech- absence of spoken words. Dependent - Helper did all the effort. Resident did none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity.Review of Resident #3's care plan reflected:Resident #3 has impaired cognitive function r/t anoxic brain injury.-Date Initiated: 12/22/2024. Goal included. - Resident #3 will have needs adequately met through the review date.-Date Initiated: 12/31/2025. Intervention included- Monitor/document /report to MD any changes in cognitive function, specifically changes in level of consciousness, mental status.-Date Initiated: 12/22/2024 requires tube feeding r/t dysphagia, anoxic brain injury-Date Initiated: 06/15/2024. Goal included. - insertion site will be free of s/sx of infection through the review date.-Date Initiated: 06/15/2024. Resident #3 will be free of aspiration (inhaling foreign materials into the airway or lungs) through the review date. -Date Initiated: 06/15/2024. Interventions included: Check placement prior to feeding and medication administration.-Date Initiated: 06/29/2024. Check residual before medications and feedings; return contents after each check.-Date Initiated: 06/29/2024. Resident #3 has Oxygen Therapy r/t chronic respiratory failure, tracheostomy status.-Date Initiated: 06/15/2024. Goal included- will have no s/sx of poor oxygen absorption through the review date.-Date Initiated: 06/15/2024. Intervention included- May use oxygen at 2-5 l/m via trach mask to keep saturation level above 92% every shift for hypoxia (low oxygen in the blood).-Date Initiated: 06/29/2024.Record review of Resident #3's order summary report reflected: -Assess before &after a treatment - O2 Sat, Resp. Rate, Pulse, Breath sounds (Key-0=Clear, 1=Wheezing, 2=Pleural rub, 3=Rales, 4= Stridor 5=Other breath sounds (if other document in Progress Note). Total time in minutes to assist with tx and assessments two times a day for SOB related to chronic respiratory failure with hypoxia. Start date: 07/01/2025.-Check O2 sat Q shift and PRN as needed. Start date: 02/14/2025.-Check O2 sat Q shift and PRN every shift for preventative. Start date: 02/14/2025.- Lisinopril Oral Tablet 5 MG (Lisinopril) Give 1 tablet via PEG-Tube one time a day for hypertension.related to hypertensive heart disease without heart failure. Start date: 02/15/2025.During an observation of medication administration on 05/17/2026 approximately at 7:08 a.m. revealed RN A came out of the room # 209 holding a blood pressure cuff in her hands and placed the blood pressure cuff on the top of the nurses' cart that was at the door. RN A sanitized her hands and moved the nurses' cart next door. RN A picked up the BP cuff from the nurses' cart after sanitizing her hands went to Resident #3's room. Resident #3's signage noted, outside of his door, resident was on EBP. RN A applied the BP cuff on Resident #3's left ancle and obtained his BP reading. RN A placed the BP cuff inside of the nurses' cart. RN A satanized her hands and proceeded to prepare Resident #3's medications. RN A pulled the BP cuff out of the nurses' cart and disinfected it after documenting Resident #3's given medications in MAR. RN A failed to disinfect a reusable blood pressure cuff between residents.In an interview on 05/13/2026 at 8:37 a.m. with CNA J, she stated she had been working in the facility for about 2 years. She could not recall when she had her last training on providing peri care to residents with foley catheters. CNA J stated that she had infection control in-service training last week, the training did cover hand hygiene, using PPEs when providing care to the residents in EBP rooms. She stated she usually did not provide peri care to the residents with foley catheters since she always worked in the secure care unit, and there are no residents with foley catheters. She stated that she was asked to provide a peri care with foley bag in a different unit yesterday.In an interview on 05/13/2026 at 9:17 a.m. with the Treatment Nurse, she stated she was not aware that the facility requires to label the wound dressing by writing the date and initials on the resident's wound dressing because using a sharpie on the resident's dressing might be an infection control issue. She stated she will confirm this with her supervisor. Treatment nurse stated that not labeling the wound dressing potentially could cause a wound infection because it would not be clear when and who changed the resident's wound dressing the last time. She stated that resident's foley bag must be placed below the resident's bladder, but it should not be laying on the floor because the resident can get a UTI.In an interview on 05/13/2026 at 11:33 a.m. with RN A, she stated that she did not sanitize the BP cuff before and after obtaining Resident #3's BP and placed the BP cuff inside of the nurses' cart. She stated that the blood pressure cuffs should be sanitized between every resident-use to prevent the spread of infections. RN A stated the foley bag must be placed inside of the privacy bag and kept below the resident's bladder. She stated that the Foley bag could be hung on the resident's bed rails but it can't be left laying on the floor because it was an infection control issue.In an interview on 05/13/2026 at 4:47 p.m. with the DON, she stated that the proper peri care provided for a resident with foley bag was going from clean to dirty from top to bottom using one wipe and throwing it after each swipe. She stated that the labia must be left untouched in the middle because of the insertion of the catheter at meatus. DON stated that the catheter must be held 2 inches below the insertion site, and the catheter must be cleaned going downward. DON stated if the foley bag that was inside of the privacy bag touched floor, it might be because the bed was lowered too low. DON stated she had not seen the residents' Foley bags laying on the floor, but if it is on the floor, it must be a resident threw the Foley bag on the floor. DON stated that she needed to confirm with the corporate if residents' wound dressings should be labeled with date and time. She stated that staff wanted to make sure that residents were comfortable and writing with a sharpie on the wound dressing applied on the resident's wound might make residents uncomfortable. She stated that the facility might start applying a piece of a brown tape with the date, time and initials on the wound dressing, but she was not sure if it would stay there. She stated that the Treatment nurse applied a brown tape on the Resident #74's wound dressing later. She stated that it was important to know when and who has changed the wound dressings so wound care is not skipped. DON stated that regular wound dressing changes were important, so a wound was healing and not getting infected. She stated that staff were expected to sanitize BP cuffs before and after using it to obtain a residents' blood pressure reading.In an interview on 05/14/2026 at 7:24 a.m. with ADON, she stated that she had been working there for 10 years. She was also an infection preventionist. She stated she was providing infection control in-service training weekly. She stated the trainings cover hand hygiene protocol: Staff must wash hands before and after providing direct care for residents and to sanitize hands before and after going to residents' rooms. She stated that Foley bags must be inside of the privacy bag and not touching a floor. She stated she did not understand the rationale for this, but the policy was stating it. She stated that she did not think that sanitizing BP cuffs before and after using it to obtain residents' BP can affect infection control. She stated that it did not affect residents so much. ADON stated that after providing wound care, the new wound dressing should be dated or at least should be stated verbally, this was important to know when the previous wound care was done.In an interview on 05/14/2026 at 5:26 p.m. with the ADM, he stated that he was trained in infection control; he completed CII modules last year. ADM stated that the infection control modules covered hand hygiene protocol such as sanitizing hands before and after going to the residents' rooms, staff must wash hands when hands are visibly soiled. He stated that hand hygiene was important to prevent spread of infection. He stated that if the Foley bag inside of privacy bag touched a floor, then staff can replace the privacy bag using gloves. He stated if a Foley bag had partially come out of the privacy bag then it should not be on the floor because it potentially can cause UTI.Record review of the facility's undated policy titled Wound Treatment Management did not reflect the specific requirements or instructions to label a new dressing with the date, time, and the initials of the staff who provided a wound care.The facility did not provide the wound care policy/procedures that was requested from DON at 11:46 a.m. on 05/12/2026.Record review of facility's Nursing Policy and Procedure Manual titled Perineal Care female (With or without catheter dated 2003 and revised December 8, 2009, reflected: a. Wipe across the pubis areab. Separate inner labia and using a different surface, wash down the center over the urethral area, wiping downward from front toward back and stopping at the base of labia.Record review of facility's undated Nursing Policy and Procedure Manual titled Catheter Care reflected:10. Be sure the catheter tubing and drainage bag are kept off the floor.14. Hold catheter tubing to one side and support against leg to avoid traction or unnecessary movement of the catheter while washing perineum.15. Keep drainage bag below level of bladder when cleaning the urethral area:16. Gently wash, rinse and dry around the juncture of the catheter and meatus. If using pre-moistened no-rinse disposable wash cloths, rinsing is not required)17. Then wash the catheter from the meatus down the tube about 3 inches.The facility did not provide a policy/procedure on reusable medical devices/equipment that was requested from the RCN around 7:47 a.m. on 05/14/2026.

Based on interviews, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and failed to protect and promote the rights of the residents for 1 of 8 (Resident #24) residents observed for dignity. The facility failed to ensure Resident #24 had her chin and neck hair trimmed. These failures could place residents at risk of experiencing humiliation, degradation, and a decreased quality of life.The findings included: Review of Resident #24's face sheet dated 05/14/26 reflected a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included down syndrome (genetic condition caused by the presence of an extra copy of chromosome 21 leading to developmental delays and distinct physical features), muscle weakness, and need for assistance with personal care. Review of Resident #24's quarterly MDS assessment dated [DATE] reflected a BIMS score of 02 indicating severe cognitive impairment. Section GG for functional abilities reflected a - (no information) in the areas are of:Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. Review of Resident #24's care plan last revised on 04/20/26 reflected Resident #24 has an ADL self-care performance deficit/ decreased mobility, debility, muscle weakness with interventions that included:Bathing: requires staff x1 for assistanceDressing: requires staff x1 for assistanceThe care plan did not contain information on the required level of care related to personal hygiene related to shaving. During an observation on 05/12/26 at 05:05 PM Resident #24 was observed in the hall, she was observed to have excessive chin and neck hair approximately 1/3 inch in length. During an observation and interview on 05/14/26 at 09:47 AM Resident #24 was observed in the hall self propelling in wheelchair. She was still observed to have her chin and neck hair. Resident #24 stated that she had her last shower the day before on 05/13/26, she stated staff did not assist her with grooming her chin and neck hair but have in the past. She stated she was not able to maintain it on her own. She stated having the chin and neck hair did not make her feel good and Resident #24 appeared embarrassed and to shy away from the question of someone taking notice. She stated she has told staff in the past that it bothered her. During an interview and observation on 05/14/26 at 10:25 AM with CNA P, she stated she was the CNA that cared for Resident #24 and was the CNA that provided Resident #24 with her shower on 05/13/26. She stated that Resident #24 required assistance with showers and grooming. She stated that on 05/13/26 she did not notice any facial hair on Resident #24 so she did not ask the resident if she wanted it trimmed or assist her with it. She stated if she needed to determine the type of assistance a resident required she would look on the Kardex in the residents chart and it would list what help if any they required for grooming/ personal hygiene. CNA P was observed looking at the Kardex for Resident #24 and CNA P stated she could not see anything in the Kardex indicating the level of assistance Resident #24 required, that it was not there. She stated that regardless if they see female residents with chin or facial hair they would take care of it, CNA P stated having facial hair is not feminine and could make them feel bad. At this time Resident #24 was observed self propelling in front of surveyor and CNA P and CNA P took notice of the facial hair. She once again claimed she did not notice it 05/13/26 but would take care of it. During an interview and observation on 05/14/26 at 11:05 PM with LVN Q she stated she worked with Resident #24, she stated staff were to look on the point of care to determine the assistance requirements for residents to include grooming/ shaving if its something they need help with. LVN Q sated facial hair on females has the potential to make them feel less attractive and it could affect their self-esteem; it's a dignity issue. During an interview on 05/14/26 at 11:25 AM MDS Coordinator stated that grooming related to facial hair is something that can be reflected on a care plan if the resident required assistance with it. MDS Coordinator stated that as a woman if she had facial hair, it would make her self-conscious and was possibly a dignity issue. During an interview on 05/14/26 at 11:37 AM the DON stated she was not aware of Resident #24's facial hair and when asked how it could make a resident feel she stated it's a personal preference. She stated the level of assistance required should be listed under the category of grooming in the care plan. During an interview on 05/14/26 at 04:42 PM the Administrator, stated a negative impact of assistance not being provided with shaving to female residents was the potential to impact their emotions in a negative way. Review of the facility undated Resident Rights policy reflected: A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizes each resident's individuality. The facility must protect and promote the rights of the resident.Respect and Dignity: The resident has the right to be treated with respect and dignity.

Based on observation, interview, and record review, the facility failed to ensure the comprehensive assessment accurately reflected the resident's status for 1 (Resident #24) of 8 residents reviewed for accuracy of assessments. The facility failed to ensure the MDS dated [DATE] was updated to reflect all of Resident #24's current functional abilities. This failure could place residents at risk of inaccurate assessments and not receiving appropriate care according to their status.Findings include: Review of Resident #24's face sheet dated 05/14/26 reflected a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included cerebral atherosclerosis (buildup of plaque in the arteries suppling blood to the brain leading to narrowed, hardened vessels and reduced blood flow), down syndrome (genetic condition caused by the presence of an extra copy of chromosome 21 leading to developmental delays and distinct physical features), muscle weakness, and need for assistance with personal care. Review of Resident #24's quarterly MDS assessment dated [DATE] reflected a BIMS score of 02 indicating severe cognitive impairment. Section GG for functional abilities- OBRA/Interim reflected a - (no information) in the following areas:Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth and manage denture soaking and rinsing with use of equipment.Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower.Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable.Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear.Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable.Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene).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.Tub/shower transfer: The ability to get in and out of a tub/shower.Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.The MDS assessment reflected section GG was signed off by MDS Coordinator and the final signature was the DON under signature of RN assessment coordinator verifying assessment completion. Review of Resident #24's care plan last revised on 04/20/26 reflected Resident #24 has an ADL self-care performance deficit/ decreased mobility, debility, muscle weakness with interventions that included:Bathing: requires staff x1 for assistanceBed mobility: requires staff x1 for assistanceDressing: requires staff x1 for assistanceEating: requires staff x1 assistanceToilet use: requires staff x1 for assistanceWalking: requires staff x1 for assistanceThe care plan did not contain information on the required level of care related to personal hygiene related to shaving. During an interview and observation on 05/14/26 at 11:25 AM with MDS Coordinator, she stated the purpose of the MDS assessment was to help determine the needs of the residents and help identify care plan triggers. She stated the MDS assessment was to be updated on admission, quarterly, and annually. She stated it was the responsibility of the MDS nurse to complete and an RN would sign off on accuracy going on to say if you sign your name on it you are responsible for it. She stated it helps create an individualized care plan so the team can identify problems and where to go for interventions. The MDS coordinator stated the MDS assessment should be completed in its entirety and ADL needs should be addressed. At this time the MDS Coordinator was asked to pull up the most recent completed MDS assessment for Resident #24 and was observed reviewing the assessment dated [DATE]. The MDS Coordinator stated section GG was not completed and it should have been. During an interview on 05/14/26 at 11:37 AM with the DON, she stated that the purpose of the MDS assessment was its related to patient care, coding, and the comprehensive care plan is where it comes in. She stated it was the expectation that it was coded correctly according to the assessment of the nurses. She stated section GG relates to a residents functional ability. She stated that as long as a section shows green it reflected it was ready to close out and that was what she was signing off on. She stated she was attesting that its ready to be closed, she stated the MDS nurse was responsible for ensuring all sections are completed. The DON stated with Resident #24 that section GG was not intentionally left uncompleted, that it was her understanding based on a corporate directive that they did not have to complete all of section GG of the MDS assessment. She stated that along with the system giving her the green indication was why she signed off on it. A policy on MDS assessments and accuracy/ completion of assessments was requested at this time; the DON stated they did not have a policy but that they followed the RAI manual. During an interview on 05/14/26 at 4:42 PM with the Administrator, he stated it was his expectation that the MDS was accurate and reflected what was going on with the resident at the time. He stated it was the responsibility of the MDS nurse to complete it and then should be verified once signed by an RN. He stated if section GG for functional abilities is missing or changes it should be updated to be accurate. He stated the MDS assessment had the potential to affect the care plan and it could potentially affect the care provided resulting in the current care not being accurate. The Administrator confirmed that there was no current policy related to MDS assessments and that they followed the RAI manual. Record review of the CMS Final MDS 3.0 RAI Manual version 1.20.1 October 2025 reflected:Assessment of the GG self-care and mobility items is based on the resident's ability to complete the activity with or without assistance and/or a device. This is true regardless of whether or not the activity is being/will be routinely performed (e.g., walking might be assessed for a resident who did/does/will use a wheelchair as their primary mode of mobility, stair activities might be assessed for a resident not routinely accessing stairs).OBRA/Interim: The Interim Payment Assessment (IPA) (A0310B = 08) is an optional assessment that may be completed by providers in order to report a change in the resident's PDPM (payment driven payment model) classification. OBRA assessments (A0310A = 01 - 06) are required for residents in Medicare-certified, Medicaid-certified, or dually certified nursing homes and are outlined in Chapter 2 of this Manual. For Section GG on the IPA Interim Payment Assessment (IPA) or an OBRA assessment, providers will use the same 6-point scale and activity not attempted codes to assess the resident's usual functional performance during the 3-day assessment period.Coding Instructions:When coding the resident's usual performance, use the six-point scale, or use one of the four activity was not attempted codes to specify the reason why an activity was not attempted.A dash (-) indicates No information. CMS expects dash use to be a rare occurrence.

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 2 of 8 residents (Resident #32 and Resident #50) reviewed for dietary services. 1. The facility failed to ensure Resident #32 received his prescribed diet of pureed texture. 2. The facility failed to ensure Resident #50 received his prescribed diet of mechanical soft texture. These failures placed residents at risk of choking, aspiration (inhaling food), and diminished quality of life. Findings included: 1. A record review of Resident #32's face sheet dated 5/14/2026 reflected an [AGE] year-old female admitted on [DATE] with diagnoses of Parkinson's disease (neurological disorder), protein-calorie malnutrition, muscle weakness, muscle wasting and atrophy (muscle loss), need for assistance with personal care, unspecified abnormalities of gait and mobility. A record review of Resident #32's MDS assessment dated [DATE] reflected a BIMS of 6, which indicated severely impaired cognition. Resident #32's MDS assessment reflected that she required substantial/maximal assistance with eating. A record review of Resident #32's care plan last revised on 5/07/2026 reflected that she had complained of chewing problems and her diet was changed to a pureed texture. Intervention included to provide and serve diet as ordered. A record review of Resident #32's orders reflected an order dated 5/06/2026 for a pureed diet. An observation on 5/12/2026 at 12:31 PM revealed Resident #32 was sitting at the dining room table with a plate of pureed food in front of her. Resident #32 was not eating, her plate was untouched, and she had a brownie near her plate. An observation on 5/12/2026 at 12:32 PM revealed the SLP came by Resident #32's table, picked up the brownie, and walked away. During an interview on 5/12/2026 at 12:33 PM, the SLP stated, no she did not know why Resident #32 was served a brownie when she was on a pureed diet and that was why she took the brownie away. The SLP stated that sometimes the special instructions on the tray ticket did not change when diets were updated. During an observation and interview on 5/14/2026 at 12:02 PM, Resident #32 was observed sitting in the dining room. Resident #32 stated that she had not had any incidents of choking. During an interview on 5/14/2026 at 12:06 PM, CK M stated that he worked on 5/12/2026 and he figured the brownie for Resident #32 was soft enough. During an interview on 5/14/2026 at 1:22 PM, the SLP stated that she changed Resident #32's diet order because of her involuntary movements. The SLP stated that Resident #32 would have been okay if she ate the brownie. During an interview on 5/14/2026 at 12:44 PM, the DON stated that dietary and nursing checked trays during meal service to make sure the diet matched what was served. The DON stated that Resident #32's diet was recently changed but the note on her ticket, which reflected that she was to be served a brownie, was not removed. The DON stated that the Dietary Manager trained staff on texture-modified diets. The DON stated that if residents on a pureed diet ate regular textured foods, they could cough or choke. During an interview on 5/14/2026 at 4:55 PM, the Administrator stated that the Dietary Manager trained dietary staff on food consistency and that nurses checked for tray accuracy during meals to make sure that residents on a pureed diet were not served a regular diet. When asked how residents could be impacted if they were not served meals according to their diet order, the Administrator stated they would be at risk for choking. 2. A record review of Resident #50's face sheet dated 05/14/2026 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of cerebral palsy (lifelong condition caused by brain damage or abnormal development, affecting a person's ability to move, maintain posture, and balance), major depressive disorder (a severe mood disorder causing persistent feelings of sadness, hopelessness, and a loss of interest in activities), and anemia (body lacks enough healthy red blood cells or hemoglobin to carry adequate oxygen to your tissues). A record review of Resident #50's MDS assessment dated [DATE] reflected a no BIMS score; the resident was rarely/never understood. A record review of Resident #50's care plan last revised on 05/12/2026 reflected a focus of Resident #50 was at risk for choking related to chewing problem, diet - mechanical soft texture with intervention dated 09/09/2021 CNA to report to nurse any signs of resident choking. Observation on 05/12/2026 at 6:03 PM revealed Resident #50 alone in his room with a firm, not soft cookie on his dinner tray. Observed that when the cookie was turned on its side and tapped against the tray, it did not bend but remained hard. Observation on 05/13/2026 at 7:55 AM revealed Resident #50 alone in his room with a solid round sausage patty on his breakfast tray. During an interview with an interpreter on 05/13/2026 at 12:44 PM with CNA R, she said if something looked too hard or chewy on Resident #50's plate they had to notify the kitchen and get substitute food. CNA R said Resident #50 did not eat in the dining room because he preferred to eat in his room and no one could get him to eat in the dining room. CNA R said if she was concerned about something that was on Resident #50's plate she would immediately notify the nurse who oversaw reviewing his food. CNA R said when the food came out of the kitchen a nurse reviewed it before the food was distributed. During an interview on 05/14/2026 at 1:16 PM the DOR/SLP said a sausage patty and firm cookie should not have been on Resident #50's food trays. The DOR/SLP said Resident #50 should have a regular diet and naturally soft, finely chopped, ground food. The DOR/SLP said he should not have hard cookies or food that was not finely chopped because he might aspirate (inhaling food that is not properly cut or chewed is a significant risk, as large, solid pieces can block the airway or lead to pneumonia if they reach the lungs) or choke. The DOR/SLP said it was the responsibility of all the staff to make sure Resident #50 got the correct diet on his meal tray. During an interview on 05/14/2026 at 2:01 PM with the Cook, he said the kitchen checked resident trays for the food to make sure it matched the diet of the residents. The [NAME] said sometimes things got on the resident's tray that should not have been on the tray and they tried to fix it as soon as they found it. The [NAME] said he learned that the cookies should be ground up crumbly. The [NAME] said that on 05/12/2026 the menu listed they were going to serve cupcakes but instead they served the harder round cookie instead of the soft cupcake. During an interview on 05/14/2026 at 1:12 pm the DON said Resident #50 was care planned for a regular mechanical soft diet and he should not have the round, not cut up sausage for breakfast. The DON said the possible negative effect of Resident #50 not having food that was mechanical soft was that there was a possibility he could choke.Record review of facility policy Meal Service and Snacks, undated, reflected diets such as regular, renal (relating to, involving, or located in the region of the kidneys), and diabetic may be combined with texture modification or other consistency changes. All modifications are based upon the residents' needs. Cut up or shopped meats or other foods are provided when the resident requires them. Ground consistency involved the actual grinding of meat or other specified food, usually through a food grinder or processor. Frequently, meat is the only food that needs to be ground. Ground foods are served to residents with chewing or swallowing problems

Based on observation, interview, and record review, the facility failed to ensure it was free of a significant medication error for 1 of 1 (Resident # 74) resident reviewed for pharmacy services.The facility failed to ensure Resident # 74 received scheduled medication within the ordered liberalized time range: 07:00am-09:00am, 11:30am-2:00pm, 6:30pm-10:30pmThis deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, worsening or exacerbation of chronic medical conditions, and hospitalization.Findings Included:Record review of Resident #74's undated face sheet reflected a 65-year female was admitted to the facility on [DATE]. Her diagnoses included Parkinson's disease without dyskinesia, without mention of fluctuations (refers to the early or stable phases of the disease where patients maintain predictable symptom control without involuntary movements or off/on medication swings), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (cognitive decline that impacts daily life, but lacks co-occurring behavioral, psychiatric, or mood issues), unspecified abnormalities of gait and mobility (walking or movement difficulties e.g., shuffling, limping, imbalance where the precise underlying cause is not yet identified or documented), need for assistance with personal care (need for help with activities of daily living).Record review of Resident #74's quarterly MDS assessment dated [DATE] reflected no BIMS due to the MDS not yet being completed. Resident #74's cognitive skills for daily decision-making assessment reflected: Severely impaired - never/rarely made decisions.Record review of Resident #74's undated care reflected:Resident #74' has Parkinson's -Date Initiated: 12/07/2024 Goal included- will remain free of further s/sx, discomfort or complications related to Parkinson's disease through review date. -Date Initiated: 11/20/2025. Interventions included- Give medications as ordered by the physician. Monitor/document side effects and effectiveness.-Date Initiated: 12/07/2024. Monitor/document/report to MD PRN any s/sx of aspiration or dysphagia: choking, fever, coughing. Refer to ST for any dysphagia problems.-Date Initiated: 12/07/2024. Monitor/document/report to MD PRN s/sx of Parkinsons complications: Poor balance, constipation, poor coordination, insomnia, dysphagia, tremors, gait disturbance, incontinence, muscle cramps or rigidity, decline in ROM, skin breakdown, mood changes, decline in cognitive function.-Date Initiated: 12/07/2024. Resident #74 has impaired cognitive function and impaired thought processes r/t dementia.-Date Initiated: 11/25/2024. Goal included-Resident #74 will maintain current level of cognitive function through the review date.-Date Initiated: 11/20/2025. Interventions included- Administer meds as ordered.-Date Initiated: 11/25/2024. Monitor/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. -Date Initiated: 11/25/2024.Record review of Resident #74's order summary report reflected:-Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa). Give 1 tablet by mouth three times a day for Parkinsonrelated to Parkinson disease without dyskinesia, without mention of fluctuations. Start date: 01/17/2025. Record review of Resident # 74's scheduling details reflected:Medication: Carbidopa-Levodopa Oral Tablet 25-100 MG.Medication class: Antiparkinson and related therapy agents.Dose of administrating quantity:1Frequency: Three times a day.Schedule type: Every day.Facility Time code: TID LibRelated diagnosis: Parkinson's disease without dyskinesia, without mention of fluctuations.For (indications for use): Parkinson.Time Range(s): 07:00am-09:00am, 11:30am-2:00pm, 6:30pm-10:30pmRecord review of Resident # 74's Carbidopa-Levodopa Oral Tablet 25-100 MG medication administration audit report from 04/01/2026 to 05/14/2026 reflected Resident # 74 received the medication Carbidopa-Levodopa Oral Tablet 25-100 MG earlier than the liberalized medication pass time of 07:00 a.m.-09:00 a.m. on: 04/01/2026 at 06:20 a.m.,04/02/2026 at 06:17 a.m., 04/03/2026 at 06:09 a.m., 04/04/2026 at 06:01 a.m., 04/05/2026 at 06:45 a.m., 04/06/2026 at 06:09 a.m.,04/2026 at 06:29 a.m., 04/12/2026 at 06:38 a.m., 04/15/2026 at 06:27 a.m., 04/16/2026 at 06:35 a.m., 04/21/2026 at 06:36 a.m., 04/22/2026 at 06:31 a.m., 04/24/2026 at 06:27 a.m., 04/25/2026 at 06:09 a.m., 04/26/2026 at 06:08 a.m., 04/27/2026 at 06:15 a.m., 05/02/2026 at 06:18 a.m., 05/03/2026 at 06:30 a.m., and 05/13/2026 at 06:30 a.m.Resident # 74 received the medication Carbidopa-Levodopa Oral Tablet 25-100 MG later than the liberalized (flexible schedule) medication pass time of 07:00 a.m.-09:00 a.m. on: 04/14/2026 at 11:17 a.m., 04/17/2026 at 11:30 a.m., 04/18/2026 at 12:16 p.m., 04/20/2026 at 10:48 a.m., and 05/06/2026 at 10:49 a.m.Resident # 74 received medication Carbidopa-Levodopa Oral Tablet 25-100 MG earlier than the liberalized medication pass time of 11:30 am-2:00 pm on: 04/01/2026 at 11:18 a.m., 04/02/2026 at 11:12 a.m., 04/03/2026 at 11:15 a.m., 04/08/2026 at 10:58 a.m., 04/10/2026 at 11:10 a.m., 04/13/2026 at 11:23 a.m., 04/14/2026 at 11:25 a.m., 04/15/2026 at 11:04 a.m., 04/17/2026 at 11:30 a.m., 04/21/2026 at 11:16 a.m., 04/22/2026 at 11:07 a.m., 04/24/2026 at 10:58 a.m., 04/25/2026 at 10:31 a.m., 04/27/2026 at 11:16 a.m., 04/30/2026 at 11:02 a.m., 05/01/2026 at 11:49 a.m., 05/03/2026 at 10:52 a.m., 05/06/2026 at 10:49 a.m., 05/11/2026 at 10:48 a.m., and 05/12/2026 at 10:55 a.m.Resident # 74 received medication Carbidopa-Levodopa Oral Tablet 25-100 MG earlier than the liberalized medication pass time 6:30 pm-10:30 p.m. on: 04/05/2026 at 5:59 p.m., 04/06/2026 at 5:46 p.m., 04/10/2026 at 6:09 p.m., 04/24/2026 at 6:20 p.m., 04/28/2026 at 6:16 p.m., 05/01/2026 at 6:14 p.m., 05/04/2026 at 6:02 p.m., 05/06/2026 at 6:19 p.m., and 05/10/2026 at 6:19 p.m.Record review of Resident # 74's medication administration audit report reflected she received her medication Carbidopa-Levodopa medication 56 times outside of the liberalized medication pass time order from 04/01/2026 to 05/14/2026. Resident # 74 received double doses of the medication due to the morning medication dose of Carbidopa-Levodopa being administered with the afternoon medication dose simultaneously or too close to each other: On 04/14/2026-the morning dose was administered at 11:17 a.m. and the afternoon dose was administered at 11:25 a.m. On 04/17/2026 -the morning dose was administered at 11:30 a.m. and the afternoon dose was administered at 11:30 a.m. On 04/18/2026 -the morning dose was administered at 12:16 p.m. and the afternoon dose was administered at 12:16 p.m. On 04/20/2026 -the morning dose was administered at 10:48 a.m. and the afternoon dose was administered at 1:13 p.m. On 05/01/2026 -the morning dose was administered at 09:34 a.m. and the afternoon dose was administered at 11:49 a.m. On 05/06/2026 -the morning dose was administered at 10:49 a.m. and the afternoon dose was administered at 10:49 a.m. On 05/10/2026 -the morning dose was administered at 09:45 a.m. and the afternoon dose was administered at 12:16 p.m.During interview on 05/14/2026 at 3:30 p.m. with NP, she stated that medications should be administered within an hour before or an hour after the scheduled time, administering Sinemet (carbidopa/levodopa) medication 2 hours later can cause tremors and dyskinesia. She stated giving this medication close to two doses would affect residents. She stated it was better when the doses are separated out. She stated she prefers there to be a bigger medication gap between when medication is administered, and she would want to be notified so she can make changes to the dosing time schedule.During an interview on 05/14/26 at 5:30 p.m. with the ADM, he stated if Parkinson's medication (Carbidopa-Levodopa) was late all the time then residents could have increased tremors, and it would affect their therapy. He stated that dyskinesia (movement disorders characterized by involuntary, erratic, and uncontrollable muscle movements, such as fidgeting, writhing, twisting, or jerking) can affect therapy and eating. He stated if the medication was administered constantly late, it affects residents psychosocially.During an interview on 05/15/2026 at 11:26 a.m. with the MD, she stated that she did not know anything about Sinemet (Carbidopa/Levodopa) medication. She stated that it should be consistent with the time, and she would not recommend the liberalized time administration for this medication. She stated if it was a multi-vitamin then it could be liberalized but if a resident is getting 2 or 3 doses, something given 3 times a day should not be liberalized because there was a chance of doses being given too close together, and the resident could have adverse effect of being overdosed and medication was not meant to be given that way. She stated the Parkinson's medication should be given 3 times a day. She stated that this has been written by the neurologist, and if they were at home, they would get it when they woke up - if they were at home the medications could not be given every 8 hours because the medication was given 3 times a day, and they were getting it 3 times a day. She stated that it works better if the medication was given 3 times every 8 hours around the clock, but that would not happen if they were at home.During an interview on 05/15/2026 at 12:32 p.m. with the DON, she stated liberalized time for medications was a window time; morning time means you can give the morning medication 6:30 a.m. - 10:30 a.m. - it was given a bigger window to administer the medications. She stated the Sinemet (Carbidopa-Levodopa) medication should not be liberalized. She stated that the MD controls liberalized timing. She stated if it is liberalized medication, then there was a window of 4 hours, technically the medication could be given an hour before or an hour later outside of the window. She stated, If the morning medication was given at 11:00 a.m. or 11:30 a.m., and the next medication was given at 12:00 p.m., then it would be considered a double dose. She stated, in nursing, if the same medication is given 30 minutes apart, that is considered double dosing, and nursing judgment is not to give at the same time. She stated that if medication is given too close together, they would have a big side effect, and she has not seen it. She stated nurses were not documenting the given medication immediately in the MAR, and if they are documenting all medications given at the end of their shifts, it makes look like a dose to dose. She stated that when the liberalization policy changed the staff was in-serviced in new policy.During an interview on 05/15/2026 at 1:32 p.m. with the RNC, she stated that when medication times were liberalized, they cannot go beyond the time frame. It would be an error if the medication was given 60 minutes earlier or after the liberalized medication time; it would be a medication error if the liberalized medication was given outside of the liberalized time range. She stated if a nurse calls the doctor and tells the doctor that a resident wants her morning and evening medication given together and the doctor gives the okay to do so, it would be documented in the progress note. Carbidopa-Levodopa medication is used to control tremors, rigidity, and muscle spasms in patients with Parkinson's. She stated that this medication was time sensitive; it is extended release. She stated she expected nurses and med aides to give medication as ordered. RNC stated that If Carbidopa-Levodopa was not given on time, she did not believe it would impact the resident if they missed the dose, but the doctor must be notified about the missed dose and the doctor will be giving an order, and nurses was expected to follow those directions. She stated that she doesn't expect missed doses to happen often, it is not a current practice to give the same medication an hour apart from one another, a med aide should let her nurse know before giving medication too close together. The med aide was expected to communicate with the nurse; the nurse then will communicate it to the doctor and then document that she contacted the doctor.Record review of the facility's Pharmacy Policy and Procedure, titled Liberalized Medication Policy dated 2006 and revised 01.06.2026 reflected: We are expanding the allotted time for some medications to be given using the AM, PM, AM/PM and TID lib time codes.This will impact medications scheduled in the morning, afternoon and in the evening and two-three times per day medication orders.TID lib= may be given from 6:30 am-10:30 am, 11:30 am-2 pm, 6:30pm-10:30pmTID lib time code-combining the three-time parameters set above. This indicates a medication is set to be given three times per dayIf a physician's order specifically states the time of day a medication is to be given, then the facility must administer it at the time specified.The facility could continue to have traditional times for any medication scheduled more than 2-3 times per day, i.e. QID, Q6H, Q4H, etc.There are some medications that are to be given every day that will be given at a specific time such as Synthroid. These will continue to be given at a time as suggested by the manufacturer and current industry practices.The DON, Consultant Pharmacist, Medical Director, and any other members of the clinical team deemed necessary have reviewed and approved the liberalized medication pass policy and procedure and will review each resident's medications and adjust medication administration times if needed based on ISMP High Alert Medication list and other current standards of practice.

Based on interviews and record reviews, the facility failed to ensure residents were free from verbal abuse for 1 of 4 residents (Resident #1) reviewed for abuse. The facility failed to prevent [CNA B], from verbally abusing Resident #1 on 11/23/2025 at 3:15 PM. This failure could place residents at risk of emotional distress, fear, decreased quality of life and further abuse. Findings included:Record review of Resident #1's admission record dated 01/06/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. His relevant diagnoses included: SCHIZOPHRENIA is characterized by(delusions, hallucinations and psychosis.), MAJOR DEPRESSIVE DISORDER (mood disorder that causes a persistent feeling of sadness), GENERALIZED ANXIETY DISORDER (a mental health condition that causes fear, worry and feeling of being overwhelmed).Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 06, indicating Resident #1's cognition was severely impaired. Section E- Behavioral Symptom reflected Resident #1 did not exhibit any behaviors.Record review of Resident #1's quarterly care plan assessment dated [DATE] reflected Resident #1 had the potential to demonstrate verbally abusive behaviors. Goal: The resident will demonstrate effective coping skills through the review date. Interventions include notifying the charge nurse of any abusive behaviors. During a phone interview of Family #1, dated 01/06/2026 at 2 p.m. it was revealed that Resident # 1 was upset because [CNA B] did not change the channel when he asked her to. Record review of [CNA A]s written statement she provided on 11/23/2025, reflected on Sunday 11/23/2025 I and [CNA C] were in [Resident #1]'s room to change him, and [CNA B] helped us change the resident. When we were done, [CNA B] started cursing at the resident. She said '['fuck me, no fuck yourself, you stupid ass. I have rights just like you] . She was very upset. I let the Charge Nurse know what was going on. Record Review of [CNA C]s written statement on 11/23/2025, reflected, on Sunday 11/23/2025, [CNA B] had [Resident # 1's bed control and she was raising the head of the bed. Resident # 1 asked [CNA B] for the control because he wanted to do it himself. I saw Resident # 1 with the remote in his hand and he was yelling at [CNA B], Fuck You!. Resident # 1 was very mad, and [CNA B] yelled back at him telling him We are here cleaning your ass!, Don't tell us Fuck you!, Resident # 1 and [CNA B] were both yelling at each other.Record Review of LVN A's written statement on 11/23/2025, reflected on Sunday 11/23/2025 at 3:15 PM, he stated, I was sitting at the nurse's station and a staff [CNA A] ) reported to me that another staff [CNA B] had an altercation with Resident # 1. I spoke to [Resident # 1] who told me what happened. [CNA B] requested that she be able to apologize to Resident # 1, but I instructed her not to go into the resident room. During an interview on 01/06/2026 at 11:05 a.m., [CNA A]stated, I heard[CNA B] say to [Resident # 1] fuck you and she said, I've got rights just like you, you don't talk to me like that. [CNA A] stated she had been trained in ANE. [CNA A] stated, If a staff member uses foul language towards a resident, which could make them feel bad and possibly hurt their feelings. During an interview on 1/06/2026 at 11:39 a.m., with LVN A was approached by[CNA A]to report an altercation between [CNA B] and Resident # 1. He stated [CNA A], [CNA B], and [CNA C] had just finished changing Resident # 1 when the altercation occurred. He stated, [CNA B] was remorseful for using foul language, but I said, you cannot go into the room and I reported the incident to the ADM. LVN A stated, [CNA B]'s employment has been terminated.During a phone interview on 1/06/2026 at 12:30 p.m., revealed [CNA B]stated, I was assisting 2 other [CNA A] s. I was using the remote control to the bed when Resident # 1 told me that he wanted to do it. So, I reached across the bed and the remote dropped on the resident. She stated, Resident # 1 said to her, [you are an ugly fucking face]. She stated I told him He was not to speak to me that way and then I repeated his words back to him. She stated, at that time, the other CNAs only heard me repeating those words to him. She stated, I was asked to leave the facility, and I was fired. During an interview on 01/06/2026 at 3:30 p.m., it was revealed that ADM had been informed of an altercation between Resident # 1 and [CNA B]immediately after the incident. [CNA B] was immediately removed from the facility by LVN A. An investigation was completed, and it was found that [CNA B]had been verbally abusive to Resident # 1. ADM was called by LVN A immediately after the incident. ADM stated, we followed procedure by removing the employee from the facility and assessing Resident # 1. Resident # 1's skin assessment was clear, and no injuries were noted. At time of resident assessment, it was reported that 'Resident did not exhibit any signs of distress'. Employee [CNA B]) was terminated, and a report was sent to the nursing board. He stated, it was their expectation that all residents should be always treated with dignity and the CNA should not have replied to Resident # 1 in such a derogatory manner. He stated a review of the employee's file confirmed that [CNA B] had been trained on ANE and Resident Rights during orientation. Record review of the facility's Abuse/ Neglect Policy dated 3/29/2018 reflected: Policy The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart.Definitions3. Verbal Abuse, and use of oral or written or gestured language that willfully includes disparaging and derogatory terms to the resident.Training. The facility will train through orientation and on-going in- services on issues related to abuse/ neglect prohibition practices regularly. Prevention:The facility will provide the residents and staff with an environment free from abuse and neglect.

Based on observation, interviews, and record reviews, the facility failed to distribute and serve food in accordance with professional standards on only the 500 Hall. Staff were observed moving from one resident to another without using hand hygiene between meals. The failure places residents at risk of cross contamination and infections. Findings included:Observation on 10/16/2025 at 12:34 PM of hall 500 reflected the following:- CNAS A and CNA B were observed passing food trays to residents on the hall without hand hygiene between residents. CNAS A and While passing food trays CNA S A and CNAS B were touching residents' doors setting up food tray and moving the food cart down the hall. An interview on 10-16-2025 at 12:50 PM CNAS A. CNAS A stated that they had just started at the facility today. CNAS A stated that he did get training on hand hygiene when they did the orientation but stated that he forgot. The CNAS said if hand hygiene is not used in residence contamination and getting sick. An interview on 10-16-2025 at 12:55 PM CNAS B. CNAS B stated that she was in training. CNAS B stated that she just started this morning and received training on hand hygiene. CNAS B stated if proper hand hygiene is not used when passing food to residents, they could get sick. An interview on 10-16-2025 at 3:22 PM with LVN stated staff should sanitize their hands before grabbing food trays to give to the residents, then again before grabbing another food tray. LVN said that that was an infection control issue. The LVN said if he saw a staff member not using hand hygiene, he would remind them. The LVN said when hand hygiene was not done, it was an infection control issue. An interview on 10-16-2025 at 3:38 PM with CNA. The CNA stated that when passing out food trays she is supposed to use hand hygiene between giving food trays to residents. The CNA said when she gives a food tray to a resident, she will clean her hands and repeat the process. The CNA said she has not seen any staff not using hand hygiene at the facility and if she did, she would remind them to use hand hygiene while serving residents food. The CNA said that it was an infection control issue and not using hand hygiene put the resident at risk of getting sick. An interview on 10-16-2025 at 3:48 PM with the DON. The DON stated proper hand hygiene should be always done when giving food to residents at the facility. DON said hands should be cleaned in between trays. DON said that it was infection control and residents could get sick. DON has not witnessed staff not using hand hygiene and if she does then she will remind them and do in-service training. DON heard about CNAS A and CNAS B not using hand hygiene and already completed the in-service. Review of the facility's hand hygiene policy that was not dated revealed the following.Hand HygieneYou may use alcohol-based hand cleaner or soap/water for the following: - Before and after assisting a resident with meals

Based on interview and record review, the facility failed to ensure that medical records were accurately documented for four(Resident #1, Resident #2, Resident #3, and Resident #4) of six residents reviewed for accurate medical records. The facility failed to have documentation that they provided care to Resident #1 from 10pm to 6am from [DATE] - [DATE]. Resident #1 was on hospice and found deceased around 6am and there was no information of what care was to be provided during rounds or that Resident #1 was having a change of condition that required intervention. The facility failed to have documentation that they provided care to Residents #2, #3, and #4 from 10p to 6a from [DATE] - [DATE]. These failures could place residents at risk of not receiving timely care and services, accidents, harm, and death. Findings include: Resident #1 Review of Resident #1's admission Record, dated [DATE], reflected she was a [AGE] year old female who was admitted to the facility on [DATE], had a DNR, was receiving hospice services, and expired at the facility on [DATE]. Resident #1 had medical diagnoses that included spastic quadriplegic cerebral palsy (high muscle tone leading to stiffness and difficulty with movement that affects all four limbs, the trunk, and the face), intellectual disabilities, abnormalities of gait and mobility, other lack of coordination, and need for assistance with personal care. Review of Resident #1's Quarterly MDS, dated [DATE], reflected no BIMS documented and she was dependent on staff for all ADL care. Resident #1 was also always incontinent with urine and bowel movements. Review of Resident #1's Death in Facility MDS, dated [DATE], reflected she was discharged after expiring at the facility on [DATE]. Review of Resident #1's Care Plan, initiated [DATE], reflected she required two CNAs to assist her with bed mobility and mechanical lift transfers, one CNA to assist her with eating/drinking, dressing, and was dependent on CNAs for incontinent care and personal hygiene. CNAs were required to turn/reposition and provide incontinent care at least every two hours. Review of Resident #1's Progress Notes for [DATE] reflected there were no notes on [DATE] from 10:00 p.m. through 6:00 a.m. on [DATE]. Review of Resident #1's MAR/TAR for [DATE] reflected there were three entries from LVN B on [DATE] during the night shift, but the entries did not indicate when LVN B administered medications and treatments on [DATE] from 10:00 p.m. through 6:00 a.m. on [DATE]. Review of Resident #1's MAR Audit Report for [DATE] reflected there were no results as to when LVN B documented the three entries on [DATE] from 10:00 p.m. through 6:00 a.m. on [DATE]. Review of Resident #1's Vital Summary reflected LVN B took the following vitals on [DATE] at 1:27 a.m.: -Temperature 97.5 degrees Fahrenheit -Respirations 18 breaths per minute -Pulse 72 beats per minute -Oxygen Saturation 95% -Blood Pressure 124/74 millimeters of mercury Review of Resident #1's POC for [DATE] reflected there were no entries for ADL assistance, bed mobility, bowel incontinence, dressing, personal hygiene, hands on assistance with eating/drinking, mechanical lift transfers, thickened liquids, skin observation, snacks and fluids, toilet use, transferring, turning/repositioning, walk in corridor, and walk in room assistance on [DATE] from 10:00 p.m. through 6:00 a.m. on [DATE]. Review of Resident #1's Postmortem Assessment, signed by LVN A on [DATE] at 6:22 a.m., reflected Resident #1 was found in her bed in her room unresponsive, without respirations and pulse, fixed and dilated pupils, and body temperature indicated hypothermia and skin was cold relative to her baseline skin temperature. Resident #1 was pronounced dead by the Hospice Agency RN on [DATE] at 7:18 a.m. Review of Resident #1's Discharge Summary, signed by LVN A on [DATE] at 9:39 a.m., reflected on [DATE] at 6:22 a.m., she was observed unresponsive, without carotid pulse and breath, and with fixed/dilated pupils. Resident #2 Review of Resident #2's admission Record, dated [DATE], reflected she was an [AGE] year old female who was admitted to the facility on [DATE], had a DNR, and was receiving hospice services. Resident #2 had medical diagnoses that included senile degeneration of the brain (a group of neurological disorders that cause a progressive decline in cognitive function, including memory, reasoning, and problem-solving), generalized muscle weakness, other lack of coordination, adjustment insomnia (a type of sleep disorder that occurs when a specific stressful event or change in a person's life disrupts their normal sleep patterns), Alzheimer's disease (a progressive, neurodegenerative disorder that primarily affects the brain and causes a decline in cognitive function, particularly memory and thinking), other chronic pain, and repeated falls. Review of Resident #2's Quarterly MDS, dated [DATE], reflected no BIMS documented and she was dependent on staff for all ADL care. Resident #2 was also always incontinent with urine and bowel movements. Review of Resident #2's Care Plan, revised on [DATE], reflected she required two CNAs to assist her with bed mobility, toileting, dressing and mechanical lift transfers and one CNA to assist her with eating/drinking and personal hygiene. CNAs were required to provide incontinent care and turn/reposition her at least every two hours. Review of Resident #2's POC for [DATE] reflected there were no entries for ADL assistance, bed mobility, bowel incontinence, dressing, personal hygiene, hands on assistance with eating/drinking, mechanical lift transfers, skin observation, snacks and fluids, toilet use, transferring, turning/repositioning, walk in corridor, and walk in room assistance on [DATE] from 10:00 p.m. through 6:00 a.m. on [DATE]. Resident #3 Review of Resident #3's admission Record, dated [DATE], reflected she was a [AGE] year old female who was admitted to the facility on [DATE], had a DNR, and was receiving hospice services. Resident #3 had medical diagnoses that included vascular dementia (a type of dementia caused by damage to the blood vessels in the brain, leading to reduced blood flow and oxygen supply), overactive bladder, other lack of coordination, abnormalities of gait and mobility, dementia (a general term for the decline in memory, thinking, and reasoning skills, affecting daily life), insomnia, and need for assistance with personal care. Review of Resident #3's Quarterly MDS, dated [DATE], reflected she had a BIMS score of 10, which indicated she had moderate cognitive impairment. Resident #3 also required supervision with eating, partial/moderate assistance with oral hygiene, substantial/maximal assistance with showering, dressing, personal hygiene, bed mobility, and dependent on staff for toileting, and transfers. Resident #3 was also always incontinent with urine and bowel movements. Review of Resident #3's Care Plan, revised [DATE], reflected she required two CNAs to assist her with bed mobility, toileting, dressing and mechanical lift transfers, one CNA to supervise her with eating/drinking, and one CNA to assist her with personal hygiene. CNAs were required to provide incontinent care and turn/reposition her at least every two hours. Review of Resident #3's POC for [DATE] reflected there were no entries for ADL assistance, bed mobility, bowel incontinence, dressing, high risk for falls monitoring, personal hygiene, hands on assistance with eating/drinking, mechanical lift transfers, skin observation, snacks and fluids, toilet use, transferring, turning/repositioning, walk in corridor, walk in room assistance and behavior monitoring on [DATE] from 10:00 p.m. through 6:00 a.m. on [DATE]. Resident #4 Review of Resident #4's admission Record, dated [DATE], reflected she was an [AGE] year old female who was admitted to the facility on [DATE], had a DNR, and was receiving hospice services. Resident #4 had medical diagnoses that included Alzheimer's disease, convulsions (involuntary, rhythmic muscle contractions and relaxations that cause uncontrolled shaking and jerking of the body, often accompanied by a temporary loss of consciousness), generalized muscle weakness, abnormalities of gait and mobility, other lack of coordination, dementia and need for assistance with personal care. Review of Resident #4's Quarterly MDS, dated [DATE], reflected she had a BIMS score of 3, which indicated she had severe cognitive impairment and she was dependent on staff for all ADL care. Resident #4 was also always incontinent with urine and bowel movements. Review of Resident #4's Care Plan, revised [DATE], reflected she required two CNAs to assist her with bed mobility, toileting, and mechanical lift transfers and one CNA to assist her with dressing, eating, and personal hygiene. CNAs were required to provide incontinent care and turn/reposition her throughout the day and as needed. Review of Resident #4's POC for [DATE] reflected there were no entries for ADL assistance, bed mobility, bowel incontinence, dressing, personal hygiene, mechanical lift transfers, skin observation, snacks and fluids, toilet use, transferring, turning/repositioning, walk in corridor, and walk in room assistance on [DATE] from 10:00 p.m. through 6:00 a.m. on [DATE]. Review of the facility's Staff Schedule, dated [DATE], reflected LVN B and CNA C were assigned to work on Residents #1, #2, #3, and #4's hallway on [DATE] from 10:00 p.m. through 6:00 a.m. on [DATE]. LVN A and CNA G were also assigned to work on Residents #1, #2, #3, and #4's hallway on [DATE] from 6:00 a.m. through 2:00 p.m. Attempts to call CNA C were made on [DATE] at 12:48 p.m. and [DATE] at 9:44 a.m. CNA C did not return the calls before exit. Attempts to call LVN B were made on [DATE] at 12:50 p.m. and [DATE] at 9:49 a.m. LVN B did not return the calls before exit. During a group interview with CNA D and CNA E on [DATE] at 1:08 p.m., they stated CNAs and nurses were responsible for checking on and providing treatment and care to residents at least every two hours. They stated CNAs documented care in residents' POC during their shift. They stated residents needed to be checked on and provided treatment and care so they did not develop worsening conditions. They stated the DON reminded CNAs daily to check on and provide care to residents at least every two hours, as needed, or upon request. They stated the nurses, ADON and DON were responsible for overseeing and ensuring CNAs checked on and provided care to residents daily by asking the CNAs if they were performing care on residents. During an interview with LVN A on [DATE] at 1:18 p.m., he stated the CNAs and nurses were responsible for checking on and providing treatment and care to residents at least every two hours. He stated CNAs documented care in residents' POC after completing the task and said, If the CNAs did not do it right away, then they could forget to document later. LVN A stated he did not know where the nurses documented treatment and care after completing the task. LVN A stated residents could be at risk of developing injuries and other worsening conditions if they were not being checked on and provided treatment and care. He stated the ADON reminded the CNAs and nurses every couple of days about checking on and providing treatment and care to residents. LVN A stated he did not know who was responsible for overseeing and ensuring CNAs and nurses checked on and provided treatment and care to residents, but he believed residents' POCs were reviewed to ensure CNAs completed the tasks. LVN A stated he believed he found Resident #1 unresponsive during his first set of rounds on [DATE]. LVN A stated he was unsure if Resident #1 had been expired for some time on [DATE] when he conducted her postmortem assessment on [DATE]. LVN A stated he described Resident #1's body temperature as hypothermia and skin was cold relative to her baseline skin temperature because that was one of the options the postmortem assessment provided while he completed the assessment. LVN A stated he recalled speaking with the previous shift (LVN B), who worked on [DATE] from 10:00 p.m. through 6:00 a.m. on [DATE] and he believed there were no reported concerns from the previous shift (LVN B). During an interview with RN F on [DATE] at 1:39 p.m., she stated CNAs and nurses were responsible for checking on and providing treatment and care to residents at least every two hours, as needed, and as requested. She stated CNAs documented care in residents' POC after completing the task. She also stated nurses documented treatment and care in residents' TAR after completing the task. She stated residents could be at risk of worsening conditions if they were not being checked on and provided treatment and care. She stated the ADON and DON in-serviced CNAs and nurses on checking on and providing treatment and care frequently. She also stated the ADON and DON were responsible for overseeing and ensuring CNAs and nurses checked on and provided treatment and care to residents. During an interview with the ADON on [DATE] at 2:23 p.m., she stated CNAs and nurses were responsible for checking on and providing treatment and care to residents at least every two hours, as needed, and upon request. She stated CNAs documented care in residents' POCs. She stated nurses documented care in residents' progress notes. She stated she and the DON reminded the CNAs and nurses daily about checking on and providing treatment and care. She stated she and the DON were also responsible for overseeing and ensuring CNAs and nurses were checking on and providing treatment and care by reviewing residents' POCs daily and reeducating if needed and said, Whatever was in the care plan was in POC and must be completed. During an interview with the ADM on [DATE] at 9:30 a.m., he stated the facility did not have policy and procedure on rounding or checking on residents. During an interview with the MD on [DATE] at 10:37 a.m., he stated that he was unsure what the facility's expectations were on checking on residents and what frequency was acceptable. He stated that he would think residents should be checked on at least once a shift and said, Anything could happen in that time. Residents should be peeked on. If a resident could not express their needs or access their call button, that could be a problem. Should get in touch with those residents. Residents who have specific needs, such as being changed, definitely need to be checked on at least once a shift. Any changes in mental status that would be important as well. He also stated it was unacceptable to not check on a resident for a whole shift. He also said, If a resident were cold to touch when found deceased , which would indicate that resident was not breathing, had no pulse, and then someone would pronounce their death. If someone was cold to touch, they were probably dead for at least 4 hours, maybe 6 hours or so. I would guess probably 4-6 hours or so, maybe closer to 6 hours because there is lots of mass to corroborate before becoming cold. During an interview with the NP on [DATE] at 10:45 a.m., he stated that if a resident had a change in condition, he expected residents to be checked on more frequently. He also stated that he expected residents on hospice services to be checked on more frequently. He clarified that more frequently meant at least every two hours and explained the nurses and CNAs would alternate who checked on the residents every hour. He stated it was not acceptable to not check on residents for a whole shift and said, Still need to check on hospice or long term residents at least every two hours. Residents were different. If focus were pain management, resident could have uncontrollable pain and need to be checked on every shift. If resident were hospice resident, you never know when resident would have a change in condition. Residents needed to be checked on more often, that is why they were on hospice. He also said, If a resident is cold to touch when found deceased , it would indicate that resident was deceased for maybe 6 or 5 hours, but it depends on resident status and condition before the death. During a confidential interview with the CE on [DATE] at 11:35 a.m., they stated CNAs were expected to check on residents every hour and as many times as needed. They also stated CNAs were expected to document care in residents' POCs during their shifts. They stated another female CNA (CNA G) was already working on Resident #1's hall on [DATE] at 6:00 a.m. because CNAs worked in pairs of two on each hallway. They observed Resident #1 lying in her bed, her eyes were not open or halfway open, stiff when they tried to lift her arm, cold when they touched her, pale, head was turned in one direction, and they suspected Resident #1 was dead on [DATE] at 6:00 a.m. They stated they notified LVN A, asked when Resident #1 passed away. LVN A rushed over to the room, and notified the night shift nurse (LVN B). They stated no one knew that Resident #1 passed away and LVN A and LVN B tried to argue that Resident #1 had just passed away during the 6:00 a.m. through 2:00 p.m. shift on [DATE]. An attempt to call CNA G was made on [DATE] at 11:52 a.m. CNA G did not return the call before exit. Review of the facility's Care Plan policy and procedure, undated, reflected, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment .Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs .The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. Care planning drives the type of care and services that a resident receives. Review of the facility's Documentation policy, dated 2003, reflected, Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. It has legal requirements regarding accuracy and completeness, legibility and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets (daily, weekly, monthly, discharge). Documentation also occurs in the clinical software Point Click Care. Goal 1. The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. 2. The facility will ensure that information is comprehensive and timely and properly signed. Procedure .6. Document completed assessments in a timely manner and per policy. 7. Complete documentation in the electronic health record in a timely manner. Each entry will be dated and timed. Each entry will be signed with proper signature and title. 8. Documentation during and following an acute episode, following an event, and during physiologic, mental, or emotional changes or instability . 10. Document or check information on flow sheets each shift or as appropriate for the care or treatment being monitored.

Based on interviews and record review, the facility failed to properly discharge and include all other necessary information, including a copy of the resident's discharge summary, and any other documentation, to ensure a safe and effective transition of care for 1 of 7 residents (Resident #1) reviewed for transfer and discharge requirements. 1. The facility failed to provide all necessary information and/or documentation for a safe and effective transition to the resident, responsible party (RP), and ombudsman for Resident #1. 2. The facility failed to document a discharge summary or plan for a safe discharge for Resident #1. This failure could place residents at risk of not receiving the necessary care and services when discharged to meet their physical and psychological needs. Findings include: Review of Resident #1's face sheet dated 04/17/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included vascular dementia (dementia caused by damage to brain tissue resulting in changes to memory, thinking, and behavior) with mood disturbance, major depressive disorder (mental disorder characterized by a persistent low mood, loss of interest or pleasure in activities), type 2 diabetes mellitus (chronic condition characterized by insulin resistance and elevated blood sugar) with diabetic neuropathy (nerve damage), need for assistance with personal care, acquired absence of right leg below knee, and acquired absence of left leg below knee. Resident #1's face sheet also reflected he was not his own RP. Review of Resident #1's comprehensive MDS assessment dated [DATE] revealed a BIMS score of 12 indicating moderate cognitive impairment . Section GG for Functional Abilities revealed Resident #1 required partial/moderate assistance with transfers (chair, bed, toilet, and tub/shower); Resident #1 also required partial/moderate assistance with toileting hygiene and dressing, and supervision or touch assistance with oral hygiene and showers/baths. Review of Resident #1's additional BIMS assessment dated [DATE] reflected a BIMS score of 6 indicating severe cognitive impairment. Review of Resident #1's care plan last revised 02/09/25 reflected Resident #1 has impaired cognitive function and impaired thought process related to dementia with interventions that include engage the resident in simple structured activities that avoid overly demanding tasks and needs supervision/assistance with all decision making. Care plan also reflected non-compliance with care and behavioral problems identified, Resident #1 refuses blood sugar checks most of the time, Resident #1 is non-compliant with diet which could prevent wound healing, Resident #1 resists ADL/incontinent care at times, and Resident #1 has a behavior problem related to throwing call light on the floor. Care plan also identified Resident #1 receives antidepressant medication. Review of Resident #1's nursing progress notes from dates 04/01/25-04/17/25 did not reveal any notes from facility in discharge planning or discussion of discharge. It did not reflect notes on notification to Resident #1, Resident #1's RP, or Ombudsman of discharge. Review of Resident #1's Notification of Discharge dated 04/15/25 revealed a discharge with an effective date of 05/15/25 for failure to pay for provided services. The address of discharge reflected, resident choice. In an interview on 04/17/25 at 01:17 PM, Resident #1 stated he was issued a discharge notice for non-payment but was supposed to be getting help with a Medicaid application. He stated he believed he was not getting sufficient help in the process and that he relied on skilled nursing services because he was not able to do some things on his own. Resident #1 stated he believed he would be able to go back to his old home if he was discharged . In an interview on 04/17/25 at 2:32 PM, the ADM stated Resident #1 was issued a discharge notice for non-payment and was not compliant with assisting the facility with his Medicaid application by providing bank statements. He stated Resident #1 was told by the facility that they would take him to the bank but that Resident #1 put it off. The ADM stated they have not taken the resident to the bank and have not been able to get him to provide bank statements. The ADM stated the Ombudsman was at the facility 04/15/25 and she was made aware of the discharge. He stated they are still working on a discharge plan and they would see if he was able to go back home, or find another SNF that would accept Resident #1 therefore there is no discharge summary or documentation other than the discharge notice. In an interview on 04/17/25 at 03:10 PM, the DON stated Resident #1 is in skilled nursing because he needs assistance with his care. She stated the resident had Dementia and that he had family that is RP. The DON stated that to her knowledge the son did not have control of the finances for Resident #1 and was not able to assist. In an interview on 04/17/25 at 03:34 PM, with the Ombudsman stated she was at the facility on 04/15/25 and asked the facility if Resident #1 was issued a discharge notice to which the facility said no. She stated she was told by the facility they would not be discharging the resident and that they would instead work on a payment plan and trying to get his Medicaid pending application completed. The Ombudsman stated that not having an address on the discharge notice is not appropriate and not considered an appropriate or safe discharge. She stated that it is everyone's right to a safe discharge, she said she would be returning to the facility to make an appeal to ensure they find appropriate placement for Resident #1 and have a plan in place. In an interview on 04/17/25 at 3:43 PM, the SW stated she had spoken to Resident #1's RP and she was advised Resident #1 did not have a livable home to go to. The SW stated that the house Resident #1 speaks of has broken windows, no running water, and is not habitable. The SW stated Resident #1 was not cognitively intact and difficult to believe what he says because Resident #1 fabricates a lot of stories. The SW stated Resident #1's RP had attempted to get statements for Medicaid pending application but said it was difficult as Resident #1 is non-compliant. The SW stated that at this moment they were not sure where the resident would go and they were still trying to find placement. In an interview on 04/17/25 at 04:41 PM, Resident #1's RP stated Resident #1 was not cognitively well and unable to make decisions for himself. The RP stated he had tried to assist Resident #1 in getting bank statements, but Resident #1 made it difficult for him even with having POA over him. The RP stated he lives out of the country and that it is difficult to assist with any care Resident #1 needs. The RP stated that at times Resident #1 has verbalized he does not care if he ends up at a homeless shelter and was not sure where the resident could safely be discharged to. The RP stated he did not want to have anything else to do with Resident #1's care and that Resident #1's family is not willing to help him. He stated Resident #1 lived with him before the SNF but that it was no longer an option. The RP stated Resident #1 had psych issues, and that he needs help with decision making and help with getting financial records and hopes the state or another government agency would take over his care. The RP stated he would like Resident #1 to have a safe discharge but is not sure where he would go and had not been advised what the facilities plan is. Review of the facility Discharge or Transfer to Another Facility policy last revised 04/10/24 revealed: Facility Initiated Discharge The facility will permit each resident to remain in the facility, and not transfer or discharge the resident from the facility. In the following limited circumstances, this facility may initiate transfers or discharges: A. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; B. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; C. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; D. The health of individuals in the facility would otherwise be endangered; E. The resident has failed, after reasonable and appropriate notice to pay, or have paid under Medicare or Medicaid, for his or her stay at the facility. F. The facility ceases to operate. Documentation To demonstrate that any of the circumstances permissible for a facility to initiate a transfer or discharge as specified in A-F on the previous page have occurred, the medical record will show documentation of the basis for transfer or discharge. This documentation must be made before, or as close as possible to the actual time of transfer or discharge.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure DM wore a beard guard while in the kitchen. This failure could place residents who ate food from the kitchen at risk for foodborne illness. Findings included: Observation on 3/17/25 at 12:12 PM-1:00 PM revealed DM with beard guard down under chin with visible facial hair while serving lunch meal trays in dining room. Further observation revealed DM going in and out of kitchen 5 different times without beard guard on facial hair visible. Observation on 3/18/25 at 11:45 AM of DM in kitchen preparing Brussels sprouts with beard guard down under chin facial hair visible. Observation on 3/19/25 at 11:55 AM of DM in kitchen preparing lunch meal trays with beard guard down under chin facial hair visible. Interview on 3/19/25 at 12:35 PM the DM stated hair nets or cap and beard guard on facial hair is present are required for all staff while in the kitchen. The DM stated it could negatively affect a resident if hair restraints are not worn by a resident receiving food with hair in it. The DM states it is his responsibility to ensure hair restraints are worn by all staff in the kitchen. The DM could not provide answer as to why he did not properly wear a beard guard while in the kitchen even though he has facial hair. Interview on 3/19/25 at 3:31 PM DON stated hair restraints are to be worn by everyone in the kitchen. The DON stated a negative of not wearing a hair restraint would be hair in the food. The DON stated the DM was responsible for ensuring hair restraints were worn by everyone in the kitchen. Interview on 3/19/25 at 5:11 PM the ADM stated his expectation was that hair restraints were to be worn by all staff in the kitchen. The ADM stated it could negatively affect residents if hair restraints are not worn by hair getting into the food. The ADM stated all kitchen staff are responsible for wearing hair restraints and that ultimately the DM is responsible for ensuring hair restraints are worn by all staff in the kitchen. Review of facility Dress Code policy undated reflected: 1. Facial hair must be neatly trimmed, and dietary staff must wear hair restraints/nets. 2. Dietary staff must wear hair nets while in the dietary department. Dietary staff with facial hair must wear beard nets while in the dietary department.

Based on interviews and record reviews, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 3 (Resident #47, Resident #59, and Resident #70) of 8 residents reviewed for care plans. The facility failed to ensure Resident #47's, #59's, and #70's care plan was revised to reflect the change of activity level. This failure placed residents at risk of not having their needs reviewed and revised when needed to ensure appropriate care is being provided. Findings include: Resident #47 Review of Resident #47's face sheet, dated, 03/19/2025, reflected a [AGE] year-old female who was admitted on [DATE]. Resident #47 had diagnoses which included cerebral palsy, unspecified (caused by changes in the developing brain that disrupt its ability to control movement and maintain posture and balance), severe intellectual disabilities ( major delays in development- average mental age of between 3 and 6 years, and individuals have limited communication skills), and autistic disorder ( a condition characterized by difficulties in social interaction and communication, along with restricted behaviors and interests). Review of Resident #47's Annual MDS, dated [DATE], reflected Resident #47was unable to complete the BIMS. Resident #47 had poor short- and long-term memory recall. She had unclear speech. Resident #47 had disorganized thinking (rambling or irrelevant conversation) and was easily distracted. Resident #47's activity preference was bed bath, snacks between meals, staying up past 8:00 PM and family involved in care decisions. Review of Resident #47's Quarterly MDS, dated [DATE], Resident #47 was unable to complete the BIMS. Resident #47 had poor short- and long-term memory recall. She did not speak. Resident #47 declined to respond to concern of social isolation. Review of Resident #47's Comprehensive Care Plan, with completion date of 12/29/2024 reflected Resident #47 had impaired cognitive function and impaired thought process related to intellectual disabilities. Resident #47 had nonverbal communication. Interventions: (initiated on 10/10/2024)- Engage Resident #47 in simple, structured activities that avoid overly demanding tasks. Provide a program of activities that accommodates the resident's abilities. Resident #47 had a communication impairment related to intellectual disabilities. Interventions: (initiated on 10/10/2024) Provide a program of activities that accommodates Resident #47's communication abilities. Review of Resident #47's One-On-One Activity Participation Record from January 2025 to March 2025, reflected Resident #47 was to receive one-on-one activities three times per week. Resident #47 would fall asleep when assisted out of her room . Resident #47 was assessed by the activity department on the one-on one Activity Participation Record from January 2025 to March 2025; she needed one-on-one activities . Her activity preference was watching cartoons and, listening to music (did not specify what type of music). In an interview on 03/19/2025 at 4:15 PM the Activity Director stated Resident #47's care plan was not revised to reflect she needed one-on-one activities. She stated anytime a residents activity level changed and it was not time for their care plan to be updated, the staff was expected to revise the care plan to show the current activity needs of a resident. The Activity Director stated she was expected to revise Resident #47's care plan. She stated if the staff viewed Resident #47's care plan the staff would not know Resident #47 needed one-on-one activities and this may affect their quality of life such as feeling isolated or become depressed . Resident #59 Review of Resident #59's face sheet, dated, 03/19/2025, reflected an [AGE] year-old female who was admitted on [DATE]. Resident #59 had diagnoses which included senile degeneration of brain, not elsewhere classified (decline in memory and thinking skills, often associated with aging, though it was not a normal part of aging), Alzheimer's disease (affects memory, thinking and behavior), adjustment insomnia (a temporary sleep problem that arises due to stressful life events or life changes) and chronic pain (persistent pain that lasts for three months or longer, or beyond the expected healing time, and can significantly impact daily life. Review of Resident #59's Admission MDS, dated [DATE], reflected the resident was rarely or never understood. Resident #59 had poor short- and long-term memory recall. She was unable to complete the BIMS on the MDS. Her decision-making ability was moderately impaired (decisions were poor; Resident #59 required cues and supervision). She had difficulty focusing and was easily distracted. Resident #59 had ramble (lack of a clear point or focus) conversation. Resident #59 had mood symptoms such as the following: 1. Feeling or appearing depressed or hopeless ( experiencing persistent sadness, a lack of motivation, and a sense that things will never improve or that there's no way to improve your situation). 2. Trouble falling or staying asleep or sleeping too much. 3. Feeling tired or having little energy. Resident #59 was unable to respond if she felt lonely or isolated. Resident #59's activity preferences was the following: 1. Activities somewhat important a. Listening to music b. Going outside to get fresh air when the weather was good. c. Do things in group of people d. Do your favorite activities. 2. Activities not very important a. Have books, newspapers, and magazines to read. b. Keep up with the news. c. Being around animals. d. Participate in religious services or practices. Resident #59's Quarterly MDS, dated [DATE], reflected Resident #59 had poor short- and long-term memory recall. She is able to recall staff names and faces. Resident #70's decision making ability was severely impaired. She had difficulty focusing and was easily distracted. Resident #59 had ramble (lack of a clear point or focus) conversation. Resident #59 had the following mood symptoms: 1. Trouble falling asleep or sleeping too much. 2. Trouble concentrating on things, such as reading the newspaper or watching television. 3. Poor appetite or overeating. Record review of Resident #59's Comprehensive Care Plan, with a completion date on 02/28/2025, reflected Resident #59 had impaired cognitive function and impaired thought processes related to dementia and senile degeneration of the brain. Intervention: Engage Resident #59 in simple, structured activities, that avoid overly demanding tasks. Provide activities programs to accommodate Resident #59's abilities. Intervention: Use task segmentation to support Resident #59's short term memory deficits. Resident #59 had a communication problem related to speaks Korean and confusion. Family member stated Korean was mostly nonsensical. Use the Korean communication chart. Intervention: Provide a program of activities that accommodates Resident #59's communication abilities. Record review of Resident #59's One-on-One Activity participation record reflected Resident #59 was to receive one-on-one interaction 5 days a week. In an interview on 03/19/2025 at 4:15 PM the Activity Director stated Resident #59's one-on- one activities began 03/05/2025. The Activity Director stated she did not know why her care plan was not revised to reflect Resident #59 being on one-on-one activity program. She stated anytime there was a change in a resident's physical, mental or even activity level, the change was to be documented on the care plan. The Activity Director stated Resident #59's interventions did not match what was documented on the one-on one activity participation record. She stated Resident #59's care plan needed to be revised on 02/28/2025 to reflect her activity level of needing one-on-one activities . She stated the staff viewed the care plan would not know Resident #59 needed one-on-one activity visits. She stated she was responsible for the activity care plans. Resident #70 Review of Resident #70's face sheet, dated, 03/19/2025, reflected a [AGE] year-old female who was admitted on [DATE]. Resident #70 had diagnoses which included vascular dementia, unspecified severity (problems with reasoning, planning, judgement , memory, and other thought processes caused by brain damage from impaired blood flow to your brain where the severity was not specified), adjustment insomnia (a temporary sleep problem that arises due to stressful life events or life changes), and polyosteoarthritis, unspecified (multiple joints had pain, stiffness, and loss of function). Review of Resident #70's Admission MDS, dated [DATE], reflected the resident had a BIMS score of 3, which indicated her cognition was severely impaired. Resident #70 had disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject) and was easily distracted. Resident #70 had difficulty keeping track of what was being said. Resident #70's activity preference reflected the following: 1. Activities somewhat important a. Listening to music b. Being around animals c. Do things in group of people 2. Activities not very important a. Have books, newspapers, and magazines to read. b. Keep up with the news c. Go outside to get fresh air when weather was good. d. Participate in religious services or practices 3. Important, but can't do or no choice a. How important was it to you to do your favorite activities. Review of Resident #70's Quarterly MDS, dated [DATE], reflected the resident had a BIMS score of 3, which indicated her cognition was severely impaired. Resident #70 felt depressed or hopeless 7-11 days prior to the MDS being completed. Resident #70 had the following concerns: 1. Trouble falling or staying asleep or sleeping too much. 2. Feeling tired or having little energy. 3. Trouble concentrating on things, such as reading the newspaper or watching television. Review of Resident #70's Comprehensive Care Plan, with completion date of 01/17/2025 reflected Resident #70 had impaired cognitive function and impaired thought process related to dementia. Interventions: Engage Resident #70 in simple, structured activities that avoid overly demanding tasks. Provide a program of activities that accommodates the resident's abilities. Resident #70 had a communication impairment related to language barrier (unable to speak the same language and impaired cognition (difficulties with thinking, learning, remembering, using judgement, and making decisions). Resident #70 speaks Spanish, however, understand some English. Interventions: Provide a program of activities that accommodates Resident #70's communication abilities. Intervention : Refer to Speech Therapy. Validate Resident #70's message by repeating aloud. Provide Resident #70 translation as needed to communicate with the resident or call family member to assist with translation as needed. Resident #70 had little or no activity involvement related to decreased vision; will participate in activities that don't require vision. Intervention: Modify the resident's daily schedule, treatment plan as needed to accommodate activity participation. Provide monthly activities calendar. Invite/encourage the resident's family members to attend activities with resident in order to support participation. Resident #70 had impaired visual function related to glaucoma (an eye condition that damages the optic nerve - the nerve that carries messages from the retina to the brain) and macular degeneration (a condition that damages the central part of retina responsible for sharp, central vision, leading to vision loss, particularly for tasks like reading and recognizing faces). Record review of Resident #70s One-on-One Participation Record for the year 2025 reflected Resident #70 required one-on-one activities three time per week. Resident #70 is blind and speaks only Spanish. Resident #70 loved to visit with activity staff. In an interview on 03/19/2025 at 4:15 PM The Activity Director stated Resident #70 had been receiving one-on-one visits since 01/01/2025. She stated Resident #70 loved to visit in her room. The Activity Director stated Resident #70's care plan was expected to be revised to meet Resident #70's preference of having visits in her room at least three times per week beginning on 01/22/2025. She stated with her activity preference not documented on her care plan the staff would not know Resident #70's current activity plan and her activity preference. She stated Resident #70 may be encouraged by other staff to do an activity she may not prefer to do and it may affect her mood and behavior. Interview on 03/19/2025 at 11:30 The MDS Coordinator stated any time there was a change in a resident physical condition, mental condition or activity level, the residents care plan was expected to be revised to reflect the change with the resident. She stated if a resident was changed to receive one-on-one activities this was expected to be revised on the care plan of residents new activity program. She stated if staff was reviewing the care plan the staff would not know the resident did not want to attend group activities they were on the one-on-one activities in their room. She stated this may affect resident's mood if staff assisted a resident to an activity that did not meet the residents needs or preference. Interview on 03/19/2025 at 9:36 AM The Director of Nurses stated all care plans are to be revised any time when there is a change of condition with a resident's care, mental status, and activity needs. She stated the information on the care plans would be on the Kardex ( the tool CNAs uses to know what type of care and needs for each resident). She stated if a resident care plan was not revised when their activity level changed the CNAs would not have that information on the Kardex and would not know the resident's activity preference. She stated the resident's mood or behavior may change if the CNAs attempted to assist resident out of their room to attend a group activity and the resident's preference was to do activities in their room. Record review of the Facility's Comprehensive Care Planning, not dated, reflected the resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on observations, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for three of eight residents (Resident#20, Resident #77, and Resident #56 ) reviewed for ADL care. 1. The facility failed to ensure Resident #20's and Resident # 77's nails were cleaned, trimmed, and did not have any rough edges. 2. The facility failed to ensure Resident # 56 was free of facial hair on 3/17/25-3/19/25. These failures could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem. Findings included: 1.Review of Resident #20's face sheet, dated, 03/19/2025, reflected a [AGE] year-old male who was admitted on [DATE] and readmitted on [DATE]. Resident #20 had diagnoses which included need for assistance with personal care ( helping individuals with activities of daily living like bathing, dressing, toileting, grooming, and eating), unspecified sequelae of cerebral infarction (the long-term consequences or complications that arise following a stroke. Not enough blood was getting through certain blood vessels in the brain), muscle weakness ( lack of muscle strength- muscles did not move very easily), lack of coordination ( inability to control muscle movements) , and type 2 diabetes mellitus with hyperglycemia (a chronic condition- when you have persistently high blood sugar levels). Review of Resident #20's Quarterly MDS, dated [DATE], reflected the resident had a BIMS score of 1, which indicated his cognition was severely impaired. Resident #20 required partial/moderate assistance ( helper does less than half the effort) with personal hygiene, upper body dressing, showers, oral hygiene, and toileting hygiene. He required substantial/maximal assistance (helper does more than half the effort) with lower body dressing. Review of Resident #20's Comprehensive Care Plan, with completion date of 01/28/2025 reflected Resident #20 had an ADL Self Care Performance Deficit related to decreased activity tolerance (inability to perform or endure regular activities due to factors like pain or underlying health conditions), decreased mobility ( loss or difficulty in the ability to move around independent), and impaired cognition ( a decline in mental abilities that affects a person's thinking, memory, and decision-making processes). Interventions: Assist with personal hygiene. Assist with bathing: check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. If diabetic, the nurse will provide toenail care. Observation and interview on 3/17/2025 at 11:20 AM, revealed Resident # 20 was in his room lying in bed. He had a blackish/ brownish substance underneath the middle ring and fore fingernails on her right hand. Resident #20's ring and middle fingernail on her right hand were uneven around the edges. Resident #20 was not interview able. Resident #77 Record review of Resident #77's face sheet, dated 03/19/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #77 had diagnoses which included Alzheimer's disease ( affects memory, thinking and behavior), need assistance with personal care (helping individuals with activities of daily living like bathing, dressing, toileting, grooming, and eating), lack of coordination ( affects the ability to control and execute smooth, purposeful movements). Record review of Resident #77's Quarterly MDS Assessment, dated 12/17/2024, reflected the resident had a BIMS score of 3, which indicated her cognition was severely impaired. Resident #77 required partial/moderate assistance ( helper does less than half the effort) with personal hygiene, showers, and toileting hygiene. Resident #77 Required supervision or touching assistance ( helper sets up or cleans up. Helper assists only prior to or following the activity) with the following: upper and lower dressing, eating, and oral hygiene. Record Review of Resident #77's Comprehensive Care plan, with a completion date on 3/12/2025, reflected Resident # 77 had an ADL Self Care Performance Deficit related to Alzheimer's disease. Intervention: Personal Hygiene- Resident #77 required one staff to assist with personal hygiene. Bathing- Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. If diabetic, the nurse will provide toenail care. Review of Resident #77's Nurses Notes, dated 03/03/2025 to 03/19/2025 reflected Resident #77 did not refuse nail care. She was aggressive during mouth care on 03/16/2025. Observation and interview on 02/04/2025 at 10:37 AM, revealed Resident #77 was sitting in her wheelchair on the secure unit toward middle of the hall. Her nails on her right hand were not smooth around the edges. She had a blackish brownish substance underneath her middle and ring fingernails on her right hand. Resident #77 was not interview able. Interview on 03/17/2025 at 12:50 PM LVN B stated the nurses were responsible for residents with diagnosis of diabetes with nail care such as trimming, cleaning, filing. She stated the CNAs were responsible for all other residents' nail care. LVN B stated if a resident had brownish/blackish substance underneath their nails and if a resident swallowed the substance there was a possibility a resident may become ill such as stomach problems nausea and vomiting. LVN B stated if a resident refused any type of care, the nurse would document the refusal in the nurse's notes. She stated Resident #20 did not refuse care. LVN B stated Resident #77 refuses care such as showers and changing her clothes. She stated no one had reported to her Resident #77 refused nail care. LVN B stated she had worked with Resident #20 and Resident #77 for several weeks. She stated she had been in- serviced on nail care, however, she did not recall the date. In an interview on 03/17/2025 at 1:30 PM, CNA E stated the CNAs were responsible for cleaning, trimming, and filing all residents' nails except for the residents with a diagnosis of diabetes. She stated the nurses were responsible for all the residents' nails with a diagnosis of diabetes. CNA E stated the residents nails were usually cleaned on their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill such as vomiting and diarrhea. She stated a resident may cause a skin tear if their fingernails were not smooth. CNA E stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. She stated she had given care to Resident # 20 and Resident #77, and she was not aware of Resident #20 refusing care, however, Resident #77 s ometimes refused showers. CNA E stated she did not know the last time these residents nails were trimmed or cleaned. She stated if any resident refused care it was reported to the nurse and the nurse would document the refusal in the nurses note. She stated she was in-serviced on nail care. CNA E stated she did not recall the date of the nail care in-service. Interview on 03/19/25 at 10:30 AM, RN A stated the nurses, and the CNAs were responsible for nail care. She stated the nurses were responsible to trim and clean all resident's nails with a diagnosis of diabetes. She stated it was the CNAs responsibility to clean and trim all other residents' nails during showers or as needed. She stated if there was a blackish substance underneath the resident's nails, there was a possibility the substance had bacteria. RN A stated if a resident swallowed the bacteria there was a possibility a resident may become ill with stomach problems such as vomiting. RN A stated if a resident refused nail care the nurses would document the refusal in nurses' notes. RN A stated she was in-serviced on nail care; however, she did not recall the date. Interview on 03/19/25 at 09:36 AM, the Director of Nurses stated if a resident ingested the blackish substance on their fingers or underneath their fingernails, there was a possibility the substance may be some type of bacteria, however it would be difficult to determine if the blackish/ brownish substance was bacteria. She stated it was a possibility a resident may become sick if ingested the blackish/ brownish substance. The Director of Nurses did not elaborate of what type of sickness a resident may endure if ingested a blackish/brownish substance. She stated the CNAs were responsible for all residents' nails such as cleaning, trimming, and filing except for the residents with diabetes (a disease that occurs when your blood sugar, is too high). She stated any resident with a diagnosis of diabetes the nurse was responsible for these residents' fingernails. She stated she would need to refer to nurses notes to determine if Resident #20 and Resident #77 refused nail care. The Director of Nurses did not provide this information prior to exit. 2. Record review of Resident # 56 admission face sheet reflected an [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Resident # 56 had diagnosis of diabetes mellitus (a long term condition in which the body has trouble controlling blood sugar levels), hypertension (elevated blood pressure), anxiety disorder, hyperlipidemia (increased fat particles in the blood), hypothyroidism (underactive thyroid), cerebral infarction (stroke), schizoaffective disorder bipolar type (a mental health condition that combines symptoms of schizophrenia and bipolar disorder), major depressive disorder (clinical depression), dementia (a group of conditions that cause a progressive decline in cognitive function), abnormalities of gait and mobility, and muscle weakness. Review of Resident # 56's quarterly MDS dated [DATE] reflected a BIMS score of 5 indicating severe cognition impairment. Further review indicated Resident # 56 required partial to moderate assistance with personal hygiene (combing hair, shaving, applying makeup, washing/drying face, and hands). Review of Resident # 56's care plan dated 4/6/24 reflected an ADL self-care performance deficit related to dementia and schizoaffective disorder. Interventions include bathing Mon, wed, Fri 6-2 pm. Encourage the resident to participate to the fullest extent possible with each interaction. Review of Resident # 56's POC personal hygiene ADL task log revealed limited assistance provided on 3/15/25-3/19/25. Review of Resident # 56's nursing progress notes dated 3/19/25 10:04 AM reflected no documented refusal of ADL care or personal hygiene care. Observation and Interview on 3/17/25 at 1:57 PM revealed Resident # 56 in bed resting. Resident was neatly dressed. Resident was observed with facial hair. Resident stated the food was good, and she likes playing bingo. Resident unable to answer any other questions. Resident was not able to be further interviewed due to cognition status. Observation and Interview on 3/19/25 at 9:29 AM revealed Resident up ambulating around the room going through a box of beads. Resident was dressed in clean clothes with her hair pulled back in a ponytail. Resident was observed still to have facial hair. When asked about the facial hair, the resident stated she lets the nurses shave her face during showers. Interview on 3/19/25 at 9:37 AM CNA J stated Resident # 56 helps with her showers and with toileting as she can. CNA J stated resident will help put water on herself and try to wash her hair and that she washes her peri area. CNA J stated resident gets showers in the evening. CNA J stated that the staff shave the residents face. Interview on 3/19/25 at 9:45 Am with CNA K st ated Resident # 56 helps with her showers and with toileting as much as she can. CNA K stated the resident will wash her own hair and mainly just needs help with her peri area. CNA K stated when she showers resident if resident has facial hair, she will shave her face. CNA K stated resident was always very receptive to care and does not refuse care. Interview on 3/19/25 at 3:31 PM the DON stated it was her expectation that female resident with facial hair were shaved on their scheduled shower day when they receive their showers. Unless the resident has documentation that they prefer to have the facial hair. The DON stated it was the responsibility of the CNA to complete the residents ADLs as scheduled. The DON stated that Resident # 56 refused her shower on Monday 3/17/25 and staff did not document the refusal until 3/19/25. The DON stated staff were supposed to document in the resident chart of the ADL completion or refusal on the day the instance occurred. The DON could not give reason as to why documentation had not occurred on Monday of Resident # 56 refusal. Interview on 3/19/25 at 5:11 PM with the ADM stated he expected that facial hair on women to be shaven when ADL care was performed. The ADM stated if the resident refused or it to keep the hair was a preference then he expected that to be documented. The ADM stated if female residents were not shaved and had facial hair it can negatively affect their mood and make them feel not as feminine. The ADM stated the CNA, charge nurse, and ADON were responsible for ensuring ADL care was being performed. Review of the Facility's Policy on Nail Care, dated 2003, reflected Nail management is the regular care of toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle are and is usually done during the bath. Nails can become thinner and more brittle in the elderly and thicker. Goals: 1. Nail care will be performed regularly and safely. 2. The resident will be free from abnormal nail conditions. 3. The resident will be free from infection. 48917

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 (Resident # 7, Resident #17, Resident #33, Resident #36, Resident #44, and Resident #51) of 9 residents reviewed for infection control. 1. The facility failed to ensure Student Nurse A sanitized or washed her hands prior to touching contaminated surfaces (her shirt, wheelchair arm rest, and clothes of other residents) prior to touching Resident #33, Resident #44, Resident #7, and Resident #36's food. 2. The facility failed to ensure Student Nursing Aide G sanitized or washed his hands prior to touching contaminated surfaces (his shirt, wheelchair arm rest, and clothes of other residents) prior to touching Resident #17's and Resident #51's food. These failures could place residents at risk of transmission of disease and infection. Findings included: Observation on 03/17/25 at 12:07 PM was conducted on 200 Hall during lunch tray pass. Student Nurse Aide A was observed taking a lunch tray from the cart to Resident #33 and did not conduct handwashing/hand hygiene. She then took a lunch tray from the cart to Resident #44 and did not conduct handwashing/hand hygiene. Student Nurse Aide A then returned to the cart and took another lunch tray to Resident # 36 and did not conduct handwashing/hand hygiene between residents. Student Nurse Aide A then returned to the cart and took a lunch tray to Resident #7 and assisted with positioning and setting up the tray. Student Nurse Aide A did not conduct hand washing or hand hygiene when or after leaving Resident #7's room. Interview on 03/17/2025 at 12:27 PM with Student Nurse A revealed she might have forgotten to wash or sanitize her hands when passing out the residents' trays. Student Nurse A stated she had been in-serviced on hand hygiene and infection control since working at the facility. Observation on 03/17/2025 at 12:10 PM thru 12:25 PM Student Nurse Aide G was delivering trays to the residents in the dining room on the secured unit. He touched the right side of his scrub top with his right hand. Student Nurse Aide G continued to deliver meal trays to residents and did not wash or sanitize his hands. He delivered meal tray to Resident #17. Student Nurse Aide G touched the arm of her wheelchair and touched her left side of her blouse. He began to set up her meal tray. He removed the cellophane off the cake and touched the left side of the cake and the left side top of the cake when he removed the cellophane. Student Nurse Aide G delivered Resident #51's meal tray and touched Resident #51's right side of wheelchair arm rest. Student Nurse Aide G removed cellophane off the cake. He touched the top of the cake and the right side of the cake when removed the cellophane. Interview on 03/17/2025 at 12:40 PM Student Nurse G stated he washed hands before he began to pass out the meal trays. He stated he did touch his scrub top; arm rest of wheelchair and he may have touched Resident #17's blouse. Student Nurse G stated he did not wash or sanitize his hands during passing resident's trays and when he touched contaminated items such as his shirt, other resident clothes, or wheelchair arm rest. He stated he did touch Resident #17's and Resident #51's cake when he removed the cellophane. He stated there was a possibility that bacteria from his hand may transfer to Residents cake. Student Nurse G stated there was a potential for the resident become ill from cross contamination such as stomach problems. (he did not elaborate on what type of stomach problems). He stated he was trained in CNA school on infection control and hand hygiene. Student Nurse G stated he also went through orientation and training at this facility on infection control and hand hygiene. He stated when he was hired at the facility he went through training and had been given in-services on hand hygiene and infection control since he was hired. Student Nurse G stated he did not recall the exact date when he was hired. Interview on 03/17/2025 at 12:50 PM LVN B stated all staff was expected to wash and sanitize hands after passing each meal tray. She stated if any staff touched any contaminated item the staff was expected to wash or sanitize hands immediately. LVN B stated if staff does not wash or sanitize their hands and touch residents' food there was a possibility the food may become contaminated with bacteria. She stated there was a possibility a resident may become ill with vomiting or diarrhea if ingested certain types of bacteria. She stated she had been in-service on hand hygiene and infection control but did not recall the date. Interview on 03/18/25 at 10:14 AM with the DON revealed hand washing/hand sanitization between each resident was the best practice, and hand hygiene should be conducted by all staff members, between each resident when passing out resident trays. The DON further stated the risk to the residents was cross-contamination and bacteria getting in their food, which could cause gastrointestinal illness. Interview on 03/19/25 at 03:25 PM with the ADM revealed his expectation was that hand hygiene should be conducted between each resident during meal tray pass. The ADM stated it could negatively affect a resident if hand hygiene was not performed by a diminished quality of life and risk of getting an infection. The ADM stated it was everyone's responsibility to perform correct hand hygiene. Record review of Student Aide G's personnel record on 03/19/2025 at 8:30 AM he was hired on 01/31/2025. He received his certificate of completion the course of study prescribed by the Texas health and Human Service Commission for Nurse Aide Training dated on 01/22/2025. He received orientation, training and completed CNA Proficiency Audit on 01/31/2025. During the training, Student Aide G was trained on infection control awareness such as: 1. Proper handwashing 2. Prevent cross contamination 3. Universal precaution 4. Contact precaution 5. Droplet precaution Record review of the facility's Policy on Hand Hygiene, not dated, reflected staff my use alcohol-based hand cleaner or soap/water for the following: before and after assisting a resident with meals Record review of the facility's policy on Infection Control Plan, dated 03/2022 reflected, The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. To assure that the facility develops, implements, and maintains an Infection Prevention and Control Program in order to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. The program will prevent and control outbreaks and cross-contamination using transmission-based precautions in addition to standard precautions by implementing hand hygiene (handwashing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination.

Based on observation, interview, 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 one (Resident #1) of three residents reviewed for quality of care. The facility failed to: - Ensure Resident #1 was transferred per her transfer status (hoyer lift with two-person assistance) on two occasions on [DATE]. On the first occasion, LVN A and CNA B lost their grip and Resident #1 slid to the ground. LVN A, CNA B, and CNA C transferred her from the ground to the bed without a hoyer lift. Approximately 24 hours later her legs were swollen, red, and warm to touch. She was transferred to the ER where she was diagnosed with two femur fractures. During surgery to repair the fractures, she had an embolism and subsequently passed away. - Ensure LVN A completed a fall assessment or documented the incident after Resident #1 slid to the ground during an inappropriate transfer. The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This deficient practice could place residents at risk for falls, injuries, hospitalization , and death. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of age-related osteoporosis (a condition that weakens the bones and increases the risk for fractures). Review of Resident #1's admission MDS assessment, dated [DATE], reflected a BIMS score of 13, indicating she had no cognitive impairment. Section GG (Functional Abilities and Goals) reflected assistance with sitting to standing and chair/bed-to-chair transfers were not attempted due to medical condition or safety concerns. Review of Resident #1's admission care plan, dated [DATE], reflected she was at risk for falls with an intervention of utilizing a mechanical lift with staff x2 to assist with transfers. It further reflected she had an ADL self-care performance deficit with an intervention of requiring a lift for all transfers. Review of Resident #1's physician progress notes, dated [DATE], reflected the following: . [Resident #1] moves all 4 extremities without issues. She uses her wheelchair to propel around the facility. Review of Resident #1's progress notes, dated [DATE] at 9:15 PM and documented by LVN D, reflected the following: [Resident #1] observed going right back to sleep after waking up. O2 sat 81% on room air. HR 100. Left knee swollen and warm to touch . Review of Resident #1's progress notes, dated [DATE] at 10:42 PM and documented by LVN D, reflected the following: Send [Resident #1] to ER for eval and TX. Review of Resident #1's Transfer Form, dated [DATE], reflected the reasons for transfer to the hospital were AMS and lethargy. Review of Resident #1's hospital documentation, dated [DATE], reflected the following: Admission Diagnosis: Sepsis secondary to UTI Discharge Diagnosis: Suspected fat vs pulmonary embolism, Bilateral distal femoral fractures date of death : [DATE] Time of death: 3:28 PM Hospital course: [Resident #1] was initially treated for sepsis due to presumptive UTI based on urinalysis and CT abdomen report . because [Resident #1] complained of pain on both legs, an x-ray was done which revealed bilateral distal femoral fractures. [Resident #1] unfortunately was unable to provide accurate account of how she sustained these injuries. She said she fell but can't tell how or when. [Resident #1] was taken to the operating room earlier today for IM nailing of bilateral femur fractures. Following the IM nailing of left femur fracture [Resident #1] developed sudden onset of hypotension and briefly lost pulse . Altogether she had close to a dozen of these episodes of slowly worsening hypotension, followed by PEA, re-initiation of CPR resulting in ROSC and hypertension . resuscitative efforts were aborted after close to 3 hours of off and on CPR. During a telephone interview on [DATE] at 12:30 PM, LVN A stated she worked with Resident #1 on [DATE]. She stated around 9:30 PM, Resident #1 was sitting on the edge of the bed with her legs hanging off. She stated she kept saying she wanted to go to the kitchen and was very insistent. She stated she got CNA B and they each grabbed her for either side. She stated they lost grip of her, and she slid to the floor. She stated she did not realize she was a hoyer transfer. She stated she got CNA C to bring in a hoyer lift and they utilized the lift to transfer her. She stated the resident seemed stable and that was why she had not done an incident report. She stated she knew now she should have reported it and completed an incident report. She stated she waited until [DATE] to notify the facility of the incident because after being interviewed by the BON and police department, she realized she needed to give them all the details. During a telephone interview on [DATE] at 11:00 AM, CNA B stated she worked with Resident #1 on [DATE]. She stated it was close to end of her shift (10:00 PM) and she was doing her last rounds. She stated she heard LVN A call for help and found her in Resident #1's room. She stated Resident #1 was sitting at the end of the bed and was wanting to go to the dining room. She stated Resident #1 kept trying to get up. She stated she told LVN A they could not get her up because they did not know her transfer status as she was new to the facility. She stated LVN A stated, Well, let us just get her up. She stated she kept telling her they should not. She stated they ended up getting on either side of her and attempted to lift her, but she was too heavy, and she slid to the floor with LVN A behind her. She stated she went and got CNA C and the three of them transferred Resident #1 from the floor to her bed without a hoyer lift. She stated she was not aware she had been a hoyer transfer. She stated at the time, she did not think it had been considered a fall but had recently learned differently. She stated if she had seen the resident on the floor without a nurse present, she would have gotten a nurse immediately. She stated because LVN A had been there, she thought she was going to report it and document it. During a telephone interview on [DATE] at 10:30 AM, CNA C stated she worked with Resident #1 in July of 2024. She stated in the evening of [DATE] she was called to Resident #1's room by CNA B and saw Resident #1 on the floor with one leg crossed over the other and LVN A sitting behind her. She stated they did not use a hoyer lift to get her off the floor because it was difficult to utilize a hoyer when someone was on the floor. She stated LVN A held one side of her while CNA B held the other side of her, and she lifted her legs. She stated she did not see LVN A assess her after getting her into bed. She stated she did not seem to be in pain at that moment. She stated the next day, [DATE], Resident #1 was a completely different person. She stated she was not responding, was staring at the ceiling, and was grimacing as if she was in a lot of pain. She stated when Resident #1's FM got there later that day ([DATE]) she told her to make sure they sent her to the hospital because she did not look good. She stated she would have expected the nurse to treat the incident as a fall because she was on the floor. She stated the nurse she should have assessed her and documented the incident. During an interview on [DATE] at 11:23 AM, the NP stated he had not been working at the facility in July (2024) and did not know Resident #1. He stated if a resident slid to the floor, it would be considered a fall and he would expect a nurse to do a full assessment (including ROM), notify the NP/MD to let them know what was going on, and conduct neurological checks to ensure there was no change in condition. He stated if a resident was on the ground and required a hoyer transfer, it may be okay to utilize staff (if there were enough) because some hoyer lifts did not go all the way to the ground. He stated a possible injury that could occur if a resident slid to the ground could be an internal hematoma and they could for sure break their femur in that situation. He stated the elderly were very fragile and it was important to assess, follow-up, watch for changes in condition or pain. He stated that was why the on-coming nurse should be notified of any incidents and it must be documented. He stated documentation was extremely important because if you did not document it, whatever was going on with a resident could be missed. He stated an embolism could result from a femur fracture as it was a big bone. He stated it could happen within 24 hours or a few weeks. During an interview on [DATE] at 11:47 AM, the SC stated she was not notified of any fall in July of 2024 for Resident #1. She stated she believed it happened on the weekend and she did not work weekends. She stated if she had been notified about it, she would have notified the DON/ADON. She stated she was not told about the incident until that month ([DATE]) when a nurse (LVN A) was fired because of it. She stated a resident sliding to the ground would be considered a fall. She stated after LVN A was fired, all nursing staff were in-serviced on falls and the importance of documentation. During an interview on [DATE] at 12:55 PM, the ADON stated she was the one who conducted the in-services to all nursing staff after they were made aware of the incident that happened with Resident #1 (on [DATE]) on [DATE]. She stated in-services were conducted on abuse and neglect, fall prevention, a fall is a fall - whether a resident slid to the floor, incident reports, and documentation. She stated she also in-serviced on saying what you see and to never be a false witness for an incident. She stated all nursing staff should know a resident's transfer status before transferring a resident. She stated the aides were able to see transfer statuses in the POC and nurses could see transfer statuses in the residents' care plan. She stated documentation was very important; if you did not document, it did not happen. She stated nurses should document anything going on with a resident including incidents or a change in condition. During an interview on [DATE] at 2:54 PM, the DON stated her expectations on resident transfers were that they were safe, utilized the amount of assistance the resident needed, utilized gait belts, and hoyer transfers were with two staff members. She stated aides could find a residents' transfer status in their POC system and the nurses found the status in the residents' care plans. She stated not following a resident's transfer status could result in injury. She stated if a resident slid to the floor during a transfer, which would be considered a fall. She stated her expectations after a resident fall were that the nurse completed an assessment, vitals, notify the NP, document, and complete and incident report. She stated documentation was important to ensure everyone was on the same page. She stated LVN A and all staff they interviewed after Resident #1 sustained the fractures denied ever seeing her on the floor or providing an inappropriate transfer. She stated they were not aware of the incident until LVN A came and reported it to them on [DATE]. She stated LVN A, CNA B, and CNA C were all terminated at that time. Review of the facility's undated Hydraulic Lift Policy reflected the following: The hydraulic lift is a mechanical device used to transfer a resident from and to the bed and chair. It is reserved for those who are paralyzed, obese, or too weak to transfer without complete assistance. Review of the facility's Preventative Strategies to Reduce Fall Risk Policy, revised [DATE], reflected the following: . 5. Incident Reporting: Reported falls will be thoroughly investigated to assess fall risk factors and contributing factors in order to provide a safe environment for the resident(s). Review of the facility's Documentation Policy, dated 2003, reflected the following: Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. It has legal requirements regarding accuracy and completeness, legibility and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medication sheets, incident reports and summary sheets (daily, weekly, monthly, discharge). . 8. Documentation during and following an acute episode, following an event, and during physiologic, mental, or emotional changes or instability. Review of the facility's Abuse and Neglect Policy, revised [DATE], reflected the following: Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The ADM and DON were notified on [DATE] at 3:15 PM that a past non-compliance IJ situation had been identified due to the above failures. It was determined these failures placed Residents #1 in an IJ situation on [DATE]. The facility implemented the following interventions: During an interview on [DATE] at 11:38 AM, CNA H stated she had been recently in-serviced on transfer statuses, falls, and reporting what you saw. She stated she could find a residents' transfer status in the POC. She stated a hoyer lift transfer required two people and you should never transfer a resident before checking their transfer status. She stated anytime a resident was on the ground, it would be considered a fall. She stated she would get a nurse immediately and would not move the resident herself. During an interview on [DATE] at 12:59 PM, LVN I stated she had recently been in-serviced on abuse and neglect, transfers, reporting, documentation, and classification of falls. She stated any change of plane such as sliding to the floor was considered a fall. She stated if a resident was found on the floor, she would assess for injuries, attempt ROM, complete an assessment, and document in the progress notes. She stated documentation was important so everyone knew what was going on with the resident and could watch for adverse effects. She stated she would notify the NP and DON immediately. Observation on [DATE] at 1:10 PM revealed the ADON demonstrating how the hoyer lift could descend low enough to lift a resident off the ground. During an interview on [DATE] at 1:33 PM, MA E stated when she worked with Resident #1 in July (2024) she never complained of pain. She stated she was recently in-serviced on falls, transfers, using gait belts, documentation, and hoyer transfers. She stated she would look in the POC to see a resident's transfer status. She stated if a resident slid to the ground during a transfer, it would be considered a fall. She stated if she found a resident on the ground, she would stay with the resident and call for help. She stated she would not move the resident or sit them up and would keep them calm until a nurse got there to assess them. She stated the Abuse and Neglect Coordinator was their Administrator and different types of abuse included financial, verbal, emotional, and physical. During an interview on [DATE] at 1:45 PM, LVN G stated their Abuse and Neglect Coordinator was their Administrator and different types of abuse included physical, verbal, and emotional. She stated she was recently in-serviced on changes in position (resident going from a higher to a lower level) and that it would be considered a fall. She stated when there was a fall she would assess the resident, take vitals, ask questions, and observe for blood or injury. She stated if there were visible injuries, she would send them out to be evaluated. She stated she would also complete an incident report, fall assessment, skin assessment, and document in the progress notes. She stated she would notify the NP and DON immediately. She stated when a resident was admitted they were evaluated by therapy for their transfer status, or their family would let them know. She stated she would find a resident's transfer status in their EMR. She stated she was also in-serviced on being truthful and documenting what she saw. She stated if a resident falls, she would call it a fall, and follow through with what she needed to do next. During an interview on [DATE] at 1:57 PM, CNA G stated the Administrator was the Abuse and Neglect Coordinator and types of abuse included verbal, physical, and mental. He stated he would never transfer a resident without knowing their transfer status which could be located in their POC. He stated if a resident was on the ground for whatever reason, it was considered a fall. He stated he would not move the resident until a nurse assessed them because something could be broken, and they needed to be assessed. He stated he was also in-serviced on being truthful about what you saw/heard regarding residents. He stated there always needed to be two people when providing a hoyer transfer. Review of Employee Disciplinary Reports for LVN A, CNA B, and CNA C, dated [DATE], reflected they had been terminated. Review of an in-service entitled Falls and Fall Documentation, dated [DATE], reflected all nursing staff were in-serviced on the following: MD/NP, DON/ADON and/or Nurse Manager MUST be notified. ANY change of plane is a fall. Fall meaning: A fall is an unintentional change in position from a higher to a lower level, such as a resident falling out of bed or from a chair. Skin observation and ROM assessment must be completed and all should be documented accordingly. Immediate actions after a fall: check for injuries, call for help, support and comfort resident, post-fall assessment and interventions, document the fall, review fall risk factors, implement fall prevention strategies. Review of an in-service, dated [DATE], reflected all nursing staff were in-serviced on locating transfer statuses for residents. Review of an in-service entitled Hoyer Transfer, dated [DATE], reflected all nursing staff were in-serviced on their Total Mechanical Lift Competency Checklist. Review of an in-service, dated [DATE], reflected all nursing staff were in-serviced on their Abuse and Neglect Policy. The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review, the facility failed to ensure the 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 residents reviewed for accidents and hazards. The facility failed to: - Ensure Resident #1 was transferred per her transfer status (hoyer lift with two-person assistance) on two occasions on [DATE]. On the first occasion, LVN A and CNA B lost their grip and Resident #1 slid to the ground. LVN A, CNA B, and CNA C transferred her from the ground to the bed without a hoyer lift. Approximately 24 hours later her legs were swollen, red, and warm to touch. She was transferred to the ER where she was diagnosed with two femur fractures. During surgery to repair the fractures, she had an embolism and subsequently passed away. - Ensure LVN A completed a fall assessment or documented the incident after Resident #1 slid to the ground during an inappropriate transfer. The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This deficient practice could place residents at risk for falls, injuries, hospitalization , and death. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of age-related osteoporosis (a condition that weakens the bones and increases the risk for fractures). Review of Resident #1's admission MDS assessment, dated [DATE], reflected a BIMS score of 13, indicating she had no cognitive impairment. Section GG (Functional Abilities and Goals) reflected assistance with sitting to standing and chair/bed-to-chair transfers were not attempted due to medical condition or safety concerns. Review of Resident #1's admission care plan, dated [DATE], reflected she was at risk for falls with an intervention of utilizing a mechanical lift with staff x2 to assist with transfers. It further reflected she had an ADL self-care performance deficit with an intervention of requiring a lift for all transfers. Review of Resident #1's physician progress notes, dated [DATE], reflected the following: . [Resident #1] moves all 4 extremities without issues. She uses her wheelchair to propel around the facility. Review of Resident #1's progress notes, dated [DATE] at 9:15 PM and documented by LVN D, reflected the following: [Resident #1] observed going right back to sleep after waking up. O2 sat 81% on room air. HR 100. Left knee swollen and warm to touch . Review of Resident #1's progress notes, dated [DATE] at 10:42 PM and documented by LVN D, reflected the following: Send [Resident #1] to ER for eval and TX. Review of Resident #1's Transfer Form, dated [DATE], reflected the reasons for transfer to the hospital were AMS and lethargy. Review of Resident #1's hospital documentation, dated [DATE], reflected the following: Admission Diagnosis: Sepsis secondary to UTI Discharge Diagnosis: Suspected fat vs pulmonary embolism, Bilateral distal femoral fractures date of death : [DATE] Time of death: 3:28 PM Hospital course: [Resident #1] was initially treated for sepsis due to presumptive UTI based on urinalysis and CT abdomen report . because [Resident #1] complained of pain on both legs, an x-ray was done which revealed bilateral distal femoral fractures. [Resident #1] unfortunately was unable to provide accurate account of how she sustained these injuries. She said she fell but can't tell how or when. [Resident #1] was taken to the operating room earlier today for IM nailing of bilateral femur fractures. Following the IM nailing of left femur fracture [Resident #1] developed sudden onset of hypotension and briefly lost pulse . Altogether she had close to a dozen of these episodes of slowly worsening hypotension, followed by PEA, re-initiation of CPR resulting in ROSC and hypertension . resuscitative efforts were aborted after close to 3 hours of off and on CPR. During a telephone interview on [DATE] at 12:30 PM, LVN A stated she worked with Resident #1 on [DATE]. She stated around 9:30 PM, Resident #1 was sitting on the edge of the bed with her legs hanging off. She stated she kept saying she wanted to go to the kitchen and was very insistent. She stated she got CNA B and they each grabbed her for either side. She stated they lost grip of her, and she slid to the floor. She stated she did not realize she was a hoyer transfer. She stated she got CNA C to bring in a hoyer lift and they utilized the lift to transfer her. She stated the resident seemed stable and that was why she had not done an incident report. She stated she knew now she should have reported it and completed an incident report. She stated she waited until [DATE] to notify the facility of the incident because after being interviewed by the BON and police department, she realized she needed to give them all the details. During a telephone interview on [DATE] at 11:00 AM, CNA B stated she worked with Resident #1 on [DATE]. She stated it was close to end of her shift (10:00 PM) and she was doing her last rounds. She stated she heard LVN A call for help and found her in Resident #1's room. She stated Resident #1 was sitting at the end of the bed and was wanting to go to the dining room. She stated Resident #1 kept trying to get up. She stated she told LVN A they could not get her up because they did not know her transfer status as she was new to the facility. She stated LVN A stated, Well, let us just get her up. She stated she kept telling her they should not. She stated they ended up getting on either side of her and attempted to lift her, but she was too heavy, and she slid to the floor with LVN A behind her. She stated she went and got CNA C and the three of them transferred Resident #1 from the floor to her bed without a hoyer lift. She stated she was not aware she had been a hoyer transfer. She stated at the time, she did not think it had been considered a fall but had recently learned differently. She stated if she had seen the resident on the floor without a nurse present, she would have gotten a nurse immediately. She stated because LVN A had been there, she thought she was going to report it and document it. During a telephone interview on [DATE] at 10:30 AM, CNA C stated she worked with Resident #1 in July of 2024. She stated in the evening of [DATE] she was called to Resident #1's room by CNA B and saw Resident #1 on the floor with one leg crossed over the other and LVN A sitting behind her. She stated they did not use a hoyer lift to get her off the floor because it was difficult to utilize a hoyer when someone was on the floor. She stated LVN A held one side of her while CNA B held the other side of her, and she lifted her legs. She stated she did not see LVN A assess her after getting her into bed. She stated she did not seem to be in pain at that moment. She stated the next day, [DATE], Resident #1 was a completely different person. She stated she was not responding, was staring at the ceiling, and was grimacing as if she was in a lot of pain. She stated when Resident #1's FM got there later that day ([DATE]) she told her to make sure they sent her to the hospital because she did not look good. She stated she would have expected the nurse to treat the incident as a fall because she was on the floor. She stated the nurse she should have assessed her and documented the incident. During an interview on [DATE] at 11:23 AM, the NP stated he had not been working at the facility in July (2024) and did not know Resident #1. He stated if a resident slid to the floor, it would be considered a fall and he would expect a nurse to do a full assessment (including ROM), notify the NP/MD to let them know what was going on, and conduct neurological checks to ensure there was no change in condition. He stated if a resident was on the ground and required a hoyer transfer, it may be okay to utilize staff (if there were enough) because some hoyer lifts did not go all the way to the ground. He stated a possible injury that could occur if a resident slid to the ground could be an internal hematoma and they could for sure break their femur in that situation. He stated the elderly were very fragile and it was important to assess, follow-up, watch for changes in condition or pain. He stated that was why the on-coming nurse should be notified of any incidents and it must be documented. He stated documentation was extremely important because if you did not document it, whatever was going on with a resident could be missed. He stated an embolism could result from a femur fracture as it was a big bone. He stated it could happen within 24 hours or a few weeks. During an interview on [DATE] at 11:47 AM, the SC stated she was not notified of any fall in July of 2024 for Resident #1. She stated she believed it happened on the weekend and she did not work weekends. She stated if she had been notified about it, she would have notified the DON/ADON. She stated she was not told about the incident until that month ([DATE]) when a nurse (LVN A) was fired because of it. She stated a resident sliding to the ground would be considered a fall. She stated after LVN A was fired, all nursing staff were in-serviced on falls and the importance of documentation. During an interview on [DATE] at 12:55 PM, the ADON stated she was the one who conducted the in-services to all nursing staff after they were made aware of the incident that happened with Resident #1 (on [DATE]) on [DATE]. She stated in-services were conducted on abuse and neglect, fall prevention, a fall is a fall - whether a resident slid to the floor, incident reports, and documentation. She stated she also in-serviced on saying what you see and to never be a false witness for an incident. She stated all nursing staff should know a resident's transfer status before transferring a resident. She stated the aides were able to see transfer statuses in the POC and nurses could see transfer statuses in the residents' care plan. She stated documentation was very important; if you did not document, it did not happen. She stated nurses should document anything going on with a resident including incidents or a change in condition. During an interview on [DATE] at 2:54 PM, the DON stated her expectations on resident transfers were that they were safe, utilized the amount of assistance the resident needed, utilized gait belts, and hoyer transfers were with two staff members. She stated aides could find a residents' transfer status in their POC system and the nurses found the status in the residents' care plans. She stated not following a resident's transfer status could result in injury. She stated if a resident slid to the floor during a transfer, which would be considered a fall. She stated her expectations after a resident fall were that the nurse completed an assessment, vitals, notify the NP, document, and complete and incident report. She stated documentation was important to ensure everyone was on the same page. She stated LVN A and all staff they interviewed after Resident #1 sustained the fractures denied ever seeing her on the floor or providing an inappropriate transfer. She stated they were not aware of the incident until LVN A came and reported it to them on [DATE]. She stated LVN A, CNA B, and CNA C were all terminated at that time. Review of the facility's undated Hydraulic Lift Policy reflected the following: The hydraulic lift is a mechanical device used to transfer a resident from and to the bed and chair. It is reserved for those who are paralyzed, obese, or too weak to transfer without complete assistance. Review of the facility's Preventative Strategies to Reduce Fall Risk Policy, revised [DATE], reflected the following: . 5. Incident Reporting: Reported falls will be thoroughly investigated to assess fall risk factors and contributing factors in order to provide a safe environment for the resident(s). Review of the facility's Documentation Policy, dated 2003, reflected the following: Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. It has legal requirements regarding accuracy and completeness, legibility and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medication sheets, incident reports and summary sheets (daily, weekly, monthly, discharge). . 8. Documentation during and following an acute episode, following an event, and during physiologic, mental, or emotional changes or instability. Review of the facility's Abuse and Neglect Policy, revised [DATE], reflected the following: Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The ADM and DON were notified on [DATE] at 3:15 PM that a past non-compliance IJ situation had been identified due to the above failures. It was determined these failures placed Residents #1 in an IJ situation on [DATE]. The facility implemented the following interventions: During an interview on [DATE] at 11:38 AM, CNA H stated she had been recently in-serviced on transfer statuses, falls, and reporting what you saw. She stated she could find a residents' transfer status in the POC. She stated a hoyer lift transfer required two people and you should never transfer a resident before checking their transfer status. She stated anytime a resident was on the ground, it would be considered a fall. She stated she would get a nurse immediately and would not move the resident herself. During an interview on [DATE] at 12:59 PM, LVN I stated she had recently been in-serviced on abuse and neglect, transfers, reporting, documentation, and classification of falls. She stated any change of plane such as sliding to the floor was considered a fall. She stated if a resident was found on the floor, she would assess for injuries, attempt ROM, complete an assessment, and document in the progress notes. She stated documentation was important so everyone knew what was going on with the resident and could watch for adverse effects. She stated she would notify the NP and DON immediately. Observation on [DATE] at 1:10 PM revealed the ADON demonstrating how the hoyer lift could descend low enough to lift a resident off the ground. During an interview on [DATE] at 1:33 PM, MA E stated when she worked with Resident #1 in July (2024) she never complained of pain. She stated she was recently in-serviced on falls, transfers, using gait belts, documentation, and hoyer transfers. She stated she would look in the POC to see a resident's transfer status. She stated if a resident slid to the ground during a transfer, it would be considered a fall. She stated if she found a resident on the ground, she would stay with the resident and call for help. She stated she would not move the resident or sit them up and would keep them calm until a nurse got there to assess them. She stated the Abuse and Neglect Coordinator was their Administrator and different types of abuse included financial, verbal, emotional, and physical. During an interview on [DATE] at 1:45 PM, LVN G stated their Abuse and Neglect Coordinator was their Administrator and different types of abuse included physical, verbal, and emotional. She stated she was recently in-serviced on changes in position (resident going from a higher to a lower level) and that it would be considered a fall. She stated when there was a fall she would assess the resident, take vitals, ask questions, and observe for blood or injury. She stated if there were visible injuries, she would send them out to be evaluated. She stated she would also complete an incident report, fall assessment, skin assessment, and document in the progress notes. She stated she would notify the NP and DON immediately. She stated when a resident was admitted they were evaluated by therapy for their transfer status, or their family would let them know. She stated she would find a resident's transfer status in their EMR. She stated she was also in-serviced on being truthful and documenting what she saw. She stated if a resident falls, she would call it a fall, and follow through with what she needed to do next. During an interview on [DATE] at 1:57 PM, CNA G stated the Administrator was the Abuse and Neglect Coordinator and types of abuse included verbal, physical, and mental. He stated he would never transfer a resident without knowing their transfer status which could be located in their POC. He stated if a resident was on the ground for whatever reason, it was considered a fall. He stated he would not move the resident until a nurse assessed them because something could be broken, and they needed to be assessed. He stated he was also in-serviced on being truthful about what you saw/heard regarding residents. He stated there always needed to be two people when providing a hoyer transfer. Review of Employee Disciplinary Reports for LVN A, CNA B, and CNA C, dated [DATE], reflected they had been terminated. Review of an in-service entitled Falls and Fall Documentation, dated [DATE], reflected all nursing staff were in-serviced on the following: MD/NP, DON/ADON and/or Nurse Manager MUST be notified. ANY change of plane is a fall. Fall meaning: A fall is an unintentional change in position from a higher to a lower level, such as a resident falling out of bed or from a chair. Skin observation and ROM assessment must be completed and all should be documented accordingly. Immediate actions after a fall: check for injuries, call for help, support and comfort resident, post-fall assessment and interventions, document the fall, review fall risk factors, implement fall prevention strategies. Review of an in-service, dated [DATE], reflected all nursing staff were in-serviced on locating transfer statuses for residents. Review of an in-service entitled Hoyer Transfer, dated [DATE], reflected all nursing staff were in-serviced on their Total Mechanical Lift Competency Checklist. Review of an in-service, dated [DATE], reflected all nursing staff were in-serviced on their Abuse and Neglect Policy. The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, 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 one (Resident #1) of five residents reviewed for quality of care, in that: The facility failed to ensure Resident #1's Eliquis (blood thinner) was held two days before a tooth extraction procedure, subsequently causing him to go without the procedure, leaving him in pain, and feeling frustrated and neglected. This failure placed residents at risk of frustration, uncontrolled pain, 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 with diagnoses including spastic quadriplegic cerebral palsy (a form of cerebral palsy that affects both arms and legs), epilepsy (seizures), bipolar disorder, major depressive disorder, and muscle wasting and atrophy (wasting away). Review of Resident #1's quarterly MDS assessment, dated 03/01/24, reflected a BIMS of 15, indicating he was cognitively intact. Section L (Oral/Dental Status) reflected he had no issues. Review of Resident #1's quarterly care plan, revised 02/15/24, reflected he had a potential for uncontrolled pain with an intervention of monitoring/recording/reporting to nurse when he complained of pain or requested pain treatment. Review of Resident #1's physician order, dated 12/28/23, reflected Eliquis Oral Tablet - 5 MG - Give 1 tablet by mouth twice a day. Review of Resident #1's dental records, dated 05/17/24, reflected the following: Treatment Notes: Comprehensive review of medical hx completed . Discomfort noted by [Resident #1] . Recommend extracting remaining maxillary detention NV. [Resident #1] is on blood thinner, PCP stated it should be held before any extractions. It further reflected he was put on Clindamycin (antibiotic) 150 mg - 3 times daily for 5 days for chronic abscess. Review of Resident #1's progress notes, dated 05/17/24 and documented by LVN A, reflected the following: [Resident #1] requested to be seen by dentist. [Resident #1] was notified that he is on anticoagulant and a tooth extraction will not be completed if needed after assessment. Another appointment can be scheduled for 5/28/24 and [Resident #1]'s anticoagulant medication (Eliquis) will be on hold 2 days or more prior to the extraction per NP recommendation . Review of Resident #1's dental records, dated 05/28/24, reflected the following: .Extraction was recommended by previous dental provider. [Resident #1]'s Eliquis was not held prior to today's visit . The PCP was contacted by the ADON to obtain approval to proceed with extraction. However, the PCP did not approve for the extraction procedure to proceed without Eliquis being held . It is recommended for Eliquis to be held 48 hours prior to extraction procedure. Review of Resident #1's progress notes, dated 05/28/24 and documented by the DON, reflected the following: [Resident #1] was scheduled for dental procedure today and extraction was unable to be performed due to [Resident #1]'s Eliquis that was not held . Review of Resident #1's physician order, dated 05/28/24, reflected Eliquis needed to be stopped two days prior to dental extraction and two days after dental extraction. During an observation and interview on 05/29/24 at 10:14 AM revealed Resident #1 in his room watching television. He stated he was supposed to have been taken off his blood thinner to receive dental work due to the pain in his tooth. He stated he told the SW a few weeks ago he wanted to be seen by the dentist because of his tooth pain. He stated he saw the dentist and he was told he had an infection in his tooth and they would return to remove the tooth and he was put on antibiotics. He stated the facility knew the dentist would be back the day prior (05/28/24). He stated when he spoke to the DON yesterday and told her he was unable to have his tooth removed due to his Eliquis not being held, she replied, Oh well. He stated he told the DON, You do not understand the amount of pain I am in! He stated he was able to eat but could only chew on one side of this mouth. He stated his regular pain medications managed his everyday pain but he felt like the pain in his tooth was now radiating. He stated he was extremely frustrated with the facility and felt it was a disservice and he was being neglected. During a telephone interview on 05/29/24 at 10:34 AM, Resident #1's NP stated it was brought to her attention (she could not remember who brought it to her attention) that Resident #1 would be needing a tooth extraction. She stated the nurse who informed her was not sure of the exact date and she told the nurse to let her know because his Eliquis would need to be held two days prior and two days after the extraction. She stated she never heard anything after that. She stated she felt like it was a break-down in communication because it could have gone in as a general order without any specific dates. She stated, to her, she would have thought, Hey, that was important - I need to get that in immediately! She stated she 100% thought the ball was dropped and would speak to the DON to ensure something like that did not happen again. She stated no resident should have to live with tooth pain as it could be unbearable. She stated she was glad the facility staff caught the fact that his Eliquis had not been held prior to yesterday (05/28/24) because it could have been bad if Resident #1 had the procedure without it being held because he was on such a high dose. During a telephone interview on 05/29/24 at 11:13 AM, the DSA with the dental company utilized by the facility stated Resident #1 was seen on 05/17/24. She stated he was not initially scheduled to be seen but was added by the facility SW that same day. The dentist that saw him recommended extractions for the next visit and the facility's PCP stated his blood thinner would need to be held prior to the extractions. She stated she reached out to the facility a month prior to the visits and sends out a preliminary list. She stated she sends out a final list of residents that will be seen by the dentist about a week prior to the appointment. She stated she called the SW at the facility on 04/02/24 and confirmed via mail regarding the visit on 05/28/24. She stated the final list of residents to be seen on 05/28/24 was sent out on 05/21/28 and Resident #1 was included in the list. During a telephone interview on 05/29/24 at 11:21 AM, the SW stated sometime back in May (2024) Resident #1 was in her office filing a grievance (unrelated to tooth pain) when another resident came in and asked about dental services and Resident #1 requested to be seen as well at that time. She stated when any resident had an upcoming appointment, she put it in as an announcement in their EMR system. She stated that was where nurses would see that there was an upcoming appointment and would ensure the resident was ready for it. She stated that after residents are seen by the dentist, she forwarded the progress notes to the DON. She stated she could not recall when the dental company gave her the final list for the visit on 05/28/24 but knew it would have been well over 48 hours in advance. She stated she heard Resident #1 was not able to get his tooth extracted on 05/28/24. She stated she used to work in dentistry and knew that dental pain could be extremely uncomfortable. She stated she knew the DON offered for Resident #1 to go to the ER because he told her how much pain he was in, but that he had declined. During an interview on 05/29/24 at 11:37 AM, RN C stated she had worked the previous day (05/28/24) with Resident #1. She stated that whoever made the appointments would tell the nurses verbally or would give them paperwork and the nurse would schedule transportation if needed. She stated if it was an in-house appointment such as podiatry or dental, the SW would notify the nurse in the morning meeting. She stated if there was a medication that needed to be held prior to a visit, then the NP was notified. She stated she was not aware of a planned extraction for Resident #1 and she had not received any information about the dentist appointment. During an interview on 05/29/24 at 12:24 PM, the DON stated any nurse could enter orders if they came from the NP. She stated nurses are notified of upcoming appointments on their EMR system. She stated Resident #1 went to the SW earlier in May (2024) about something unrelated to dental services. She stated another resident inquired about the dentist and Resident #1 requested to be on the list. She stated he did not say why and did not mention any pain. She stated on 05/17/24 they did an exam and put him on antibiotics. She stated the dentist would be returning on 05/28/24. She stated there was a recommendation from the dentist to hold his Eliquis, but that was not an order, just a recommendation. She stated the NP was notified and she wrote the order, but it somehow never got put into the system. She stated it was a standing recommendation that never became an order. She stated Resident #1 was unable to get his tooth extracted the day prior (05/28/24) because the NP did not want him to unless his blood thinner had been held since he was on such a high dose and took it twice a day. She stated he was not in pain and did offer for him to go to the ER but he declined. She stated she was not sure if the ER provided services such as teeth extractions. She reiterated that holding the Eliquis was just a recommendation and it was left for the judgement of the physician. Review of the facility's Appointments Policy, dated 2023, reflected the following: . 3. Prior to the appointment staff will assist the resident as needed to prepare for the appointment. Review of the facility's Dental Services Policy, dated 2023, reflected the following: Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. 1. Oral health services are available to meet the resident's needs.

Based on observation, interview and record review the facility failed to receives adequate supervision to prevent accidents for 2 of 8 residents (Residents #1 and 2) reviewed for falls. The facility failed to ensure Residents #1 and #2's care plan interventions related to falls and a fall risk assessment tool were implemented. Resident #1 fell on [DATE] and sustained a hip fracture requiring surgical intervention. This failure placed residents at risk of falls. Findings include: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses including vascular dementia, muscle weakness, unsteadiness on feet, lack of coordination, abnormalities of gait and mobility, muscle wasting and atrophy (complete wasting away of part of the body), and need for assistance with personal care. Review of Resident #1's quarterly MDS assessment, dated 03/08/24, reflected a BIMS score of 05, indicating a severe cognitive impairment. It reflected she required substantial/maximal assistance with transfers and used a wheelchair. The section on falls reflected she had no falls since the prior assessment. Review of the care plan for Resident #1, dated 11/06/23, reflected the following: [Resident #1] has multiple risk factors for falls such as but not limited to: Dementia, history of falls, New environment, Unsteady gait and hypoglycemia (low blood sugar). HX of Fall in facility. [Resident #1] will be free from falls through next review. The following interventions were listed: Assess and assist resident to bathroom as indicated. Complete fall risk assessment upon admission, and PRN. Encourage resident to have wheelchair by bed side. Encourage/assist resident to utilize footwear with non-skid soles. Ensure pathways are clutter free. Fall interventions such as call light in reach, encourage me to call for assistance. Fall mat placed at bedside. Keep resident closer to the nursing station. Medication review for high-risk meds and psychological referral. Monitor vital signs/neuro checks as indicated. Notify physician and responsible party if a fall occurs. Place bed in lowest position. Place personal belongings within reach. Provide adequate lighting. PT/OT eval and treat if indicated. Staff to have resident redirected to more supervised area when up in chair. Review of Fall Risk Assessments for Resident #1 reflected one was conducted on 11/06/24 and 03/29/24 with none completed in between. Both assessments noted Resident #1 had a high risk of falls. Review of incidents for Resident #1 reflected falls on 11/06/24 and 03/29/24. Review of the incident for Resident #1's fall on 03/29/24 reflected she fell after attempting to transfer herself from her chair to her bed without calling for assistance and sustained a femoral (hip) fracture. No falls after her re-admission on 04/03/24 were reflected. Review of nursing progress notes for Resident #1 reflected the following, documented by LVN D: 03/29/24 04:20 PM [Resident #1] was transferred to a Hospital on 03/29/2024 4:20 PM related to Falls send for Head Ct-scan. 03/29/24 04:53 PM CNA was passing and saw resident on the floor and resident fell out her wheelchair. CNA called the nurse and another CNA. Nurse went to see resident and saw resident on floor. Resident was asked did she hit her head and she stated yes. Resident hit her head and bruise was on the forehead. vitals signs done: B.P:128/60, Pulse:68, Resp:18, Tempr:97.4, Oxygen:97% RA. On call NP notified. DON/ADON aware. Resident RP self. 03/29/24 05:00 PM After CNA told resident was on floor and nurse went to room; assessed resident. resident was on floor with her stomach facing down near to bed and asked resident how she fell and resident was not able to answer how she fell ed. Resident state 'I don't know how I fell .' Review of hospital records for Resident #1 reflected the following dated 03/29/24 06:44 PM Left nondisplaced femoral subcapital fracture (fracture of the neck of the thigh bone). Pt. is 81y f presenting to the hospital after an unwitnessed fall at her nursing home. Pt is now s/p L femur perc pinning (surgical procedure in which steel pins are entered through the skin to set a bone. Review of nursing progress notes for Resident #1 reflected the following, documented by LVN D: 04/03/24 03:40 PM Resident readmitting to facility. She remains assigned room [ROOM NUMBER]A. Call to notify family of her arrival with no answer to phone. Unable to get weight noting fractures. Will continue to monitor. Review of the significant change MDS assessment for Resident #1, dated 04/15/24, reflected she was completely dependent with transfers and used a wheelchair. Review of an ad hoc QAPI meeting sign-in sheet dated 04/02/24 reflected the QAPI committee was present, and the unwitnessed fall with injury sustained by Resident #1 was the topic of the meeting. Review of a QAPI tool titled, Fall Unwitnessed/Unexplained by Resident with Injury Monitoring reflected the following quality monitoring tools were documented as completed by the DON from 04/02/24 through 04/18/24 with no findings of non-compliance with facility protocol and no additional findings: -10 nursing staff members per week how to locate fall prevention interventions. Document dates/times, the staff members name, if they responded correctly, and any corrective action if needed. -During incident/event review in stand-up, the Don and Admin will monitor for falls and will investigate each fall to ensure that interventions at the time of the fall were in place and determine if additional interventions are required. Care plan and initiate any intervention changes at that time. -The DON and/or ADON will review at least three times per week to ensure all fall interventions are in place. -At least five times per week the Don/designee will monitor any resident unwitnessed falls or hit their head during the fall to ensure neuros are complete and physician was notified of new negative changes in neuro status. -At least five times per week the DON/designee will interview any resident that has fallen in the last seven days to determine if they have unaddressed pain or uncontrolled pain. Enter yes or no for unaddressed/uncontrolled pain in the column. During an interview on 04/03/24 at 02:57 PM, CNA E stated she was the aide who discovered Resident #1 had fallen on 03/29/24. CNA E stated she had helped Resident #1 go to the toilet at about 03:50 PM and had helped her back into her wheelchair. CNA E stated she had offered to help Resident #1 get into bed and lay down, but Resident #1 wanted to stay in her wheelchair in her room. CNA E stated Resident #1 spent a lot of time in the area by the nurse's station because she got sad and liked to see the people, but she was not sad the day she fell . CNA E stated she gave Resident #1 the call button and reminded her to use, locked her wheelchair brakes, and continued rounds. CNA E stated Resident #1 did not really self-ambulate in her wheelchair. CNA E stated she heard Resident #1's roommate yelling half an hour, so CNA E ran to the room, and Resident #1 was laying on the floor face down in front of her wheelchair. CNA E stated she went to get the nurse at that time, and the nurse took over. CNA E stated she had been in-serviced on fall prevention after the incident occurred. During an interview on 04/03/24 at 03:05 PM, RN F stated she did the assessment after Resident #1 fell on [DATE], because it was a Friday afternoon, and she was the RN in the building. RN F stated Resident #1 said she hit her head and had a bump on her head, so they sent her out to the hospital. RN F stated they really had not had to worry about Resident #1 being impulsive lately and it was a surprise she stood up that day. RN F stated the interventions for Resident #1 were the usual interventions to prevent falls: therapy, low bed, fall mat, call light, non-slip footwear. RN F stated these interventions were all in place at the time of Resident #1's fall on 03/29/24. Observation on 04/03/24 at 04:25 PM revealed Resident #1 returned to the facility on a stretcher carried by EMS personnel. She had some facial bruising visible. She was greeted by several staff members and chatted with them as she was waiting for her bed to be ready to transfer into. She said hello and smiled but did not participate in an interview. Observation on 04/18/24 at 10:30 AM revealed Resident #1 asleep in her bed, one side of which was up against the wall and was set in the lowest position with a fall mat next to the other side. Her bedside table was next to her with a pitcher of fresh ice water and a television remote. The call button was clipped to her pillowcase and rested under her hands folded across her upper abdomen. Her room was tidy, well-lit, and her wheelchair was next to her bed with locked brakes. Observation on 04/18/24 at 11:37 AM revealed Resident #2 in the therapy gym at the facility with PT A. She was wearing purple non-skid socks, and PT A assisted her with standing. She had great difficulty and was completely dependent on PT A for assistance. She bore very little weight when she stood, which was only for two seconds. After she sat back down she said That was very hard, but it didn't hurt so much. PT A assisted her in her wheelchair (total assistance) to the common area in front of the nurse's station, where he placed her wheelchair next to another female resident who greeted her in a friendly way. The two residents chatted and looked out the window for the next hour. Resident #1 did not attempt to stand or bend down. The receptionist was seated at the desk within eyeline of Resident #1 the entire time. At 12:40 PM, the DON assisted Resident #1 to the dining room, where she spent the next hour eating lunch, drinking coffee, and talking with her tablemates. At 01:42 PM, CNA B moved Resident #1 in her wheelchair to her room, pulled back her bedsheets, and CNA B and C assisted Resident #1 into bed using a gait belt. CNA B asked Resident #1 to lean forward and applied the gait belt as CNA C locked her wheelchair brakes. CNA B asked if Resident #1 was ready, and Resident #1 said, You bet. CNA C explained they were going to count to three and help her stand up, and CNA B counted to three. They shifted her over to the bed, and she said, Thank you sir, you saved my rear end. During interviews on 04/18/24 between 02:00 PM and 02:30 PM, CNA B, CNA C, and LVN D each reported they had been recently in-serviced on fall prevention in general and specific fall prevention for Resident #1. During an interview on 04/18/24 at 02:32 PM, the NP stated she was the primary physician designee for Resident #1 and saw Resident #1 two-three times per week. The NP stated she did not think Resident #1's fall could have been prevented, because she was impulsive at times, did not always want to stay at the nurse's station, and the facility did not provide 1:1 supervision for her. The NP stated the facility was aware of recurrent falls and continued to attempt interventions for them, but unfortunately Resident #1 would sometimes get up for one reason or another. The NP stated Resident #1 could be redirected, but her short-term memory was not very good, and she would forget the redirection quickly. The NP stated it would not be realistic for every resident with these characteristics to have one-to-one supervision all the time, so they did the best they could with reminders and frequent checks. Observations on 04/18/24 at 02:10 PM and 02:49 PM revealed Resident #1 laying in her bed, which was in low position, fall mat next to the bed, and call button in her hand. She was asleep, and her wheelchair was next to her bed with the brakes locked. Her room was tidy, and well-lit. Review of Resident #2's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses including hemiplegia and hemiparesis following cerebral infarction (paralysis on one side of the body from a stroke), lack of coordination, muscle wasting and atrophy (complete wasting away of part of the body) and need for assistance with personal care. Review of Resident #2's quarterly MDS assessment, dated 03/02/24, reflected he was independent with transfers and used a wheelchair. The section on falls reflected he had no falls since the prior assessment. Review on 04/03/24 of the care plan for Resident #2, dated 11/06/23, reflected the following: [Resident #2] has multiple risk factors for falls such as: hemiparesis/hemiplegia left nondominant side. Risks for injury from falls will be minimized through next review. Complete fall risk assessment upon admission, quarterly and PRN. Review of Fall Risk Assessments for Resident #2 reflected one was conducted on 10/20/23 and none completed since. The assessment noted a low risk of falls. Review of incidents for Resident #2 reflected a fall on 10/20/23. During interview and observation on 04/03/24 at 04:29 PM, Resident #2 stated he had not fallen in the facility, that he remembered. He was seated in a wheelchair next to his bed, was clean and groomed, and his environment was free of hazards. During an interview on 04/03/24 at 03:54 PM, the DON stated she was the person primarily responsible for ensuring care plan interventions were implemented. She stated most interventions went on the CNA documentation system or the TAR so they would be completed each day. The DON stated the fall risk assessments were completed by the charge nurses when the system triggered it was time for them to be completed. She stated the system triggered the fall risk assessments triggered quarterly and the charge nurses working on the day they triggered were responsible for completing them. The DON stated she did not know why they had not been completed for Residents #1 and #2 since their last falls, but they should have been done. She stated she trained nurses to complete required assessments as soon as they started their shifts. She stated she monitored for compliance with the system by pulling reports and going over them in morning meetings. The DON stated she needed to investigate further and stepped out for a few minutes. When she returned, she stated the new company, which had bought the facility in June 2023, did not have the quarterly fall risk assessments triggered to send an alert on the EMR they set up for the facility but only required annual and PRN, when there was a fall. She stated they had identified an issue and would have to audit the whole facility to make sure there were no other examples of this. The DON stated fall risk assessments were important because patient assessments were how they knew the patients' needs. Review of in-services from January 2024 to April 2024 reflected an in-service on Fall Prevention conducted 04/02/24 and signed by the nursing staff. Review of the facility's policy, dated 10/05/16, titled Preventative Strategies to Reduce Fall Risk reflected the following: Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. After risk is assessed, individualized nursing care plans will be implemented to prevent falls.

Citation Text for Tag 0600, Regulation FF14 Based on interview and record review, the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice for one (Resident #1) of six residents reviewed for pain, in that: Facility nursing staff failed to apply a fentanyl patch for pain on Resident #1 on 11/15/23 as ordered and he experienced pain. This failure could place residents at risk of experiencing pain and/or not getting therapeutic benefits of prescribed medications. The findings included: Review of Resident #1's face sheet, dated 09/8/23, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 was admitted on hospice services. Resident #1 had diagnoses which included neoplasm (tumor) of cheek mucosa (soft tissue) and chronic respiratory failure with hypoxia (lack of adequate oxygen at tissue level). Review of Resident #1's Admission MDS assessment, dated 08/21/23, indicated Resident #1 had a BIMS of 06, which indicated moderate impaired cognition. ADVANCE Review of Resident #1's Care plan, revised 8/18/23, revealed a focus on the potential of uncontrolled pain related to cancer of the cheek mucosa. The goal listed is Resident #1 will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Interventions listed include, Administer analgesia PER MD ORDER AND VALIDATE EFFECTIVENESS and Anticipate [Resident #1's] need for pain relief and respond immediately to any complaint of pain. Review of the facility Medication Error report, dated 11/17/23, revealed a description of the following: It was noted today that resident had fentanyl patch on, dated 11/12/23 and was expected to be changed on 11/15/23. Family visited and was concerned. Resident was provided pain medication immediately and investigated on fentanyl patch placement on 11/15/23. Medication Mar was audited immediately and was confirmed that fentanyl patch was not applied on 2-10 p.m. shift on 11/15/23 but the nurse documented administered. Hospice, MD/NP notified. The report notes LVN A stated he had made a mistake by documenting that he applied the patch but did not. Review of Resident #1's Physician Orders Summary, dated 11/18/23, revealed the following medications for pain: On 11/16/23 an updated order for fentanyl 100mcg /hour patch to be applied every 72 hours for pain and fentanyl 25mcg/hour patch to be applied every 72 hours for pain. On 8/15/23 orders for morphine sulfate oral solution 20 mg/ml, give 0.25 ml by mouth every 1 hour as needed for moderate pain, Morphine sulfate oral solution 20 mg/ml, give 0.5 ml by mouth every 1 hour as needed for moderate pain. Morphine sulfate oral solution 20 mg/ml, give 0.75 ml by mouth every 1 hour as needed for moderate pain. Morphine sulfate oral solution 20 mg/ml, give 1 ml by mouth every 1 hour as needed for moderate to severe pain. On 10/26/23 orders were added for Hydrocodone-Acetaminophen oral tablet 10-325mg every 6 hours as needed for pain. Review of Resident #1's September TAR revealed on 11/15/23, LVN A initialed the site for administration of a fentanyl patch 100 mcg/hour at 6:09 p.m. and initialed for removal of the previous patch at the same time. On 11/17/23 at 3:15 p.m. and 3:17pm the fentanyl 100mcg and 25 mcg patches were initialed as applied. Continued review revealed Hydrocodone-Acetaminophen 10-325mg one tablet had been given on 11/16/23 at 1:37 p.m. and 11/17/23 at 12:08 p.m. none was documented as given on 11/15/23. No Morphine sulfate was given on 11/15/23, 11/16/23 or 11/17/23. Review of Resident #1's control substances count sheets revealed on 11/15/23 at 11:30 p.m. five fentanyl patches of 100 mcg had been delivered. The first usage of the 100mcg patch was administered on 11/17/23. On 11/10/23 fentanyl 25mcg/hour patch had been delivered. The first usage of the 25mcg patch was administered on 11/17/23. Review of Resident #1's Progress Notes revealed on 11/15/23 LVN A documented at 9:04 p.m. an order was placed for fentanyl patch every 72 hours, 25mg/hour. Apply one patch transdermal (to skin) every 72 hours for pain place with 100 mcg patch. Remove old patch before placing new one and remove per schedule. Interview on 11/18/23 at 1:44 p.m. with LVN A revealed he stated that the omission of Resident #1's Fentanyl patch not having been applied was a mistake. He stated Resident #1 was new to his hall and the 100-mcg patch was not available, but the 25mcg patch were in cart. LVN A stated he went to the previous hall to check if they had the 100 mcg patches, and they did not. LVN A stated on that same day the hospice nurse had changed the order for fentanyl dosage and he had documented the changed order and intended to give the medication when it arrived. LVN A confirmed he had not notified the MD or NP about the missed dosage due to the medication not being available. LVN A stated the medication did not arrive before the end of his shift and he had forgotten about it as it was a hectic day. LVN A stated he did receive counseling from the DON about initialing the TAR when he had not yet given the medication or removed the patch to be replaced. LVN A stated had initialed the TAR in error. LVN A stated Resident #1 does notify the staff when he is in pain and had as needed orders for pain relief. LVN A did not recall if he had given other pain medications on 11/15/23 but does not recall the Resident #1 indicating he was in pain. Interview on 11/18/23 at 11:37 a.m. with a FM revealed they had visited Resident #1 after receiving a call from the hospice aide on 11/17/23 stating Resident #1 was acting like he was in pain or was anxious. The FM was not aware if the hospice aide had informed the facility nurse. The FM stated Resident #1 could let the facility nursing staff know that he wanted pain medication and will say, give me the shot. The FM stated none of the medications are in an injection form but that is how he communicates pain, and the staff know what he means. The FM stated they had recently received a call from the hospice nurse stating she had increased the dosage of fentanyl so they were looking to see if he had the new dosage amount and saw the patch, he had on was dated 11/12/23, when it should have said 11/15/23 and it was not the increased dosage as it was just one patch instead of two. The FM stated they informed the nurse who told the DON, and the DON came to talk to them. The DON had initially told the FM a patch had been given on the 15th according to the TAR, but she would investigate it. She said later the DON came back and said she had spoken to the nurse and the medication was not available, but he had signed indicating it had been given. The FM did not know the circumstances of why the fentanyl was not available on the 15th as it should have been, but it was there on the 17th. The FM stated after the DON's investigation they gave Resident #1 the correct dosage which, they had but Resident #1 had to wait till the investigation was over and they knew he was in pain. The FM was uncertain how long of a time it had been, but it seemed like hours to them. The FM did not know if another pain medication had been given at the time they were waiting. Interview on 11/18/23 at 12:20 p.m., 2:07 p.m. and 5:30 p.m. with the facility DON revealed she first became aware of Resident #1 not receiving his fentanyl patch on 11/17/23. DON stated when she looked at the TAR it indicated it had been given but when she looked at the control sign out sheet the previous box had been emptied with all patches accounted for and the replacement box was not received until 11:30 p.m. on 11/15/23 with no dosages out of the new box so the fentanyl could not have been given by LVN A at the time he documented. LVN A admitted he had incorrectly initialed the medication as given. The nurse should notify the MD or NP if a dose of medication was missed but he had forgotten it was not administered so he had not notified. The dosage comes five in a pack, and it should have been ordered by the nurse that applied the patch on 11/12/23 as there were no more 100mcg patches. The hospice nurse calls the order into the pharmacy but our nurses document that an order was changed. DON stated it was recognized there was a problem and conducted an inservice on initialing and checking the placement. We included on the TAR a check off for each shift to check the placement and date of the patch to ensure it has been given. A coaching form was completed for LVN A on 11/17/23. Interview on 11/18/23 at with the facility Adm revealed that it was recognize that there was a medication error. The nurse had documented incorrectly and do think that the medication should had been ordered at the time of last dose or prior. Will have inservice on reordering medications. The nurse that made the documentation that was not accurate had been counseled and the DON is performing checks on similar medications. Review of the facility's abuse/neglect policy and procedure revised on 03/29/2018 revealed the following: Abuse/Neglect The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. And a definition which included, 7. Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the facility policy and or procedure for reordering medications was requested was not provided prior to exiting

Based on observations, interviews, and record reviews, the facility failed to ensure that each resident had a right to be free from neglect for 1 of 65 residents (Resident #2) reviewed for neglect. The facility failed to check the AED device to ensure it had an active status, was cleaned, without visible defects, did not have a low battery, and in operating condition before using it on Resident #2 prior to EMS arrival on [DATE]. Resident #2 passed away at the facility on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 9:08 P.M. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of pain, mental anguish, emotional distress, physical harm, diminished quality of life, and death. Findings include: Review of Resident #2's face sheet dated [DATE]. revealed he was a [AGE] year-old male with an admitted [DATE]. Resident #2 was diagnosed with unspecified chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related issues), unspecified sepsis (when an infection a person already had triggered a chain reaction throughout their body), unspecified pneumonia (an infection that affects one or both lungs), unspecified dementia, generalized muscle weakness, oral phase dysphagia (occurs when it is difficult to control the bolus (mass) of food and transporting it to the back of the mouth), unspecified hyperlipidemia (an excess of lipids or fats in a person's blood that can increase their risk of heart attack and stroke because the blood cannot easily flow through their arteries), unspecified hypothyroidism (a condition where there is not enough thyroid hormone in a person's bloodstream and their metabolism slows down), unspecified thrombocytopenia (a condition that occurs when the platelet count in a person's blood was too low), umbilical hernia without obstruction or gangrene (soft swelling or bulge near the naval), and unspecified Alzheimer's disease. Resident #2 had full code status, which indicated CPR and all other resuscitation procedures would be provided to keep him alive. Resident #2 was discharged on [DATE]. Review of Resident #2's entry MDS assessment dated [DATE] revealed he reentered the facility from an acute hospital on [DATE] and was originally admitted to the facility on [DATE]. Review of Resident #2's comprehensive MDS assessment dated [DATE] revealed there was no BIMS score indicated. The assessment also revealed Resident #2 required extensive assistance with one person physical assistance for bed mobility, dressing, eating, and personal hygiene. The assessment revealed Resident #2 also required extensive assistance with two person physical assistance with toilet use. Review of Resident #2's care plan reviewed and completed on [DATE] revealed he had impairments such as Alzheimer's disease, unspecified and dementia without behavioral disturbance, had a behavior problem related to picking objects off the floor that were not food items, wandering and pacing, had COPD, had episodes of nausea and vomiting, was disoriented to place, had memory loss, had hyperlipidemia related to elevated cholesterol levels, had hypothyroidism, had chewing/swallowing problems, had hypertension, had communication problem related to Alzheimer's Dementia, soft spoken, mumbled his words, unable to make needs known and relied on staff to meet his needs, had depression and history of symptoms such as sadness and self isolation, had ADL self care deficit related to decreased endurance, dementia, depression and general weakness, had potential for complications and/or injury related to anticoagulant therapy, had a full code status, and had severe impairment with decision making skills as evidenced by staff and family assuming wants and needs at most times and did not typically voice wants and needs to staff. Review of Resident #2's pulse summary revealed the last entry was on [DATE] at 7:42 P.M. and indicated 74 BPM regular, which indicated he had a normal heart rate range. Review of Resident #2's O2 stats summary revealed the last entry was on [DATE] at 7:41 P.M. and indicated 95.0 % room air, which indicated he had a normal oxygen level range. Review of Resident #2's blood pressure summary revealed the last entry was on [DATE] at 11:53 A.M. and indicated ,d+[DATE] MMHG sitting I/arm, which indicated he had a normal blood pressure range. Review of Resident #2's assessments revealed the most recent assessments completed was a 12-hour skilled nurse's note and weekly nurse's summary note on [DATE]. Review of Resident #2's 12-hour skilled nurse's note dated [DATE] at 6:00 P.M. revealed he had no chest pains, edema, shortness of breath, cough, unclear lung sounds, irregular respirations, loss of liquids/solids from mouth when eating or drinking, holding food in mouth/cheeks or residual food in mouth after meals, complaints of difficulty or pain when swallowing, and other skin findings present. The note also revealed Resident #2's decision making was severely impaired, he never or rarely made decisions, was rarely/never understood when making himself understood, and his memory was okay. The note revealed the physician/NP was not notified of any negative changes. The note also revealed Resident #2 was not on any transmission-based precautions and had no new physician drug orders. The note was signed on [DATE] by RN C. Review of Resident #2's weekly nursing summary dated [DATE] at 6:05 P.M. revealed he had short-term memory impairment, Alzheimer's, severely impaired cognitive skills for decision making, did not have cognition changes during the day, exhibited wandering one to three days, did not exhibit verbal behavioral symptoms directed toward others, exhibited physical behavioral symptoms directed towards others one to three days, was rarely/never understood when expressing ideas and wants, unable to make needs known, was always continent of bowel and urinary, had no changes in bowel or bladder continence, walked unassisted, self-transferred, had no pain, had no decrease in food intake, no significant weight loss, able to get out of bed and chair without assistance, and had not suffered any psychological stress or acute disease in the past three months. The note was signed by RN C on [DATE]. Review of Resident #2's nursing progress note dated [DATE] at 1:17 A.M. revealed the following: Resident #2 lying in bed with eyes closed. Opened when spoken to. No vomiting observed. No complaints at this time. Respiration rate even and unlabored. Skin was warm and dry to touch. Safety precautions in place. Note was signed by LVN D. Review of Resident #2's nursing progress note dated [DATE] at 8:37 A.M. revealed the following: 5:00 A.M. Resident #2 was observed lying in bed with his eyes closed. Head of bed elevated. Noticed dark thin fluid on his face. Attempted to arouse Resident #2 without success. Alerted team for assistance to bring AED device and crash cart. Attempted to get BP and 02 Sat, no reading. Assessed blood glucose reading 120. Palpated pulse, very faint pulse observed. No lung sound on auscultation. Nothing observed in Resident #2's oral cavity at this time. Alerted staff to call EMS. Resident #2 laid on floor. AED device pads placed and compression started per AED instructions. Per EMS continue CPR until paramedics arrived. Paramedics arrived and continued CPR unsuccessfully. EMS MD called time of death at 6:07 A.M. Notified ON-CALL NP reported death .Family was notified and they gave funeral home of choice .Resident #2 was cleaned, and put back in bed for arrival of family. Family arrived. Local PD gave case number and left the building. Mortician arrived and transported body until the Funeral home had a chance to pick up Resident #2. Note was signed by LVN D. During an interview on [DATE] at 1:35 P.M., ADM stated Resident #2 passed away at the facility on [DATE]. During an interview on [DATE] at 4:22 P.M., ADM stated LVNs used the AED device when administering basic emergency life support to a resident. Observation on [DATE] at 4:26 P.M. revealed there was a light, green-colored AED device on the crash cart and a yellow-colored AED device in a case mounted to the wall behind the crash cart. During an interview on [DATE] at 4:27 P.M., ADON A stated an LVN, who worked on the night shift from 6:00 PM through 6:00 AM, checked the light, green-colored AED device once daily. ADON A stated the night shift LVN documented the status of the light, green-colored AED device on a AED device status sheet located in a binder that was stored on the crash cart. Observation on [DATE] at 4:38 P.M. revealed ADON A turned on the light, green-colored AED device. The device displayed a green check mark and indicated, Change battery. Battery low. Charge device. The pads were disposable, sealed in its original packaging, and had an expiration date indicating [DATE]. During an interview on [DATE] at 4:40 P.M., ADON A stated the LVN changed the battery whenever the light, green-colored AED device indicated it had a low battery. ADON A stated the facility was replacing the light, green-colored AED device because it had a low battery. ADON A stated she was not sure if an AED device would work on a resident if the battery indicated it was low. ADON A stated the light-green colored AED device was used on Resident #2 on [DATE]. ADON A stated the AED device was not working when it was used on Resident #2. ADON A stated LVN D used the AED device on Resident #2 when he coded. ADON A stated LVN E and LVN F were present when LVN D used the AED device on Resident #2. During an interview on [DATE] at 5:03 P.M., LVN D stated she saw Resident #2 to check his thyroid between 4:15 A.M. and 4:30 A.M. on [DATE]. LVN D stated she attempted to check Resident #2's vitals and found he had a faint pulse. LVN D stated she alerted LVN E and LVN F to bring the crash cart. LVN D stated she checked Resident #2's blood sugar, which was 120. LVN D stated she then had a CNA help her bring Resident #2 to the floor. LVN D did not know the name of the CNA. LVN D stated she connected the light, green-colored AED device to the disposable pads, turned on the AED device, and the AED device indicated low battery after she started compressions. LVN D stated the AED device did not initially indicate low battery. LVN D stated the AED device directed her when to clear Resident #2, there was no shock, and to start compressions. LVN D stated the AED device did not shock Resident #2 when she used it on him. LVN D stated EMS was alerted and en route. LVN D stated before EMS arrived at the facility, she started compressions until the police came. LVN D stated she switched to using the police's AED device because the light, green-colored AED device indicated low battery and batteries needed to be changed. LVN D stated she continued compressions and using the police's AED device until EMS arrived at the facility. LVN D stated EMS took over when they arrived at the facility and started using their automatic compression device. LVN D stated EMS was on the phone with their MD, conducted a procedural documentation check, vital check on Resident #2, and system check. LVN D stated EMS worked on Resident #2 for 40 minutes, were unsuccessful, and had their MD call his time of death. LVN D stated the AED device was checked daily. LVN D stated night shift staff checked daily and day shift staff checked at times daily. LVN D stated the AED check was documented on a AED device status sheet that was in a binder stored on the crash cart. LVN D stated she was not sure if the AED device was checked before it was used on Resident #2. LVN D stated she was trained on AED device usage and maintenance. LVN D could not recall when she was given the training and last in-serviced on AED device. During an interview on [DATE] at 5:20 P.M., LVN E stated she was passing out the morning medications to residents when LVN D called her to bring over the crash cart. LVN E stated she took the crash cart over to LVN D and saw Resident #2 laying in his bed. LVN E stated LVN D told her that Resident #2 was warm and responding when she checked on him earlier around 4:00 A.M. and 4:30 A.M. LVN E stated LVN D told her that Resident #2 was not responding when she checked on him around 5:00 A.M. LVN E stated LVN D asked her to call 911. LVN E stated she called 911 and provided EMS with information over the phone. LVN E stated she saw a CNA run out of Resident #2's room, grab the light, green-colored AED device, and return to the room. LVN E did not know the name of the CNA. LVN E stated there was one AED device for the facility. LVN E stated when she came back to the room, she saw Resident #2 was on the floor. LVN E stated she saw another CNA was also in the room. LVN E did not know the name of the CNA. LVN E stated LVN D started performing CPR and administering the AED device on Resident #2. LVN E stated the AED device indicated the battery was low and needed to be changed. LVN E stated LVN D applied the AED device on Resident #2 twice. LVN E stated she ran out to call LVN F. LVN E stated the AED device indicated battery was low and needed to be changed when LVN F was in the room. LVN E stated LVN F and LVN D switched back and forth with performing CPR on Resident #2. LVN E stated she went and let EMS into building and EMS took over. LVN E stated she was not sure if EMS used their own AED device or the facility's light, green-colored AED device. LVN E stated LVN D called and informed the DON about Resident #2 passing away. LVN E stated she was not sure when the police arrived at the facility. LVN E stated she did not know how often the AED device was supposed to be checked. LVN E stated AED device checks were documented on a AED device status sheet in a binder that was stored on the crash cart. LVN E stated she did not know if the AED device was checked before it was used on Resident #2. LVN E stated she was trained on AED device use, maintenance, and documentation. LVN E stated she did not receive the training at the facility. LVN E stated she was not recently in-serviced on AED device at the facility. During an interview on [DATE] at 5:44 P.M., LVN F stated she was at 200 hall when LVN E informed her that something was happening on 300 hall. LVN F stated she went to Resident #2's room. LVN F stated LVN D informed her that Resident #2 coded. LVN F stated she saw Resident #2 was already on the floor and LVN D was performing CPR. LVN F stated she saw the light, green-colored AED device was already on and indicating charge battery. LVN F stated she saw LVN D attempt to use the AED device on Resident #2. LVN F stated when LVN D put the pad on Resident #2's body, the AED device indicated do not touch resident, clear away, battery low, and need a new battery. LVN F stated she tried to figure out how to charge the AED device battery while LVN D performed CPR before EMS arrived. LVN F stated when EMS took over, they used their own AED device. LVN F stated every shift was supposed to check the AED device daily. LVN F stated LVNs checked the AED device and documented the check on a AED device status sheet in the binder stored at the crash cart. LVN F stated she was not sure if the AED device was checked before it was used on Resident #2. LVN F stated she was trained on AED device use and maintenance when she started her employment at the facility. LVN F stated she was in-serviced on AED device use and maintenance. LVN F could not remember when she was last in-serviced on AED device. During an interview on [DATE] at 6:18 P.M., ADM stated he did not know what was handwritten on the bottom of the facility's emergency cart checklist for [DATE] because it was not initialed by anyone. During an interview on [DATE] at 6:41 P.M., ADM stated the light, green-colored AED device was used on Resident #2. ADM stated the AED device was checked daily for operating status and as needed. ADM stated the AED device status was documented on a AED device status sheet in the binder stored next to the AED device. ADM stated the LVNs on the night shift checked the AED device daily. ADM stated the nurse manager checked the AED device status sheet. ADM stated nurse management was defined as the DON, ADON, treatment nurse, or any staff member who oversaw the LVNs. ADM stated according to nurse's progress note, the AED device was in operating condition when it was used on Resident #2. ADM did not know if the AED device indicated low battery and battery needed to be changed when it was used on Resident #2. ADM did not know if the AED device went off when it was turned on and used on Resident #2. ADM stated according to the nurse's progress note, staff used the AED device on Resident #2 prior to EMS arriving at the facility. ADM did not know if EMS used the facility's AED device or their own AED device. ADM stated he started his employment in [DATE] and since he started, there was no training given to staff on AED device use and maintenance. ADM stated he was not sure if staff were in-serviced on AED device use and maintenance. ADM did not know why the AED device status stopped being checked and documented after [DATE]. ADM stated he was not sure if the nurse managers were supposed to check the AED device status sheets daily or weekly. ADM stated according to the nurse's progress note, Resident #2 coded in the morning on [DATE], staff performed CPR, grabbed additional staff, got the crash cart and AED device, and Resident #2 passed away. ADM stated he was not sure if there were any other emergency units that arrived other than EMS. ADM stated Resident #2 never had an incident in the past where staff had to perform CPR and administer the AED device on him. During an interview on [DATE] at 8:12 P.M., DON stated LVN D contacted her on [DATE] at 5:41 A.M. and informed her that Resident #2 coded and EMS was at the facility. DON stated she thought LVN D was informing her that Resident #2 was going to the hospital. DON stated She asked LVN D at 5:47 A.M. if she performed CPR on Resident #2. DON stated LVN D told her that she performed CPR on Resident #2 until EMS arrived at the facility. DON stated she later missed two calls from LVN D at 6:14 A.M. DON stated she returned LVN D's call at 6:18 A.M. DON stated LVN D told her to check her text message sent at 6:08 A.M. DON stated the text message said, 607 TOD EMS MD. DON stated she called LVN D at 6:18 A.M. and asked clarification on TOD, which was time of death, and who was EMS MD. DON stated LVN D explained to her that EMS MD was EMS's MD, who pronounced Resident #2's death. DON stated she contacted ADON A and instructed her to have LVN D notify law enforcement, Resident #2's RP and NP. DON stated she came to the facility and saw law enforcement was still at the facility and LVN D filling out documents. DON stated LVN D informed her that Resident #2 had a history gastrointestinal issues and aspiration. DON stated LVN D also told her that Resident #2's vitals were fine. DON stated LVN D told her that around 4:00 A.M., she observed Resident #2 had liquid by around his mouth . DON stated LVN D also told her that CPR was performed before EMS arrived. DON stated LVN D also informed her that the AED device needed to be checked out because it kept giving a warning indicating low battery. DON stated LVN D told her that the AED device kept operating and giving the indicator to change battery. DON stated LVN D told her that staff ended up using EMS's AED device. DON stated she asked LVN D if the AED device had been showing the indicator of low battery. DON stated LVN De told her that LVN F or another nurse mentioned the AED device indicated low battery and change battery before. DON stated LVN D told her that she did not know when LVN F or another nurse mentioned the AED device indicated low battery and change battery. DON stated LVNs were supposed to check to make sure the AED device worked at the beginning of the night shift. DON stated the first time the AED device was reported not working was the morning of [DATE]. DON stated she went to the crash cart to check the inventory sheet. DON stated she informed ADON A because she was in charge of checking the crash cart. DON stated staff determined the AED device was working if the green light was indicated when turning it on. DON stated she informed ADON A or one of the other management staff about the AED device not working. DON stated she checked the emergency cart inventory sheet and found handwritten notes from staff who checked the AED device on [DATE] and indicated AED needed servicing. DON stated the handwritten notes on the bottom of emergency cart checklist should have been entered onto the AED device status sheets. DON stated she did not know who made the handwritten notes on the emergency cart inventory sheet. DON stated according to crash cart inventory sheet, the last time the AED device was checked was during the night shift on [DATE]. DON stated staff did not notify management about the AED device status. DON stated the night shift LVN checked the AED device daily. DON stated the AED device battery was low because the machine was failing and the battery needed to be replaced. DON stated the light, green-colored AED device was used on Resident #2. DON stated the ADON verified LVNs checked the AED device and documented the status on the AED device status sheets. DON stated the ADON was supposed to check the AED device once every morning and sporadically. DON stated ADON A told her that she notified the ADM about the AED device needing to be changed. DON stated she did not know when ADON A told the ADM about the AED device needing to be changed. DON stated ADON A did not notify her of the AED device batteries needing to be changed nor the AED device having a low battery. During an interview on [DATE] at 8:48 P.M., ADM stated he was not notified by ADON A about the AED device needing to have batteries changed nor it having low battery until the morning of [DATE]. ADM stated he had never been told prior to [DATE] about the AED device status. During an interview on [DATE] at 8:52 P.M., ADON A stated she checked to make sure LVNs checked the AED device and documented the status on the AED device status sheets. ADON A stated she checked once daily during the day shift. ADON A stated two weeks ago, she reviewed the emergency cart inventory sheet and saw handwritten notes indicating the AED device needed servicing. ADON A stated she did not know who made the handwritten notes on the emergency cart inventory sheet. ADON A stated she knew an LVN from the night shift made the handwritten notes. ADON A stated she went to the ADM two weeks ago and informed him about the AED device battery needing a service. ADON A stated she saw the ADM contact Corporate MR and informed her about the AED device status. ADON A stated Corporate MR told her and the ADM that the battery was back ordered. ADON A stated the facility got a new AED device on [DATE] because the battery in the light, green colored AED device was not functioning and the battery was back ordered. ADON A stated staff did not notify her about the AED device battery being low and needing to be replaced. ADON A later stated LVN D informed her that the AED device battery was low and needed to be changed . ADON A stated she informed the ADM on [DATE] that the AED device battery needed to be changed because it was indicating low. ADON A stated LVN D did not explain why the AED battery was low. During an interview on [DATE] at 9:25 P.M., ADM stated he contacted and asked Corporate MR prior to Resident #2's incident on [DATE] to order a new AED device because the light, green-colored device looked outdated and old. Review of the facility's grievance logs from July and [DATE] revealed there were no grievances filed regarding neglect, falls, or pain. Review of the facility in-services revealed staff were trained on the following: -Resident neglect and abuse [DATE] 8:00 A.M.-9:00 A.M. -Use of progress notes documentation [DATE] 6:00 P.M.-[DATE] 6:00 P.M. -Reporting of concerns and incidents [DATE] 6:00 P.M.-[DATE] 6:00 P.M. -Ongoing and oncoming shift staff to do rounds [DATE] -Abuse and neglect [DATE] -Abuse and neglect [DATE] Review of the facility's Defibtech DDU-100 Operator Checklist (AED Device Status Sheet) for [DATE] revealed the light, green-colored AED device was checked from [DATE] through [DATE]. The checklist also revealed the Active Status indicator did not flash green from [DATE] through [DATE]. The checklist revealed the unit was clean and without visual defects from [DATE] through [DATE]. The checklist also revealed the unit was not clean and without visible defects from [DATE] through [DATE] . There were no other entries completed on the checklist. The checklist also revealed the manually run initiated test was not performed and pads were not replaced. The checklist revealed the date of battery pack expiration and date of pad expiration was not indicated. Review of the facility's emergency cart checklist for [DATE] revealed there were entries from [DATE] through [DATE] reflecting all emergency crash cart items were accounted for. The checklist also revealed below the page there were handwritten entries in black pen indicating the following: ,d+[DATE] AED needs service ,d+[DATE] AED needs service ,d+[DATE] AED needs service ,d+[DATE] AED ,d+[DATE] AED ,d+[DATE] AED needs servicing ,d+[DATE] AED needs servicing ,d+[DATE] AED ,d+[DATE] AED ,d+[DATE] AED needs servicing ,d+[DATE] AED Review of the facility's know your AED machine reference guide dated [DATE] revealed the following: .However, if you are needing a replacement, it must be approved prior to submitting the purchase order due to the cost . Also be mindful of the battery pack which can run low and need to be replaced or that may expire and need to be replaced. Documenting the date of your AED battery is now part of your monthly central supply sweep. When your battery gets within two months of expiring, submit a purchase order and order a new one. Review of the facility's abuse/neglect policy and procedure revised on [DATE] revealed the following: Abuse/Neglect The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart . 7. Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the facility's cardiopulmonary resuscitation policy and procedure revised on [DATE] revealed the following: Cardiopulmonary resuscitation (CPR) is a method of providing systemic circulation by manual chest compression and oxygen by mouth-to-mouth breathing or providing air to the lungs via ambu bag. The procedure is performed to prevent death following cardiac or pulmonary arrest. Once initiated, it is continued until spontaneous circulation and respirations are restored, or until emergency services assume responsibility for resuscitation. CPR can be delivered by one or two persons. In residents with a terminal or irreversible disorder and in whom death is anticipated, an order can be w1itten and recorded indicated that resuscitation should not be performed. This decision is identified by a No Code order that is documented on the clinical record. The decision for No Code is usually made by the physician and family members and can also be included in the resident's advance directive. The facility will have at least 1 staff member who is trained in CPR/BLS at all times in the facility. Complications that result from the procedure include rib fracture, mural thrombi or emboli, and abdominal distention. Goals Breathing and pulse will be reestablished in the resident. Procedure 1. Assess for unresponsiveness. Tap the resident's shoulder and ask the resident if he/she is alright. 2. When the resident is unresponsive, immediately call for emergency help and notify staff of Code Blue. Call for emergency assistance. Ensure that the first responder calls EMS and returns to the scene with an AED (defibrillator). If you are alone and cannot alert anyone to call EMS. YOU MUST call EMS prior to beginning CPR and obtain the AED. 3. After EMS has been called, implement the CPR protocol as outlined below (Chest compressions - Airway- Breathing (C-A-B)). 4. Ensure that the resident is not in dangerous area. If the resident is located in a dangerous area, move the resident to a safe location to perform CPR 5. Check the unresponsive resident for a pulse for no longer than 10 seconds . c. Adult - check for pulse at carotid artery 6. If no pulse, place a back board under the resident if the resident is in bed. Ensure that the resident is lying on their back on a hard surface (floor, back board) 7. Begin chest compressions at a rate of 100 compressions per minute. 16. Complete 5 sequences of chest compressions/breaths before checking the pulse again . Note: No matter what stage of CPR you are in, when the AED arrives stop what you are doing and connect the AED to the resident 17. As soon as the AED is available power the device on and apply the pads as indicated to the resident's chest wall. If hair is present, quickly shave the area. so that the pads come in contact with the skin. 18. Follow all directions the AED provides. 19. Continue CPR as directed by the AED until EMS arrives 20. The facility will maintain an emergency cart with at least the following supplies: a. Backboard b. Ambu bag c. 02 and administration set d. Disposable Gloves e. Crash cart (ER cart/AED) is checked daily. PRN and restocked immediately after a code is completed. 21. The family member and/or legal representative will be notified immediately in the change of the resident's status. The nurse will notify the attending physician immediately of the change in the resident's status. 22. Document all care given and resident's response to treatment. 23. The facility will document all code blue episodes. This failure resulted in the identification of an IJ on [DATE] at 7:54 P.M. The ADM was notified and provided with the IJ template on [DATE] at 9:08 P.M. The following Plan of Removal was submitted by the facility and accepted on [DATE] at 2:59 P.M.: Plan of Removal Immediate Jeopardy On [DATE] an abbreviated survey was initiated at the facility. On [DATE] the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an Immediate Jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: state the issue you will find the info on the template you were provided. F600 The facility failed to check the AED device to ensure it had an active status, clean, without visible defects, did not have a low battery, and in operating condition after [DATE]. Action: As of [DATE] the AED has been replaced with a new AED by the Administrator. Start Date: [DATE] Completion Date: [DATE] Responsible: The Administrator. Action: An in-service was on [DATE] that the night shift charge nurses will check that the AED is functioning properly as evidence by the machine is clean without visual effects and that indicator light is flashing green 7 days per week. All charge nurses and agency nurses if used that are not present on [DATE] will be in-serviced before the start of their next scheduled shift in-service will be provided by DON/designee. All new staff and agency nurses if used will be in-serviced/trained at new hire orientation on going p [TRUNCATED]

Based on observations, interviews, and record reviews, the facility failed to provide basic emergency life support immediately when needed, including cardiopulmonary resuscitation (CPR), for 1 of 65 residents (Resident #2) reviewed for advance directives. The facility failed to check the AED device to ensure it had an active status, was cleaned, without visible defects, did not have a low battery, and in operating condition before using it on Resident #2 prior to EMS arrival on [DATE]. Resident #2 passed away at the facility on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 9:08 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents who are full code status at risk of death. Findings include: Review of Resident #2's face sheet dated [DATE]. revealed he was a [AGE] year-old male with an admitted [DATE]. Resident #2 was diagnosed with unspecified chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related issues), unspecified sepsis (when an infection a person already had triggered a chain reaction throughout their body), unspecified pneumonia (an infection that affects one or both lungs), unspecified dementia, generalized muscle weakness, oral phase dysphagia (occurs when it is difficult to control the bolus (mass) of food and transporting it to the back of the mouth), unspecified hyperlipidemia (an excess of lipids or fats in a person's blood that can increase their risk of heart attack and stroke because the blood cannot easily flow through their arteries), unspecified hypothyroidism (a condition where there is not enough thyroid hormone in a person's bloodstream and their metabolism slows down), unspecified thrombocytopenia (a condition that occurs when the platelet count in a person's blood was too low), umbilical hernia without obstruction or gangrene (soft swelling or bulge near the naval), and unspecified Alzheimer's disease. Resident #2 had full code status, which indicated CPR and all other resuscitation procedures would be provided to keep him alive. Resident #2 was discharged on [DATE]. Review of Resident #2's entry MDS assessment dated [DATE] revealed he reentered the facility from an acute hospital on [DATE] and was originally admitted to the facility on [DATE]. Review of Resident #2's comprehensive MDS assessment dated [DATE] revealed there was no BIMS score indicated. The assessment also revealed Resident #2 required extensive assistance with one person physical assistance for bed mobility, dressing, eating, and personal hygiene. The assessment revealed Resident #2 also required extensive assistance with two person physical assistance with toilet use. Review of Resident #2's care plan reviewed and completed on [DATE] revealed he had impairments such as Alzheimer's disease, unspecified and dementia without behavioral disturbance, had a behavior problem related to picking objects off the floor that were not food items, wandering and pacing, had COPD, had episodes of nausea and vomiting, was disoriented to place, had memory loss, had hyperlipidemia related to elevated cholesterol levels, had hypothyroidism, had chewing/swallowing problems, had hypertension, had communication problem related to Alzheimer's Dementia, soft spoken, mumbled his words, unable to make needs known and relied on staff to meet his needs, had depression and history of symptoms such as sadness and self isolation, had ADL self care deficit related to decreased endurance, dementia, depression and general weakness, had potential for complications and/or injury related to anticoagulant therapy, had a full code status, and had severe impairment with decision making skills as evidenced by staff and family assuming wants and needs at most times and did not typically voice wants and needs to staff. Review of Resident #2's pulse summary revealed the last entry was on [DATE] at 7:42 P.M. and indicated 74 BPM regular, which indicated he had a normal heart rate range. Review of Resident #2's O2 stats summary revealed the last entry was on [DATE] at 7:41 P.M. and indicated 95.0 % room air, which indicated he had a normal oxygen level range. Review of Resident #2's blood pressure summary revealed the last entry was on [DATE] at 11:53 A.M. and indicated ,d+[DATE] MMHG sitting I/arm, which indicated he had a normal blood pressure range. Review of Resident #2's assessments revealed the most recent assessments completed was a 12-hour skilled nurse's note and weekly nurse's summary note on [DATE]. Review of Resident #2's 12-hour skilled nurse's note dated [DATE] at 6:00 P.M. revealed he had no chest pains, edema, shortness of breath, cough, unclear lung sounds, irregular respirations, loss of liquids/solids from mouth when eating or drinking, holding food in mouth/cheeks or residual food in mouth after meals, complaints of difficulty or pain when swallowing, and other skin findings present. The note also revealed Resident #2's decision making was severely impaired, he never or rarely made decisions, was rarely/never understood when making himself understood, and his memory was okay. The note revealed the physician/NP was not notified of any negative changes. The note also revealed Resident #2 was not on any transmission-based precautions and had no new physician drug orders. The note was signed on [DATE] by RN C. Review of Resident #2's weekly nursing summary dated [DATE] at 6:05 P.M. revealed he had short-term memory impairment, Alzheimer's, severely impaired cognitive skills for decision making, did not have cognition changes during the day, exhibited wandering one to three days, did not exhibit verbal behavioral symptoms directed toward others, exhibited physical behavioral symptoms directed towards others one to three days, was rarely/never understood when expressing ideas and wants, unable to make needs known, was always continent of bowel and urinary, had no changes in bowel or bladder continence, walked unassisted, self-transferred, had no pain, had no decrease in food intake, no significant weight loss, able to get out of bed and chair without assistance, and had not suffered any psychological stress or acute disease in the past three months. The note was signed by RN C on [DATE]. Review of Resident #2's nursing progress note dated [DATE] at 1:17 A.M. revealed the following: Resident #2 lying in bed with eyes closed. Opened when spoken to. No vomiting observed. No complaints at this time. Respiration rate even and unlabored. Skin was warm and dry to touch. Safety precautions in place. Note was signed by LVN D. Review of Resident #2's nursing progress note dated [DATE] at 8:37 A.M. revealed the following: 5:00 A.M. Resident #2 was observed lying in bed with his eyes closed. Head of bed elevated. Noticed dark thin fluid on his face. Attempted to arouse Resident #2 without success. Alerted team for assistance to bring AED device and crash cart. Attempted to get BP and 02 Sat, no reading. Assessed blood glucose reading 120. Palpated pulse, very faint pulse observed. No lung sound on auscultation. Nothing observed in Resident #2's oral cavity at this time. Alerted staff to call EMS. Resident #2 laid on floor. AED device pads placed and compression started per AED instructions. Per EMS continue CPR until paramedics arrived. Paramedics arrived and continued CPR unsuccessfully. EMS MD called time of death at 6:07 A.M. Notified ON-CALL NP reported death .Family was notified and they gave funeral home of choice .Resident #2 was cleaned, and put back in bed for arrival of family. Family arrived. Local PD gave case number and left the building. Mortician arrived and transported body until the Funeral home had a chance to pick up Resident #2. Note was signed by LVN D. During an interview on [DATE] at 1:35 P.M., ADM stated Resident #2 passed away at the facility on [DATE]. During an interview on [DATE] at 4:22 P.M., ADM stated LVNs used the AED device when administering basic emergency life support to a resident. Observation on [DATE] at 4:26 P.M. revealed there was a light, green-colored AED device on the crash cart and a yellow-colored AED device in a case mounted to the wall behind the crash cart. During an interview on [DATE] at 4:27 P.M., ADON A stated an LVN, who worked on the night shift from 6:00 PM through 6:00 AM, checked the light, green-colored AED device once daily. ADON A stated the night shift LVN documented the status of the light, green-colored AED device on a AED device status sheet located in a binder that was stored on the crash cart. Observation on [DATE] at 4:38 P.M. revealed ADON A turned on the light, green-colored AED device. The device displayed a green check mark and indicated, Change battery. Battery low. Charge device. The pads were disposable, sealed in its original packaging, and had an expiration date indicating [DATE]. During an interview on [DATE] at 4:40 P.M., ADON A stated the LVN changed the battery whenever the light, green-colored AED device indicated it had a low battery. ADON A stated the facility was replacing the light, green-colored AED device because it had a low battery. ADON A stated she was not sure if an AED device would work on a resident if the battery indicated it was low. ADON A stated the light-green colored AED device was used on Resident #2 on [DATE]. ADON A stated the AED device was not working when it was used on Resident #2. ADON A stated LVN D used the AED device on Resident #2 when he coded. ADON A stated LVN E and LVN F were present when LVN D used the AED device on Resident #2. During an interview on [DATE] at 5:03 P.M., LVN D stated she saw Resident #2 to check his thyroid between 4:15 A.M. and 4:30 A.M. on [DATE]. LVN D stated she attempted to check Resident #2's vitals and found he had a faint pulse. LVN D stated she alerted LVN E and LVN F to bring the crash cart. LVN D stated she checked Resident #2's blood sugar, which was 120. LVN D stated she then had a CNA help her bring Resident #2 to the floor. LVN D did not know the name of the CNA. LVN D stated she connected the light, green-colored AED device to the disposable pads, turned on the AED device, and the AED device indicated low battery after she started compressions. LVN D stated the AED device did not initially indicate low battery. LVN D stated the AED device directed her when to clear Resident #2, there was no shock, and to start compressions. LVN D stated the AED device did not shock Resident #2 when she used it on him. LVN D stated EMS was alerted and en route. LVN D stated before EMS arrived at the facility, she started compressions until the police came. LVN D stated she switched to using the police's AED device because the light, green-colored AED device indicated low battery and batteries needed to be changed. LVN D stated she continued compressions and using the police's AED device until EMS arrived at the facility. LVN D stated EMS took over when they arrived at the facility and started using their automatic compression device. LVN D stated EMS was on the phone with their MD, conducted a procedural documentation check, vital check on Resident #2, and system check. LVN D stated EMS worked on Resident #2 for 40 minutes, were unsuccessful, and had their MD call his time of death. LVN D stated the AED device was checked daily. LVN D stated night shift staff checked daily and day shift staff checked at times daily. LVN D stated the AED check was documented on a AED device status sheet that was in a binder stored on the crash cart. LVN D stated she was not sure if the AED device was checked before it was used on Resident #2. LVN D stated she was trained on AED device usage and maintenance. LVN D could not recall when she was given the training and last in-serviced on AED device. During an interview on [DATE] at 5:20 P.M., LVN E stated she was passing out the morning medications to residents when LVN D called her to bring over the crash cart. LVN E stated she took the crash cart over to LVN D and saw Resident #2 laying in his bed. LVN E stated LVN D told her that Resident #2 was warm and responding when she checked on him earlier around 4:00 A.M. and 4:30 A.M. LVN E stated LVN D told her that Resident #2 was not responding when she checked on him around 5:00 A.M. LVN E stated LVN D asked her to call 911. LVN E stated she called 911 and provided EMS with information over the phone. LVN E stated she saw a CNA run out of Resident #2's room, grab the light, green-colored AED device, and return to the room. LVN E did not know the name of the CNA. LVN E stated there was one AED device for the facility. LVN E stated when she came back to the room, she saw Resident #2 was on the floor. LVN E stated she saw another CNA was also in the room. LVN E did not know the name of the CNA. LVN E stated LVN D started performing CPR and administering the AED device on Resident #2. LVN E stated the AED device indicated the battery was low and needed to be changed. LVN E stated LVN D applied the AED device on Resident #2 twice. LVN E stated she ran out to call LVN F. LVN E stated the AED device indicated battery was low and needed to be changed when LVN F was in the room. LVN E stated LVN F and LVN D switched back and forth with performing CPR on Resident #2. LVN E stated she went and let EMS into building and EMS took over. LVN E stated she was not sure if EMS used their own AED device or the facility's light, green-colored AED device. LVN E stated LVN D called and informed the DON about Resident #2 passing away. LVN E stated she was not sure when the police arrived at the facility. LVN E stated she did not know how often the AED device was supposed to be checked. LVN E stated AED device checks were documented on a AED device status sheet in a binder that was stored on the crash cart. LVN E stated she did not know if the AED device was checked before it was used on Resident #2. LVN E stated she was trained on AED device use, maintenance, and documentation. LVN E stated she did not receive the training at the facility. LVN E stated she was not recently in-serviced on AED device at the facility. During an interview on [DATE] at 5:44 P.M., LVN F stated she was at 200 hall when LVN E informed her that something was happening on 300 hall. LVN F stated she went to Resident #2's room. LVN F stated LVN D informed her that Resident #2 coded. LVN F stated she saw Resident #2 was already on the floor and LVN D was performing CPR. LVN F stated she saw the light, green-colored AED device was already on and indicating charge battery. LVN F stated she saw LVN D attempt to use the AED device on Resident #2. LVN F stated when LVN D put the pad on Resident #2's body, the AED device indicated do not touch resident, clear away, battery low, and need a new battery. LVN F stated she tried to figure out how to charge the AED device battery while LVN D performed CPR before EMS arrived. LVN F stated when EMS took over, they used their own AED device. LVN F stated every shift was supposed to check the AED device daily. LVN F stated LVNs checked the AED device and documented the check on a AED device status sheet in the binder stored at the crash cart. LVN F stated she was not sure if the AED device was checked before it was used on Resident #2. LVN F stated she was trained on AED device use and maintenance when she started her employment at the facility. LVN F stated she was in-serviced on AED device use and maintenance. LVN F could not remember when she was last in-serviced on AED device. During an interview on [DATE] at 6:18 P.M., ADM stated he did not know what was handwritten on the bottom of the facility's emergency cart checklist for [DATE] because it was not initialed by anyone. During an interview on [DATE] at 6:41 P.M., ADM stated the light, green-colored AED device was used on Resident #2. ADM stated the AED device was checked daily for operating status and as needed. ADM stated the AED device status was documented on a AED device status sheet in the binder stored next to the AED device. ADM stated the LVNs on the night shift checked the AED device daily. ADM stated the nurse manager checked the AED device status sheet. ADM stated nurse management was defined as the DON, ADON, treatment nurse, or any staff member who oversaw the LVNs. ADM stated according to nurse's progress note, the AED device was in operating condition when it was used on Resident #2. ADM did not know if the AED device indicated low battery and battery needed to be changed when it was used on Resident #2. ADM did not know if the AED device went off when it was turned on and used on Resident #2. ADM stated according to the nurse's progress note, staff used the AED device on Resident #2 prior to EMS arriving at the facility. ADM did not know if EMS used the facility's AED device or their own AED device. ADM stated he started his employment in [DATE] and since he started, there was no training given to staff on AED device use and maintenance. ADM stated he was not sure if staff were in-serviced on AED device use and maintenance. ADM did not know why the AED device status stopped being checked and documented after [DATE]. ADM stated he was not sure if the nurse managers were supposed to check the AED device status sheets daily or weekly. ADM stated according to the nurse's progress note, Resident #2 coded in the morning on [DATE], staff performed CPR, grabbed additional staff, got the crash cart and AED device, and Resident #2 passed away. ADM stated he was not sure if there were any other emergency units that arrived other than EMS. ADM stated Resident #2 never had an incident in the past where staff had to perform CPR and administer the AED device on him. During an interview on [DATE] at 8:12 P.M., DON stated LVN D contacted her on [DATE] at 5:41 A.M. and informed her that Resident #2 coded and EMS was at the facility. DON stated she thought LVN D was informing her that Resident #2 was going to the hospital. DON stated She asked LVN D at 5:47 A.M. if she performed CPR on Resident #2. DON stated LVN D told her that she performed CPR on Resident #2 until EMS arrived at the facility. DON stated she later missed two calls from LVN D at 6:14 A.M. DON stated she returned LVN D's call at 6:18 A.M. DON stated LVN D told her to check her text message sent at 6:08 A.M. DON stated the text message said, 607 TOD EMS MD. DON stated she called LVN D at 6:18 A.M. and asked clarification on TOD, which was time of death, and who was EMS MD. DON stated LVN D explained to her that EMS MD was EMS's MD, who pronounced Resident #2's death. DON stated she contacted ADON A and instructed her to have LVN D notify law enforcement, Resident #2's RP and NP. DON stated she came to the facility and saw law enforcement was still at the facility and LVN D filling out documents. DON stated LVN D informed her that Resident #2 had a history gastrointestinal issues and aspiration. DON stated LVN D also told her that Resident #2's vitals were fine. DON stated LVN D told her that around 4:00 A.M., she observed Resident #2 had liquid by around his mouth . DON stated LVN D also told her that CPR was performed before EMS arrived. DON stated LVN D also informed her that the AED device needed to be checked out because it kept giving a warning indicating low battery. DON stated LVN D told her that the AED device kept operating and giving the indicator to change battery. DON stated LVN D told her that staff ended up using EMS's AED device. DON stated she asked LVN D if the AED device had been showing the indicator of low battery. DON stated LVN De told her that LVN F or another nurse mentioned the AED device indicated low battery and change battery before. DON stated LVN D told her that she did not know when LVN F or another nurse mentioned the AED device indicated low battery and change battery. DON stated LVNs were supposed to check to make sure the AED device worked at the beginning of the night shift. DON stated the first time the AED device was reported not working was the morning of [DATE]. DON stated she went to the crash cart to check the inventory sheet. DON stated she informed ADON A because she was in charge of checking the crash cart. DON stated staff determined the AED device was working if the green light was indicated when turning it on. DON stated she informed ADON A or one of the other management staff about the AED device not working. DON stated she checked the emergency cart inventory sheet and found handwritten notes from staff who checked the AED device on [DATE] and indicated AED needed servicing. DON stated the handwritten notes on the bottom of emergency cart checklist should have been entered onto the AED device status sheets. DON stated she did not know who made the handwritten notes on the emergency cart inventory sheet. DON stated according to crash cart inventory sheet, the last time the AED device was checked was during the night shift on [DATE]. DON stated staff did not notify management about the AED device status. DON stated the night shift LVN checked the AED device daily. DON stated the AED device battery was low because the machine was failing and the battery needed to be replaced. DON stated the light, green-colored AED device was used on Resident #2. DON stated the ADON verified LVNs checked the AED device and documented the status on the AED device status sheets. DON stated the ADON was supposed to check the AED device once every morning and sporadically. DON stated ADON A told her that she notified the ADM about the AED device needing to be changed. DON stated she did not know when ADON A told the ADM about the AED device needing to be changed. DON stated ADON A did not notify her of the AED device batteries needing to be changed nor the AED device having a low battery. During an interview on [DATE] at 8:48 P.M., ADM stated he was not notified by ADON A about the AED device needing to have batteries changed nor it having low battery until the morning of [DATE]. ADM stated he had never been told prior to [DATE] about the AED device status. During an interview on [DATE] at 8:52 P.M., ADON A stated she checked to make sure LVNs checked the AED device and documented the status on the AED device status sheets. ADON A stated she checked once daily during the day shift. ADON A stated two weeks ago, she reviewed the emergency cart inventory sheet and saw handwritten notes indicating the AED device needed servicing. ADON A stated she did not know who made the handwritten notes on the emergency cart inventory sheet. ADON A stated she knew an LVN from the night shift made the handwritten notes. ADON A stated she went to the ADM two weeks ago and informed him about the AED device battery needing a service. ADON A stated she saw the ADM contact Corporate MR and informed her about the AED device status. ADON A stated Corporate MR told her and the ADM that the battery was back ordered. ADON A stated the facility got a new AED device on [DATE] because the battery in the light, green colored AED device was not functioning and the battery was back ordered. ADON A stated staff did not notify her about the AED device battery being low and needing to be replaced. ADON A later stated LVN D informed her that the AED device battery was low and needed to be changed . ADON A stated she informed the ADM on [DATE] that the AED device battery needed to be changed because it was indicating low. ADON A stated LVN D did not explain why the AED battery was low. During an interview on [DATE] at 9:25 P.M., ADM stated he contacted and asked Corporate MR prior to Resident #2's incident on [DATE] to order a new AED device because the light, green-colored device looked outdated and old. Review of the facility's Defibtech DDU-100 Operator Checklist (AED Device Status Sheet) for [DATE] revealed the light, green-colored AED device was checked from [DATE] through [DATE]. The checklist also revealed the Active Status indicator did not flash green from [DATE] through [DATE]. The checklist revealed the unit was clean and without visual defects from [DATE] through [DATE]. The checklist also revealed the unit was not clean and without visible defects from [DATE] through [DATE] . There were no other entries completed on the checklist. The checklist also revealed the manually run initiated test was not performed and pads were not replaced. The checklist revealed the date of battery pack expiration and date of pad expiration was not indicated. Review of the facility's emergency cart checklist for [DATE] revealed there were entries from [DATE] through [DATE] reflecting all emergency crash cart items were accounted for. The checklist also revealed below the page there were handwritten entries in black pen indicating the following: ,d+[DATE] AED needs service ,d+[DATE] AED needs service ,d+[DATE] AED needs service ,d+[DATE] AED ,d+[DATE] AED ,d+[DATE] AED needs servicing ,d+[DATE] AED needs servicing ,d+[DATE] AED ,d+[DATE] AED ,d+[DATE] AED needs servicing ,d+[DATE] AED Review of the facility's know your AED machine reference guide dated [DATE] revealed the following: .However, if you are needing a replacement, it must be approved prior to submitting the purchase order due to the cost . Also be mindful of the battery pack which can run low and need to be replaced or that may expire and need to be replaced. Documenting the date of your AED battery is now part of your monthly central supply sweep. When your battery gets within two months of expiring, submit a purchase order and order a new one. Review of the facility's cardiopulmonary resuscitation policy and procedure revised on [DATE] revealed the following: Cardiopulmonary resuscitation (CPR) is a method of providing systemic circulation by manual chest compression and oxygen by mouth-to-mouth breathing or providing air to the lungs via ambu bag. The procedure is performed to prevent death following cardiac or pulmonary arrest. Once initiated, it is continued until spontaneous circulation and respirations are restored, or until emergency services assume responsibility for resuscitation. CPR can be delivered by one or two persons. In residents with a terminal or irreversible disorder and in whom death is anticipated, an order can be w1itten and recorded indicated that resuscitation should not be performed. This decision is identified by a No Code order that is documented on the clinical record. The decision for No Code is usually made by the physician and family members and can also be included in the resident's advance directive. The facility will have at least 1 staff member who is trained in CPR/BLS at all times in the facility. Complications that result from the procedure include rib fracture, mural thrombi or emboli, and abdominal distention. Goals Breathing and pulse will be reestablished in the resident. Procedure 1. Assess for unresponsiveness. Tap the resident's shoulder and ask the resident if he/she is alright. 2. When the resident is unresponsive, immediately call for emergency help and notify staff of Code Blue. Call for emergency assistance. Ensure that the first responder calls EMS and returns to the scene with an AED (defibrillator). If you are alone and cannot alert anyone to call EMS. YOU MUST call EMS prior to beginning CPR and obtain the AED. 3. After EMS has been called, implement the CPR protocol as outlined below (Chest compressions - Airway- Breathing (C-A-B)). 4. Ensure that the resident is not in dangerous area. If the resident is located in a dangerous area, move the resident to a safe location to perform CPR 5. Check the unresponsive resident for a pulse for no longer than 10 seconds . c. Adult - check for pulse at carotid artery 6. If no pulse, place a back board under the resident if the resident is in bed. Ensure that the resident is lying on their back on a hard surface (floor, back board) 7. Begin chest compressions at a rate of 100 compressions per minute. 16. Complete 5 sequences of chest compressions/breaths before checking the pulse again . Note: No matter what stage of CPR you are in, when the AED arrives stop what you are doing and connect the AED to the resident 17. As soon as the AED is available power the device on and apply the pads as indicated to the resident's chest wall. If hair is present, quickly shave the area. so that the pads come in contact with the skin. 18. Follow all directions the AED provides. 19. Continue CPR as directed by the AED until EMS arrives 20. The facility will maintain an emergency cart with at least the following supplies: a. Backboard b. Ambu bag c. 02 and administration set d. Disposable Gloves e. Crash cart (ER cart/AED) is checked daily. PRN and restocked immediately after a code is completed. 21. The family member and/or legal representative will be notified immediately in the change of the resident's status. The nurse will notify the attending physician immediately of the change in the resident's status. 22. Document all care given and resident's response to treatment. 23. The facility will document all code blue episodes. This failure resulted in the identification of an IJ on [DATE] at 7:54 P.M. The ADM was notified and provided with the IJ template on [DATE] at 9:08 P.M. The following Plan of Removal was submitted by the facility and accepted on [DATE] at 2:59 P.M.: Plan of Removal Immediate Jeopardy On [DATE] an abbreviated survey was initiated at the facility. On [DATE] the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an Immediate Jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: state the issue you will find the info on the template you were provided. F678 The facility failed to check the AED device to ensure it had an active status, clean, without visible defects, did not have a low battery, and in operating condition after [DATE]. Action: As of [DATE] the AED has been replaced with a new AED by the Administrator. Start Date: [DATE] Completion Date: [DATE] Responsible: The Administrator. Action: An in-service was on [DATE] that the night shift charge nurses will check that the AED is functioning properly as evidence by the machine is clean without visual effects and that indicator light is flashing green 7 days per week. All charge nurses and agency nurses if used that are not present on [DATE] will be in-serviced before the start of their next scheduled shift in-service will be provided by DON/designee. All new staff and agency nurses if used will be in-serviced/trained at new hire orientation on going prior to start shift. Start Date: [DATE] Completion Date: [DATE] Responsible: DON/DESIGNEE Action: An in-service was started on [DATE] with all charge nurses that if they notice that the indicator light is not flashing green the charge nurse is to notify the Administrator and DON immediately 7 days a week. All charge nurses that are not present on [DATE] will be in-serviced before the start of their next scheduled shift. All new staff / agency staff if used will be in-serviced at new hire orientation on going. Start Date: [DATE] Completion Date: [DATE] Responsible: DON/DESIGNEE. Action: An ADHOC QAPI meeting was conducted on [DATE] to conduct a root cause analysis, discuss the deficient practice and plan of correct. Attendees interdisciplinary team (department heads) Start Date: [DATE] Completion Date: [DATE] Responsible: Area director of Operations, Regional Compliance Nurse, Administrator, DON, and Medical Director. Action: The Medical Director was notified of the immediate jeopardy and ADHOC QAPI by the Admi [TRUNCATED]

Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for 1(Resident #1) of 4 residents reviewed for pest control. 1. The facility failed to ensure the building was free of roaches. 2. The facility failed to ensure Resident #1 didn't have roaches crawling on her, which caused bites on her arm and upper back. These failures placed residents at risk for disease, infection, harm, and a diminished quality of life. Findings included: Record review of Resident #1's, undated, face sheet revealed a [AGE] year-old-female with an admitted [DATE]. Resident #1 had diagnoses which included hemiplegia and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infraction (A lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) affecting the left non-dominant side and chronic pain. Record review of Resident #1's quarterly MDS assessment, dated 04/21/2023, revealed a BIMS score of 08, which indicated moderately impaired cognition. Record review of Resident #1's progress notes, dated 07/14/2023, reflected: The Hospice Aide reported to nurse that while she was attending to Resident in room [ROOM NUMBER], the bed and whole room was infected with cockroaches. Please follow. Record review of the facility's pest control treatment record, dated 07/14/2023, reflected: Rm 216 German Roaches. Facility requested additional service- Met with maintenance to take care of German roach issue happening in room [ROOM NUMBER]. Upon inspection I could confirm that there were German roaches around the nightstands and around the bed . I successfully killed about 60 German roaches .the 2 rooms adjacent room [ROOM NUMBER] were also treated. Record review of Resident #1's Care Plan, revised 07/17/2023, revealed Resident #1 was at risk for pain related to neuropathy (disease or dysfunction of one or more peripheral nerves typically causing numbness or weakness). The resident had limited physical mobility related to Contractures, Neurological deficits, weakness, had an ADL Self Care Performance Deficit Activity Intolerance, Disease Process related to neurological disease. Record review of Resident #1's physician order, dated 07/17/2023, reflected: Benadryl Allergy Oral Tablet 25 MG (Diphenhydramine HCl) Give 25 mg by mouth every 8 hours as needed for Itching for 5 Days. Hydrocortisone External Cream 1 % (Hydrocortisone [Topical]) apply to affected area topically two times a day every 5 day(s) for Insect bites. Record review of Resident #1's skin assessment, dated 07/17/2023, reflected: Insect bites (3 total) right medial forearm: 1 at medial posterior, 2 at medial antecubital fold. 2 at right scapula. During an observation on 07/18/2023 at about 11:25 a.m., revealed Resident #1 had two spots on the right upper, inner hand: 3 spots at right upper lateral back. The spots were small red bumps with white centers (pus-like). During an interview on 07/18/2023 at 11:22 a.m., Resident #1 stated she saw the roaches on her bedside table, and some were crawling on her. Resident #1 stated one of the roaches bit her on her neck and she was immediately moved to another room while her room was sprayed. Resident # 1 stated the bites itched. Resident #1 stated she would like to go back to her original room. Resident #1 stated she kept snacks in the bed with her to eat as needed. During an interview on 07/18/2023 at 11:30 a.m., the DON stated she was made aware of roaches being in Resident #1's room on 07/14/2023. The DON stated Resident #1's bed was immediately stripped off bedding and Resident #1 was taken to the shower. The DON stated a skin assessment was done while Resident #1 was in the shower and there were no skin issues noted. The DON stated all residents on the 200 hall were assessed and there was no evidence of roaches . The DON stated on 07/17/2023, while Resident #1 was being showered, the staff noted some spots on Resident #1 and a skin assessment was conducted. The DON stated the NP was notified via pictures and the NP ordered medications (Benadryl and Hydrocortisone) to treat insect bites and itching. The pictures were no longer on the DON's phone. During an interview on 07/18/2023 at 12:27 p.m., the Maintenance Director stated there was a pest control and maintenance logbook at the nurse's station for staff to communicate with him. The Maintenance Director also stated the Pest Control company usually treated the facility once a month and as needed. He stated he was made aware of Resident #1's room, on 07/14/2023. He stated Resident #1 was immediately transferred to another room and pest control came out and treated the room. Along with the 2 adjacent rooms. The Maintenance Director stated he again treated Resident #1's room on 07/17/2023 with raid roaches' bombs. During an interview on 07/18/2023 at 12:42 p.m., CNA A stated she worked with Resident #1 on 07/14/2023, the day the cockroaches were found on the resident. CNA A stated the Hospice Aide notified her (CNA A) of the cockroaches and she notified the DON, ADON and the Maintenance Director. CNA A stated Resident #1 was immediately moved to another room and the room was treated by pest control same day. CNA A stated staff were asked to check all rooms and beds in the facility for roaches and there were no other rooms noted with roaches. CNA A stated Resident #1 usually ate in bed and had lots of food in her room brought by family. CNA A stated they were in-serviced on pest control on 07/17/2023. During an interview on 07/18/2023 at 2:24 p.m., the Administrator stated he had been employed at the facility for about a week. The Administrator stated pest control went to the facility monthly and as needed. The Administrator stated pest control was at the facility on 07/14/2023 after roaches were seen on Resident #1. The Administrator stated on 07/17/2023 the DON sent pictures to the NP regarding the marks on Resident #1 and the NP told the DON it was bites from the roaches. During an observation on 07/18/2023 at about 2:20 p.m. in room [ROOM NUMBER] revealed had multiple dead cockroaches in the restroom, in the draws and on the floor. On 07/18/2023 at 2:38 p.m. an interview was attempted with the NP and was unsuccessful. Record review of the facility's in-services reflected an in-service titled Pest Control, dated 07/17/2023 with 14 participants. Record review of the facility's Pest control and maintenance log reflected no documentation of cockroaches in room [ROOM NUMBER]. Record review of facility's grievance log from 05/2023 to 07/18/2023 reflected no concerns of cockroaches. Record review of the facility's policy titled, Insect and Rodent Control, dated 2012, reflected: The facility will maintain an effective pest control program in order to provide an insect and vermin free food service department. Arrangements are made with a reputable company for regular spraying for insects which includes rodent control when required. Sanitation of facility will be maintained per other stated sanitation policies to prevent food sources, breeding places, etc. for insects or rodents. According to the CDC, The cockroach is considered an allergen source and an asthma trigger for residents. Although little evidence exists to link the cockroach to specific disease outbreaks, it has been demonstrated to carry Salmonella typhimurium, Entamoeba histolytica, and the poliomyelitis virus.

Based on interviews and record review, the facility failed to notify Resident #1, Resident #1's representative (RP), and a representative of the Office of the State Long-Term Care Ombudsman in writing and in a language they understood, of: a) the discharge and the reasons for the discharge for Resident #1, b) the effective date of the discharge for Resident #1, c) a statement of Resident #1's appeal rights and how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request, d) the name, address and telephone number of the Office of the State Long-Term Care Ombudsman, e) the mailing and email address and telephone number of the agency responsible for the protection and advocacy of Resident #1 under the Protection and Advocacy for Mentally Ill Individuals Act. These failures caused Resident #1 to develop psychosocial distress and emotional harm in the setting of mental illness when resident was discharged from BHH #1 and taken to an alternate nursing facility. These failures caused Resident #1 to be inappropriately discharged and without benefit of advocacy by representative of Office of the State Long-Term Care Ombudsman and/or agency responsible for the protection and advocacy of individuals with a mental disorder. Findings included: Record review of Resident #1's face sheet dated [DATE] revealed he was an [AGE] year-old male that was initially admitted to the facility on [DATE]. Responsible party, RP, per face sheet dated [DATE], was indicated to be family member. Face sheet dated [DATE] included diagnoses of: Memory Deficit following Cerebrovascular Disease (memory deficit after a stroke), Major Depressive Disorder, Transient Ischemic Attack (a brief stroke-like attack), Lack of Coordination, Muscle Wasting and Atrophy (decrease in size of muscle due to loss of muscle tissue), Cerebral Infarction (blockage of blood flow in the brain which causes a stroke or stroke-like symptoms), Occlusion and stenosis of bilateral carotid arteries (blockage and narrowing of arteries which supply blood to the brain), Cognitive Communication Deficit (difficulty with thinking and verbalization to communicate), among other diagnoses. Record review of Resident #1's Quarterly MDS (resident assessment tool required by Centers for Medicare and Medicaid) dated [DATE] indicated that: Resident #1 had clear comprehension of understanding verbal content according to section B0700 of the MDS dated [DATE]. Resident #1 was able to make himself understood in expressing ideas and wants through verbal or non-verbal expression according to section B0700 of the [DATE] MDS. Resident #1 had a BIMS score of ,d+[DATE], indicating moderately impaired cognition, according to his MDS dated [DATE], section C0200 through section C0500. There was no evidence of acute change in mental status from Resident #1's baseline per section C1310 of MDS dated [DATE]. Resident #1 did not have inattentive behavior, disorganized thinking, or altered level of consciousness according to section C1310 of the [DATE] MDS. Section D0200, Resident Mood Interview on the [DATE] MDS indicated: Resident #1 did have little interest or pleasure in doing things ,d+[DATE] days over the previous two-week period; had felt down, depressed, or hopeless ,d+[DATE] days over the previous two-week period; felt tired/had little energy for ,d+[DATE] days over the previous two-week period; had trouble concentrating for ,d+[DATE] days over the previous two-week period. had thoughts that he would be better off dead or of hurting himself in the previous two-week period, 0 days; was having trouble sleeping or was overeating or had poor appetite 0 days over the previous two-week period. Section E0100 of the MDS dated [DATE] indicated that there were no potential indicators of psychosis. Section E0200 of the MDS dated [DATE] indicated that Resident #1 was having no behavioral symptoms; behavioral symptoms were further defined as physical or verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others. Section E0800 of the MDS dated [DATE] indicated that Resident #1 was not exhibiting care rejection or wandering behaviors. Record review of RN Progress Note dated [DATE] revealed that Resident #1 .was trying to exit the building, pt (patient) verbalized wanting to die because he feels he is useless and his son also calls him useless and .was crying all morning between 9 am and 1030 when he tried to escape and was decline (sic) by staff members. Pt (patient) is still on Q15 (every 15 minutes checks) and one on one. Record review of LVN A's Progress Note dated [DATE] revealed that Resident #1 was being monitored one on one for suicidal ideation and self-harm, slept well, and was being checked on every 15 minutes. Record Review of LVN B's Progress Note dated [DATE] revealed Resident continues one on one observation due to suicide/self harm prevention. Q15 (every 15 minutes) checks are also in place. No behaviors changes noted during shift . Record review of SW Progress Note dated [DATE] revealed that SW was attempting placement of Resident #1 in BHH #1; note revealed placement attempts of Resident #1 at three other facilities; note did not include consultation with RP or Resident #1 in determining alternate facility placement. Record review of SW progress note dated [DATE] revealed that Resident #1 was accepted into BHH #1; note stated Resident was accepted into (BHH #1) and will complete evaluation and treatment over the next two weeks. The acceptance came after the resident agreed to voluntarily get help from (BHH #1) then return . Record review of Resident #1's Care Plan with review date of [DATE] revealed that recent hospitalization for suicidal ideation was added to Resident #1's Care Plan on [DATE] and was active at time of discharge. Interventions for Resident #1 included: Notify physician and family, one on one monitoring and observation, approaching resident calmly/unhurriedly, attempting to refocus, counsel/listen, psych (psychology, psychiatry services) consult, medication (psychotropics), and medication review. Interventions for Resident #1 Care Plan suicidal ideation entry did not include behavioral health rehospitalization and/or attempts to find alternate nursing facility which may better meet Resident #1's needs. Record review of Resident #1's Care Plan with review date of [DATE] revealed the following: Resident #1 and family wish to remain at the facility for long term care, initiated [DATE] and active at discharge. Resident #1 has a diagnosis of depression, initiated on [DATE] and current at time of discharge. Interventions for Resident #1 related to depression include: administer medications as ordered and monitor/document for side effects and effectiveness, arrange for a psych (psychology/psychiatry services) consult and follow up as indicated, and monitor/document/report to Practitioner (APRN, MD) signs and symptoms of depression. Record review of Resident #1's Care Plan, with [DATE] review date, revealed initially Resident #1 refused service coordination with local mental health authority but accepted coordination with local mental health authority on [DATE] and active at time of discharge. Resident #1 was identified as having PASRR positive status related to mental illness: mood disorder related to attempt to harm self, identified on [DATE]. Record review of Resident #1's Care Plan, with review date of [DATE] revealed interventions including: the staff will continue to encourage and praise Resident #1 for making independent decisions, the staff will respect the choices that Resident #1 makes, the staff will take time explaining to Resident #1. These interventions were initiated on [DATE] and active at time of discharge. Resident #1 is able and does make wants/needs known to staff, initiated [DATE] and active at time of discharge. Care Plan with review date of [DATE] indicated that Resident #1 demonstrated independence in decision-making. Record review of Resident #1 Care Plan indicated that Resident #1 is at risk for depression related to recent death of spouse (who had lived in facility with him) and had behavior problem in the form of verbalizing threat of self-harm, initiated [DATE] and active at time of discharge. Resident #1 has had inappropriate behavior related to acute episodes of suicidal ideations, initiated [DATE] and active at time of discharge. Resident #1 had a hearing deficit, initiated [DATE] and active at time of discharge. Record review of the facility-initiated Discharge Notification dated [DATE] was signed by ADM. The Discharge - Unable to Meet Needs - Physician/NP/PA Statement contained within Discharge Notification was signed by MD and dated [DATE]. Discharge Notification dated [DATE] and MD statement contained therein dated [DATE] indicated that discharge was necessary for Resident #1's welfare as the facility was not able to provide the level of care required for Resident #1's exhibition of self-harming behaviors. The Discharge - Unable to Meet Needs - Physician/NP/PA Statement, dated [DATE], contained within the Discharge Notification dated [DATE], indicated that the facility efforts to meet Resident #1's needs included being seen by psychiatrist and psychological services and one on one monitoring until Resident #1 was discharged to a more appropriate setting. The Discharge - Unable to Meet Needs - Physician/NP/PA Statement, dated [DATE], indicated that the new facility would provide the following to meet the needs of Resident #1: Resident was sent to the hospital for further evaluation and treatment. The resident needs a facility that is geared towards psychiatric issues in a geriatric resident. The Discharge Notification dated [DATE] did not indicate the name of a receiving nursing facility or behavioral health hospital where Resident #1 would be discharged to. Documentation which indicated that Resident #1 and/or OMB and/or RP received a written copy of Discharge Notification could not be provided by facility. Documentation which indicated that Resident #1 and/or OMB and/or RP was verbally notified could not be provided by facility. There was no evidence of an additional Discharge Notification issued after resident was accepted to an alternate nursing facility as noted in SW Progress Notes of [DATE]. Record review of written notification that OMB was notified of Resident #1 discharge was inclusive of an email dated [DATE] from OMB to SW which indicated that OMB was trying to reach SW to have a conversation with SW regarding a safe discharge; OMB indicated in email that she was unable to reach SW by phone. It is unknown if Resident #1 was the subject of the safe discharge that was indicated on the email dated [DATE]. ADM was unable to provide other written record of discharge notification to OMB regarding Resident #1 after request made by investigator on [DATE] at 5:30 pm. Record review of the SW Progress Note dated [DATE] indicated that a transfer packet was submitted to BHH #1 at RP request. SW Progress Note dated [DATE] indicated that SW had also contacted three nursing facilities to attempt placement for Resident #1. There is no documentation to indicate that RP or Resident #1 were consulted regarding alternate nursing facility placement or that this had been requested or initiated by Resident #1 or RP. Record review of the Progress Note dated [DATE], written by SW, stated that .resident agreed to voluntarily get help from (BHH #1) then return to (facility). Progress Notes dated [DATE], written by SW, revealed that Resident #1 was sent to BHH #1 on [DATE] at 8:30 pm, the day prior to the written entry. Progress note dated [DATE], written by SW, indicated that ADM scheduled transportation to BHH #1. Further review of the Progress Note by SW dated [DATE] revealed that Resident #1 would be re-evaluated prior to re-entering the facility. Progress note by SW dated [DATE] revealed that Resident #1 had been accepted by an alternate nursing facility. Record review of the APRN Progress Note dated [DATE] revealed that Resident #1 was oriented to person, place, and situation and had appropriate insight. APRN Progress Note dated [DATE] indicated that Resident #1 had mild MDD with situational depression and was started on an anti-depressant medication and a psychology/psychiatry consult was placed. Record review of the Psychology Diagnostic Assessment signed by PSP on [DATE] revealed that Resident #1 had a remote (1967) past-history of suicide threat involving a gun, more recent history (December, year unknown) of suicide attempt using a telephone cord for which the facility hospitalized him at BHH #2 and history at facility of trying to bite his wrist to make himself bleed to death (date unknown) after his roommate's TV was left on for consecutive nights. Current risk factors indicated on Psychology Diagnostic Assessment on [DATE] revealed Suicidal Ideation: None, History of, history of ideation when wife became very ill and died . Recent suicide attempt - sent to (BHH #2). No current suicidal ideation. Record review of Psychology Diagnostic Assessment signed by PSP on [DATE] revealed that Resident #1 was scored ,d+[DATE] on Geriatric Depression Scale, indicative of severe depression. Further review of the Psychology Diagnostic Assessment revealed that Resident #1 is not currently a danger to self or others and has situational depression; treatment plan indicated combined mental health therapy services once every ,d+[DATE] weeks for ten sessions with medication to manage his depression. There were no records provided by facility to indicate that local or State mental health authority was notified or consulted in pending discharge of Resident #1. There was no evaluation found in EMR or provided by facility to indicate that Resident #1 was re-evaluated at facility after discharge from BHH #1. Record review of undated facility Suicide Threat policy indicated Policy Statement and Policy Interpretation and Implementation. Suicide Threat Policy Interpretation and Implementation section indicated the actions to take during the acute suicide threat and then actions which would be taken once the resident is stable. The policy does not include or list an intervention involving alternate placement outside of facility or transferring or discharging a resident when this occurs. There was no Discharge Summary located in electronic medical record for record review. Facility was unable to provide Discharge Summary for Resident #1. Interview with the ADM on [DATE] at 5:30 pm revealed that Resident #1 was discharged to BHH #1 on [DATE]. The ADM stated that she told RP that Resident #1 would be re-evaluated when he came back from BHH #1 to determine if he was appropriate for the facility. The ADM stated that Resident #1 was banging head against the rails of bed and wall trying to kill himself. The ADM stated that Resident #1 had been in facility for four years and that his family member had been there for many years; Resident #1's family member had recently passed away in [DATE] and ADM stated that being at facility was felt to be a trigger for Resident #1's suicidal behavioral The ADM stated that acceptance at alternate nursing facility #1 was obtained prior to Resident #1's discharge to BHH #1. The ADM did not indicate reason for plan to re-evaluate Resident #1 after he was discharged from BHH #1 for re-admission to facility while simultaneously obtaining acceptance for Resident #1 at alternate nursing facility #1. ADM stated that Resident #1 had past-history of attempting to harm himself prior to and after admission to the facility which was exacerbated a few months prior to discharge with death of family member who had been in the facility with him. Interview with the SW on [DATE] at 1:55 pm revealed that Resident #1 had past suicide attempts prior to entering facility. The SW stated that Resident #1's behavior at facility included banging head on floor and walls while stating that he wanted to die. The SW stated that Resident #1 had been placed one on one with a caregiver who could supervise him. The SW stated that she did not see paperwork submitted to facility from BHH #1 when Resident #1 was being discharged from BHH #1. The SW stated that the plan for Resident #1, when he was sent to BHH #1 on [DATE], was that at discharge time from BHH #1, Resident #1 would be re-evaluated for return. The SW stated that Resident #1 was not notified in writing or verbally prior to leaving for BHH #1 that he would be going to Alternate Nursing Facility #1 as the plan was to re-evaluate Resident #1 after he finished treatment at BHH #1. The SW stated that she felt that the discharge paperwork from BHH #1 contained information which was the deciding factor against return of resident #1 to facility. The SW stated that she did not see the information sent from BHH #1 to facility at time of discharge from BHH #1. Interview with the RP on [DATE] at 12:00 pm revealed that call was made from ADM on [DATE]; The ADM stated to RP that facility was not taking Resident #1 back. The RP stated that BHH #1 also called her on [DATE] and stated that it was their understanding that Resident #1 was being returned to facility upon discharge that day; BHH #1 stated that there had been an agreement made prior to admission of Resident #1 for inpatient behavioral health that the facility would accept Resident #1 back. The RP received a phone call at 6:30 pm on [DATE] from Resident #1 and stated that Resident #1 was upset and crying on the phone. The RP stated that Resident #1 had been picked up at BHH #1, put in a transport van, and taken to Alternate Nursing Facility #1 without explanation or information. The RP stated that Resident #1 was disoriented and scared being in a new environment that he was unfamiliar with. The RP stated that Resident #1 stated that he had not agreed to go to Alternate Nursing Facility #1. The RP stated that Resident #1 had not been notified by facility of discharge and had trouble getting information from anyone at BHH #1 on [DATE], date of discharge from BHH #1. Resident #1 stated that he asked the transportation personnel where he was going when he was being transported to Alternate Nursing Facility #1 and did not get an answer. The RP stated that an emailed copy of the Discharge Notification for Resident #1 from the facility was received to personal email on [DATE]. RP stated in interview that she had been notified by phone on unknown date by SW and ADM that Resident #1 had been accepted at Alternate Nursing Facility #1. Discharge Protocol Packet: Page 1: discharge date : Perform the following actions: (enter the date completed for each action): Discharge - Unable to Meet Needs - Physician/NP/PA Statement on page 2 completed., Discharge Notice on page 3 completed. Discharge Notice Provided to the following: Resident Representative: Check if Not Applicable/Present: Ombudsman: Other Facility: (Only required if the resident is currently at another facility, i,e, hospital; psych center, etc.) Check if Not Applicable Has APS been notified of this discharge? If Yes, date of notification: Page 2: Discharge- Unable to Meet Needs- Physician/NP/PA Statement: Resident Name: 1. What are the specific resident needs the facility cannot meet? 2. What were the facility efforts to meet those needs? 3. What are the specific services the new facility will provide to meet the needs of the resident which cannot be met at the current facility? MD/NP/PA Signature: Date:

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and failed to ensure the resident remained free of accident hazards as possible for one (Resident #1) of 82 residents. The facility failed to provide an environment free from accidents and hazards over which the facility had control and provided supervision to prevent avoidable accidents. On 02/18/2023, Resident #1 was able to elope from the facility using the 200-hallway emergency alarmed exit door. The 200-hallway door was used temporarily as the facility main entrance and exit from 02/04/2023 until 03/01/2023. After seeing Resident #1's wheelchair empty outside of the 200-hallway exit door, facility staff began looking for Resident #1 within the facility. When he was not located immediately, facility elopement procedures were followed. Approximately 12 hours later the resident telephoned his family member, who called the facility and informed them of Resident #1's location. According to wuweatherunderground (https://www.wunderground.com/history/daily/[NAME]/date/2023-2-18) the weather was as follows: High temperature - 55, Low temperature - 26, Average temperature - 41.88, Precipitation zero. The facility is in a high traffic area with a speed limit on of 45 miles per hour on street where the facility is located. Observation of street directly in front of the 200-hallway exit exhibited very high traffic with two-way lanes with a median separating the lanes. Resident #1 was retrieved by facility staff nurse at a location 5.13 driving miles away from the facility, was returned to the facility, was assessed, and found to have no injuries. An IJ was identified on 3/9/2023. The IJ began on 2/18/2023 and removed on 2/18/2023. The facility took action to remove the IJ before the survey began. While the IJ was removed on 2/18/2023, the facility remained out of compliance at a scope of Isolated and a severity level of no actual harm with a potential for more than minimal harm because all staff had not been trained on elopement policies, in-services on exit seeking behaviors, and conduct a QAPI had not been conducted regarding the elopement incident. While the front door had been fixed the facility failed to retrain staff on elopement policies, in-services on exit seeking behaviors, and failed to conduct a QAPI regarding the elopement incident. This deficient practice could place residents at risk for serious injury, serious harm, serious impairment, or death likely. Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and failed to ensure the resident remained free of accident hazards as possible. Findings included: Review of Resident #1's Face Sheet, undated, revealed a [AGE] year-old-male admitted to the facility on [DATE] with a diagnosis of schizophrenia, (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation), unspecified. Unstable burst fracture (an injury in which the vertebra, the primary bone of the spine, breaks in multiple directions) of first lumbar vertebra (a bones forming the backbone, level with the anterior end of the ninth rib) subsequent encounter for fracture with routine healing. Review of Resident #1's Care Plan, initiated 01/27/2023, revealed Resident #1 exhibited impaired social interaction, hallucinations (an experience involving the perception of something not present) and disturbed through process (altered understanding of situations) and cognition (the process of acquiring knowledge) that interfered with daily living. The care plan revealed he was, .at risk for elopement r/t (related to) able to ambulate/locomotion per self, desire to go home, exit seeking behaviors. The care plan revealed he demonstrated manipulative, destructive, insensitive, and disrespectful behavior. Review of Resident #1's Elopement Risk Assessment, dated 01/27/2023, revealed a score of 23. The Risk Assessment evaluation scale revealed a score of 5 or more is considered to be a risk for elopement. Review of Resident #1s Minimum Data Set (MDS) dated [DATE] revealed serious mental illness and a BIMS score of 11 indicating moderate cognitive impairment. Review of local Police Department accident data sheet dated 02/04/2023 revealed a car collided into the portico (a structure consisting of a roof supported by columns at regular intervals, typically attached as a porch to a building) of the main entrance of the nursing home. Interview on 03/07/2023 at 9:50 AM with ADMIN revealed at the accident occurred at approximately 7:30 PM on 02/04/2023 and Resident #1 was missing for approximately 12 hours on 02/18/2023. Interview on 03/08/2023 at 12:46 PM with the RDBO revealed when he arrived at the facility on the date of the collision the fire department was taping off the front entrance with caution tape and told him the regular entrance to the facility could not be used because safety concerns of structural damage. The RDBO revealed a decision was made to use the 200-hallway door for the entrance/exit. The RDBO revealed he was not concerned about using 200-hallway door because he installed a new Safety Technology International Exit Door Alarm: Key Lock. The RDBO revealed to disarm the 200-hallway exit door, a key was inserted at the bottom front of the box (the keyhole was clearly visible) and turned horizontally to turn off the alarm to allow people to enter and exit the facility and to arm the door, the key was inserted and turned vertically. Observation on 03/07/2023 at 12:46 PM of the 200 Exit Alarm Key Lock revealed a visible to all viewers easy to follow diagram on in the alarm key lock that displayed the instructions on how to activate and deactivate the alarm on the 200-hallway. Interview on 03/10/2023 at 4:45 PM with the ADMIN revealed that beginning 02/06/2023 the receptionist, who worked 7:00 AM until 4:00 PM Monday - Friday was given the responsibility to let people in and out of the facility and to use the alarm key to arm and disarm the door. When the receptionist was not at the facility the AA, HA, or charge nurse for the 200-hallway were responsible for letting people in and out of the building with the alarm key and arming and disarming the door. Interview on 03/07/2023 at 12:26 PM with the receptionist who explained she first saw the damage to the entry on Monday 02/06/2023. She said it was appeared that they absolutely could not go through the front door because it was cautioned off with tape. She explained there was a sign and arrows directing people enter using the 200-hallway door. After about a day and a half she moved her desk to the room across from the 200-hallway door. The facility had installed a doorbell and when someone would ring the bell, she would use the key to disarm the door and when they exited, she would use the key to arm the alarm. She revealed she kept the key in her pocket. Receptionist revealed that the key to the alarm that she used for the 200-hallway when the front door was not working with the administrator. The receptionist reported when she left for the day, she physically handed the key for the 200-hallway alarm to the evening a charge nurse or the administrator. Observation on 03/07/2023 at 9:30 AM revealed facility front door fully functioning, and employee came to the front door and used keypad to allow access to the facility. No observations of residents approaching the front door or attempting to use the keypad. Nursing station and reception desk in clear view of front door with no obstruction of front door alarm and keypad. Interview on 03/09/2023 at 3:23 PM with LVN A who worked PRN (as needed) revealed that when she worked on the 200-hallway during the time the front entrance was not being used, she kept the alarm key with her and did not leave the key in the keyhole. Observation and interview on 03/08/2023 at 12:46 PM with the RDBO revealed small nail sized hole in the wall to the right of the nurse's station. The RDBO revealed the evening of 02/04/2023 he put a nail in the wall where the small hole was observed and put a, big red keyring holding the 200-hallway exit door disarm key on the nail. The RDBO said he put the key there so it would be easily accessible to the staff to let people in and out of the facility. Interview on 03/10/2023 at 4:45 PM with the ADMIN revealed he was unaware the RDBO had put the key that armed and disarmed the entry and exit to the 200-hallway on a key ring next to the nurse's station visible to residents. Interview on 03/08/2023 at 9:42 AM with CNA A revealed it took a long time to get the front door fixed and if any of staff heard the doorbell ring, they would let them in. At the beginning only the nurses had the alarm key but, it started to get too much and eventually the key was left in the emergency alarm. Interview on 03/09/23 at 12:30 PM with the MD revealed that at some point the key was left in the keyhole of the 200-hallway because staff would get frustrated. Interview on 03/09/2023 at 4:08 PM with R#2 in room [ROOM NUMBER]A located at the end of the 200-hallyway next to the exit door indicated he observed the key left in the alarm several times. Review of in-service entitled Topic: Complete Visual Check on the 200 Hall Doors dated 02/04/2023 with trainer/education by the ADON. Interview on 03/07/2023 at 12:26 PM the receptionist revealed Resident#1 vigilantly watched her letting people in and out of the 200-hallway door. She revealed Resident# 1 watched her for one full day. The receptionist did not tell the ADMIN, the DON, or the ADON about Resident#1 watching the door. When the receptionist asked if she felt Resident #1 was exit seeing the receptionist relayed, oh yea, he was exit seeking. She revealed that she kept the key in the desk draw of the room located across from the 200-hallway door. The receptionist revealed she was always in the room across the when she was working. Interview on 03/09/2023 at 12:35 PM the receptionist revealed she told the SW Resident #1 was very intelligent and was watching her when she was letting people in and out of the 200-hallway door. Interview on 03/07/2023 at 9:50 AM the ADMIN revealed that Resident #1 was exit seeking. Interview on 03/08/2023 at 9:42 AM with CNA A revealed Resident #1 was clearly exit seeking and he would punch the numbers on the 400-hallway exit door keypad and she would tell him, get back over here. She revealed Resident #1 was very smart and paid attention and was going down the 200-hallway paying attention, too much. CNA A revealed she told the ADON, all the time that he was punching in number on the keypad. Interview on 03/07/2023 at 5:25 PM with ADMIN revealed that because the WanderGuard was not working it affected how the staff kept eyes on the residents and revealed that because of the possible harm to the resident the facility increased staffing and visual checks of the residents and conducted elopement drills. The ADMIN revealed he was pushing for corporate to fix the door. Interview on 03/07/2023 at 9:50 PM the ADMIN revealed that Resident #1's room was on the 400- hallway but he walked around everywhere - sometimes he used his wheelchair and sometimes he did not. Interview on 03/07/2023 at 1:25 PM with LVN B, the 200-hallwy nurse on 02/18/2023, and she works the 6:00 AM to 6:00 PM shift. She revealed she remembered him talking to her and he was unintelligible, and she was busy passing out medications and did not notice where he went or what time she spoke with him. She discovered Resident #1 was missing when the facility began elopement protocols. Interview on 03/08/2023 at 9:42 AM with CNA A revealed on 02/18/2023 at 7:15 AM she saw Resident #1's wheelchair, empty, outside of the emergency exit door of the 200-hallway and went to go look for him in his room on the 400-hallway. When CNA did not find him in his room, she located his nurse RN A and asked if RN A had seen him. RN A said she had not seen him. CNA A revealed that they began searching for Resident #1 both in and outside the facility. Interview on 03/07/2023 at 9:50 AM with the ADMIN revealed that on 02/18/2023 at about 7:45 AM he received a call from RN A that Resident #1 could not be located in or around the facility and the ADMIN instructed RN A to initiate elopement protocols. The ADMIN revealed RN A told him she called the police and informed police about a missing resident, but RN A said the police. Interview on 03/07/2023 at 9:50 AM with the ADON revealed that Resident #1 was retrieved by her at approximately 8:00 PM on 02/18/2023 from a CVS and the ADON returned with him to the facility. Review of Resident #1's progress notes dated 02/19/2023 reveal that at approximately 8:00 PM on 02/18/2023 the ADON completed a bedside assessment revealing normal blood pressure and temperature with zero signs of distress or pain noted and zero skin issues noted. Resident was discharged Against Medical Advice on 02/18/2023. Review of Resident #1's face sheet dated 03/08/2023 revealed under the area of contacts it read, responsible party - self. Interview on 03/07/2023 at 9:50 the ADMIN revealed the front entrance was the most secure entrance and exit to the facility because it was visible from the nurse's station, visible from the receptionist area, and visual from the ADMIN office. Additionally, it had a secure keypad, and alarm, and is wired for WanderGuard (a device worn on the wrist or ankle to trigger alarms and prevent wander-prone residents from leaving unattended). Review of Resident #1's order summary report dated 03/09/2023 reveals an order in place to check WanderGuard placement and function every shift beginning 02/15/2023. Interview on 03/07/2023 at 9:50 AM of ADMIN revealed the front entrance of the building was not being used because of the collision from 02/04/2023 until 03/01/2023. The ADMIN revealed that he did not have the authority to make a financial decision regarding making building repairs to the facility. He revealed that on 02/04/2023 the CEO phoned him and said that he wanted to go through the insurance company of the owner of the car who collided with the building because it would increase the premium cost of the facility insurance if they used the facility insurance. Interview on 03/09/2023 at 1:00 PM with the COO revealed the facility was waiting on the insurance company of owner of the car who caused the damage to the front of the facility to appraise the damage and make payment for the damages before making repairs to the main entrance. Review of estimate from construction company dated 02/07/2023 reveals that the repair cost to the front entrance portico was $7,500. Review of email from the facility owner to the facility CFO and ADMIN dated 02/27/2023 stating, we cant wait on insurance to cover this. It's a hazard to residents. We will have to get reimbursed from the insurance company. Interview on 03/07/2023 at 1:26 PM with the FMD revealed that the facility was waiting for an estimate from the car insurance company of the owner of the car who caused the damages before they made the repairs. He constantly called the insurance company to make sure they were going to pay for it and the insurance company was non-responsive. He revealed that he told that to the insurance company that it was a safety concern. He revealed that the work to repair the front entry began on Monday 02/27/2023 and ended on 03/01/2023. Review of facility Inservice Elopement Drill dated 02/17/2023, 02/19/2023, 02/19/2023, 02/22/2023. Review of the facility's Elopement and Wandering policy revised December 2007 reveals: 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 2. The staff will assess at risk individuals for pension initially correctable risk factors related to unsafe wandering 3. The resident care plan will indicate the resident is at risk for elopement or other safety issues interventions to try to maintain safety will be included in the resident care plan. 4. Nursing staff will document circumstances related to unsafe actions, including wandering, by resident. 5. Staff will institute a detailed monitoring plan, is indicated for residents who are assessed to have a high risk of allotment for other unsafe behavior. 6. Staff will notify the administrator and director of nursing's immediately and will institute appropriate measures (including searching) for any resident who is discovered to be missing from the unit or facility. Facility was notified on 03/09/2023 at 5:10 PM that an IJ situation had been identified due to the above failures. It was determined these failures placed Residents #1 in an IJ situation on 02/18/2023. The facility implemented the following interventions: On 03/04/2023 repairs were completed on the portico of the main front entry door equipped with a keypad entry and exit, WanderGuard Alarm, fire alarm, and visibility of residents from the nurse's station, receptionist, and ADMIN's office. After the completion of the front entry repairs neither the 200-hallways door or any other facility emergency exit doors were opened and closed using a key to alarm and disarm doors.

Based on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for Resident #1 reviewed for accidents and supervision. The facility failed to ensure Resident #1 did not ingest a decorative bead resulting in a choking incident during lunchtime. Status post a successful Heimlich Maneuver Resident #1 was returned to her baseline. For precautionary measures, she was sent to the hospital for further assessment. Resident #1's x-ray indicated Resident #1 had moderate left lower lob airspace disease, atelectasis versus pneumonia. Resident #1 expired days later at the hospital. This failure could place residents identified with dementia at risk for potential death or brain damage due to lack of oxygen from choking. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 5:05 PM, While the IJ was removed on [DATE] at 5:00 PM, the facility remained out of compliance at scope of isolated and severity level of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. Findings included: Record review of Resident #1's, undated, face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included of Alzheimer's Disease((loss of memory) dementia(memory loss) hypertension(high blood pressure),major depressive disorder (sadness), hyperlipemia (increased cholesterol),bipolar disorder(mood swings), insomnia(sleeping disorder), kidney disease(renal failure), rheumatoid arthritis(inflammation of joints), depression(sadness) and dysphagia (difficulty swallowing). Record review of Resident #1's quarterly MDS, dated [DATE], revealed Resident#1's BIMS Summary score was 2, which indicated severe cognitive impairment. Record review of Resident #1's progress notes, dated [DATE] written by DON, revealed Resident #1 noted choking and gargling during lunch. Record review of Resident #1's, undated care plan revealed diet puree thin liquids divided plate, was at risk for injury diet alteration related to Dementia, poor safety awareness, self ambulates, and displays severe impairment with decision making skills. Interview on [DATE] at 11:53 AM, with the DON stated Resident #1 at lunch time on [DATE] was in the dining room appeared to be choking and gargling. LVN A noticed something was in Resident #1's mouth and tried to take it out. LVN performed the Heimlich Maneuver on Resident #1 and decorative objects expelled from Resident #1's mouth. It was unclear when Resident #1 obtained the fall decorations from the commons area or when Resident #1 placed them in her mouth. Interview on [DATE] at 12:00 PM, with the Administrator stated it was unclear when Resident #1 obtained the fall decorations from the commons area or when Resident #1 placed the objects in her mouth. Resident #1 at lunchtime was choking and LVN performed the Heimlich Maneuver and determined Resident #1 had choked on decorations that were placed in the commons area for the Thanksgiving Holiday. Interview on [DATE] at 1:30 PM, with the Administrator and DON stated the facility did not have a policy for residents to be monitored. The facility was an open community and staff redirected residents to designated locations. There was no policy on dementia care or accidents when they occurred. Interview on [DATE] at 2:59 PM, with LVN A stated she went to assist Resident #1 in the dining room at lunch time when she was alerted there was an emergency situation going on. LVN A quickly pulled out Resident #1's chair and performed the Heimlich Maneuver. Decorative objects expelled from Resident #1's mouth. LVN stated it was unclear when Resident #1 obtained the decorations that were placed out in the commons area. LVN was not aware of the policy for dementia care or monitoring. Interview on [DATE] at 3:13 PM, with RN C stated the incident with Resident #1 occurred in the dining room at lunch time. RN C noticed Resident #1 coughing while she was assisting another resident and noticed something was in her mouth. She yelled for help and LVN A did the Heimlich Maneuver on Resident #1 and pieces of decorations came out Resident #1's mouth. RN C did not know when the resident obtained the decorations. The decorations were from the common's areas in the facility. RN C stated she was not aware of the policy on dementia care or a monitoring policy. She stated policies were important for guidance to follow to prevent injury or death. Interview on [DATE] at 4:33 PM, with CMA A stated she was in the dining room at lunch time when Resident #1 started choking. LVN performed the Heimlich Maneuver and objects came out of Resident #1 that looked like the fall decorations in the common's areas of the facility. CMA A was not aware of the monitoring policy and residents were directed if they were wanderers CMA A stated when policies were not in place injuries could occur. Interview on [DATE] at 5:15 PM, with RN A stated she was not in the building when the incident occurred. She stated there was no policy she was aware of to care for dementia patients. The facility was an open community and there was no monitoring policy to monitor residents at the facility. Wanderers were directed to their designated areas when found in other areas. RNA A stated it was important to have policies in place to prevent injuries or death of a resident. Interview on [DATE] at 1:26 PM, with CMA B stated she received no dementia care or monitoring of residents training. She was not aware of any policy on monitoring residents. She stated she directed the resident's that walked the halls back to areas with staff. CMA B stated it was important to have the proper training to be able to care for resident's needs. Not able to provide the needs of residents may cause a resident to become ill. Interview on [DATE] at 2:05 PM, with CNA A stated she had nit had any training on dementia care. She was not aware if a policy of monitoring residents. She was not aware of a policy of monitoring residents. She stated she directed residents from the halls to designated areas. She stated she had not had any training on dementia care. She was not aware of a policy of monitoring residents. She stated when she have questions, she got help from the DON. CNA A stated it was important to have proper training to care for residents to prevent illness or injuries. Interview on [DATE] at 2:45 PM, with CMA C stated she was not aware of a policy on dementia care or monitoring residents. CMA C stated she directed residents when she found them to the front of the facility when they were found wandering in halls . CMA C stated it is important to follow policies to prevent injuries. Interview on [DATE] at 2:50 PM, with CNA B stated she was unaware of a policy for caring for dementia residents. She stated she directed the residents from various areas of halls to designated areas with staff. CNA B stated she had She had not trained on dementia care and if she had questions, she asked the DON. CNA B stated it was important to have training to be able to care for the resident's needs. Interview on [DATE] at 2:57 PM, with RN B stated she could not recall a dementia care policy or a monitoring policy. Staff directed residents that were wanderers when they found residents in halls. The facility was an open community for residents. RN B stated it was important for the residents to remain safe to prevent injuries or illness. Record review of a photo on [DATE] at 2:00 PM, revealed the objects of fall decorations that were expelled from Resident #1 mouth during the choking incident. The identified objects appeared to three decorative beads and a piece of yarn. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 5:05PM. The Administrator were notified. The Administrator was provided with the IJ template on [DATE]. The following Plan of Removal submitted by the facility was accepted on [DATE] at 5:00PM. Pflugerville Health Care Center Plan of Removal [DATE] Impact Statement: On [DATE] one resident was identified with the potential to be impacted by this deficient practice. The facility failed to provide adequate supervision for 1 of 9 residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not ingest a decorative bead, causing a choking incident. Resident #1 was ordered a pureed diet and was not known to place unpureed food in her mouth when not supervised. The notification of the immediate jeopardy states as follows: On 11.15.2022 an abbreviated survey was initiated at Pflugerville Health Care Center. The Surveyor has determined that the conditions at the center constitute immediate jeopardy to resident health. Identify residents who could be affected-4 residents have been identified Problem 1: The facility failed to ensure Resident #1 did not ingest a decorative bead, causing a choking incident. Resident #1 was ordered a pureed diet and was known to place unpureed food in her mouth when not supervised. Action Taken: ? Action Item - Safe Environment Check: o Administrator and/or Maintenance Director completed a sweep/physical audit of all items in the communal areas that had the potential to pose a choking hazard (e.g) any other decor in the facility). This was completed on [DATE]. o The administrator and Maintenance Director will conduct weekly facility safety checks to ensure that all items that present a choking hazard to residents are removed. o All items that met the following criteria were removed on [DATE]: decorations that could be easily removed, mouth-sized pieces, or decor that can be confused for food items, such as berries, candies, etc. Items removed were tracked on the Sweep Facility Audit form. o Start Date:[DATE] o End Date:[DATE] and Ongoing o Who is Responsible: ADON o Who will Monitor: Administrator/DON o Action Item - Education o All Staff -working all shifts- have been educated on the following topics. this training began on [DATE] and was completed on [DATE]. The facility's Medical Director has been involved. All staff on vacation and or new staff will be required to complete and sign the in-service before they are allowed to work on the floor. o Education and training will be included in the newly hired staff orientation to include agency staffing personnel. (Not utilizing agency staff currently) o Briefing of the incident with Resident #1. o Training on supervision of residents and choking procedures. Monitoring of the Plan of Removal revealed the following: Observation on [DATE] at 12:00 PM Staff monitoring residents eat lunch and no decorations were visually seen throughout the facility. Observation on [DATE] In-service conducted, and testing completed by staff on dementia policy. Interview on [DATE] at 3:12 PM - 4:26 PM revealed staff were able to identify abuse and neglect and describe different types of abuse and neglect. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 5:00PM. The facility remained out of compliance at a severity of actual harm and a scope of J due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observations, interviews, record reviews, the facility failed to provide an environment that was free from accident hazards for three (Resident #86, Resident #3, and Resident #47) of four residents reviewed for falls. The facility failed to investigate to determine the causative factors of the falls to help prevent and/or reduce risk for falls and implement new fall interventions. This failure resulted in Resident #86 sustaining a right [CONDITION(S)] as the These failures could place residents who require supervision at risk of accidents or injury resulting in a fall. Findings included: 1. A review of Resident #86's face sheet indicated Resident #86 was admitted on [DATE] with diagnoses that included a fracture of the left femur, muscle weakness, muscle wasting and atrophy, lack of coordination, and repeated falls. A review of the 5-day entry Minimum Data Set (MDS), dated [DATE], indicated that Resident #86 had a Brief Interview for Mental Status (BIMS) score of 99 out of 15, which indicated significant cognitive impairment, as the resident was unable to complete the interview. Resident #86 required extensive assistance of one person with bed mobility, transfer, and toileting. Resident #86 required supervision with set-up for eating. A review of the care plan, initiated on 10/08/2021, indicated the resident was at risk for falls related confusion, gait balance problems, dementia, and poor safety awareness. Further review of the care plan indicated interventions in place were to anticipate the resident's needs, safe environment with glare-free light, a working and reachable call light, the bed in low position at night, and educate resident's family about safety reminders and what to do if a fall occurs. A further review of the care plan indicated there were no updates to the care plan since it was implemented on 10/08/2021. A review of the fall risk assessment, completed on 10/07/2021, indicated the Resident #86 scored a 21, which meant the resident was considered a high fall risk. A review of an incident report, dated 10/07/2021, indicated Resident #86 fell while attempting to transfer themself from the wheelchair to a chair. A further review of the incident report indicated no causal factors related to the fall or appropriate interventions were identified. A review of an incident report, dated 10/08/2021, indicated staff notified the nurse that Resident #86 grabbed the side rail in the hall and slid out of the wheelchair onto the floor. A further review of the incident report indicated no causal factors related to the fall or appropriate interventions were identified. A review of an incident report, dated 10/12/2021, indicated staff notified the nurse that Resident #86 was found on the floor in the dining room. The resident complained of pain to the lower extremity, and an x-ray was ordered. A further review of the incident report indicated no causal factors related to the fall or appropriate interventions were identified. A review of Resident #86's progress note, dated 10/12/2021 at 11:00 AM, revealed the nurse practitioner was notified of the x-ray results of a right [CONDITION(S)], and the resident was sent to the emergency room for further medical evaluation. A review of a progress note, dated 10/17/2021 at 4:00 PM, revealed Resident #86 readmitted back into the facility with a diagnosis of a right [CONDITION(S)] that required surgical repair. An interview on 11/10/2021 at 12:37 PM with LVN N revealed that when a fall occurred it was handled as either a witnessed or unwitnessed fall. A witnessed fall required staff that witnessed the fall to write a statement about what they observed. LVN N stated staff should have assessed for injuries and range of motion (ROM) and started neurological checks if the fall was unwitnessed or if the resident hit their head. LVN N further stated that after staff completed their assessment and the resident was safe, staff could return the resident back to their prior position, check vitals, and ask about any pain. Staff should make sure the family and physician were contacted and made aware. LVN N said staff should have charted a progress note in the electronic medical record (EMR) and an incident report. LVN N stated all unwitnessed falls were placed on close monitoring for 72 hours to ensure there was no head injury. LVN N further stated nursing staff completing the reports were not responsible for identifying root cause or appropriate interventions because the DON completed that and updated the care plan. LVN N stated Resident #86 was a fall risk, and she placed the resident on one-to-one supervision during the shifts she worked. LVN N stated that Resident #86 was not placed on official one-to-one supervision by the facility, but due to Resident #86's lack of safety awareness, LVN N felt the resident would benefit from additional supervision. However, that information was not communicated with the DON. LVN N stated that information was passed through shift reports, and she was not sure what level of supervision Resident #86 received on other shifts. LVN N stated she was not sure what the current fall interventions in place were for Resident #86. An interview on 11/10/2021 at 3:46 PM with RN O revealed that after a fall, nursing staff would first assess a resident and check for range of motion and pain level. RN O stated if the fall was unwitnessed, staff would start neurological checks, and if it was witnessed, they would get a statement from the staff that observed the fall. RN O stated staff contacted family and the physician to make them aware of the fall. RN O said nursing staff completed a progress note in the EMR and an incident report related to the fall, but that she did not look at the current care plan during that process. RN O stated nursing staff were not responsible for identifying root cause or appropriate interventions, and that the DON would discuss the falls information during morning meetings, which was when root cause and interventions would be identified. RN O stated that was why there was not a care plan update or root cause identified after the fall incident reports she completed. RN O stated the DON should have completed that after the falls. An interview on 11/10/2021 at 4:16 PM with LVN P revealed that after a fall occurred, staff should first assess the resident and observe for any injuries, and then return the resident back to their prior position if able. LVN P further stated the family, and the physician should have been contacted and made aware of the fall, and staff should complete a fall incident report. LVN P stated nursing staff could identify interventions, but the DON was responsible for updating the care plan. LVN P stated he ensured staff watched Resident #86 closely, but he was not sure if staff on other shifts supervised Resident #86 as closely. LVN P stated it was not documented for Resident #86 to receive any specific level of supervision. LVN P also stated that nursing staff were not responsible for updating care plans after a fall because the DON completed that. LVN P stated there wasn't any follow-up or further directives given by administrative staff after Resident #86 had falls in relation to safety interventions. An interview on 11/11/2021 at 9:44 AM with CNA Q revealed Resident #86 was a fall risk and the resident had a low bed but did not have a fall mat. CNA Q stated staff should have been monitoring the resident closely throughout the day, but that Resident #86 stayed in bed most of the time. CNA Q stated she was not aware of any other current interventions in place for the resident. An interview on 11/11/2021 at 11:42 AM with LVN S revealed that after a fall, nursing staff should have assessed the resident for injuries, and if able, return the resident back to their prior position. LVN S stated nursing staff completed an incident report and contacted the family and physician. LVN S further stated if the fall was unwitnessed staff would have started neurological checks for 72 hours, but nursing staff did not identify root cause or appropriate interventions. LVN S stated the DON and the ADON would have completed that and ensured the care plan was updated. LVN S stated nursing staff identified interventions for an immediate need, but the ADON and the DON identified long-term interventions. LVN S stated that on 10/12/2021, Resident #86 was up early and out of the room in a wheelchair. LVN S stated she was not sure if there were any specific requirements for supervision for the resident, but she remembered she was the only nurse in the facility that morning and the CNA was the only CNA staff on that hall. LVN S stated she did not know how Resident #86 got to the dining room that morning or if CNA staff was monitoring the resident. LVN S stated she did not know how the fall occurred or how she concluded the fall was a result of the resident trying to transfer unassisted. LVN S stated she just remembered the CNA coming to get her to assess the resident after the fall occurred. LVN S stated she requested the resident have an x-ray because she suspected the resident had an injury to the leg. The resident complained of pain when their leg was moved. An interview on 11/11/2021 at 1:27 PM with the Director of Nursing (DON) revealed that after a resident had a fall, nursing staff should have assessed the resident for injuries and started neurological checks if the fall was unwitnessed. The DON stated that a fall incident report should have been completed and the family, physician/nurse practitioner, and the DON should have been notified. The DON stated staff were responsible for informing the physician or nurse practitioner in detail about any possible injuries and for following any new orders given. The DON stated nursing staff should identify new interventions and the MDS nurse should have updated the care plan to reflect any new interventions. The DON stated there was a fall committee meeting in which all falls were reviewed to ensure that all the steps related to a fall's investigation were completed. The DON stated she was aware the falls process was broken until recently, when she had been putting new steps in place to address the falls process. The DON stated that in September 2021 she started a falls committee along with a process called quick fall meeting to address high fall risk residents quickly. The facility was still in the process of identifying who would be responsible for overseeing the falls process and ensuring all the steps were completed after a resident had a fall. The DON also stated that if staff identified a resident as needing one-to-one supervision, that should be reported to administrative staff to ensure continuity of care and documented as such. An interview on 11/11/2021 at 1:59 PM with the MDS nurse revealed that nursing staff could identify immediate interventions after a fall, and that information was given to the DON to discuss in the falls meetings. The MDS nurse stated the care plan would be reviewed and updated during that meeting. The MDS nurse further stated the interventions for Resident #86 were not appropriate for fall prevention, and that she was currently in the process of updating the care plan with appropriate interventions. An interview on 11/11/2021 at 3:40 PM with the Administrator revealed that after a fall occurred, nursing staff should assess the resident and ensure they were safe, then notify the DON, administrator, physician, and the family. The Administrator stated prevention related to falls should be individualized and specific to each resident's needs, and that staff should put interventions in place after falls and make sure that care plans were updated. The Administrator stated he was not surprised that care plans were not being updated after falls due to continued changes in staffing. 2. A review of Resident #3's face sheet indicated Resident #3 was admitted with diagnoses that included falls, restlessness and agitation, delusional disorder, [CONDITION(S)], dementia, and essential hypertension. A review of the quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident #3 had a Brief Interview for Mental Status (BIMS) score of 99 out of 15, which indicated the resident was unable to complete the interview. Resident #3 required extensive assistance of one person with bed mobility, transfer, eating, and toileting. A review of the care plan revealed there was no care plan implemented related to fall risk. Further review revealed fall risk was implemented on the care plan on 11/11/2021. A review of the fall risk assessment, completed on 05/17/2021, indicated Resident #3 scored a 19, which meant the resident was considered a high fall risk. A review of an incident report, dated 05/17/2021, indicated Resident #3 was found on the floor beside the bed with a laceration to the left eye that required steri-strips. A further review of the incident report indicated no causal factors related to the fall were identified and no care plan was implemented related to fall risk. A review of an incident report, dated 07/14/2021, indicated Resident #3 was found on the floor beside the bed. A further review of the incident report indicated no causal factors related to the fall were identified and no care plan was implemented related to falls risk. A review of an incident report, dated 08/16/2021, indicated Resident #3 was found lying on the floor beside the bed. A further review of the incident report indicated no causal factors related to the fall were identified and no care plan was implemented related to falls risk. An interview on 11/11/2021 at 9:44 AM with CNA Q revealed Resident #3 had a fall mat at their bedside, and the bed stayed in a low position. CNA Q stated she was not aware of any other current interventions in place for the resident. An interview on 11/11/2021 at 10:02 AM with CNA R revealed he was not aware that Resident #3 was a fall risk, but that staff kept pillows around the resident while they were in bed to keep the resident from falling out of the bed. They also kept the bed in a low position. CNA R stated he wasn't aware of any other interventions for Resident #3. An interview on 11/11/2021 at 1:59 PM with the MDS nurse revealed that nursing staff could identify immediate interventions after a fall, and that information was given to the DON to discuss in the falls meetings. The MDS nurse stated the care plan would be reviewed and updated during that meeting. The MDS nurse verified that Resident #3 did not have a care plan related to falls until it was identified during the survey process, but that one was initiated as of 11/10/2021. 3. A review of Resident #47's quarterly Minimum Data Set (MDS), dated [DATE], revealed diagnoses including humerus fracture, fracture of sacrum, adult failure to thrive, protein-calorie malnutrition deficit, repeated falls, and feeding difficulties. Resident #47 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The MDS identified the resident weighed 110 pounds, and the resident had one fall in the month prior to the MDS assessment. A review of the care plan for Resident #47 regarding accidents and falls, created on 08/12/2021 and revised on 11/06/2021, revealed interventions including a safe environment and low bed, utilizing appropriate adaptive equipment, anticipating and meeting needs, maintaining the call light within reach, encouraging the resident to participate in activities, ensuring the resident was wearing appropriate footwear, and using a wheelchair and walker as needed. A review of physician's orders, dated 11/2021, revealed that anti-skid strips to the floor were ordered on 08/10/2021. Observation of Resident #47 on 11/08/2021 at 10:45 AM revealed the resident lying in bed, with the head of the bed elevated. There were no skid strips on the floor near the bed, and the bed was not in the low position. Observation of Resident #47 on 11/09/2021 at 8:30 AM revealed the resident lying in bed, with the head of the bed elevated. There were no skid strips on the floor near the bed, and the bed was not in the low position. Observation of Resident #47 on 11/10/2021 at 12:24 PM revealed the resident lying in bed, with the head of the bed elevated. There were no skid strips on the floor near the bed, and the bed was not in the low position. Observation of Resident #47 on 11/11/2021 at 9:26 AM revealed the resident lying in bed, with the head of the bed elevated. There were no skid strips on the floor near the bed, and the bed was not in the low position. During an interview on 11/11/2021 at 9:28 AM, CNA L stated the nurses informed them of any special needs for a resident, such as a fall mat, side rails, or low bed. CNA L noted they used a Kiosk to document anything that occurred with a resident. CNA L reported that the Kiosk did not inform them of any special needs for residents, such as braces, fall mats, or a low bed. During an interview on 11/11/2021 at 9:42 AM regarding how nurses were made aware of any special requirements for residents, such as braces, fall mats, or a low bed, Licensed Vocational Nurse (LVN) M stated the facility had care plan meetings with families and, after the meeting, the MDS nurse told staff about any special needs for residents. LVN M stated there were intervention items in the care plans as well. During an interview on 11/11/2021 at 9:54 AM regarding how nurses were made aware of any special requirements for Resident #47, such as a low bed or non-skid strips on the floor, LVN J stated they would have an order for any special items or needs. LVN J also stated the Director of Nursing (DON) informed them if there were special needs. When asked if Resident #47 had any interventions in place to help prevent falls, LVN J stated, Nothing really, just monitor close. LVN J also stated there were no interventions listed in the care plan for Resident #47 to help prevent falls. During an interview on 11/11/2021 at 9:50 AM, CNA K stated information regarding any special requirements for residents, such as braces, fall mats, or a low bed, was on the Kiosk. CNA K denied that Resident #47 had any special safety measures in place to help prevent falls, stating, Just keep [the resident] warm, sit [the resident] up in the bed when needed .help in the chair. That's all I know. During an interview on 11/11/2021 at 1:26 PM, the DON confirmed Resident #47 was a fall risk, noting the resident had fallen on 08/08/2021, 08/20/2021, and 09/26/2021. When describing interventions in place to help prevent falls, the DON stated the resident's bed was to be in a low position and there were to be non-skid strips on the floor. The DON confirmed after observing Resident #47's room that these interventions were not in place. The DON stated the CNAs should use the Cardex tab on the Kiosk to see what interventions should be utilized. The DON stated that when care plans were updated, the Cardex was updated as well with any new interventions. The DON confirmed that no interventions were updated after the fall on 08/20/2021 for Resident #47. The DON expressed surprise that nurses and CNAs did not know where to find interventions for fall management, noting staff would be in-serviced immediately. During an interview on 11/11/2021 at 3:40 PM, the Administrator stated the expectation for preventing falls was to complete an assessment and analyze the root cause of the fall. When asked how interventions and changes were communicated to staff, the Administrator stated through the Kiosk, care plans, and education. A review of the facility policy, titled, Falls-Clinical Protocol, revised 09/2021, revealed, .for an individual who has fallen, staff will attempt to define possible causes with twenty-four hours of the fall. Staff will document risk factors for falling in the resident's chart and discuss the resident's fall risk.

Based on observation interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 80 of 80 residents (Residents #1-80) reviewed for infection control. A. The facility failed to ensure they administered COVID-19 health assessments for the resident before an outbreak to identify illness, and for residents during an outbreak to identify the transmission of the COVID-19 virus. B. The facility failed to ensure staff were able to identify and report signs and symptoms of COVID-19 and provided care to residents while having COVID-19 Symptoms. C. The facility failed to ensure a staff member was washing hands and wearing mask when providing care to the residents. D. The facility failed repeating the COVID-19 testing for residents every 3-7 days after an outbreak and until 14 days have passed with no new positive cases in staff and residents. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 10/10/2020. While the IJ was removed on 10/14/2020, the facility remained out of compliance at a severity level of actual harm at a scope of widespread due to staff needing more time to monitor the plan of removal for effectiveness. This failure could place residents at risk for the transmission of COVID-19 and death. Findings included: A. Review of Resident #15's Face Sheet reflected she was a [AGE] year-old female admitted on [DATE]. Her [DIAGNOSES REDACTED]. Constipation was added on 12/26/2019. Review of Resident #15's Quarterly MDS dated [DATE] reflected a Brief Interview of Mental Status (BIMS) score of 13 which indicated she was cognitively intact. Resident required extensive assistance of one to two staff for care and was frequently incontinent of bowels. Review of Resident #15's Care Plan reflected there was no date on the care plan and Resident #15 required; Isolation precautions specifically related to COVID-19 Infection. Goal: I will not experience any signs and symptoms of COVID-19 infection. Interventions included; Please observe me for (i.e. cough, shortness of breath, fever, wheezing, aching all over, diarrhea, etc.) and inform my doctor when seen. Please observe me for the emergency warning signs (i.e. trouble breathing, persistent pain or pressure in my chest, any new confusion or inability to arouse me, and if my lips or face is blue in color). Notify my doctor and ensure that I get medical attention immediately. Please listen to my lung sounds, noting areas of decreased or absent ventilation and presence of adventitious sounds. Please monitor my vital signs and notify my doctor for those out of range. Review of Resident #15's Order Summary Report printed on 10/08/20 reflected the following orders: -07/07/2019; Record Vital Signs on electronic health record on every Sunday. -09/16/2020; Vital Signs every day every shift. -10/05/20 (ordered to start on 10/05/20); Please monitor for signs and symptoms of COVID-19 (Fever, Cough, Shortness Breath, Malaise, Body Aches, fatigue) document and notify physician/Nurse Practitioner of any significant findings. Check Body temperature every shift for Preventative measures document signs and symptoms in Progress note and Notify Medical Doctor/Nurse Practitioner. Review of Resident #15's Progress Notes reflected there were no Progress Notes entered from 8/11/2020 to 9/20/20 regarding her health status or for COVID-19 symptom assessment and monitoring. The Progress Notes reflected; -09/21/2020 at 1:37 PM; Resident states she experienced loose stools and requested medication for loose stools/diarrhea. None noted but will monitor. (There were no further entries until three days later.) -09/24/2020 at 5:39 AM; Resident had two episodes of loose stools this shift. No other issues noted. Remains afebrile. Temp 5:00 AM 97.7. (There were no further entries until five days later.) -09/29/2020 at 11:21 AM; Resident alert, resting in bed, vitals: 106/60, 82, 18, 97.1, 97%, complains of just not feeling well, intermittent diarrhea and sore throat. Nurse Practitioner notified and gave orders per COVID test to be done today, charge nurse called in test, confirmation # . (There were no further entries until the next morning.) -09/30/2020 at 5:47 AM Resident continue on contact isolation for COVID-19 infection, with precaution in progress, respiration even and unlabored, skin warm and dry to touch, denied pain or any discomfort, no diarrhea on shift, call light within reach, will continue to monitor. -09/30/2020 4:39 PM I spoke with Resident's mother to inform her that she had tested positive for COVID. Resident had already called her mom to let her know. We will inform her of any changes of condition. Signed Social Worker. -09/30/2020 5:10 PM Point of Care COVID-19 test performed . positive. Specimen sent to lab for verification .result pending. Resident moved to quarantine area. Staff in full PPE and resident wearing an N95 during move. -10/01/2020 2:32 PM Asleep with respirations at 16, deep and even. Oxygen saturation is at 96% on room air. She remains on COVID-19 isolation . after a positive test. The next entry was on 10/05/2020 at 5:55 a.m. Resident continues on isolation for COVID19 infection, with precaution in progress, respiration even and unlabored, afebrile, skin warm and dry to touch, denied pain or any discomfort, call light within reach, incontinent care provided, fluids encourage, will continue to monitor. The facility was not able to provide any further assessment records or documented assessments of Resident #15 between 10/01/2020 and 10/05/2020 while she was on the isolation unit, COVID-19 positive and at risk for sudden decline or death after surveyor made multiple requests for any other assessment documents. The facility provided vital sign records. Review of the facility Infection Control Tracking log reflected Resident #15 tested COVID-19 positive on 09/30/20. Review of the Weights and Vitals Summary for oxygen saturation reflected Resident #15's oxygen saturation was measured one time in May 2020, four times in June 2020, three times in July 2020, and eight times in August 2020. Recorded for September 2020; from 09/01/20 to 09/15/2020 there was one entry dated 09/06/20. Starting on 09/17/2020 there were usually twice a day entries and occasionally three times a day entries. Once Resident #15 was ordered to be tested for COVID-19 on 09/29/2020; -09/29/20 at 4:44 AM 96%, 9:43 AM 95%, and 6:39 PM 95%. -09/30/20 at 9:15 AM 96% and 7:33 PM 96%. -10/01/20 at 5:36 AM 96%, 7:36 AM 96% and 11:20 PM 96%. -10/02/20 at 9:23 AM 97% and 3:35 PM 96%. -10/03/20 No monitoring of oxygen saturation documented. -10/04/20 No monitoring of oxygen saturation documented. -10/05/20 at 8:14 AM 97% and 7:35 PM 96%. -10/06/20 at 7:53 AM 98% and 6:02 PM 97%. -10/07/20 at 6:52 AM 97% and 9:42 AM 96%. Review of Resident #15's paper chart reflected there were no COVID-19 monitoring assessments. There were no written nursing assessment entries since January 17, 2020. Review of Resident #15's electronic health record reflected there were no head to toe assessments in the Assessment tab and there were no COVID-19 symptom monitoring assessments or Medication or Treatment Administration Records with COVID-19 symptom monitoring. Review of the facility Infection Control tracking log reflected Resident #15 tested COVID-19 positive on 09/30/2020. Review of Resident #16's Face Sheet reflected she was an [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16's Quarterly MDS dated [DATE] reflected a BIMS score of 14 which indicated she was cognitively intact, required limited assistance with her activities of daily living (ADLs) and used a walker for mobility. Review of Resident #16's COVID-19 Nursing Care Plan with no date reflected; Acute COVID-19 Infection I require isolation .I will not experience any signs and symptoms of the COVID-19 infection . 6. Please listen to my lung sounds, noting areas of decreased or absent ventilation and presence of adventitious sounds. 8. Please monitor my vital signs and notify my doctor for those out of range. 10. Please observe me for (i.e. cough, shortness of breath, fever, wheezing, aching all over, diarrhea, etc.) and inform my doctor when seen. 11. Please observe me for the emergency warning signs (i.e. trouble breathing, persistent pain or pressure in my chest, any new confusion or inability to arouse me, and if my lips or face is blue in color). Notify my doctor and ensure that I get medical attention immediately. Review of Resident #16's Order Summary Report dated 10/07/20 reflected she was admitted to Hospice services on 09/15/2020. An order dated 09/16/2020 reflected; vitals every shift for COVID-19 precautions. There was no order for COVID-19 assessments. Review of Resident #16's electronic Progress notes for September 2020 reflected; -09/02/20 No side effects from antianxiety - [MEDICATION NAME]. -09/08/20 Dental concerns were noted. -09/13/20 8:16 PM [MEDICATION NAME] Suspension 1 mg per 2 ml one vial inhale orally two times a day for [MEDICAL CONDITION]. -09/14/20 10:47 AM Oxygen at two liters per minute per nasal cannula as needed related to [MEDICAL CONDITION] with Exacerbation. Oxygen administered at 2 liters per minute complains of SPO2 88%. -09/14/20 10:52 AM Oxygen at two liters per minute per nasal cannula as needed related to [MEDICAL CONDITION]. PRN Administration was: Effective Oxygen 93% at 2 liters per minute. -9/14/20 12:35 PM Point of Care test performed .positive. Resident moved to quarantine room .staff in full PPE & N-95. Resident with N-95 during room move. -9/14/20 12:43 PM NP spoke with family. Resident requested palliative care . -9/15/20 8:45 AM Nurse in facility to enroll onto Hospice Services. 7:14 PM nebulizer on hold due to COVID-19 status. 7:15 PM nebulizer on hold. 7:16 PM Oxygen at 2 liters per minute per nasal cannula Effective. 11:46 PM [MEDICATION NAME] 20 mg/ml. Give 0.25 ml by mouth every two hours as needed for pain/or shortness of breath. -9/16/20 4:18 PM Afebrile No resp (respiratory) difficulties oxygen at two liters per nasal cannula. Breath sounds clear to auscultation. No complaints of pain or discomfort. Ambulates to bathroom with use of walker. Appetite fair. Hospice into visit with resident. No new orders. Alert and oriented times three. Will continue to monitor. -9/18/20 4:04 PM Medication Administration Note [MEDICATION NAME] HCL 4 mg tablet medication give for complaints of nausea. 9:39 PM [MEDICATION NAME] HCL 4 mg effective. -9/19/20 5:25 AM Resident continues on contact Isolation for Positive COVID-19 test, denied pain or any discomfort, V/S within limit, on oxygen at two to three liters per minute, saturation at 93%, patient refused both meals only ate apple sauce for both meals at 11:25 PM will continue to monitor. 11:20 PM Resident continue on contact isolation for COVID-19 positive, she is alert currently in bed resting, on continuous oxygen 2-3 liters per minute, oxygen saturation 92% denies pain or acute distress, ate 25% dinner, will continue to monitor. -9/20/20 5:30 AM Resident continues on Isolation, respiration even and labored, skin warm and dry to touch. Denied pain or any discomfort, vital signs within normal limit, incontinent care provided, call light within reach, will continue to monitor. Oxygen saturation at 92%. -9/21/20 6:02 AM Resident continues on Isolation Respiration even and labored, skin warm and dry to touch. Denied pain or any discomfort, vital signs within normal limit, on oxygen at three liters per minute, saturation at 93%, incontinent care provided, call light within reach, will continue to monitor. 3:31 PM [MEDICATION NAME] 0.5 mg and [MEDICATION NAME] 50 mg held due to sleepiness. -9/22/20 12:13 AM [MEDICATION NAME], Tylenol, [MEDICATION NAME], . (not given). 1:49 AM Resident change in condition, saturation 75-77% with four liters of oxygen, respiration 30-33, blood pressure unable to read, after few moments respiration started decreasing, body getting cold and not responding, hospice informed .resident respiration became shallow and resident not responding, passed at 10:47 PM, hospice pronounced death, informed DON, body taken to mortuary. Review of Resident #16's paper Progress Notes reflected the last assessment was documented 08/02/2020. Review of Resident #16's Treatment Administration Record dated 09/01/200 to 09/30/20 reflected there were vital signs recorded three times a day from 09/16/20 to 09/20/20 but not before 09/16/20. There was no entry for signs and symptoms of COVID-19. Review of Resident #16's Weights and Vitals Summary reflected there were no temperatures recorded from 11/17/2019 until 9/14/20 at 6:30 p.m., when Resident #16 had a temperature of 101.2 degrees Fahrenheit. The next recorded temperature is 9/15/20 at midnight; 100.2 F. There was no documented COVID-19 symptom temperature monitoring prior to the [DIAGNOSES REDACTED]. Review of Resident #16's electronic health record reflected there were no head to toe assessments in the Assessment tab and there were no COVID-19 symptom monitoring assessments or Medication or Treatment Administration Records with COVID-19 symptom monitoring. During an interview on 10/09/2020 at 3:00 p.m., the Respiratory Therapist was asked, Where can you find information to review residents under your care for signs and symptoms of COVID-19 before you go in the room and see them? I go to the individual nurse and ask if there have been any changes in the resident. It is a verbal communication. He stated he has been caring for residents when they were tested for COVID-19 and had become positive. He further stated once a resident became known to be COVID-19 positive he stopped seeing them until they were no longer in isolation. In addition, he only saw them if they were his patients for other reasons and not for COVID-19 recovery. During an interview on 10/07/20 at 12:40 p.m., The ADON stated the facility policy was for the nurses to do every shift (12-hour shifts) or three times a day assessments on the residents. She stated the assessments were on paper until they were instructed to put them in the computer, but she did not know when that was. The facility was able to provide 17 pages of hand written Vital Signs COVID-19 Every shift screening forms. One page daily from 09/09/20 to 09/16/20 for one hall (200) for one shift. In addition, there was one page for hall 200 dated 9/16/20 with no shift identified. From 09/17/20 to 09/27/20 there was one page daily for hall 500 (no shift identified). Six of the 17 pages reflected an answer in the Short of Breath and Lung Sounds columns. Every document showed there were no indications of COVID-19 symptoms for Resident #79, Resident #6, Resident #11, Resident # 90, Resident #14, Resident #4, Resident #23, Resident #19, Resident #26, Resident #28, Resident # 93, Resident #15, Resident # 85, Resident #34, Resident #35, Resident # 36, Resident # 37, Resident #40, Resident # 41, Resident # 42, Resident # 43, Resident #92, Resident # 45, Resident #46, Resident # 47, Resident # 48, Resident # 49, Resident # 50, Resident # 18, Resident # 51, Resident #52, Resident # 53, Resident # 56, Resident # 57, Resident # 58, Resident # 59, Resident #61, Resident #24, Resident # 63, Resident # 64, Resident # 17, Resident # 65, Resident # 66, Resident #68, Resident #12, Resident # 69, Resident # 32, Resident #33, Resident # 71, Resident # 27, Resident # 3, Resident #76, Resident # 77, Resident # 78, Resident # 2, Resident # 80, Resident # 81, Resident # 82, Resident # 83, Resident # 84, Resident # 31, Resident #86, Resident # 88, Resident # 89, Resident # 1, Resident #91, Resident # 74, Resident #95, Resident #96, Resident # 21, Resident # 94, Resident # 38, Resident # 7, Resident # 98, Resident #99, Resident #62. Review of the Infection Control Tracking Log dated September 2020 reflected there was a COVID-19 outbreak in the facility and there were 50 residents diagnosed with [REDACTED]. A 56th resident was diagnosed on [DATE]. During an interview conducted 10/07/20 at 1:25 p.m., the DON stated Yes, we should put residents on isolation that have symptoms of COVID-19. I don't see two loose stools as a need for testing. We notify the MD when there are symptoms. If he orders the test for the resident, we perform it. We are testing all staff and residents that have previously been negative tomorrow (10/08/20). I cannot find all three shifts (paper) documentation of COVID-19 assessments. I am now aware of that and we have a mandatory in-service tomorrow to address the charting assessment. There is a lot of notes in each chart and you would have to go to the progress notes, the vital signs, the assessments and different places to see the total assessment of each resident. The DON stated she could not provide the papers the nurses had written on and she was not sure when the facility started doing the vital sign monitoring. During an interview conducted on 10/07/20 at 5:30 p.m., LVN F stated she was a 6:00 PM to 6:00 AM Charge Nurse. She stated she assesses every resident for lung sounds and vital signs. She listed symptoms of COVID-19 as; diarrhea, nausea, coughing, body aches, fever and loss of smell or taste. She stated the assessment is to be documented in the electronic health record on an assessment order. She stated the documentation was a new thing. LVN F further stated the facility nurses work 12-hour shifts. She stated she does not do any residents twice on her shift and the facility has been on 12 hour shifts for two weeks. She stated, I don't do anyone twice. During an interview conducted on 10/07/20 at 5:45 p.m., RN G stated, We assess the resident every shift for signs of COVID-19 such as fever, falls, runny nose, flu like symptoms, diarrhea, headache. I do every resident once. If they change, we will write it in a progress note. Before, it was on paper. We took vital signs on every resident every day and put it on paper if there was a change, we wrote progress notes. During an interview conducted on 10/08/2020 at 1:00 p.m., the MDS Coordinator stated, There are no COVID-19 flow sheets that are resident specific in the resident charts (prior to the addition of the electronic record COVID-19 assessment which was initiated for all residents on 10/05/20). The MDS Coordinator reviewed the electronic chart under the Assessment tag and any other area to ensure there were no other areas of the electronic health record that held resident assessments. During an interview conducted 10/08/20 at 1:05 p.m., the ADON stated On 8/4/20 we were doing once a month testing per CDC guidelines. The (four positive residents) were quarantined and we scheduled our mass testing for September 2020. We tested every resident and I am sure we tested them all on 8/4. When surveyor asked how she had tracked to ensure she tested every resident she first said she just knows everyone then she said she used a room roster. When surveyor requested to see the room roster to ensure every resident was tested the ADON stated she didn't have it. The ADON continued, On 9/14/20 we tested several (five) residents because we did Point of Care testing of staff and there were three positive staff. On 9/14/20 (we tested ) those residents were that were not feeling well due to going by their assessment. We only tested five (residents) and they were all positives. On 9/15/20 we tested the whole building due to staff positives. On 9/22/20 we only tested a few due to the public health department gave us our results verbally for the 9/15 testing and when we got the results, it did not match what they had verbally told us. They gave us the wrong results. We highlighted the roster who was positive and who was negative as they gave us the report on the phone. Then when we received the results it did not match. We conducted point of care testing on those and found more positives. During an interview conducted on 10/08/2020 at 1:43 p.m., Physician R stated; I had 26 residents at the facility and 14 tested positive. If it is not documented, it is not done. I assumed it was being done. I can certainly see that the residents may be needing assessment. I want my residents assessed every eight hours. We want the guidelines followed as closely as possible. That is why they establish guidelines to keep the spread down. Quarantine does stop the spread of [MEDICAL CONDITION]. During an interview conducted on 10/08/20 at 2:15 p.m., the Nurse Practitioner stated, They were monitoring the vital signs on my residents on paper. They were documenting the vital signs on paper. I told them to put the information in the electronic health record. I have reminded them a few times. Because I don't go to the building every day, but I want to monitor my residents, I look in their charts almost daily to check on the residents. I didn't see any vital signs in the electronic health record. I was wanting to see progress notes and vital signs. I have noticed there were no progress notes for days at a time. I have talked to the DON and ADON a couple of times because I need to monitor my residents. During an interview conducted on 10/09/20 at 11:25 a.m., surveyor requested from the Regional RN the Residents' COVID-19 signs and symptoms sheets from 3/1/20 through 10/9/20. Regional RN was able to provide surveyor the binders of COVID-19 sign and symptoms from 7/29/20 through 10/09/20. Regional RN stated that they were not able to find the binders for the months of March, April, May, June, and July and added they were looking for them. The facility was not able to provide the requested documentaion of COVID-19 signs and symptoms sheets from 3/1/20 through 7/28/200 by the exit date on 10/19/20. During an interview conducted on 10/10/20 at 1:25 p.m., Resident #31 stated that staff never asked her for any specific signs or symptoms of COVID-19. During an interview conducted on 10/10/20 at 1:31p.m. Resident # 82 stated that since March, staff had not asked him for a specific symptom of COVID-19. He stated the staff took his temperature and vital signs but never asked if he was having any cough or shortness of breath. During an interview conducted on 10/10/10 at 1:36 p.m., Resident # 81 stated that staff had not been asking him for specific symptoms of COVID-19. He stated that they placed him under oxygen treatment because his oxygen saturation levels were low but not because they asked him for symptoms. During an interview conducted on 10/10/20 at 2:00 p.m., surveyor requested the Residents' COVID-19 signs and symptoms sheets from 3/1/20 through 7/28/200 from the Regional RN. Regional RN stated they were not able to find the binders with the requested documentation. The facility was not able to provide the requested documentaion of COVID-19 signs and symptoms sheets from 3/1/20 through 7/28/200 by the exit date on 10/19/20. During an interview conducted on 10/10/20 at 7:07 p.m., Regional RN stated that the nurses were responsible to monitor, ask and document residents for signs and symptoms of COVID-19. He stated that if it was not documented it didn't happen. He stated he was aware that there was an issue in the facility regarding documentation. He stated that DON was responsible of making sure that staff was documenting residents COVID-19 signs and symptoms collected during the screening. He stated that staff should screen residents every shift for signs and symptoms of COVID-19. He stated that staff should ask specific questions to residents regarding signs and symptoms of COVID-19, such as if resident was experiencing fatigue, loss of smell, or cough. During an interview conducted on 10/10/20 at 7:43p.m. ADM stated that he expected from staff to be screened and documenting resident's COVID-19 signs and symptoms. He stated that documentation and medical record should be available upon request. B. Review of Resident #55's laboratory results with a collection date of 9/15/20 reflected resident was positive for COVID-19. Review of Resident #55's progress notes dated 9/16/20 reflected that Resident on day two droplet precaution as PUI, good appetite ate 100% breakfast, no pain or discomfort noted at this time, will continue to monitor. Review of Resident #55's progress notes dated 9/17/20 reflected that resident's sister was informed that resident was COVID-19 positive. Review of Resident #55's progress notes dated 9/19/20 reflected that Resident stable, no SOB, afebrile, clear lung sound, ate 90% of his breakfast and lunch. Review of Resident #55's progress notes dated 9/20/20 reflected that Resident stable, ate 100% of his dinner, afebrile and no SOB. Oxygen saturation 97% and no indication of pain. Review of Resident #55's progress notes dated 9/20/20 reflected that Resident is isolation for COVID-19, afebrile with temperature of 97.6, Oxygen saturation of 90%, blood pressure 130/75, fatigued and weak, has good appetite Review of Resident #55's progress notes dated 9/20/20 reflected that Resident continued on contact isolation for COVID-19 positive result, he was alert, resident presented coughing and NP was notified. Review of Resident #55's progress notes dated 9/24/20 reflected that resident continued on isolation for COVID-19, ate 80% of his meals, blood pressure 137/90, and oxygen saturation levels of 94%. Review of Resident #55's progress notes dated 9/28/20 reflected that resident continued on isolation for COVID-19, oxygen saturation levels of 90%, and ate 75% of lunch, resident didn't eat breakfast and was sleepy all the time. Review of Resident #55's progress notes dated 10/01/20 reflected that resident continued on contact isolation precautions for COVID-19. Resident was alert, responsive but declined. Review of Resident #55's progress notes dated 10/3/20 at 7:52a.m, reflected that resident had an increase of temperature, respiration and blood pressure dropped, resident was not responding to any stimulus. Further review reflected Resident in the dying process. Review of Resident #55's progress notes dated 10/3/20 at 4:41p.m, reflected that resident was unresponsive, blood pressure was 107/70, temperature 103.6 F at morning, oxygen saturation levels of 78%. Review of Resident #55's progress notes dated 10/3/20 at 7:15 p.m., reflected that resident was unresponsive, not breathing, resident heart rate was not heard for one minute. Further review reflected that nurse pronounced death at 7:05p.m. Review of the Employee test result tracker provided by Regional RN on 10/10/20 at 11:57 a.m. through email reflected CNA D and RN A tested postive for COVID-19 between the week of 9/07/29 and 9/11/20. Review of the Pflugerville Care Center schedule for Monday 9/07/20 section of calloffs reflected that CNA D called off for 6:00a.m. to 2:00p.m. 200 CNA shift. Review of the Pflugerville Care Center schedule for Wednesday 9/08/20 reflected that RN A was assigned to work the 300 hall from 6:00a.m. to 2:00p.m. Review of the Pflugerville Care Center schedule for Wednesday 9/09/20 section of calloffs reflected that CNA D called off for 6:00a.m. to 2:00p.m. 300 CNA shift. Review of the Pflugerville Care Center schedule for Thursday 9/10/20 section of calloffs reflected that CNA D called off for 6:00a.m. to 2:00p.m. 300 CNA shift. Review of the Pflugerville Care Center Sign-in-Sheet for Thursday 9/10/20 reflected CNA D employee signature for shift 6:00a.m to 2:00p.m. for 300 hall. During an interview with the RN A on 10/05/20 at 3:01p.m. The RN A stated that she had a runny nose and headache before she was tested . She stated that she shared this information with two of her friends. She stated that she thought it was seasonal allergies [REDACTED]. During an interview conducted with the DON and ADON on 10/05/20 at 12:57p.m. They stated that the RN A was asymptomatic and found she was positive on the weekly testing performed on 9/8/20 using the POC testing. They stated that the RN A worked in the facility with no symptoms. They stated that on 9/10/20 the CNA D was tested using the POC and tested positive for COVID-19. They stated that they immediately sent the CNA D home after the results. They stated that the CNA D worked a couple hours with loss of taste and loss of sense and smell and added that they tested her half way through her shift. They stated that after she was positive, they questioned her for every symptom of COVID-19 and that she admitted she was just realizing she had loss of taste and smell. They stated that the facility performed an in-service due to the CNA D failure to report the COVID-19 symptoms to the facility staff. During an interview conducted by phone on 10/10/20 at 11:03a.m., CNA D stated that she tested positive for COVID-19 on 9/10/20 at the facility. She stated that on Monday 9/7/20 she called the facility to report she was having symptoms of flu and informed them she was not able to go to work. She stated that the staffing coordinator instructed her to call back when she was feeling better. The CNA D stated that on Wednesday 9/9/20 she called the facility to inform them that she was no longer having symptoms of flu and that she was feeling better. CNA D stated that the staffing coordinator didn't ask for specific symptoms related to COVID-19. The CNA D stated that the staffing coordinator asked if she got tested for COVID-19 and stated that she informed the staffing coordinator she hadn't been tested for COVID-19. The CNA D stated that the staffing coordinator instructed her to come back to work on Friday 9/10/20 and that they would test her for COVID-19 at the facility. The CNA D stated that she showed up to the facility to work the morning shift at 6:00a.m. She stated that she assisted with transfers, incontinence care and feeding residents from the 300 hall from 6:00a.m. until 8:30a.m. She stated she was wearing a N95 but added that she was not wearing a face shield or gown when she was providing care to the residents. She stated she got tested after 8:30a.m. since the administrative staff started their shifts at 8:00a.m. She stated that before she got tested for COVID-19 she mentioned to one of the nurses that was going to conduct the test that she still had loss of smell and taste. She stated that the nurse mentioned to her that loss of smell and taste were symptoms of COVID-19. The CNA D stated that she was not aware that loss of smell and taste were symptoms of COVID-19 until that moment. She stated that the facility didn't provide any training to identify the signs and symptoms of COVID-19. She stated that if the residents would communicate to her that they were having loss of smell and taste she would not be able to identify them as a symptom of COVID-19 until the date she informed the facility she was having those symptoms. During an interview conducted by phone with the RN A on 10/10/20 at 4:13 p.m., she stated that she had a runny nose one day before she was tested . She stated she got tested on [DATE] as part of the mandatory weekly test. She stated that the staff should inform the DON and ADON if they were experiencing COVID-19 symptoms. She stated that runny nose and headache were considered symptoms of COVID-19. RN A stated she didn't report these (TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure 2 of 4 residents reviewed for pressure sores, did not develop pressures and/or did not receive the necessary care and services to prevent worsening when Resident #1 and Resident 2 A. Resident #1 was admitted on [DATE]. Licensed staff did not perform regular skin assessments and on 06/30/14 an unstageable pressure sore (until enough slough is removed to expose the depth of the base of the wound-therefore stage cannot be determined) was identified under the lower edge of a poorly fitting immobilizer on the right malleolus (the bony prominence on each side of the ankle joint). On Monday morning, 08/25/14, the facility treatment nurse, LVN-Z, found the original and discontinued poorly fitting immobilizer was in place on Resident #1 ' s right leg from 08/23/14 to 08/25/14, which caused the lower half of the healing unstageable pressure sore to re-open. B. The facility failed to identify, treat and prevent worsening of a reddened area on Resident #2's left 2nd toe from 08/18/14 to 08/27/14 when the toe was found to have a Stage II pressure sore (partial thickness loss of dermis presenting as an intact or open/ruptured serum filled blister with a red wound bed). These failures resulted in an identification of an Immediate Jeopardy (IJ) on 08/27/14. While the IJ was removed on 08/28/14, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. This deficient practice could place all 13 residents assessed at moderate to high risk for pressure sores at risk for developing pressure sores or worsening of existing pressure sores and pain. The Findings Include: A. Review of a face sheet for Resident #1 reflected she was [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an admission MDS for Resident #1 dated 06/17/14 reflected the following: · Severely Impaired Cognition · At risk for developing a pressure ulcer · A Stage II pressure sore on the buttocks on admission · Frequent Moderate pain with as needed pain medication Review of a Care Plan for Resident #1 dated 06/24/14 revealed the following: Problem: Resident s at risk for pressure ulcers due to impaired mobility, use of leg brace and pain 2nd to weakness and recent fracture. Approaches: weekly and as needed skin assessments, observe skin in showers. Review of a Braden Scale (assessment for predicting pressure sore risk) for Resident #1 dated 06/13/14 reflected a score of 11. A total score of 12 or less represents High Risk. Review of physician ' s progress note dated 06/30/14 for Resident #1 reflected the following: Physical therapy reported newly identified wound on resident ' s right lateral malleolus and requested recommendation. Opening of the wound measures 2 cm round with additional inflamed peri-wound extending to 5 cm. Wound bed yellow/beige slough covered with bloody drainage. Wound cleansed with wound cleanser, applied silver alginate, foam dressing with 4 x 4 gauze secured with dressing tape. Reapplied immobilizer with padding to affected leg. Notified wound care nurse of findings along with the type of dressing applied to protect, pending her evaluation. Order written for dressing to protect pending wound nurse intervention along with order to refer to Orthopedic for new immobilizer. PT (physical therapy) to re-measure and order new immobilizer when appropriate. Review of physician orders [REDACTED]. In an interview on 08/26/14 at 8:52 am, during initial tour, treatment nurse, LVN Z, stated Resident #1 had a facility acquired unstagable pressure sore on her right malleolus that was first identified by a physical therapy staff member on 06/30/14. LVN Z went on to say that the pressure sore was caused due to the right leg immobilizer Resident #1 was admitted with was too long and caused rubbing and pressure to the area. When asked why the pressure sore was first identified as large and unstagable, LVN Z replied nursing staff was not checking the skin under the immobilize for signs of breakdown. Review of weekly skin assessments and daily skilled nursing notes for Resident #1 revealed the following: No documentation of a weekly skin assessment from 06/18/14 to 07/01/14 and none from 07/08/14 to 07/22/14. Review of skilled nursing notes from 06/13/14 to 08/01/14 revealed 6 days of no nursing documentation on any shift, and 33 days where no skin issues were indicated in the skin assessment area on the form, despite the fact from 06/13/14 there was a Stage II on the buttocks and as of 06/30/14 the unstagable pressure was present as well. The documentation for the skin assessment dated [DATE] reflected bruises, a Stage II on the buttocks and a right leg immobilizer in place. There was no documentation of the unstagable wound on the right malleolus or indication there was a dressing in place on the right malleolus. In an interview on 08/26/14 at 3:45 pm, during the review of the weekly skin assessment's the DON, stated she was unaware skilled nursing notes were not being completed and/or skin assessments documented on the form in the area of ' Skin Condition-check all that apply. ' Review of treatment nurse notes for Resident #1 dated 07/01/14 reflected: Right malleolus unstagable pressure ulcer secondary to immobilizer rubbing. Measurements 4 cm x 3 cm x non measurable black and yellow tissue with serous drainage. Applied Santyl and alginate; covered with foam dressing and secured. Immobilizer padded with sheep skin. Preventative measures already in place- air mattress and heel protectors. This was the first documentation of the pressure sore. During an interview on 08/27/14 at 4:00 pm the Director of Therapy stated Resident #1's unstagable pressure sore was found on 06/30/14 during a PT session. The Director of therapy went to say she had wanted Resident #1 to be evaluated by an orthopedic physician for a proper fitting immobilizer, but the appointment was not until 07/16/14. When the pressure was found on 06/30/14 the decision was made to take measurements and a shorter immobilizer was ordered on [DATE] and received on 07/10/14. The Director of Therapy stated when the immobilizer was delivered she in-serviced the staff on duty on Resident #1 ' s hall for proper placement and how to open the device for care and assessments and placed a photocopy of the immobilizer on the wall for any other staff to use as a reference. Review of an in-service conducted on 07/11/14 by the Director of Therapy reflected the topic content was Lower Extremity Immobilizer Positioning for Resident #1. Attendees signatures included a licensed nurse and 2 CNA's. An observation on 08/26/14 at 8:55 am of Resident #1's right malleolus pressure sore revealed it was 1.5 cm x 0.5 x 5.0 cm in length. The pressure sore was vertical and linear and the lower half of the area was open with slight drainage. Resident #1 grimaced and quietly moaned when her right leg was moved for treatment and observation. During the observation LVN Z stated when she came to work on Monday 08/25/14; the previous long, ill-fitting immobilizer was in place on Resident #1 ' s right leg which caused the lower half of the pressure sore to re-open. LVN Z further stated she didn ' t 't ' know how the old immobilizer had found its way back into use , but she had removed it so it would not be used again. LVN Z stated the initial immobilizer had been replaced on 07/10/14 by a shorter, better fitting one that had been ordered by the physical therapy department when the pressure sore was first identified. LVN Z added she had told the DON about the healing unstagable wound reopening in the morning focus meeting on 08/25/14 and had documented it in her treatment notes so the concern could be addressed with all direct care staff. She further added she had spoken to the direct care staff on duty that was caring for Resident #1 on 08/25/14. The Stage 2 pressure sore on the buttocks was healed. In a continued interview with the DON on 08/26/14 at 3:00 pm the DON reviewed Resident #1 ' s comprehensive care plan and stated there were no interventions in the care plan for checking the skin under the immobilizer each shift and no updates when the immobilizer was changed to a shorter one on 07/10/14. The DON stated after the unstagable wound was first identified on 06/30/14, checking the skin under the immobilizer each shift was added to Resident #1 's TAR on 07/01/14, but the expectation of nurses would have been to assess the skin under immobilizer each shift and with weekly and as needed skin assessments. The DON went on to say the system for scheduled skin assessment assignments is by room and hall, rather than to a specific nurse. The charge nurse on duty is responsible for completing 2-3 residents per day and if the charge nurse does not do them they are reassigned to the wound care nurse. The DON confirmed ultimately she and the treatment nurse are responsible for ensuring residents are receiving weekly head to toe skin assessments and that they are documented. The DON also stated the facility has many new and prn (as needed) licensed staff employed and for the most part they rotate duty on the 4 halls so they can be familiar with all of the residents. During review of Resident #1 's shower/bath documentation reflected there was no documentation in the electronic care tracker or on shower sheets to support Resident #1 received a shower or bed bath during the following time periods: 06/17/14 - 06/24/14, 07/02/14; 07/02/14-07/08/14 and 08/14/14 - 08/21/14. In an interview on 08/26/14 at 3:45 pm the DON confirmed there was no documentation to support if Resident #1 received a shower or bath during the above mentioned time frames Review of physician orders [REDACTED].#1 revealed Wound care to right malleolus as follows: Change dressing every 2-3 times a week. Cleanse with wound care cleanser, apply to red peri-area [MEDICATION NAME] cream. [MEDICATION NAME] AG to open area. Cover with doughnut shaped foam dressing to off load pressure. Secure with gauze wrap. Offloading boot on at all times while in bed. In an interview on 08/27/14 at 8:45 am LVN W stated she worked the weekend of 08/23/14 - 08/24/14 and had been asked by LVN X to stay over on 08/24/14 to do wound care for residents. LVN W stated she was the charge nurse on duty for the hall where Resident #1 resides and she had seen a long immobilizer in place on her right leg on 08/23/14 and 08/24/14. LVN W also stated she did not do a dressing change on 08/24/14 Resident #1 because she saw LVN X ' s initial on the TAR and thought it had been done. LVN W stated she was a new graduate nurse; she had been at the facility for 3 months and had not received any instructions on the change of immobilizers for Resident #1. When asked about her responsibility as a charge nurse regarding weekly skin assessments, LVN W stated the assignment book was at the nurses ' station and assignments were by hall and room numbers and usually 2 residents per day. In an interview on 08/26/14 at 5:15 pm the weekend supervisor LVN X stated he was scheduled to be the weekend supervisor on 08/23/14 and 08/24/14, but had to work the floor because a nurse called in sick. LVN X stated he would have provided wound care if he had not had to work the floor, but instead he had assigned wound care treatments to other nurses on duty. LVN X reviewed the TAR for Resident #1 and had no explanation for why his initials were on the TAR for the 08/24/14 dressing change, but thought it might the nurse assigned to do the treatment may have put his initials on the TAR rather than their own. LVN X also stated he was not aware the old long immobilizer had been placed on Resident #1 over the weekend of 08/23/14 causing the healing unstagable wound to re-open. Review of 24 hour reports dated 07/01/14 through 07/30/14 on 08/26/14 with the DON revealed no documentation of a new immobilizer being ordered for Resident #1 or that it had been received and implemented on 07/10/14. The DON did confirm the 24 hour report is the main means of communication to and from direct care staff and information regarding the new immobilizer should have been on the report. Review of an in-service dated 07/01/14 with the DON on 08/27/14 at 10:00 am reflected: Topic/content: Immobilizers must be opened to inspect skin daily. Review of attendee signatures revealed a total of 6 licensed staff. During this review the DON confirmed only 6 licensed staff had been in-serviced out of a total of 26, including 9 prn staff and had no explanation for the other staff not being included in the training. In an interview on 08/26/14 at 3:00 pm the DON stated she could not remember if LVN Z had told her about Resident #1's wound re-opening over the weekend of 08/23/14 due to the wrong immobilizer being in place. The DON state the 24 hour report is reviewed in the focus meetings held on Monday-Friday and pertinent staff give their input regarding changes in residents' status. The DON was asked if notes are taken during the morning focus meetings and she indicated yes. ( The DON was asked on 3 separate occasions to provide notes for the 08/25/14 focus meeting, but as of exit on 08/28/14 none were received.) During an interview on 08/27/14 at 1:18 pm with the facility ' s Medical Director and Resident #1 ' s primary care provider he was informed of an Immediate Jeopardy being identified in the area of pressure sores. The Medical Director stated it was his expectations that the skin under the immobilizer for Resident #1 ' s right leg should have been assessed each shift, weekly skin assessments should have done and the correct immobilizer should be in place. The Medical Director further stated he felt it would be common nursing judgment as part of a skin assessment of a resident with an immobilizer in place to check the skin for breakdown. The Medical Director went on to say he felt communication and continuity of care was a concern at the facility and he would be meeting with the new administrator to address concerns within 24 hours. During an interview on 08/27/14 at 4:30 pm the DON stated she was not aware the therapy department had only in-serviced a total of 3 staff regarding the implementation of the new immobilizer for Resident #1. The DON further stated she would speak to the Director of Therapy to ensure all pertinent staff are in- serviced when a resident care issue that involves the use of immobilizer or adaptive devices. The DON also stated it will be the expectation the therapy staff use the facility ' s in-service forms and sign in sheets. B. Review of a face sheet for Resident #2 reflected she is [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a 14 day readmission MDS assessment dated [DATE] reflected has a BIMS score of 4 indicating severe cognitive impairment, chronic pain requiring scheduled pain medications and at risk for pressure sores. She requires assistance of one with bed mobility and ambulation in her wheelchair, and assistance of two persons for transfers. Review of Resident # 2 ' s Braden scale (assessment for predicting pressure sores) dated 07/04/14 revealed a score of 14 indicating moderate risk for development of pressure sores. Review of Resident #2's Care plan dated 07/29/14 reflected impaired skin integrity monitor with weekly and as needed skin assessments. Monitor skin with showers. Observation during wound care on 08/27/14 at 9:00 am with LVN Z revealed an undated band aide on the left 2nd toe of Resident #2 ' s right foot. When asked, LVN Z stated she was unaware of any skin issues with Resident #2 ' s toes. In an attempt to remove the band aide Resident #2 cried out in pain and said NO. LVN Z successfully removed the band aide with scissors, however Resident #2 was yelling out due to pain during the process. When the bandage was removed there was a 1 cm x 1 cm opened macerated blister with a red bed and serous drainage. In an interview with CNA B on 08/27/14 at 9:25 am she stated Resident # 1 was dressed with socks and no shoes when she came on duty at 6:00 am and she was not aware of any band aides on Resident #2 ' s toes. In an interview on 08/27/14 at 9:45 with a physical therapy student and the Director of therapy, the physical therapy student stated approximately one week ago (during the week of 08/18/14) she had noticed a red pinpoint area on the Resident #2 ' s left 2nd toe and informed the Director of Therapy who then instructed her to tell the charge nurse on duty. The Director stated the area was a pressure point due to Resident #2 ' s shoes and the fact her toes curl under her feet. The therapy student added she saw a band aide on Resident #2's left second toe the next day during a therapy session, but had not since then because she had been wearing shoes. In a telephone interview on 08/27/14 at 6:30 pm LVN U stated she could not remember if anyone from therapy had told her there was a skin issue with Resident #2 ' s toe. LVN U stated it was possible that she was told and got busy and forgot. LVN U added she thought there needed to be a system in place where any report of skin concerns from therapy should be done in writing. In an interview with the DON at 10:45 am she stated she was unable to determine who placed the band aide on Resident #2 ' s left 2nd toe and there was no nurses ' notes, physician orders, or shower sheets to indicate it was addressed by any licensed staff. The DON confirmed this was a pressure sore that facility staff was unaware of had worsened from a pinpoint red area to a Stage II pressure sore. In an interview on 08/27/14 at 5:00 pm the facility nurse practitioner stated she had not been made aware of any pressure sores on Resident #2 ' s foot until earlier in the day (08/27/14) when she was asked by the treatment nurse, LVN Z to evaluate her. Review of a telephone physician order [REDACTED]. Apply Arginate and cover with Bandage daily and as needed until healed. The order was signed by LVN Z and the facility nurse practitioner. Review of skin assessments for Resident #2 for the month of August revealed none were documented on the TAR. Review of shower sheets for Resident #2 dated 08/19/14,08/22/14, and 08/26/14 reflected the following: 08/19/14 revealed a red area in the right groin; 08/19/14 was blank and not signed by the charge nurse; 08/26/14 reflected abnormal in a selection box, but there was nothing on the diagram of a human body to indicate what was abnormal and the charge nurse had not signed off on the sheet to indicate it was reviewed. In an interview on 08/27/14 at 11:00 am the DON stated the information on the shower sheets was incomplete and confirmed there was no documentation on the August TAR to indicate weekly skin assessments were completed by licensed staff. In an interview on 08/25/14 at 5:00 pm the Corporate Nurse Consultant stated the corporation does not have policies and procedures for prevention and treatment of [REDACTED]. Review of the undated corporate Skin Management System reflected the following: 1. A head to toe body assessment will be completed for each resident upon admission and readmission. 2. Routine weekly checks will be completed on every resident, if skin is intact it will be noted as such. If a new pressure sore is noted a progress note will be started. 3. Assignments for skin assessments will be posted on a monthly calendar at the station and initialed when completed. Assignments should be by room number. These assignments are to be saved by the DON. 4. CNAs will note any alteration in skin integrity during care on the skin alert forms and turn in to the charge nurse. The facility ADM, DON, and the Corporate Regional Nurse were notified on 08/27/14 at 11:12 am that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on 08/27/14 at 11:50 am. The final Plan of Removal was accepted by the investigator on 08/28/14 at 12:36 pm. Plan of Removal Action taken for residents that have been affected include: Resident #1- Complete Head to Toe assessment on 08/26/14 by Treatment Nurse. No other skin issues identified. ADON completed head to toe assessment on 08/27/14 with no skin issues identified. Nurse Practitioner( NP) assessed wound on 08/26/14 and re-evaluated treatment to right malleolus. New orders received for silver Alginate, [MEDICATION NAME], foam dressing on 08/25/14. In-serviced staff on proper short leg brace and usage on 08/26/14. CNA assignment sheet updated to reflect proper short brace on 08/26/14. Skin checks will continue until continue to be performed until brace discontinued. Resident on scheduled [MEDICATION NAME] 4 times daily. The longer brace/immobilizer has been removed from the room and proper brace is in place on the resident as of 08/25/14. Family notified of reopening of the wound on 08/27/14. Pain evaluated on 08/27/14 by RN-T and no pain identified; more anxiety related when providing care. Notified NP of findings, received order for [MEDICATION NAME] Gel 1 mg. topically every 6 hours as needed for anxiety prior to care/treatments due to anxiety on 08/27/14. Resident #2- Complete head to toe assessment on 08/27/14 by LVN Z no other skin issues identified. NP assessed wound on 08/27/14. Received new order for silver alginate, foam dressing with wrap daily. Skin checks will continue weekly by licensed personnel. [MEDICATION NAME] scheduled every 6 hours routine. Pain evaluation completed on 08/27/14 and resident denies pain in toes and none observed during treatment. Family notified on new wound on 08/27/14. Bed cradle implemented on 08/27/14 and tennis shoes removed from room by resident's responsible party. Care plan and CNA assignment sheet updated on 08/27/14. Action taken for identification of other residents that may be affected. 100 % skin assessments on all current residents started on 08/27/14 by licensed personnel and will be completed on 08/28/14. Therapy staff in-serviced on 08/27/1 by Corporate RN and facility DON on communicating any skin issues identified during treatment on the pink skin care alert form to DON during the week and weekend supervisor during the weekend and Director of Rehab will bring a copy to morning meeting for review. All therapy staff and current therapy students will be in-serviced by 09/03/14. New employees will be educated on process during facility orientation prior to providing therapy services starting week of 09/02/14. PRN (as needed) rehab staff will receive training on communication process before any patient assignments by Director of Rehab. Weekly skin assessments forms by room number on assigned day of the week will be reviewed during the morning meeting by DON/ADON and treatment nurse starting on 08/28/14 and will be an ongoing process. Any skin assessments not completed will be placed on focus board for follow up and any omissions in skin assessments will be addressed by administration nurses and assigned to treatment nurse for completion. Any new skin issues identified and non -compliance will be reviewed and followed up by treatment nurse daily. Weekend supervisor will review skin assignments for completion and validate any skin issues identified starting on 08/30/14. CNA 's in-serviced on new skin care alert sheet by DON and Corporate RN on 08/27/14 and to be completed to all current full time staff by 09/05/14. Total CNA staff as of 08/28/14 is 28 of 34. CNAs will immediately notify charge nurse of any new areas observed during ADL care by documenting on skin alert sheet and placed in skin alert folder in 24 hour report binder. PRN staff will be inserviced by DON/designee prior to accepting direct care assignment. New employees will receive skin alert training during new hire orientation prior to receiving direct care assignment. -Nurses inserviced on skin care alert sheet on 8/27/14 by Corporate RN, and DON, a total of 5 licensed nurses out of 6 as of 8/28/14, all other licensed staff will be completed by 9/5/14. All direct care staff will not be allowed to work until inserviced on new skin system. All new employees will be inserviced in new hire orientation prior to providing direct care starting week of 9/2/14 and will be ongoing process. Nurse will initial skin alert sheet, validate skin issues and initiate treatment as needed. Nurse will place skin alert in 24 hour report for review in morning meeting starting 8/28/14 by DON/ADON/Treatment nurse. Weekend Supervisor will review skin alert sheets and validate skin issues and initiate treatment as needed on Saturday/Sunday. -DON/Designee will review admits/readmits Monday thru Friday to ensure new residents with skin issues, braces or immobilizers have been identified and treatment and monitoring has been initiated starting 8/27/14 and will be an ongoing process. Weekend Supervisor will review admits/readmits on Saturday and Sunday for follow up with residents admitted with skin issues, braces or immobilizers and validate treatments and monitoring has been initiated starting 8/30/4. -Weekly skin report will be reviewed during weekly Standards of Care meeting starting on 9/3/14 by DON/Designee to review current treatment is appropriate and no signs of deterioration, this will be an ongoing process. _DON/Nurse management designee will conduct random skin audits weekly starting on week of 9/1/14 to validate accuracy of weekly skin assessment form. Random audits will consist of 1 resident skin assessment per hallway for two months and if no issues identified will conduct randomly thereafter. Findings will be documented on weekly skin audit form and discussed in daily clinical meeting. -AMT will provide training on identifying, assessing, measuring and staging pressure ulcers to licensed staff by 9/15/14. 100% Braden scale assessments will be conducted by DON/ADON and nurse managers on 9/2/14 and completed on all current residents by 9/19/14. Care plans and C.N.A. assignment sheets will be updated to reflect findings. Treatment nurse role when wound is identified is to implement treatment monitoring form by assessing, measuring, and staging wound and identify whether treatment for [REDACTED]. Confirm Family and MD have been notified. Will provide treatment for [REDACTED]. Monitor and assess, measure and staging wound weekly and include on weekly skin report. Treatment nurse to notify MD/NP if wound has worsened and no improvement every 2 weeks and request new treatment order. Also will educate staff on any areas of concern in regards to wound assessment, care and treatment. Please accept this plan of approval. The investigator monitored the current plan of removal as follows: Interviews on 08/28/14 beginning at 1:30 pm with 5 CNAs, 3 charge nurses and 2 therapy staff members revealed staff was knowledgeable of the process for skin alert forms , weekly and prn skin assessments, reporting of newly identified skin issues, and the proper immobilizer for Resident #1. On 08/28/14 at 4:25 pm, the ADM and DON were informed the IJ was removed. However, the facility remained out of compliance at a severity of potential of more than minimal harm with a scope as pattern due the facility need to complete in-services for all staff. The treatment nurse provided a list of 13 residents with moderate to high risk for developing pressure sores.

Based on 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 one (1) of five (5) residents reviewed for falls (Resident #1). The facility failed to ensure that Certified Nursing Assistant (CNA) A and Licensed Vocational Nurse (LVN) B followed proper post-fall procedures. CNA A moved Resident #1 from the floor to her wheelchair after an unwitnessed fall on 11/01/13 before notifying a nurse. LVN B failed to begin neurological assessments (neuro checks) for Resident #1 after this same unwitnessed fall. Resident #1 fell a second time, 2 hours later, and was subsequently sent to the hospital on [DATE] where she was diagnosed with [REDACTED]. This deficient practice could affect 33 residents at the facility who are at a high risk for falls by placing them at risk for improper post-fall assessments, injuries from being physically moved after a fall before being assessed by a nurse, and possible life threatening head injuries. Findings include: Review of Resident #1's Face Sheet reflected an [AGE] year old female admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s Care Plan dated 08/16/13 reflected that Resident #1 has a history of orthostatic hypertension and may experience dizziness when sitting or standing up. Approaches include to monitor Resident #1 ' s blood pressure, and to encourage the resident to ask for help when she needs to get up. Resident #1 required extensive assistance of one staff member for bed mobility and toilet use, extensive assistance of two staff members for transfers, and limited assistance of one staff member for meals. Resident #1 was care planned for a history of falls and risk for falls. Approaches include to assist with ambulation when needed, keep mobility devices in the resident ' s reach, encourage the resident to ask for help, refer to therapy, use a low bed with a mat on the floor, add a pummel cushion to Resident #1 wheelchair, add a sensor alarm to the resident ' s bed, use a scoop mattress, and add a Dyson (non-slip) to Resident #1 ' s wheelchair. Resident #1 ' s care plan also reflected a score of 0 of 15 (score of 0-7 indicating severely impaired cognition) on the Brief Interview for Mental Status (BIMS) and that Resident #1 has severe cognitive impairments. Review of Resident #1 ' s incident report dated 11/01/13 at 3:00 pm reflected " Type of Incident: Fall, Unobserved Fall, Found on Floor. Location of Incident: Resident Room. Treatment Disposition: No Apparent Injury, Observation. Brief Description of the Incident: Resident found on floor. " Vital signs were taken and recorded under assessment and intervention section of the incident report. Resident #1 ' s temperature was 96.7 degrees Fahrenheit (F), respiratory rate was 20 breaths per minute, pulse was 77 beats per minute, and blood pressure was 147/60 millimeters of mercury (mm/Hg). Nothing is documented next to the area designated for " neuro checks " . The incident report reflected that the aid provided to the resident included that the resident was assisted to her wheelchair. Resident #1 used a low bed with a mat. Actions to minimize reoccurrence included " continue low bed with mat and sensor pad to bed " . Review of Resident #1 ' s incident report dated 11/01/13 at 4:55 pm reflected " Type of Incident: Fall, Unobserved Fall, Found on Floor. Location of Incident: Resident Room. " The treatment disposition indicated that the Resident #1 had a bump to the left side of the face above the eye. The brief description of the incident indicated that the resident was found on the floor in her room. Vital signs were taken and recorded under assessment and intervention section of the incident report. Resident #1 ' s temperature was 97.2 degrees F, respiratory rate was 20 breaths per minute, pulse was 71 beats per minute, and blood pressure was 107/57 mm/Hg. The incident report reflected that the aid provided to the resident included that the resident was assisted to her bed. Actions to minimize reoccurrence included sending the resident to the hospital and referring the resident to therapy to evaluate for positioning. During an interview on 11/14/13 at 10:32 am, CNA A stated that before the evening meal on 11/01/13, she (CNA A) was in the hallway when she heard a bed alarm going off, so she ran quickly to the sound of the alarm. CNA A stated that she then found Resident #1 lying on the floor mat in front of her bed. CNA A stated that Resident #1 said that she was ok, and CNA A then assisted Resident #1 into her wheelchair and brought the resident out to the nurse ' s station. CNA A then told the nurse (LVN B) what happened. CNA A stated that the nurse (LVN B) began checking the resident, so CNA A left the nurse ' s station. CNA A stated that later during the same shift, LVN D asked her to bring four (4) residents, including Resident #1, from the dining room to their rooms so she could check their blood sugar levels before the meal. CNA A stated that she brought Resident #1 back to her room, put her call light within reach of her wheelchair, and turned on her television for stimulation. CNA A then told LVN D that Resident #1 was in her room. CNA A stated that she heard from other staff members later in the shift that Resident #1 fell again. CNA A stated that it is post-fall protocol to notify a nurse immediately of a fall, and to not get the resident up from the ground until the nurse has assessed the resident and says it is ok to move them. CNA A stated that she knew this protocol, but it was a gut reaction to help the resident up when she saw her on the floor. During an interview on 11/14/13 at 1:15 pm, the Director of Nurses (DON) stated that for fall prevention, the facility tries to use the least restrictive interventions first. The DON stated that after a fall, the nurse should assess the resident for injuries, take vitals and begin neuro checks, and assess the need for any additional interventions. The DON also stated that the day after a fall, the nurse managers will follow up on the fall and further assess the need for additional interventions. The DON stated she was aware of Resident #1 ' s first fall on 11/01/13 at 3:00 pm, and she asked the staff if Resident #1 ' s fall prevention interventions were in place. She stated that the staff told her that Resident #1 ' s sensor alarm was sounding and in place. The DON stated that since Resident #1 ' s falls happened so close together on 11/01/13, there was no time for the facility to implement an additional intervention because the next intervention would have been a urinalysis, lab work, and medication regimen review. During an interview on 11/14/13 at 3:07 pm, LVN B stated that on 11/01/13, CNA A heard Resident #1 ' s alarm going off, so CNA A went to the resident ' s room, saw her on the floor, placed her in her wheelchair and brought her to the nurse ' s station. LVN B stated that she was at the nurse ' s station and CNA A told her about Resident #1 ' s unwitnessed fall. LVN B stated that she assessed the resident, saw no apparent injuries, and took Resident #1 ' s vital signs. When asked if she started " neuro checks " on Resident #1, LVN B stated that she did not start neuro checks after the resident ' s first fall, but she now knows that she should have. LVN B continued to state that Resident #1 fell a second time. LVN B stated that LVN D heard the resident fall to the floor, because she was checking the blood sugar of a resident in a room close to Resident #1 ' s room. LVN D ran to check on Resident #1 and called LVN B. LVN B stated that Resident #1 had a bump to the left side of her head after the second fall, and neuro checks were started at this point (after the second fall). LVN B stated that when she went to check on Resident #1 a couple of hours after the second fall, she noted facial drooping and called Emergency Medical Services (EMS) to come take the resident to the emergency room (ER) for evaluation. LVN B stated that the nurse practitioner and Resident #1 ' s family were notified. LVN B stated that after a resident has an unwitnessed fall, CNAs are supposed to notify the nurse before they move the resident. LVN B said that also after an unwitnessed fall, nurses are to begin neuro checks. LVN B stated that between Resident #1 ' s first and second fall, she did not notice any strange or uncharacteristic behaviors. LVN B stated that Resident #1 had her pummel cushion and dyson in place on her wheelchair, the wheels were locked, and her bed was in a low position with the mat placed next to it. During an interview on 11/14/13 at 10:35 am, CNA C stated that before the evening meal on 11/01/13, one of the nurses asked for some of the residents, including Resident #1, to be taken back to their rooms so the nurse could check their blood sugar levels. CNA C stated that another CNA brought Resident #1 back to her room. CNA C stated that later he heard a nurse calling for help, saying that Resident #1 had fallen (her second fall). CNA C stated that he went to Resident #1 ' s room to help, and that the nurse assessed the resident and started neuro checks, and then they assisted Resident #1 off of the floor and into her bed. CNA C stated that he was asked to take her vital signs every 15 minutes for an hour and every 30 minutes for the next two (2) hours. CNA C stated that he recorded the vital signs and the nurse interpreted the findings. CNA C stated that he also helped feed the resident in her room. CNA C stated that he noticed that her left eye was darkening. CNA C stated that Resident #1 was not complaining of pain and ate 75% of her evening meal. CNA C stated that later during the shift, he heard that Resident #1 had been taken to the hospital. During an interview on 11/14/13 at 2:53 pm, LVN D stated that she was near the area where the resident ' s second fall occurred. LVN D stated that she was helping the nurse on Resident #1 ' s hall (LVN B) with blood sugar checks because LVN B was discharging a resident. LVN D stated that she was in a room near Resident #1 ' s room when she heard something that sounded like a person falling. She ran to Resident #1 ' s room and saw that Resident #1 had been in her wheelchair with the wheels locked and pummel cushion on, but the resident had fallen out of the chair and was found in front of her wheelchair with the side of her head on the ground. LVN D stated that Resident #1 was assessed and placed in bed. Resident #1 was not complaining of pain. LVN D stated that neuro checks were started after this unwitnessed fall (the second fall). LVN D stated that after an unwitnessed fall, the resident should be assessed, vital signs should be taken, and neuro checks should be initiated. LVN D stated that the resident should be monitored for at least 72 hours and the physician should be notified about any discrepancies in the neuro checks. During an interview on 11/14/13 at 2:46 pm, the DON stated that neuro checks were not started after Resident #1 ' s first fall and that an all-staff in-service has been conducted regarding post-fall procedures. The DON stated that neuro checks were started after Resident #1 ' s second fall. The DON continued to state that neuro checks should be started after all unwitnessed falls. The DON also stated that if a CNA finds a resident on the floor, they should notify a nurse immediately. A resident should not be moved from the floor until a nurse assesses the resident. The DON stated that an in-service was also conducted regarding notifying a nurse of the fall before moving the resident from the floor. During an interview on 11/14/13 at 4:42 pm, the Administrator stated that all of the neuro checks after Resident #1 ' s second fall were normal. Review of Resident #1 ' s Nurse ' s Notes dated 11/01/13 reflected that at 3:00 pm, a CNA brought Resident #1 to the nurse ' s station stating that she was found on the floor mat in her room. The nurse assessed the resident and did not note any injuries or discomfort. Vital signs were recorded. At 4:55 pm, the nurse ' s notes reflected that Resident #1 was found on the floor in her room next to her wheelchair. The resident was " noted lying on stomach with arms crossed under her on left side of face. " A head to toe assessment was performed revealing a bump to the resident ' s face on the left side above her eye. At 6:15 pm, it was noted that a CNA was assisting the resident with dinner in her room. At 6:30 pm, it is documented that the family was notified of both of the falls. At 7:00 pm, it is noted in the nurse ' s notes that LVN B went to assess the resident and noticed facial drooping on the right side of Resident #1 ' s face and the resident ' s tongue was hanging to the right side. At 7:07 pm, the nurse practitioner was notified of the change in condition and an order was given to send Resident #1 to the emergency room for evaluation. At 7:10 pm, the family was notified. At 9:00 pm, Resident #1 was transported to the hospital via EMS. Review of Resident #1 ' s Neurological Assessment Flow Sheet dated 11/01/13 reflected that the neurological assessments of Resident #1 were started at 5:00 pm (right after the second fall). The assessments were conducted every 15 minutes for the first hour (until 6:00 pm), and every 30 minutes after that until 8:30 pm. Then the resident was transported to the hospital. Resident #1 ' s level of consciousness was documented as alert and her pupils were equal and reactive to light during each assessment. Hand grasps were documented as equal, and it was documented that the resident could move all of her extremities. Resident #1 ' s pulse, temperature, and respiratory rate were stable. Resident #1 ' s blood pressure was stable until 7:00 pm, when it dropped to 74/33 mm/Hg (normal blood pressure range: 90/60 mm/Hg to 120/80 mm/Hg). At 7:30 pm, Resident #1 ' s blood pressure was 72/35 mm/Hg. At 8:00 pm, the resident ' s blood pressure was back in normal range at 108/82 mm/Hg. Review of Resident #1 ' s SBAR (Physician/NP/PA Communication and Progress Note for New Symptoms, Signs and Other Changes in Condition) dated 11/01/13 reflected Resident #1 was noted with facial drooping to the right side at 7:00 pm and that the resident had experienced a fall from her wheelchair earlier on 11/01/13. It was noted that Resident #1 had a recent increase in her [MEDICATION NAME] that started on 10/30/13. Review of Resident #1 ' s Fall Risk Evaluation dated 10/26/13 reflected that Resident #1 had a fall risk score of 21 (total score of 10 or above represents a high risk for falls). Review of Resident #1 ' s Discharge Summary from the hospital dated 11/03/13 reflected that " This is an [AGE] year-old female who was admitted after a fall resulting in subarachnoid hemorrhage. The patient also had acute kidney injury with [MEDICAL CONDITION]. The patient also supposedly took aspirin and [MEDICATION NAME] at home and trauma was consulted and recommended no intervention for the subarachnoid hemorrhage. Repeat CT scan the next day showed that the hemorrhage had not really gotten worse. There was a [MEDICATION NAME] hemorrhage on the right side, as well, which had not been mentioned in the previous CT scan. The family just wanted conservative management, given the patient ' s age and multiorgan failure. They wanted her on IV fluids, which anesthesia was called and IV fluids were running. The patient passed away at 6:45 a.m. on 11/03/13 and was pronounced by two Registered Nurses ( RNs). " Review of the Employee Counseling Form for CNA A dated 11/04/13 reflected that a verbal and written warning was given to CNA A for assisting a resident after a fall before notifying a nurse. CNA A signed the counseling form and agreed to " immediately notify nurse if resident has a fall prior to moving or assisting resident. " Review of the Employee Counseling Form for LVN B dated 11/01/13 reflected that a verbal warning was given to LVN B for not initiating neuro checks on a resident after an unwitnessed fall. LVN B signed the counseling form and agreed to " immediately initiate neuro checks with all unwitnessed falls or falls where resident hits their head. " Review of an in-service dated 11/03/13 reflected that an all-staff in-service was conducted regarding notifying a nurse immediately after a resident fall. The objectives included: " staff will acknowledge understanding of notifying nurse prior to moving or transferring resident after falls. " Review of an in-service dated 11/04/13 reflected that an all-staff in-service was conducted regarding the topics of fall prevention, checking chair and bed sensor alarms, not leaving high fall risk residents unattended, and communicating all fall issues to the charge nurse immediately. Review of an in-service dated 11/04/13 reflected that an in-service was conducted for all nurses regarding the protocol that all unwitnessed falls will have neuro checks implemented. Review of the facility Fall Management Process policy dated February 2010 reflected that after a fall: " 1. Evaluate the resident promptly in order to identify and treat injuries. 2. Complete neuro checks if the fall was unobserved or the resident hits their head or if there was a loss of consciousness. Frequency: Every 15 minutes x 2 hours, every 30 minutes x 2 hours, every hours x 2 hours and every shift thereafter for 72 hours or until here are no longer any symptoms related to the fall. 3. Licensed nurse or designee- Initiate an incident/accident report form and place in the 24 hour notebook, until report is completed and closed. " Review of " When a Fall Occurs Four steps to take in response to a fall " from the American Journal of Nursing (http://www.nursingcenter.com/lnc/JournalArticle?Article_ID= 8) dated November 2007 reflected " Step one: assessment. When a patient falls, don't assume that no injury has occurred-this can be a devastating mistake. Before moving the patient, ask him what he thinks caused the fall and assess any associated symptoms. Then conduct a comprehensive assessment, including the following: ? Check the vital signs and the apical and radial pulses. ? Check the cranial nerve. ? Check the skin for pallor, trauma, circulation, abrasion, bruising, and sensation. ? Check the central nervous system for sensation and movement in the lower extremities. ? Assess the current level of consciousness and determine whether the patient has had a loss of consciousness. ? Look for subtle cognitive changes. ? Check the pupils and orientation. ? Observe the leg rotation, and look for hip pain, shortening of the extremity, and pelvic or spinal pain. ? Note any pain and points of tenderness. Be aware of the following warning signs: numbness or tingling in the extremities, back pain, rib pain, or an externally rotated or shortened leg. These symptoms suggest spinal cord injury, leg or pelvic fracture, or head injury. Step two: notification and communication .... Step three: monitoring and reassessment. After the patient returns to bed, perform frequent neurologic and vital sign checks, including orthostatic vital signs. Fall victims who appear fine have been found dead in their beds a few hours after a fall. " During an interview on 11/15/13 at 9:53 am, the DON stated that 33 of the residents currently admitted to the facility are at a high risk for falls.

Based on observation, interview and record review the facility failed to ensure the resident environment remained free of accident hazards and residents received adequate supervision for 4 of 6 residents reviewed for smoking (Resident #1, #2, #3, and #4) when: A) Resident #1 was allowed to smoke with oxygen (O2) running and with the oxygen tank on his wheelchair, and: B) 4 of 6 residents (Resident #1, #2, #3, and #4) reviewed for smoking were in possession of smoking supplies (i.e. cigarettes and lighters) in their rooms. This deficient practice resulted in identification of an Immediate Jeopardy(IJ) on 02/01/12 at 5:10 PM. While the IJ was removed on 02/02/12, at 9:30 AM the facility remained out of compliance at a scope of Pattern, with a Severity of Potential for More than Minimal Harm that is not IJ because all staff had not yet been in-serviced on the facility's smoking policy and the hazards of smoking with oxygen. This deficient practice placed the 6 residents who smoke in danger of fire, burns or death due to the increased oxygen saturation of combustible materials (i.e hair, clothing, etc.) and had potential to cause injury to the additional 94 residents residing in the facility in the event of fire and/or explosion of oxygen. The findings were: A) Review of Resident #1's face sheet reflected a [AGE] year old male, admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. Review of Resident #1's Behavioral Health Visit Record dated 01/31/12 reflected [DIAGNOSES REDACTED]. Review of Resident #1's care plan dated 10/11/11 reflected Problem Onset: "Resident requires oxygen therapy." Approaches included "Resident smokes with O2 on - even though medically advised against." Review of Resident #1's clinical record reflected physician orders dated 09/19/11, October 2011, November 2011, December 2011, January 2012, and February 2012 for "Oxygen: 2 liters per minute (LPM) via nasal canula continuously." There was no Physician order for [REDACTED]. Observation on 02/01/12 at 3:40 PM revealed Resident #1 is his room seated on his bed with a nasal canula in place, tubing wrapped around each of his ears and oxygen in use. The resident had a pack of cigarettes in the pocket of the shirt he was wearing. There was a portable oxygen canister in the pocket on the back of his wheelchair. There were 6 portable oxygen canisters in a carrier on the floor in the room. During interview on 02/01/12 at 3:40 PM Resident #1 stated he smoked in the smoking area throughout the day and night. Resident #1 would not discuss the facility's rules about smoking. Resident #1 stated he used oxygen via portable oxygen tank while in his wheelchair. Observation on 02/01/12 at 4:40 PM revealed Resident #1 outside seated in his wheelchair in the smoking area and he was smoking a cigarette. Resident #1 had a portable oxygen canister in the pocket on the back of his wheelchair with the oxygen tubing there on the back of his wheelchair. He was not observed wearing receiving oxygen at this time. There were three other residents (Resident #2, #3, and #4) present in the smoking area who also were smoking. There were no staff present. In an interview on 02/01/12 at 10:00 AM the Administrator stated the facility began admitting residents who smoked approximately 6 or 7 months prior. The Administrator also stated that none of the current residents who smoked required supervision as all had been assessed upon admission. During interview on 02/01/12 at 3:00 PM Certified Nurse Aide (CNA) A stated she observed Resident #1 outside in the smoking area with his oxygen running. CNA A stated she would not intervene because Resident #1 "knows better" than to smoke with oxygen on. When asked if the charge nurse or Director of Nurses (DON) told her what to do CNA A stated no because the resident knows not to smoke with oxygen on. In an interview on 02/01/12 at 3:10 PM CNA D stated she observed Resident #1 outside in the smoking area smoking cigarettes with his oxygen turned on. CNA D stated she had to go outside and tell Resident #1 to turn his oxygen off. CNA D stated this happened in the last month. CNA D stated Resident #1 had been smoking with his oxygen on for a long time, ever since admission. During interview on 02/01/12 at 3:15 PM Licensed Vocational Nurse (LVN) E stated she had observed Resident #1 going outside to smoke with his oxygen turned on. LVN E stated she had been instructed to have Resident #1 choose between the "oxygen and the cigarettes". LVN E stated Resident #1 would argue with staff but LVN E would take the oxygen tank off of the wheelchair and Resident #1 would then go outside to smoke. During interview on 02/01/12 at 3:20 PM Licensed Vocational Nurse (LVN) F stated she had observed Resident #1 in the smoking area with his oxygen running and other staff would go outside and take Resident #1's oxygen tank away each time this happened. During interview on 02/01/12 at 3:30 PM CNA B stated she had observed Resident #1 outside in the smoking area, smoking cigarettes with his oxygen turned on. CNA B stated staff had to go outside to turn Resident #1's oxygen off. In an interview on 02/01/12 at 3:35 PM Medication Aide C stated she had observed Resident #1 outside in the smoking area, smoking cigarettes with his oxygen tank on his wheelchair and in use. During interview on 02/01/12 at 3:50 PM the DON stated she was aware that Resident #1 went outside to smoke with his oxygen turned on. The DON stated that Resident #1's lighter was taken away but he was able to obtain another lighter on his own. The DON stated Resident #1 would go outside with his oxygen turned on and staff would respond by going outside to turn the oxygen off. The DON stated staff were told via a 24-hour report that they should take Resident #1's oxygen tank off of his wheelchair before he goes outside to smoke. The DON did not provide a date or time that this communication went to the staff via the 24-hour report but she stated it was a while ago. The DON stated there were no staff in-services related to Resident #1's smoking, just the 24-hour report and the information was passed on to the staff from the 24-hour report. In interview on 02/01/12 at 2:10 PM Resident #2 stated Resident #1 had smoked in the smoking area with his oxygen turned on while Resident #2 was seated nearby on multiple occasions. Resident #2 stated she had lived in the nursing facility for a few weeks and had been going to the smoking area since admission. Resident #2 stated she knew Resident #1's oxygen was turned on because she could hear the hissing sound of the oxygen running. Resident #2 stated she knew that oxygen near smoking was dangerous and she believed Resident #1 did not have the right to put her and other residents in danger. Resident #2 stated Resident #1 would sometimes smoke with just the oxygen tank on the back of his wheelchair and part of the attachments to the oxygen tank had been taken off by staff. Review of Resident #1's Daily Skilled Nurse Notes dated 12/16/11 and 01/31/12 reflected Resident #1 ambulated independently via wheelchair. Review of Resident #1's " Smoking Assessment " dated 09/19/11 reflected "Other reasons why resident may not be able to smoke independently: resident is on continuous O2." Review of Resident #1 ' s nurses notes dated 12/16/11 reflected " He continues to smoke with O2 still on ... " and nurses notes dated 12/18/11 reflected " resident was smoking with O2 running several times staff had to turn off O2. " B.1.) Review of Resident #2's Physician orders reflected an admission date of [DATE] with [DIAGNOSES REDACTED]. There was no Physician order for [REDACTED]. Record review of Resident #2's care plan dated 01/11/2012 reflected use of CPAP (Continous Positive Air Pressure) machine with oxygen. An observation on 02/01/12 at 9:20 AM revealed Resident #2 in her room, sleeping in bed using a CPAP machine which was connected to an oxygen concentrator at her bedside. During interview on 02/01/12 at 2:10 PM Resident #2 stated she was allowed to keep her cigarettes and lighter in her room or with her at all times. Review of a resident "Smoking Assessment" dated 01/11/12 reflected that Resident #2 was a safe smoker. Observation on 02/01/12 at 2:10 PM revealed Resident #2 seated in the smoking area, smoking a cigarette and she had several packs of cigarettes and a lighter in her personal zippered bag. B.2.) Review of Resident #3's face sheet reflected he was admitted to the facility 08/22/11 with [DIAGNOSES REDACTED]. Review of Resident #3's clinical record reflected a "Smoking Assessment" dated 10/25/11 which assessed him as a safe smoker. Review of Resident #3's clinical record reflected there was no Physician orders for smoking. Observation on 02/01/12 at 2:25 PM revealed Resident #3 smoking a cigarette in the smoking area. In interview on 02/01/12 at 2:25 PM Resident #3 stated that he had observed Resident #1 smoking with his oxygen tank on his wheelchair. Resident #3 stated that he believed it was safe to smoke and have oxygen turned on or to have oxygen tanks nearby. B.3.) Review of Resident #4's face sheet reflected he was admitted to the facility 12/22/11. Resident #4's clinical record included a hospital history and physical which included [DIAGNOSES REDACTED]. Review of a "Smoking Assessment" dated 12/22/12 reflected Resident #4 to be a safe smoker. Observation on 02/01/12 at 1:10 PM revealed Resident #4 in his room with a pack of cigarettes and a lighter on the table beside his chair. During interview on 02/01/12 at 1:10 PM Resident #4 stated he had observed Resident #1 smoking in the smoking area with an oxygen tank on the back of his wheelchair. Resident #4 stated the staff would make Resident #1 go inside or they would take the oxygen tank off of Resident #1's wheelchair. The facility provided their policy for smoking at 4 PM on 02/01/12. Review of the facility's smoking policy, dated November 2006 and titled "Smoking Policy for Non Smoke Free Facility" reflected "All cigarettes and lighters will be kept in a secured location preferably at the Nurses' Station. Those residents who smoke on their own will be given their pack of cigarettes and a lighter upon request. After smoking, these two items will be returned back to their prospective Nursing Stations/secured location." The Smoking policy also reflected "those residents who are cognitively alert, have a long attention span, need to be evaluated by a member of the Interdisciplinary Team and have a doctor's order to smoke, will be allowed to smoke outside the facility." The facility Administrator, DON and the facility's corporate nurse were notified on 02/01/12 at 5:10 PM that an Immediate Jeopardy had been identified due to the above failures. On 02/01/12 at 5:21 PM the facility's corporate nurse presented the surveyor with a written plan of removal which included the following: 1) Resident #1's smoking materials would be taken away and not be given back until he was discharged later that evening. Resident #1 was planned for immediate discharge at 6:15 PM 02/01/12. 2) Staff in-service on the facility's smoking policy, and smoking assessments, hazards of smoking with oxygen. 3) 100% re-assessment of all known smokers. 4) Staff to ensure that smoking items (cigarettes and lighters) are kept in safe location. 5) Smoking policy added to admission packet to inform all admits to the facility of 30 day discharge policy for failure to follow facility smoking policy. 6) In interview on 02/02/12 at 8:45 AM with the DON she stated as part of the plan of removal the social services staff were going to call families of residents who smoke to notify that all smoking materials that are brought to the facility must be given to the charge nurse to be secured. On 02/02/12 at 9:30 AM the DON provided smoking assessments which identified all residents in the facility who smoked, as Residents #2, #3, #4, #5, #6, and #7. In interview on 02/01/12 at 5:15 PM Resident #2 stated she was upset because the staff had taken away cigarettes and lighters from residents who smoked and had them locked up at the nurses' station. In interview on 02/01/12 at 5:20 PM Resident #3 stated he was upset because the staff had taken away cigarettes and lighters from residents who smoked. On 02/02/12 at 9:30 AM, the corporate nurse was informed the Immediate Jeopardy (IJ) was removed. However, the facility remained out of compliance at a scope of Pattern, with a Severity of Potential for More than Minimal Harm that is not IJ because all staff had not yet been in-serviced on the facility's smoking policy and the hazards of smoking with oxygen. On 02/02/12 at 9:30 AM the DON identified 6 residents remaining in the facility who smoked. There were 2 residents who smoked and used oxygen as needed (prn) (Residents #2 and #5). The current resident census provided by the facility was 100.