Every finding on record at Focused Care at Beechnut

Based on observation, interviews and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (CR #1) reviewed for accidents and supervision, in that:The facility failed to ensure CR #1 did not elope from the facility on 3/21/26. The facility did not realize he had left through a window in room [ROOM NUMBER] and exited the facility through the fence. Resident #1 was found by a staff member in front of a store located approximately 2.5 miles away.The non-compliance was identified as PNC. The Immediate Jeopardy (IJ) began on 03/21/26 and ended on 03/21/26. The facility had corrected the non-compliance before the survey began on 04/15/26. The IJ template was sent to the Administrator on 04/16/26 at 3:18 p.m.This failure could have placed residents with exit-seeking behaviors at risk for injury or death.Findings included:Record review of CR #1's face sheet dated 04/15/26 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and was discharged to a behavioral hospital on 3/24/26. His diagnoses included Alzheimer's disease (a progressive irreversible brain disorder), cognitive communication deficit, aphasia (communication disorder caused by brain damage), and hypertension (when the pressure in the blood vessels is too high).Record review of CR #1's quarterly MDS dated [DATE] revealed a BIMS score of 01 out of 15, indicating significant cognitive impairment. CR #1 was self-ambulated and did not use any assistive device and behavior code indicated 0. Further review of the MDS revealed CR #1 required moderate assistance with supervision with 1 staff assist.Record review of CR #1's Care Plan, initiated on 10/7/25, revealed CR #1 was identified as a high elopement risk/wanderer. Intervention: provide structured activities: toileting, walking inside and outside, reorientation strategies, including signs, picture and memory boxes. Resident resides in the faculty secure unit. The Care Plan was reviewed on 03/22/26 indicated CR #1 had an actual elopement on 03/21/26. Interventions included one-on-one supervision, in-house psychology consultation, and transfer to a more secure unit when available. The Care Plan was revised on 03/23/26.Record review of CR #1's incident report dated 03/21/26 indicated that during dinner time, CR #1 was observed eating. The resident later walked to his room and stood in the hallway by his room door. At approximately 7:00 p.m., CR #1 was not present in his room, bathroom, hallway, or other resident rooms and was not observed anywhere within the facility. Staff searched all rooms and bathrooms; however, the resident was not located.During an interview on 04/15/26 at 10:12 a.m., the ADON stated she was not aware CR #1 had expressed a desire to go home. She stated she saw CR #1 during lunch, and he was eating in the dining room. She stated she was notified by LVN N that CR #1 exited the building through the room [ROOM NUMBER] window into the courtyard and left the facility grounds after removing two fence planks. She said staff were unaware CR #1 had left the facility until approximately 7:00 p.m., when MA A attempted to administer medication to CR #1. She stated CR #1 could have sustained injury or experienced a worse outcome.During an interview on 04/15/26 at 11:31 a.m., the Activity Director stated CR #1 typically came to her office at least once weekly and expressed a desire to leave the facility and return to his home. She said she would call CR #1's RP, and at times the RP stated she was attempting to find placement closer to his home. The Activity Director said she reported CR #1 wanted to go home to the management team during a morning meeting but could not recall the date. She stated she was notified that CR #1 had left the facility and staff were unaware of the time of exit. She stated she located CR #1 in front of a store which was on a busy street, approximately 2.5 miles from the facility about 8:25 p.m. The Activity Director said CR #1 had two shirts, a jacket, and shoes on when she found him and he was eating chips and drinking juice. She said CR #1 could have hurt himself or been run over by a car because the staff did not know when he left the facility.During an interview on 04/15/26 at 12:31 p.m., the Maintenance Director stated he was called to the facility after CR #1 left without staff awareness. He reported CR #1 removed the window from the window panel because he was able to bend the long screws which held the glass, then climbed out through the window to the courtyard. He then removed two fence planks which were old and exited the facility through the opening. He said CR #1 could have sustained injury or worse while he was out in public.During an interview on 04/15/26 at 1:14 p.m., MA A stated she identified CR #1 was not in the building when she went to administer medication at approximately 7:00 p.m. She stated she asked CNA E, who reported seeing CR #1 standing in front of his room approximately 15 minutes earlier. MA A said she reported to LVN N, and they conducted a facility-wide search, and CR #1 was not found within the facility. MA A said LVN N reported the incident to management. She stated none of the staff saw him when he pulled the window out and climbed through it or when he pulled out two planks, which were observed on the ground in the courtyard, and staff assumed he left the facility through the opening in the fence. During an interview on 04/15/26 at 2:53 p.m., the DON stated she saw CR #1 on the day of elopement, and he did not exhibit behaviors indicative of elopement risk. She said she was unaware he had been requesting to go home. She reported she was later notified that CR #1 had eloped, and the staff became aware of his absence at approximately 7:00 p.m. She stated the resident exited from the building after removing the window from the frame in the room across from his room, and he exited the facility grounds through the fence after he pulled out two wooden fence planks. The DON said CR #1 was observed outside his room door 15 minutes before he exited the building without staff knowledge. She said CR #1 would have sustained a serious injury or death when he was out in the community alone.During an interview on 04/15/26 at 3:20 p.m., the Administrator stated staff were unaware CR #1 had left the facility until approximately 7:00 p.m., at which time they notified him, law enforcement, and the medical director and continued to search the facility and surrounding area. He stated the Activity Director located CR #1 in front of a store at approximately 8:20 p.m. and returned him to the facility. He stated the resident exited through a window after he had removed the glass from the frame and left the grounds through an opening created after removing two fence planks. He said he was not aware CR#1 wanted to go back home, and they have not had any resident eloped from the memory care or from the facility snice he started working in this building. The Administrator said CR #1 could have sustained injury or a worse outcome when he was away from the facility unsupervised.During an interview on 04/15/26 at 4:32 p.m., CNA E said she observed CR #1 at approximately 6:45 p.m. standing in front of his room while returning a food cart to the kitchen. She said she became aware of his absence when MA A inquired about CR #1, and a search of the facility was conducted; however, CR #1 was not located. LVN N reported the incident to the Administrator. She stated CR #1 occasionally pushed on exit doors, which other residents in the memory care unit did. She said the aides made rounds every two hours, and if an aide was going to provide care for another resident, the aide would inform the other aides. She said the memory care unit had three aides on any given shift, and the aides made rounds every two hours.During an interview on 04/17/26 at 11:51 a.m., CNA B said she was CR #1's CNA on the day he eloped from the facility. She said she last saw CR #1 around 5:30 p.m. She said CR #1 came to the dining room, took his dinner tray, and went back to his room because he liked to eat in his room. She said she did not see CR #1 again because during dinner she started getting other residents ready for bed, and another aide was seated in the living area and ensured no resident left through the exit door. She said she became aware CR #1 was not in the building when MA A asked her about CR #1. They searched for him in the memory care unit and the two units in the facility but did not find him. She then reported to LVN N, and she called the Administrator, DON, and police while they searched the whole facility. CNA B said CR #1 usually stayed in his room and came out mostly during meals. She said CR #1 was later found and brought back to the facility, and LVN N assessed him. She said CR #1 could have been struck by a car or sustained other types of injury.During an interview on 04/17/26 at 11:51 a.m., LVN N said she was the nurse on duty when CR #1 eloped from the building and left the facility grounds. LVN N said she last saw CR #1 standing by his room at 6:45 p.m. and did not know he had left the facility through the window across from his room until MA A told her she could not find CR #1 when she went to his room to administer his medication. LVN N said she reported to the Administrator and the police during and after they searched the whole facility and could not find CR #1. She said he was found in front of a store about 2 miles away by the Activity Director. LVN N said she assessed CR #1 when he was brought back to the facility around 8:30 p.m., and he denied pain and had no injuries. She noted CR #1 was placed on one-to-one monitoring immediately.Record review of the facility policy on elopement, effective date 11/01/2019, read in part .To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing. Elopement drill will be held quarterly. This was determined to be a Past Non-Compliance Immediate Jeopardy on 04/16/26 The Administrator, and DON were notified. The Administrator was provided with the IJ template on .04/16/26 at 3:18 p.m. The facility took the following actions to correct the non-compliance prior to the investigation. Impromptu QAPI RE: ElopementAdministrator, Maintenance Director, DON, ADON E, ADON O, and Medical Director (via phone) were in attendance. The purpose of the meeting was to review the incident and devise strategies to address the issue.Summary: In answering how he was able to exit the building, the incident was reviewed. He had not exhibited any unusual behaviors and was acting at his baseline. CR #1 had a room with a window that faced an interior courtyard. He had gone to room [ROOM NUMBER] and taken the window out of the frame, bending the stopper screws. He was able to exit the window, which was on ground level. This gave him access to a patio that had a fence on the property line. He pulled boards off the fence and was able to exit the property. He had been observed at mealtime eating. When he was noted to be gone, it was 7:00 p.m., and he had been seen about 15 minutes prior. When he was noted missing, staff began searching the facility and grounds. When he was not found, staff expanded the search to the neighborhood and alerted the police. Staff continued searching and located him at a dollar store at 8:10 p.m. He had water and snacks and returned to the facility with staff without incident. He had not missed any critical medications. He was not in pain and had no injuries.Problem: CR #1 was able to exit the facility. He had been observed within a reasonable amount of time. He was able to use force to open the window and exit.Goal: Ensure windows were secure and that the patio was secure.Interventions:The windows were evaluated by the Maintenance Director and reinforced as appropriate to ensure they could not be opened to allow for exit. room [ROOM NUMBER] was checked several times, and CR #1 was brought in to test the window; he could not open it.The windows and fence were to be checked weekly by maintenance to ensure they were secure.CR #1 was placed on one-to-one monitoring.CR #1 was referred to psychological services.CR #1 received an immediate eviction notice.Elopement wandering/leaving the facility training was conducted.Abuse/neglect training was conducted for all staff.CR #1 was placed on one-to-one monitoring.Performance improvement plan with immediate intervention included:Head countResident returned to facility within 90 minutesMedical Director/RP notifiedHead-to-toe assessment completedWandering/elopement evaluation on CR #1Audit on all residents to identify residents at risk for elopementCR #1 was transferred to a Behavioral HospitalMaintenance monitored all windows and fence in the memory care unit daily for 5 days and weekly until the next month and would reassess after the next monthRecord review of the facility paperwork for CR #1 one-to-one revealed it was initiated on 03/21/26 until he was discharged on 03/24/26.Record review of facility hourly head count revealed it was initiated on 03/21/26 until 04/16/26.Record review of the facility window and fence check and improvement revealed it was initiated on 03/21/26 and was still ongoing.Record review of the elopement binder dated 03/23/26 for the three halls in the facility revealed it was updated with the residents' picture, BIMS, and elopement assessment, and each book was placed at the nursing station.Record review of the facility in-service 03/21/26, 3/22/26, and 3/23/26 revealed all staff were in-serviced on abuse/neglect and elopement drills in all halls.Record review of the patio check revealed it was initiated on 03/23/26 and was still ongoing.Observation conducted on 04/15/26 at 12:50 p.m. with the Maintenance Director revealed the window in room [ROOM NUMBER] and room [ROOM NUMBER] had been secured with 1-inch metal studs instead of the long screws previously in place prior to CR #1 removing the window from the frame.Observation conducted on 04/15/26 at 12:55 p.m. with the Maintenance Director revealed the fence was old and approximately 20 planks had been replaced with new planks. During an interview on 04/15/26 between 8:30 a.m. through 12:32 p.m., ADON O, ADON M, and the Maintenance Director stated they had been in-serviced on abuse/neglect, and the Administrator was the abuse coordinator. They were able to verbalize four types of abuse/neglect, and that abuse should be reported immediately. They stated they were provided in-service on elopement and drills. They said if a resident was noted missing, the CNA would report to the nurse, who would call the Administrator and the DON, and the Administrator would oversee the search. They stated staff would continue to look for the resident inside and outside the facility, start a head count, and after 15 minutes if the resident was not found, the nurse would call the police, and the search would continue. The Administrator would divide staff into different search parties. They stated after the resident was found, they initiated an elopement drill where the resident would be hidden, and the drill would imitate an actual elopement.During an interview on 04/15/26 at 3:20 p.m., the Administrator stated CR #1 was assessed when he was brought back to the facility and did not have any injury or pain. The Maintenance Director secured the windows and checked all the fences and fixed the open area. The next day, they checked the windows daily for 5 days and conducted weekly checks until the next month, after which they would reassess. The fence was checked weekly until the next month, after which they would reassess. The Administrator stated CR #1 was placed on one-to-one monitoring as soon as he was returned to the facility until he was transferred to a behavioral hospital. The Administrator stated monitoring of the windows, the fence, and areas of the courtyard was put in place to observe areas staff could not see and to secure the windows and fence so it would not be easy for residents to remove them and exit the facility grounds. He stated the elopement drill was completed, and they reassessed all residents on C hall and reassessed residents on A hall and B hall for wander guard. The Administrator stated there was a break in the system when staff were assisting other residents, and they did not observe CR #1 manipulating the window, which had long screws that were easier to bend, and the fence was aged. He stated the corporate nurse conducted the in-service on elopement for him and the DON, and he participated in the elopement drill.During interviews on 04/15/26 between 1:03 p.m. through 1:14 p.m. and 3:16 p.m., CNA C, CNA D, MA A, CNA E, and LVN D, and on 04/16/26 between 2:24 p.m. through 4:15 p.m., [NAME], MA G, MA F, LVN Q, and on 04/17/26 between 9:44 a.m. through 12:37 p.m., CNA B, CNA H, CNA I, CNA G, LVN Q, LVN R, LVN N, LVN K, and LVN W were able to verbalize what they were in-serviced on regarding abuse/neglect, and they were able to verbalize four types of abuse/neglect. They stated the Administrator was the abuse coordinator and that abuse/neglect should be reported immediately. They stated the in-service was provided after CR #1 eloped and was brought back to the facility. They also stated they were provided in-service on elopement and elopement drills after CR #1 was found. They stated when a resident was not present in the facility, the aide would report to the nurse, who would call the Administrator and the DON while staff continued to search both inside and outside the facility grounds and continue head count. The Administrator would take charge of the elopement, and when the resident was found, the facility would initiate an elopement drill which would mimic an actual elopement.During an interview on 04/16/26 at 2:13 p.m., the DON stated all staff were provided in-service on abuse/neglect and elopement drills in all halls. She stated the three halls had binders for elopement, which were reviewed after the incident and updated. The DON stated all residents in the 300 hall were reassessed, and BIMS scores and current pictures were placed in the elopement binder because they were all at risk for elopement. They also reassessed residents in the 100 and 200 halls, and all residents at risk for wandering had wander guard devices, which were tested, and the elopement binder was also updated.

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 in 1 of 1 kitchen reviewed for food procurement in that:1-10 pounds roll of Ground Beef had a temperature of 75 degrees Fahrenheit.This failure could affect residents who ate food from the facility kitchen and place them at risk of food borne illness and disease.Observation and interview on 08/19/25 between 8:30 am and 8:40 am with the Dietary Manager revealed 1-10 pounds roll of ground beef observed. The roll was a potentially hazardous/time control for safety food as it was inappropriately being held on a pan on top of the stove. The Dietary Manager measured the roll on the stove, and it had an internal temperature 75 degrees Fahrenheit.Interview with the Dietary Manager on 08/19/25 at 8:40 AM he stated that food held with danger zone temperature could place the residents who ate food at risk of food borne illness and disease. He stated that he was responsible for training staff on proper storage and food temperature.Record review of facility's Food and Nutrition Services Policy and Procedure Manual dated revision date 08/2007 read in part .3. Cold foods shall be maintained at temperatures of 40 degrees Fahrenheit or below. Hot foods or potentially hazardous food shall have a temperature of 140 degrees Fahrenheit or above.

Based on observation, interview and record review, the facility must dispose of garbage and refuse properly for 4 of 4 dumpsters reviewed for garbage disposal. -The facility failed to ensure the dumpster lids and doors were secured.This failure could place residents at risk of infection. Observation on 08-19-25 at 8:45 am, with the Dietary Manager revealed the facility's dumpster area, which was in the lot behind the dietary department had 4 commercial -size dumpsters and the lids and doors were open. Interview on 08-19-25 at 9:00 am, with the Dietary Manager he stated that the dumpster lids always must be closed to keep vermin, pests and insects out of the dumpster and from entering the facility. He also stated that nursing, housekeeping and dietary dispose their garbage in the dumpster and place residents at risk of infection.Record review of facility policy and procedure on Waste Disposal dated June 2006, revealed: Policy, Food related garbage and rubbish is disposed of in accordance with current laws and regulations. Outside dumpster provided by garbage pick- up services will be kept closed and free of surrounding liter.

Based on observations, interviews and record review, the facility failed to ensure residents receive services in the facility with reasonable accommodation of resident needs for 3 of 5 residents (Residents #103, #101, and #36) reviewed for call lights.-The facility failed to ensure Resident #103, Resident #101's, and #36's call lights within reach.This failure could place residents at risk for a delay in care and services, increased falls, and a decreased quality of life.Resident #103Record review of Resident #103's face sheet 08/22/25 revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #103 had diagnoses which included: diabetes mellitus (high blood sugar), hypertension (high blood pressure), and Alzheimer (a progressive brain disease that cause memory loss). Record review of Resident #103 's Quarterly MDS assessment dated [DATE] revealed BIMS score of 00 of 15 indicating severely impaired cognition. Further review revealed the resident needed total care with ADL assistance with one staff assist. Record review of Resident #103's care plan dated 07/17/25 read in part . Resident #103 had ADL self-care performance deficit related to disease process Alzheimer . encourage the resident to use call light for assistance.During an observation and interview on 08/19/25 at 9:50 a.m., Resident #103 told the Surveyor he wanted to be changed because he was last changed before breakfast, and he was wet. When the Surveyor asked Resident #103 to push his call light, Resident #103 said he did not have a call light and if he had a call light, he would have called for help. The Surveyor looked around his section of the room, and there was no call light.During an observation and interview on 08/19/25 10:02 a.m., MA C said she found Resident #103's call light on top of his roommate's bed A. MA C said Resident #103 would not be able to reach the call light where it was placed. MA C said Resident #103's call light should be within the resident's reach so the resident could call for help. MA C said Resident #103 could fall if Resident #103 could not reach the call light or call the staff when he needed help. MA C said she had an in-service on call light, and she was educated that the call light should be placed within reach to prevent complications for the resident. She stated the nurse monitored the aides, and the nurse managers monitored the nurses.During an interview on 08/19/25 at 10:36 a.m., CNA U said she did not give Resident #103 his call light when he went back to bed because she could not find the call light. CNA U said Resident #103 could fall while trying to reach for the call light or while getting out of bed. CNA U stated that she had a skill check-off, which included the call light, and she was educated to ensure the call light was within reach at all times. She said the nurse monitored the aides during the shift. CNA U did not respond to why she did not give Resident #103 his call light.During an interview on 08/19/25 at 10:42 a.m., LVN D said the call light should be placed where Resident #103 could reach the call light. LVN D said Resident #103 needed the call light to call the staff for assistance. LVN D stated if the resident did not have his call light, Resident #103 could attempt to get up and fall, and the resident could get hurt. LVN D stated the call light was the aide's primary responsibility, but all nursing staff are responsible too. LVN D said the nurse monitored the aides throughout the shift, and the nurse managers monitored the nurses.During an interview on 08/21/25 at 2:35 p.m., the DON said CNA U should have placed the call light within Resident #103's reach. The DON said the resident used the call light to communicate with staff, and if the resident were not able to reach the call light, the resident would not be able to get assistance when needed, and the outcome would not be good. The DON said the resident's health could deteriorate if they could not reach any staff promptly. The DON said all the nursing staff are responsible for making sure that the resident's call light is within reach, but the aides are the first line of care. The DON said the aides and the nurses had a skill check off, and the call light was part of the care area. The DON said the aide was given an in-service about the call light, and they were educated to ensure that the call light was within the resident's reach at all times. The DON said the nurse monitors the aides throughout the shift, and the nurse manager monitors the nurse randomly.RESIDENT #101Record review of Resident #101's face sheet dated 08/22/25 revealed a male resident attended to the facility on [DATE]. Resident #101 had diagnoses which included, diabetes mellitus(high blood sugar), hypertension(high blood pressure),and myocardial infraction (blood flow to a part of the heart muscle is suddenly blocked). Record review of Resident 101's Quarterly MDS assessment dated [DATE] revealed Resident BIMS was 03 indicating severely impaired cognition. Further review of the resident MDS revealed resident needed total care with ADL assistance with one staff assist. Record review of Resident #101's care plan dated 01/25/25 read in part . Resident had ADL self-performance deficit related to disease processes. Intervention: Encourage the resident to use bell to call for assistance . During an observation and interview on 08/19/25 at 11:16 a.m., Resident #101 said she could not reach her call light and had been banging on the wall with her back scratcher to get the staff's attention. She said she wanted the remote for the bed so she could raise the head of the bed. She said she could not see or reach her call light. Observation revealed the resident's call light was hanging by the head of the bed, and the resident could not reach the call light.During an observation and interview on 08/19/25 at 11:20 a.m., LVN D came into Resident #101's room and stated that Resident #101 sometimes played with the call light, which may be why the aide placed it by the head of the bed, where she could not reach it. LVN D checked Resident #101's call light and stated that it was working. She then placed the call light under Resident #101's pillow and exited the room. The Surveyor called LVN D back and asked her where she placed the call light. LVN D said she gave Resident #101 her call light. When the Surveyor asked LVN D to locate the call light, she stated that she had placed it under the pillow. LVN D stated that she did not know why she placed the call light under Resident #101's pillow. She said Resident #101 would not be able to call for help when she needed care because she could not reach, his call light, and it could delay care for the resident. LVN D said she had an in-service on the call light, and she was educated to ensure the resident's call light was within reach. She said the nurse monitored the aides, and the nurse managers monitored the nurses.During an interview on 08/19/25 at 11:30 a.m., CNA U said she did not know that the call light was hanging on the head of the bed and Resident #101 would not be able to reach the call light and the resident could fall trying to reach for the call light, or tried to get out of bed without assistance, and she may not get care in a timely manner. CNA U stated she had an in-service on the call light and was educated to place the call light within the resident's reach at all times to facilitate quick responses to the resident's needs.During an interview on 08/20/25 at 4:28 p.m., ADON A said Resident #101's call light should be placed within reach of the resident when the resident is in bed. ADON A said everybody was responsible for making sure the call light was placed within reach for Resident #101, but the aides are the first line of care. ADON A stated that when the Resident #101 call light was not within reach, the resident would not receive the assistance needed, and the resident could fall while trying to reach the call light. She said the staff had a skill check-off and an in-service on-call light, and the aides were educated to ensure the residents' call lights were always within reach. She said she started another in-service on the call light yesterday. She said the nurses monitored the aides throughout the shift, and nurse managers would conduct random rounds to monitor the nurses.During an interview on 08/22/25 at 8:12 a.m., the Administrator said that the call light should be within reach so the resident could call for help and get the assistance needed. The Administrator stated that there would be a delay in care until a staff member entered the room to check on the resident during rounding if the resident had not pressed the call light. The Administrator stated that the nurse and nurse managers monitored the aides.Resident #36Record review of Resident #36's Face sheet revealed she was a [AGE] year old female who admitted to the facility on [DATE] with diagnosis included other abnormalities of gait and mobility, unspecified lack of coordination unspecified dementia, moderate, without behavioral disturbances, psychotic disturbances, mood disturbance and anxiety, major depressive disorder, recurrent, mild, muscle wasting and atrophy, not elsewhere classified, multiple sites, lack of coordination, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.Record review of Resident #36's Quarterly Minimum Data Set (MDS) dated [DATE] indicated that resident had a BIMS of 04 indicated severe cognitive impairment, 15 indicated intact cognition. Resident needed maximal staff assistance with more than 50 % of her care Activities of Daily Living (ADL) assistance with one staff assist: dressing, toileting, hygiene, bathing, and touch assistance with eating. Record review of Resident #36's undated Care Plan reflected resident had an Activities of Daily Living (ADL) self-care performance deficit and required staff assistance .Record review of Resident #36's Progress Notes dated 08/06/2025 at 07:26 a.m., reflected Nurses note Resident was on day 2 of 3 from a fall, no visible injuries noted, resident slept well all night, no complaints of pain or discomfort noted, all due care rendered, bed in low position, call light within reach, neuro checks in progress. During an observation/Interview attempt on 08/19/2025 at 01:22 p.m., Resident #36 sitting upright in bed, call light on the floor. Resident asleep with their face on bedside table and did not arouse to voice or sound. During an observation/Interview attempt on 08/19/2025 at 4:48 p.m., Resident #36 had not aroused to sound or voice. Resident's bed in a low position call light in place and fall mat at bedside. During an interview on 08/20/2025 at 04:41 p.m., the Administrator and the DON stated that they were not aware that Resident #36's call-light had been on the floor. They stated that they would follow up with nursing staff to ensure that the resident's call-light maintained within reach. They stated that the facility staff receive in-services routinely on answering and positioning of call-lights.During an observation/interview attempt on 08/22/2025 at 09:47 a.m., Resident #36's laid in bed asleep, with bed placement low to ground. Resident responded to voice and sound by opening her eyes and raising her hand. Resident made long blinks and reclosed her eyes and did not respond to questions asked. Call-light in place. During an observation/interview on 08/22/2025 at 09:53 a.m., AD A stated that Resident #36 had good and bad days, or rather high and low days. AD A stated that the resident was able to self-propels on her high days and, when she experienced a low day, resident would just lay in bed and sleeps. She stated that the resident's Resident Care Provider (RCP) had indicated that she would be getting resident up out of bed. She stated that they receive in-services routinely on answering and positioning of call-lights.Record review of the facility policy on bedrooms dated 2001MED.PASS, Inc. (Revised May 2017) read in part . policy interpretation and implementation #6. All resident rooms are equipped with a resident call system that allows residents to call for staff assistance. Calls are directed to either a staff member or to a centralized work area.Record review of the facility policy on resident rights dated Copyright 2022 the compliance store, LLC. All rights reserved read in part . policy explanation and compliance guidelines #5.This facility provides equal access to quality of care regardless of diagnosis, severity of condition, or payment source.

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 3 of 4 residents (Resident #103, Resident #34, and Resident #1) and 1 (Station A) of nurse's stations reviewed for infection control. 1. The facility failed to ensure CNA U followed appropriate infection control and hand hygiene procedure during incontinent care for Resident #103. 2. The facility failed to ensure LVN Z followed appropriate infection control and hand hygiene procedure during Accu check for Resident #34.3. The facility failed to ensure CNA R and LVN B followed appropriate infection control and PPE when Resident #1's Foley bag and tubing was lying on the floor, and no PPE was in the set up. 4. LVN A failed to wash her hands and follow sterile techniques while providing Resident #10 with tracheostomy care.5. The sharps container attached to LVN U's medication cart had an exposed syringe sitting at the opening of the disposal area of the sharp's container. These failures could place the residents at risk for infection. 1. Record review of Resident #103's face sheet, dated 08/22/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #103 had diagnoses which included: diabetes mellitus (high blood sugar), hypertension (high blood pressure), and Alzheimer's (a progressive brain disease that cause memory loss). Record review of Resident #103 's Quarterly MDS assessment, dated 05/21/25, revealed a BIMS score of 00 of 15, which indicated severely impaired cognition. The resident needed total care with ADL assistance with one staff assistance. Record review of Resident #103's care plan, dated 07/17/25, read in part . [Resident #103] had ADL self-care performance deficit related to disease process Alzheimer . encourage the resident to use call light for assistance. During an observation on 08/19/25 at 10:12 a.m., for Resident # 103's incontinent care revealed CNA U did not wash her hands before she donned gloves and started to provide care for Resident #34. CNA U cleaned Resident #103's peri area (perineal care or incontinent care) three times with one wipe before she discarded the wipe, and she went into the wipe packet four times with the dirty gloves she wiped the resident. CNA U did not change her glove and picked up the clean brief after she had finished cleaning the resident. MA C, who assisted CNA U, told her to change her gloves. CNA U removed the gloves, and she went into Resident #34's roommate's drawer and took another glove. She then put on the gloves without washing or sanitizing her hands and applied a clean incontinence brief to Resident #103. CNA U picked up the call light from the floor, which she stepped on several times while she provided incontinent care to Resident #34, and placed it on Resident #103's hand without disinfecting the call light. CNA U took off her gloves and left the resident's room without washing her hands.During an interview on 08/19/25 at 10:20 a.m., MA C stated CNA U should have washed her hands and set up a clean field on the bedside table. MA C said CNA U should have washed her hands before she donned her gloves and pulled out the wipes she was going to use for incontinent care to prevent her from going into the wipe packets with the dirty glove. She stated CNA U should have wiped Resident #103 once and disposed of the wipe to prevent the spread of germs. MA C stated CNA U should have disinfected the call light before she handed the call to Resident #34. MA C said CNA U made several infection control issues due to cross-contamination. MA C said CNA U should have washed her hands before she left the resident room because of cross-contamination. She said she was in serviced on infection control, which included hand washing and PPE. MA C said the nurses monitored the aides throughout the shift.During an interview on 08/19/25 at 10:22 a.m., CNA U said she was supposed to wash her hands before she donned her gloves. CNA U said she forgot to set up a clean field and to pull out the wipes she needed for incontinent care, which would have prevented her from going into the clean packet of wipes with a dirty glove. CNA U said she used one wipe multiple times instead of once when she cleaned Resident #103's private areas. She said she should have removed the dirty gloves and washed her hands before putting on a clean pair of gloves, and then washed her hands again before leaving the resident room, as it was an infection control issue because she could have spread germs from one area to another. CNA U said she should have disinfected the call light before she gave the call light it to the resident because it was on the floor and it was an infection control issue. CNA U said she had a skills check-off and infection control in-service, which included hand washing and PPE. She stated the nurse monitored the aide throughout the shift.During an interview on 08/19/25 at 10:51 a.m., LVN D said CNA U was supposed to wash her hands before she started incontinent care for Resident #103. LVN D said CNA U was supposed to wash her hands to prevent the spread of germs. LVN D said CNA D should have used one wipe two to three times before she used another wipe during incontinent care for Resident #103. LVN D said CNA U should not have used the same dirty gloves and went back into the wipes packet because of cross-contamination. LNV D said CNA U should have donned a clean glove after she washed her hands, then applied the clean incontinent brief. She stated CNA U was supposed to disinfect the call light before she gave it to the resident because the floor had germs. During an interview on 08/21/25 at 8:25 a.m., ADON A said CNA U should have had all the incontinent supplies placed on a clean bedside before she started to provide care for Resident #103. ADON A said CNA U should disinfect the bedside table, place a clean towel, and set up all the incontinent supplies. The ADON stated CNA U should have washed her hands and donned gloves before she provided care to Resident #103. ADON A said CNA U was supposed to pull out wipes from the packet to prevent her from going back into the wipe packet with dirty gloves. She said the wipes in the packet would be contaminated because CNA U used the dirty gloves and went into the packet. She said CNA U should have wiped Resident #103 once with one wipe to prevent reintroducing the germ to the clean area. She stated CNA U should have taken off the gloves and washed or sanitized her hands before donning a clean pair of gloves to prevent transferring germs from the dirty gloves to the clean brief. She said CNA U should take off her gloves and wash her hands before leaving Resident #103's room. ADON A said the nurse monitored the aides throughout the shift, and the nurse manager monitored the nurse during rounding to ensure the staff was providing care appropriate to the residents.During an interview on 08/21/25 at 2:53 p.m., the DON stated CNA U should set up the supplies on the bedside table after the table was disinfected, place a clean barrier, set up the incontinent supplies, pulled out the wipes for care, and had extra gloves. The DON said CNA U should have washed her hands before donning clean gloves. The DON said CNA U should not have entered the wipe packet with the dirty gloves because it would cause cross-contamination. The DON said CNA U should have removed the dirty gloves, washed her hands, donned another pair of gloves, and pulled more wipes from the packet. The DON said CNA U should have used the wipe once when she cleaned Resident #103 and thrown it away. The DON said when CNA U used one wipe multiple times, she was moving the germs around and, not cleaning. The DON said CNA U should have removed the dirty gloves, washed her hands, and donned another pair of gloves before touching the clean brief to prevent cross-contamination. She said CNA U should have washed her hands before leaving the room to avoid the spread of germs. The DON said CNA U should have disinfected the call light she picked up from the floor, which she had stepped on, to prevent cross-contamination. The DON said the staff had a skill check-off and in-service on infection control, which included hand washing and the use of PPE. 2. Record review of Resident #34's face sheet, dated 08/22/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included, diabetes mellitus (high blood sugar), hypertension (high blood pressure), and heart failure (heart cannot pump enough blood and oxygen to meet the body's needs). Record review of Resident #34's Quarterly MDS assessment, dated 08/06/25, revealed the BIMS was 13 out of 15, which indicated intact cognition. Resident #34 needed extensive to total care with ADL with one staff assist. Record review of Resident #34's order summary report read in part . Insulin Glargine Solution 100 UNIT/ML Inject 14 unit subcutaneously two times a day for diabetes Hold for blood sugar less than 100 mg/dl ordered date 10/21/24 During an observation on 08/20/25 at 7:06 a.m., LVN Z used the same glove she had pricked Resident #34's finger with and cleaned the blood from the resident's finger. She used the same dirty gloves which had blood and opened the strip container and took another strip from the container.During an interview on 08/20/25 at 3:43 p.m., LVN Z stated she used the same gloves that had blood from the Accu-Chek and opened the strips container and took another strip because the first strip had read an error. LVN Z stated it was due to cross-contamination because she could have contaminated all the strips in the container. LVN Z said she was in serviced on administering Accu-Check. She said she was educated to change the dirty gloves and wash her hands, and then put on a clean glove before touching a clean surface, such as the strip container. LVN Z said she forgot to remove the dirty gloves and wash her hands and donned a clean glove before she took another strip from the container. During an interview on 08/21/25 at 9:23 a.m., ADON B said LVN Z contaminated the strips when she went into the container of the strips with the used gloves, and she wiped the blood from the Resident #34's finger. ADON B said LVN Z had a skill check before she started working on the floor. She said LVN Z was in service on infection control, and it included hand washing and PPE. During an interview on 08/21/25 at 2:17 p.m., the DON said LVN Z should not take the container of the strips into Resident #34's room. The DON said LVN Z should not have used the dirty gloved hands; she pricked Resident #34's finger, wiped the blood out of the resident's finger, and opened and took a strip from the container. The DON said LVN Z should have taken the dirty gloves off, washed her hands, and put on a clean pair before she took another strip from the container. The DON said LVN Z cross-contaminated the strips in the container. The DON said LVN Z should have trashed the container of the strips. She said LVN Z had a skills check-off on Accu-Check and infection control, which included PPE and hand washing. The DON stated that nurse managers conduct random checks on the nurses.During an interview on 08/22/25 at 8:26 a.m., the Administrator stated LVN Z should have followed the clinical procedure for Accu-Check and did not think it was appropriate to use dirty gloves to take a strip from the container. He said the nurse managers should make rounds and monitor the nurses. 3. Record review of Resident #1's face sheet, dated 08/20/25, revealed a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident #1 had diagnoses which included: hypotension (low blood pressure), gastrostomy (surgical opening into the abdominal wall and into the stomach), and quadriplegia (unable to move or feel both arms and legs)Record review of Resident #1's quarterly MDS assessment, dated 06/11/25, revealed Resident #1's BIMS was 00, which indicated severely impaired cognition. Resident #1 needed total care with ADL assistance with one staff assist.Record review of Resident #1's order summary report for August 2025 read in part . Catheter: Foley Catheter 16 FR 10 CC bulb to continuous drainage related to (Dx) hydronephrosis (swelling of one or both kidneys caused by backup urine) with renal and ureteral calculous obstruction started date 04/18/25 . During an observation on 08/20/25 at 8:45 a.m., revealed Resident #1's Foley bag and tubing were lying on the floor. While LVN B and CNA R pulled the resident up and repositioned him on his back. LVN B and CNA R were not wearing their PPE. The PPE set out inside the Resident #1's room was empty, and the resident was on EBP. During an interview on 08/20/25 at 12:41 p.m., CNA R said the Foley and the tubing were on the floor, and she was Resident #1's aide. CNA R said the Foley should not be touching the floor because it was an infection control issue, and Resident #1 could be infected. CNA F said she picked up the Foley bag and the tubing from the floor and hung the Foley bag on Resident #1's bed rail. She said she did not tell LVN B because the nurse was in the room. She said she had a skill check off, and she was educated the resident's Foley bag should not touch the floor to prevent contamination of the Foley.During an interview on 08/20/25 at 2:26 p.m., LVN B stated Resident #1's Foley bag and tubing were lying on the floor, which constituted cross-contamination, and Resident #1 could develop a UTI (urinary tract infection). LVN B said she had in-service training on how to prevent the resident's Foley bag from touching the floor. She stated the Foley tube should be secured on the bed rail to prevent the Foley bag from touching the floor. LVN B said the nurses were responsible for the Foley bag, and the nurse managers monitored the nurses. LVN B said she changed the Foley bag and placed it in a plastic bag to prevent the Foley bag from touching the floor.During an interview on 08/21/25 at 8:02 a.m., the ADON A said the Foley bag and the tubing should not touch the floor because of cross-contamination. She said Resident #1 could get an infection (UTI), and the Foley bag on the floor could cause the urine to backflow into Resident #1's bladder. ADON A stated the aides were responsible because they the first line of care, and nurses monitored them throughout the shift. ADON A said the nurse managers monitored the nurses during random rounds and also checked to ensure the Foley bags were not on the floor. ADON A said if CNA F observed Resident #1's Foley bag on the floor, then LVN B should have changed the bag and the tubing. ADON A said the nurse had a skills check off, and the Foley bag was part of the incontinent care, and she did an in-service yesterday (08/20/25) after the DON brought to her attention the Foley bag touched the floor.During an interview on 08/21/25 at 3:13 p.m., the DON said Resident #1's Foley bag should not be on the floor because it was an infection control issue, and Resident #1 could get an infection (UTI). The DON said the nurse and the aides had a skill check-off and in-service on Foley care before the survey. The DON said they also provided in-services on Foley care on 08/20/25. The DON said Resident #1 was on ABT for UTI in June 12/25 (amoxicillin and Cipro 500 mg, IV).During an interview on 08/22/25 at 8:33 a.m., the Administrator stated Resident #1's Foley bag should not touch the floor because it could cause an infection, and the staff should follow the Foley care policy. He said the nurse management monitored the nursing staff.During an interview on 08/20/25 at 12:48 p.m., CNA F said if a resident was on EBP, the staff should have donned PPE while providing care to prevent cross- contamination. CNA F stated she had in-service training on infection control, which included PPE, and was educated on the importance of wearing PPE during care to prevent cross-contamination. CNA F stated she should have informed the nurse and the central supply department the PPE supply needed to be restocked to avoid providing care for the residents without proper PPE. During an interview on 08/20/25 at 2:37 p.m., LVN B stated Resident #1 was on EBP, and she was supposed to put on PPE when she and CNA F pulled Resident #1 up in bed and repositioned him on his back because she was about to administer his medications through his G-tube. LVN B stated the PPE was supposed to be stocked in Resident #1's room, but there was none in the room during medication administration until the ADON restocked the PPE in the resident's room. LVN B said staff were supposed to don PPE to prevent cross-contamination. She said she was in serviced on infection control, and she was educated to always don PPE when providing care for a resident on EBP. LVN B said the IP monitored the nurses to make sure they donned PPE while providing care for the resident on EBP. She said she did not have access to the room where the PPE was stored, and if she had the key or access, she would have stocked up the PPE.During an interview on 08/21/25 at 8:18 a.m., the ADON A said the facility had a resident on EBP to prevent the staff from passing germs to the resident. She said they had instructions posted in all residents' rooms who were on EBP about donning and doffing of PPE when providing care to the resident. She said the resident section of the room should be stocked with PPE. She said the staff could have exposed the resident to germs because they could have transferred whatever germs they had to the resident. She said the IP was responsible for stocking up the PPE. The ADON said any nursing staff could replenish the PPE supply. She said the staff were educated on stocking and using PPE while they provided care for residents on EBP.During an interview on 08/21/25 at 3:15 p.m., the DON said Resident #1 was on EBP, and LVN B and CNA R should have worn their PPE when they turned and repositioned Resident #1 in bed to prevent cross-contamination. The DON said if the PPE supplies were low, LVN B should contact the central supply or ADON to restock before the PPE supply ran out.4. Record review of Resident #10's face sheet revealed a [AGE] year-old male who was originally admitted on [DATE] and re-admitted [DATE]. His medical diagnoses included cerebral infarction,( a problem that affects muscle tone, movement, and coordination) tracheostomy status,( a procedure to help air and oxygen reach the lungs by creating an opening into the trachea[windpipe] from outside the neck) gastrostomy status,(opening and inserting tube used to feed), neuromuscular dysfunction of bladder,( lacks bladder control due to brain, spinal cord or nerve problem), seizures ( abnormal electrical brain activity), muscle wasting atrophy and lack of coordination and atrial fibrillation bradycardia .Record review of Resident #10's MDS dated [DATE], revealed the BIMS was blank because the resident was rarely or never understood. Further review revealed the staff assessed Resident #10 on mental status and found he had short-term, long-term and memory/recall ability problems. Resident #10 was totally dependent on staff for care, which meant the resident did none of the effort to complete the activity,Record review of Resident #10's Physician Orders, reviewed 05/23/2025, revealed the following:1. Tracheostomy Care every shift and PRN. Clean or change inner cannula when needed Shiley 7 (size of cannula)2.Tracheostomy site dressing change every day and PRN if soiled.3. Suction tracheostomy tube as needed to clear airway. Document results in Progress notes4. Trachestomy suctioning Q shift and PRN5. Oxygen at 4-6L/min via TracheostomyRecord review of Resident #10's Care plan, revised 01/24/2024, revealed the resident was care-planned for:Resident #10 had a Tracheostomy r/t impaired breathing mechanics-Interventions: Suction as necessary, use Universal Precautions as appropriate, maintain sterile procedure while suctioning the resident.Interview and observation of Resident #10 on 8/19/2025 at 10:00 a.m. revealed the resident was unable to answer yes or no to some questions. The resident did not appear to be in distress.Observation of Resident #10 on 8/20/2025 at 2:44 p.m., revealed the resident was observed lying in bed with the head at a 30-degree angle. Resident #10's oxygen concentrator read 6L/min. Observation of tracheostomy care on 08/20/2025 at 2:44 p.m. revealed Resident #10 was in bed with audible moist breath sounds. LVN A set up a clean field on the bedside table, checked oxygen saturation, and it was 99%. LVN A donned clean gloves, picked up a Trach Care Kit without changing gloves, opened the sterile Trach Care Kit, using the same gloves picked up the sterile box, placed it on the sterile opened kit, she opened normal saline and poured it in the box, she then grabbed the suctioning tubing connected to suction machine. Placed the suctioning tubing on the box. She changed gloves without washing hands or using hand sanitizer, then she donned sterile gloves, grabbed the sterile suction catheter in the trach kit, used the non-dominant (left hand) connected it to the suction machine at Resident #10's bed side. LVN A then used the sterile gloved right hand and removed the oxygen mask on Resident #10's trach, then inserted the suction catheter into the tracheostomy tube x 2 times, then rinsed the tubing with normal saline. In an interview on 08/20/2025 at 3:05 p.m., LVN A stated she did not wash her hands during trach care or do suctioning right. She stated she should have used sterile technique throughout , and she had last in-serviced on tracheostomy care in July 2025 and not suctioning tracheostomy with cleaned technique could result in infection or cardiac arrest. She stated she worked with Resident #10 most of the time and she was nervous. In an interview on 08/20/2025 at 4:56 p.m., with the DON, the DON stated she brought in an RT that had not been in the facility for a while, because the facility changed company management, and she would be looking for another company to perform in-services on tracheostomy. The DON said the last in-services on tracheostomy was in July 2025. The DON said LVN A always worked with Resident #10. The DON said she already did a one-on-one in-service with LVN A and would do one for all staff. She concluded she would continually remind the staff to be attentive to the procedures for infection control and she would personally monitor infection control.Record review of the facility's policy, dated (last revised 10/24/2022), Hand Hygiene Infection Control Prevention and Control Program revealed Policy: This facility considers hand hygiene the primary means to prevent the spread of infections . b. Before and after direct contact with residents .h. Before moving from a contaminated body site to a clean body site during resident care . i. After contact with a resident's intact skin . j. After contact with blood or bodily fluids . m. After removing gloves . hand hygiene is the final step. 5. During an observation on 08/19/2025 at 8:19 a.m. revealed a syringe and blue razor/shaver had not been properly disposed into the sharp's container by being placed onto of the opening. The sharp's container was located on the side of the medication cart for nurse station A . During an observation and interview on 08/19/2025 at 8:22 a.m., LVN U stated she used or failed to properly dispose the syringe and blue razer/shaver at the opening of the sharp's container but immediately disposed of the items. She stated all staff disposed of sharps on the nurse's medication carts. She stated the failure of properly disposing sharps could put residents at risk of hurting themselves, disease and/or infection.During an interview on 08/19/2025 at 05:13 p.m. with the Administrator and DON, they both stated staff were responsible for properly disposing sharps to ensure residents were not exposed to harm, disease and/or infection. During an interview on 08/19/2025 at 5:53 p.m. CNA L stated all staff disposed sharps were into the sharps containers and it was important to properly dispose to maintain infection control. Record review of the facility's policy on infection control, last revised 10/25/2022, read in part . This communities' infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.Record review of the facility's policy on Infection Control (Revised dated 06-08-21) read in part . Policy. This communities' infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The objective of our infection control policies and practices are to: a. Prevent, defect, investigate, and control infections in the community. B. Monitor infections in community for appropriateness and any trends that occur. C. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors and the public.

Based on observation, interview and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system for 1 of 5 residents (Resident #103) reviewed for call light button placement and for 3 (102, 104, and 105) of 4 resident doors reviewed for working call lights systems.The facility failed to ensure Resident #103's call light was functioning properly. The facility failed to ensure emergency call lights in the restroom was illuminated over 3 doors of rooms 102, 104 and 105 on 8/19/25These failures could place residents at risk of not being able to call for assistance when needed. Findings include: 1. Record review of Resident #103's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #103 had diagnoses which included: diabetes mellitus (high blood sugar), hypertension (high blood pressure), and Alzheimer's (a progressive brain disease that cause memory loss). Record review of Resident #103 's Quarterly MDS assessment, dated 05/21/25, revealed a BIMS score of 00 of 15, which indicated severely impaired cognition. Resident #103 needed total care with ADL assistance with one staff assist. Record review of Resident #103's care plan, dated 07/17/25, read in part . [Resident #103] had ADL self-care performance deficit related to disease process Alzheimer . encourage the resident to use call light for assistance. During an observation and interview on 08/19/25 at 9:50 a.m., Resident #103 said he had not had a call light to call for help. The Surveyor looked around and found that no call light was present in resident's area to call for help.During an observation and interview on 08/19/25 at 10:06 a.m., revealed Resident #103 was yelling that he pushed the call light, and it was not working. Resident #103 said the call light had not been working for days. Resident #103 said he could not recall how many days the call light was not working. MA C also pushed the call light and said it was not working.During an interview on 08/19/25 at 10:09 a.m., MA C said CNA U was responsible for ensuring the call light was functioning before she gave the call light to Resident #103. MA C said if the call light was not functioning, then the aide should report to maintenance. MA C said staff were supposed to notify maintenance when the call light was out of order because it was part of the in-service on-call lights. She said if Resident #103's call light was not working, then it would not prevent Resident #103 from getting hurt or get timely care. CNA U said the nurse monitored the aides throughout the shift.During an interview on 08/19/25 at 10:38 a.m., CNA U said she was supposed to check if Resident #103's call light was working before she handed the call light to Resident #103. CNA U said she was supposed to report to the nurse if the call light was not working. CNA U stated Resident #103 would not be able to call for care, which could affect the resident's health. CNA U said they had a skills check-off and an in-service on-call lights, which included notifying maintenance. She stated the nurse monitored the aide during the shift.During an interview on 08/20/25 at 2:11 p.m., the DPS said he had a maintenance log at the nursing station. The DPS said he checked the log daily to see if there were any orders for call light repair, or if the nursing staff would inform him if any call lights needed to be repaired. He said once a week, he would make rounds and check all the rooms in one hall and ensure the call lights were functioning, then the following week, he would check another hall with his assistance and ensure the call lights were working. The DPS stated he was not aware the call light in Resident #103, located by the window, was not working. The DPS said he was told to check on the call light yesterday (08/19/25) afternoon, and he checked but the call light was still not working. The DPS said he pushed the call light all the way back into the wall outlet and then pushed the reset button, and the call light started to work. He said the nurses and the aide knew what to do, but he did not train the nursing staff about the reset button. The DPS said he trained the nurses yesterday on the reset button. The DPS stated something could have happened to Resident #103 if he had not been able to reach the call light but did not state what could have happened to Resident #103.During an interview on 08/20/25 at 4:25 p.m., the ADON A said the DPS were responsible for making sure the call light was functional. The ADON said the nursing staff were supposed to log that the call light was broken in the maintenance book. She said CNA U was supposed to check if the call light was functioning before she handed the call light to Resident #103. The ADON stated if the call light was not functioning, Resident #103 would not be able to call for assistance and would not receive care in a timely manner. She said the nurses monitored the aides throughout the shift, and the nurse managers monitored the nurses during random rounding. The ADON said the nursing staff had an in-service on call lights.During an interview on 08/21/25 at 2:45 p.m., the DON said the DPS checked the call light maybe monthly to ensure the residents' call lights were working. The DON said if the CNA found out the call light for Resident #103 was not working, then she should have told the DPS and also put it on the log. The DON said even if Resident #103 had a call light and the call light was not functional, the resident would still not get help when he needed help to prevent falls, delay of care, and any health complications. The DON said CNA U should have checked and ensured the call light was working before handing it to Resident #103. The DON said the aide was the first line of care and all nurses should also ensure the call light was functioning. The DON said the nurse would monitor the aides, while the nurse managers, which included her, would monitor the nurses during random rounds. During an interview on 08/22/25 at 8:15 a.m., the Administrator said the nursing staff would call and notify the DPS to come and fix the call light and document the broken call light in the Maintenance log at the nursing station. The Administrator stated it would be ideal for the aide to check and ensure the call light was in good working condition before CNA U gave the call light to Resident #103. He said the DPS had a routine for how and when he checked and ensured the call lights in the resident rooms were functioning. The Administrator said he would find out if the DPS documented the call light checks and get back to the state surveyor.Record review of the maintenance log for 3 months (August, July and June 2025) did not reveal any repair entries for the call light in room [ROOM NUMBER] bed B.2. Observation on 8/19/25 at 1:18pm during rounds revealed emergency call lights in the restroom for 3 doors of 102, 103 and 105 were not illuminating over the room outside the door. The rooms' restroom call lights rung at the nurse's station.Interview with the Corporate Nurse on 8/19/25 at 1:20pm, she said that the lights should have lit up at the nurse's station dashboard and outside of resident rooms.Interview with LVN A on 8/20/25 at 2:30 PM, LVN A said, the light lit at the nurses station and we will respond to it . LVN A, said she did not know to report the call light not illuminating over resident's to the maintenance director and they had a log for reporting anything that needed fixing .In an interview with the Maintenance Director on 8/20/25 at 3:30 p,m ., he said he was just told about the emergency call light in the restroom not illuminating over the 3 rooms' doors. He said he had the maintenance logbook at each nurses station and he checked twice daily for stations that needed anything to be repair .Interview with the facility's ADM on 8/21/25 at 1:00 p.m. regarding emergency call light in the restroom not illuminating over the 3 rooms' doors. The ADM said he would be monitoring restroom call light more .Record review of the maintenance logbook reflected no order for emergency call lights for room's 102,104 and 105 to be repaired.Record review of the facility's policy on bedrooms, dated 2001 MED.PASS, Inc. (Revised May 2017), read in part . policy interpretation and implementation #6. All resident rooms are equipped with a resident call system that allows residents to call for staff assistance. Calls are directed to either a staff member or to a centralized work area.

Based on observation, interview, and record review, the facility failed was free of pests and rodents for the months of March 2025 and August 2025 reviewed for environment.-The facility failed to ensure the facility was free of roaches in the dining room, residents' rooms, nursing station and in the dietary department. These failures could place residents at risk of disease, infection and a decline in their physical health. Roaches were observed in the dining room, resident's rooms, nursing station and in dietary department. 2. During the group interview, some residents complained about roaches they had observed a month ago. Interview with the Dietary Manager on 08-19-25 at 9:00AM revealed that the department had issues on roaches and gnats last month, but the issue is getting better. The walls and baseboards of the kitchen appeared to be sealed with no concerns. Observation on 08-20-25 at 2:30pm, this Surveyor along with RN A sighted a small roach at the nursing station. During confidential interviews between 08-20-25 and 08-22-25, residents complained about roaches they observed a month ago (no specific dates/times provided). Interview with the Dietary Manager on 08-19-25 at 9:00AM revealed that the department had issues on roaches and gnats last month, but the issue is getting better. The walls and baseboards of the kitchen appeared to be sealed with no concerns.Record review of pest control services for the year 2024 and 2025 revealed written communications from the pest control technician which stated the following recommendations. Open entry portals were sealed by maintenance. The pest control technician did leave written communication what was sprayed if any problems or any potential problem could occur and recommendations for the facility, including:Record review of pest control service binder for the year 2025 revealed the pest control technician did treat and left written instruction and communication to prevent pest infestation. Record review of the pest control invoices for 2024 - 2025 revealed the following: 1. Invoice dated 3-22-25: Pest control interviewed Dietary Manager who reported sightings of small roaches around dish machine area. She had requested the maintenance director to seal open entry points where roaches might be coming in. Pest control technician did thorough treatment around affected areas as well as in kitchen pantry and dish room area.2. Invoice dated 4/11/25 revealed: Dietary staff noted issue of small flies in various areas. Steam application was performed in the dish room and drains throughout the kitchen to aid to control small flies.3. Invoice dated 4/17/25 revealed: Improper food storage, rest room has condition for gnats Toilet was full of bodily waste.4. Invoice dated 5/2/25: revealed: Heavy gnat activity observed. Performed a wipe down service to reduced immediate Prescence. Recommended an afterhours deep clean to address the root cause of gnat infestation. Treated kitchen. Empty resident's rooms- 101, 103, 109,113,117,120,123 and 313were treated.5. Invoice dated 5/08/25 revealed: No live roaches found. Housekeeping reported rooms had lots of activities a few months ago. Kitchen and dish area were treated. Medium levels of roaches were found under food services appliances and serving area. Condition observed: Improper food storage, kitchen ceiling leaks in dry food storage.6. Invoice dated 5-26-25 revealed: Rm. 201 and 206 reported sightings. Live activity was not observed. 5-30-25: heavy gnat activity observed, recommended on after hours deep clean to address root cause of gnat infestation. Rooms: 101,103,109,113,117,120,123,203 and 313 Maintenance Director requested the unoccupied rooms were treated. No pest activity was observed during inspection no gnats issue reported by dietary staff. room [ROOM NUMBER]: reported for roaches. Live activity was not observed. 206 cockroaches reported live activity and sign of harborage not observed.7. Invoice dated 6-13-25 revealed: Condition still exists- improper food storage in kitchen, old food found on floor in corner. Action: Ensure floor is cleaned daily with no food debris on floor. 6-27-25 dietary staff reported sightings of American roaches around sink and other areas within the kitchen. Technician recommended improper food storage, restroom area has condition for gnats. Toilet was full of bodily waste. Action- ensure floor is cleaned daily with no food debris on floor.8. Invoice dated 06/18/2025 revealed: The company used a chemical named Hydropene in the interior to treat German roaches with two resident rooms with evidence of dead roaches. The company found one cockroach nymph (baby cockroach).9. Invoice dated 07/11/2025 revealed: The company found roach activity in the kitchen and one resident room reported seeing a roach in their room.Further record review of the invoices noted that the pest control technician(s) had not left written communication for what had been sprayed, any problems, or potential problems that could have occurred, nor recommendations for the facility.

Based on Record review and interview, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System within 14 days after a facility completes the resident's assessment for 1 (CR #59) of 3 resident reviewed for MDS transmission. -The facility failed to transmit a completed Discharge MDS assessment for CR# 59 within 14 days of completion.These failures could place residents at-risk of not having their assessment and care plan completed timely, which could result in denial of services and or payment for services.Record review of CR# 59's admission Record dated [DATE] revealed a [AGE] year-old male. CR# 59 had an admission date of [DATE] and discharge date of [DATE]. CR #59 diagnoses included other cerebral palsy (refers to the types beyond the most common, Spastic Cerebral Palsy, and includes Dyskinetic Cerebral Palsy, which involves involuntary, uncontrolled movements like writhing or muscle spasms, and Ataxic Cerebral Palsy, which affects balance and coordination due to brain damage to the cerebellum) and other abnormalities of gait (deviations from typical walking patterns that don't fall under a specific pathological gait type, such as limping, toe walking, in toeing (walking with feet turned inward), or out toeing (walking with feet turned outward). Record review of CR# 59's Quarterly MDS dated [DATE] revealed that CR# 59 was admitted on [DATE]. CR # 59's BIMS Score was 9 out of 15 indicating he was moderately impaired cognitively. CR# 59 was dependent on staff for ADLs. Record review of CR# 59's Discharge MDS assessment no date provided revealed the assessment was not transmitted to CMS. Record review of CR# 59's Nurse Progress note dated [DATE] revealed that CR# 59 was transferred to a local hospital. An interview on [DATE] at 2:24 pm with MDS A, he said that the discharge MDS for CR# 59 was missed, and he would complete the assessment. He said that the facility used the RAI manual to complete assessments. He said that the MDS assessment completion were the responsibility of the MDS Coordinators. The negative outcome could be being out of compliance. During an interview on [DATE] at 4:00 PM, with the Administrator he said that the expectation would be that the MDS assessments were transmitted based on policy and that MDS is responsible for transmitting. Record review of the CMS's RAI Version 3.0 Manual, Chapter 5: Submission and Correction of The MDS Assessment revised 11/2019 revealed:5.1 Transmitting MDS data- All Medicare and/or Medicaid-certified nursing facilities or agents of those facilities must transmit required MDS data records to CMS. 5.2 Timeliness Criteria- completion timing. For all other comprehensive MDS assessments, Annual assessment updates. the completion may be no later than 14 days from the ARD. Upon a resident's entry, discharge to community, discharge to another facility or discharge deceased , a subset of items but be completed within 7 days of the Event Date.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident 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 describing services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 5 residents (Residents #15 and #78) reviewed for comprehensive care plans. 1. The facility failed to care plan Resident #15 being placed back into the secured unit on 07/31/2025. 2. The facility delayed care-planning Resident #78 for being on hospice after she was admitted on [DATE]. She was care-planned on 4/24/2025.This failure could lead to residents not having their individual, medical, functional, and psychosocial needs identified and cause a physical, mental or psychosocial decline in health. Resident #15Record review of Resident #15's face sheet dated 08/22/2025 reflected an [AGE] year-old male originally admitted to the facility on [DATE] and last re-admitted on [DATE] with medical diagnoses including Parkinson's Disease without dyskinesia (a progressive movement disorder of the nervous system with symptoms like tremors, stiffness, and impaired balance without dyskinesia (involuntary muscle movements)) Alzheimer's Disease with late onset (a progressive disease affecting memory loss and decline in cognitive abilities), dementia (general term for a decline in cognitive function affecting memory, thinking and social abilities), and cognitive communication deficit.Record review of Resident #15's care plan captured 08/22/2025, he had a focus area of being a high elopement risk or wanderer and was at risk for possible injury related to impaired safety awareness and diagnosis of dementia, with interventions including distracting residents from wandering by offering structured activities, food and conversation. Resident #15's care plan did not include being on the secured unit nor interventions. Record review of Resident #15's Quarterly MDS dated [DATE] reflected a BIMS score of 00 indicating severe cognitive impairment and being totally dependent on staff for oral, personal and toileting hygiene, showering or bathing self and eating. Resident #15 required supervision for eating. Record review of Resident #15's elopement assessment risk on 7/21/2025 revealed he scored a 3.0, indicating being a medium risk for elopement. Resident #15 was noted being cognitively impaired with poor decision-making skills, ambulating independently with or without the use of an assistive device and that he had a wheelchair and would walk around once in a while. Interventions for Resident #15 included exit alarms, being on a secured unit, frequent monitoring and staff being aware of resident's wander risk.Record review of Resident #15's progress notes, on 7/31/2025 at 9:50pm, Resident #15 was observed walking on the hallway and being aggressive with and refusing for staff to assist him and attempting to hit other residents. Resident #15's physician was notified and ordered for Resident #15 to be moved back to the secured unit. Resident #15's RP was notified and he was moved back to the secured unit with no pain or discomfort noted.Observation and interview with Resident #15 on 08/19/2025 at 9:51am, he was in the common area of the secured unit sitting in his wheelchair. Resident #15 appeared well-groomed and comfortable, and said he did not have any issues and was doing okay. In a later observation of Resident #15 on 08/22/2025 at 4:00pm, Resident #15 was observed self-propelling himself in his wheelchair down the hallway in the secured unit. Interview with LVN N on 08/22/2025 at 4:05pm, LVN N said Resident #15 had left the secured unit but came back after some behavioral concerns and displaying actions indicating he wanted to come back to the secured unit. Resident #15 had done better in the secured unit and was walking a bit and also, he had familiar faces in staff and other residents. LVN N said the family was aware of the move and had given permission for Resident #15 to return to his old unit. Resident #15 should have had an order for being in the secured unit. Interview with MDS A on 08/22/2025 at 2:15pm, they said care plans were done after any resident's change in condition. If it wasn't done it would affect the timing of care. MDS A said they were in charge of MDS. Interview with Resident #15's RP on 08/22/2025 at 4:30pm, she was aware and gave permission for Resident #15 to be in the secured unit in the last month because she heard from Resident #15's nursing staff that his behavioral symptoms improved in the secured unit. Interview with the DON on 08/22/2025 at 5:00pm, she said Resident #15 was taken out and placed back into the secured unit and that it should have been reflected back in the care plan. If his placement into the secured unit was not on the care plan, it would not reflect how to care for him. The DON said that the MDS Nurses were in charge of MDS. Resident #78Record review of Resident #78's face sheet dated 08/20/2025 reflected an [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE] with medical diagnoses including Major Depressive Disorder (a mood disorder characterized by persistent feelings of sadness and loss of interest in activities once enjoyed), Alzheimer's Disease (a progressive disease affecting memory loss and decline in cognitive abilities), hypertension (high blood pressure), dementia of unspecified severity with agitation, and cognitive communication deficit.Record review of Resident #78's care plan dated 08/22/2025, she was care-planned for Hospice care on 05/21/2025.Record review of Resident #78's total Order Summary, she had orders for hospice starting on 4/26/2025.Record review of Resident #78's Quarterly MDS dated [DATE], she had a BIMS score of 00, indicating severe cognitive impairment related to memory and thinking. Resident #78 required total assistance with toileting and showering or bathing along with personal hygiene, and she required supervision for eating and oral hygiene. Resident #78 was documented as having hospice care while a resident within the last 14 days of being at the facility. Record review of Resident #78's form titled Physician Certification of Terminal Illness dated 04/24/2025, Resident #78 was recertified on 04/24/2025 for Hospice care and signed by hospice staff on 04/24/2025.Observation and interview with Resident #78 on 08/19/2025 at 12:12pm, Resident #78 was walking in the hallway and appeared well-groomed with no odors. Resident #78 appeared distressed and said she wanted to see her family member. Staff redirected her to her room and said they were going to provide incontinent care for her and Resident #78 agreed.Interview with MDS A on 08/22/2025 at 2:15pm, they said care plans were done after any resident's change in condition. If it wasn't done it would affect the timing of care. MDS A said that Resident #78's hospice care was not care-planned because at that time the family had not decided on putting her on hospice or not. MDS A said they were in charge of MDS.Interview with LVN N on 08/22/2025 at 4:05pm, LVN N said Resident #78 had always been in the secured unit and was on hospice. Interview with the DON on 08/22/2025 at 5:00pm, she said Resident #78's hospice care might not have been care-planned upon admission because Resident #78's family was unsure if they wanted her on hospice. If her hospice orders and treatment was not on the care plan, it would not fully reflect to staff how to care for her. The DON said the MDS Nurses were in charge of MDS.Record review of the facility's policy on comprehensive care plans last revised 01/20/2021 read in part, Every resident will have an individualized interdisciplinary plan of care in place. A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission . The Care Plan is revised every quarter, significant change of condition, Annual or as the resident condition changes on an individualized basis. The Care Plan process is an ongoing review process. The resident's Care Plan will include participation from residents' representatives, external partners PASRR, Hospice, Therapy, Clinicians and not as all-inclusive.

Based on observation, interview and record review, the facility failed to ensure that resident environment remains as free of accident hazards as is possible for 1 (Resident #76) of 4 residents and 1 of 3 medication carts reviewed for accident hazards. -The DPS (Maintenance Director) left a portable flashlight with its light turned on and unsecured in Resident #76's bathroom on 09/21/2025. - The facility failed to properly dispose a blue disposable razor/shaver, and a syringe used for injections within the sharps contain attached to the side of 1 (station A) of 3 medication carts.These failures could put residents at potential risk of harming themselves or others with unsecured equipment. Findings included:Record review of Resident #76's care plan dated 08/22/2025, Resident #76 had a focus area for impaired cognitive function, cognitive loss and impaired decision-making abilities with interventions including monitoring, documenting and report as needed any changes in cognitive functions and changes in memory, general awareness and decision-making ability.Observation of Resident #76 on 08/19/2025 at 9:51am, she was seen in her wheelchair self-propelling towards the secured door and knocking on the door with her palm. Resident #76 appeared well-groomed and in no distress. Resident #76 did not respond to questions and continued to bang on the door and appeared to want to go through the secured unit doors.In a later observation on 08/21/2025 at 9:19am, Resident #76 was awake and laying in her bed. Resident #76 appeared well-groomed and comfortable. Resident #76 did not answer when asked how she was doing. CNA R explained to Resident #76 she was going to be provided incontinent care. Upon entering Resident #76's bathroom, the bathroom light was on and there was a yellow rectangular flashlight turned on placed on top of the bathroom sink. There was no one in the restroom. Interview and observation with CNA R on 08/21/2025 at 9:19am, she said she saw the DPS was repairing something in Resident #76's bathroom, and he left the light there. When asked whether it was okay to leave a flashlight unsecured in a resident's restroom, she did not answer the question but said she would let the DPS know about the flashlight in the restroom. CNA R stayed in Resident #76's room to provide incontinent care. Interview with the Administrator and DON on 08/21/2025 at 4:34pm, the Administrator said the DPS should not have left the flashlights, and he should have secured equipment by either taking it with him or putting equipment in a locked box. Residents could injure themselves with it. The Administrator said he would in-service the DPS on it. Interview with the DPS on 08/22/2025 at 11:00am, he said that he left the flashlight in Resident #76's restroom and that he should not have left the flashlight in there unsecured. The DPS said residents could take unsecured equipment and break the equipment or hit other residents and that he was in-serviced on 08/21/2025 by the Administrator to secure equipment in the building . During an observation on 08/19/2025 at 8:19 a.m. nurse station A's medication cart sharps container had a razer and syringe sitting on the opening disposal area of the sharp's container. During an observation/interview on 08/19/2025 at 8:22 a.m. LVN U stated that she had been the unit manager for Station A and the medication cart located at the station belonged to her. She stated that she had not been aware of the razer and syringe sitting on the top of the sharp's container. She stated that one of the CNAs must have shaved a resident, but she could not tell me which staff, resident or at what time the shaving occurred. She immediately disposed of the razor/shaver and syringe into the sharp's container. She stated that important of ensuring sharps were properly disposed was to ensure that no residents could hurt themselves and expose themselves to an infection or disease. During an interview on 08/19/2025 at 05:13 p.m. with the Administrator and DON, the policy on sharps disposal was requested. The ADM and DON both stated that they were not aware of the improper disposal of the sharps. They both stated that all sharps were to be properly disposed of to maintain infection control and to ensure the safety of residents who could hurt themselves and contract an infection or disease. During an interview on 08/19/2025 at 5:53 p.m. CNA L stated that all sharps including the blue shavers were to be placed within the sharp's containers on the side of the medication carts. They place them in the sharp's container connected to the med cart. She stated she was unaware of who had placed the razor/shaver and syringe at the opening of the sharp's container at nurse's station A. She stated it had been important to properly dispose of sharps to ensure residents were free of hurting themselves and contracting an infection.Record review of the facility's in-service for the maintenance department on 08/21/2025, the contents of the training read in part, securing items/tools when leaving a work area its best to take items with you or secure in a locked container .when on the memory care unit, it is very important to keep track of all items at all times. The document was signed by the DPS.Record review of the facility's policy on hazardous areas, devices and equipment, last revised July 2017 read in part, All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible .Identification of Hazards 1. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to a. Equipment and devices that are left unattended or are malfunctioning .

Based on observation, interview and record review, the facility failed to ensure that a who needs respiratory care, including tracheotomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #10) of two residents reviewed for tracheotomy care.-The facility failed to ensure LVN A used sterile technique during tracheotomy suctioning for Resident #10 on 8/20/25.This failure placed residents who required respiratory care at risk for respiratory infections, hospitalizations, and a decline in their quality of life. Record review of Resident #10's face sheet revealed he was a [AGE] year-old male who was originally admitted on [DATE] and re-admitted [DATE]. His medical diagnoses included cerebral infarction,( a problem that affects muscle tone, movement, and coordination) tracheostomy status,( a procedure to help air and oxygen reach the lungs by creating an opening into the trachea( windpipe) from outside the neck) gastrostomy status,( opening and inserting tube used to feed), neuromuscular dysfunction of bladder,( lacks bladder control due to brain, spinal cord or nerve problem), seizures ( abnormal electrical brain activity), muscle wasting atrophy and lack of coordination and atrial fibrillation bradycardia (irregular heart rhythm) .Record review of Resident #10's Care plan revised 01/24/2024 revealed resident was care-planned for:1. Resident #10 has a Tracheostomy r/t impaired breathing mechanics-Interventions: Suction as necessary, use Universal Precautions as appropriate, Maintain sterile procedure while suctioning resident Record review of Resident #10's MDS dated [DATE] revealed the BIMS was blank because the resident is rarely or never understood. Further review revealed the staff assessed Resident #10 on mental status and found he has short-term, long-term and memory/recall ability problems. Further review revealed that Resident #10 is totally dependent on staff for care, which means the resident does none of the effort to complete the activity,Record review of Resident #10's Physician Orders reviewed 05/23/2025 revealed the following:1. Tracheostomy Care every shift and PRN . Clean or change inner cannula when needed [NAME] 72.Tracheostomy site dressing change every DAY and PRN if soiled.3. Suction tracheostomy tube as needed to clear airway. Document results in Progress notes4. Trach suctioning Q shift and PRN5. Oxygen at 4-6L/min via TracheostomyInterview and observation of Resident #10 on 8/19/2025 at 10:00am revealed resident was unable to answer yes or no to some questions. Resident did not appear to be in distress.Observation of Resident #10 on 8/20/2025 at 2:44 pm, resident was observed lying in bed with the head at a 30-degree angle. Resident #10's oxygen concentrator read 6L/min. Observation of tracheostomy care on 08/20/2025 at 2:44 PM revealed Resident #10 was in bed with audible moist breath sounds. LVN A set up a clean field on the bedside table, checked oxygen saturation checked, and it was 99%. LVN A donned (put on) clean gloves, picked up Trach Care Kit without changing gloves, opened the sterile Trach Care Kit, using the same gloves picked up sterile box place it on the sterile open kit, she opened normal saline and poured it in the box, she then grabbed the suctioning tubing connected to suction machine, and placed the suctioning tubing on the box., She changed gloves without washing her hands or using hand sanitizer, then she donned sterile gloves, grabbed the sterile suction catheter in trach kit, using the non-dominant (left hand) connected it to the suction machine at Resident #10's bed side. LVN A then used the sterile gloved right hand, removed oxygen mask on Resident #10's trach, then inserted suction catheter into the tracheostomy tube x 2 times, then rinsed tubing with normal saline. In an interview on 08/20/2025 at 3:05 PM, LVN A stated she did not wash her hands during trach care or do suctioning right. She stated she should have used a sterile technique throughout, and she had last in-service on tracheostomy care in July 2025 and not suctioning tracheostomy with cleaned technique could result infection or cardiac arrest. She stated she works with Resident #10 most of the time and she was nervous. In an interview on 08/20/2025 at 4:56 PM, with the DON, when the Surveyor described the observed during trach care, suctioning for Resident #10, the DON stated she brought in an Respiratory Therapist (RT) recently that had not been in the facility for a while , because the facility changed company and she would be looking for another company to perform in-services on tracheostomy. The DON said the last in-services on tracheostomy was in July 2025. The DON said LVN A always worked with Resident #10.Requested for the policy of Tracheostomy care from the DON on 8/20/25 and 8/21/ 25 and was not provided prior to exit. Review of the website www.tracheostomyeducation.com dated 09/21/2022 reflected The upper airway plays an important role in immune defenses of the lung by filtering, humidifying, and warming inspired gases before they reach the trachea, preventing dehydration of airway secretions. The nose and oropharynx perform most of this conditioning. For the lower airways and alveoli to properly function, it is important that inspired gases are fully saturated with water vapor .With a cuffed tracheostomy tube, the airflow is redirected out through the tracheostomy tube and air does not flow through the nose or nasopharynx. The natural warming, humidification and filtration system are bypassed resulting in cool and dry air entering directly through the tracheostomy tube which can easily result in: damage to the ciliated tracheal mucosa, thickening and retention of airway secretions, impaired mucociliary transport, inflammatory changes and necrosis of epithelium, impaired [NAME] activity, destruction of cellular surface of airway causing inflammation, ulceration and bleeding , reduced lung function (atelectasis/pneumonia), increased risk of bacterial infiltration.

Based on observation, record review, and interview, the facility failed to ensure that drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles for 1 (station B) of 3 nurse medication carts reviewed for medications storage, in that:- LVN B left one medication container on top of the medication cart and went into a resident's room during medication administration.This failure could affect residents, placing them at risk for taking medication which could affect residents' health, requiring medical intervention and drug diversion. Record review of Resident #1's face sheet dated 08/20/25 revealed he was a [AGE] year-old male initial admitted to the facility on [DATE] and readmitted [DATE]. Resident #1 had diagnoses which included: hypotension (low blood pressure), gastrostomy (surgical opening into the abdominal wall and into the stomach), and quadriplegia (unable to move or feel both arms and legs)Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1's BIMS was 00 indicating severely impaired cognition. Further review of the resident MDS revealed resident needed total care with ADL assistance with one staff assist.Record review of Resident #1's order summary report for August 2025 read in part . Acidophilus Probiotic Oral Capsule 10 MG (Lactobacillus) Give 1 capsule enterally two times a day for Gut health started date 06/23/25 .During an observation on 08/20/25 at 8:45 a.m., LVN B left a medication container (Acidophilus Probiotic Oral Capsule 10 MG (Lactobacillus) on top of the medication cart and went into Resident #1's room and administered G tube medication. There were several residents propellinged around in the hallway and passed the nurse's medication cart while the medication was left on top of the medication cart unattended. During an interview on 08/20/25 at 9:28 a.m., LVN B stated that she should not have left the medication on top of the cart unattended because any resident who walked by could have taken the medication, and it could have had a negative outcome. LVN B said the family member who was talking to her distracted her. LVN B also said that anyone who passed the medication cart could have taken the medication, other than the residents. LVN B said she had a skills check on medication administration and medication storage before she started passing medication. She said the nurse managers monitored nurses during their random rounds. During an interview on 08/21/25 at 8:09 a.m., the ADON A said the nurse had a skill check on medication administration and medication storage upon hire. The ADON A said LVN B should have stored the medication in the medication cart before she left the medication cart. The ADON A said the medication is stored and locked up to prevent any resident from taking the medication, and they have residents with cognitive impairment. She said if the resident takes the medication and administers the medication to themself, the resident could have an allergic reaction, which could cause harm depending on what the medication was. The ADON A said the nurse managers made random rounds throughout the shift. She said the DON notified her that a medication was left on top of the cart unattended, and she did one one-on-one education with LVN B on the importance of storing medication in the cart and made sure the cart was locked when not in use to prevent drug diversion and residents taking medication, which could cause harm. The ADON A said the nurse managers monitored the nurses during random rounds throughout the shift.During an interview on 08/21/25 at 2:27 p.m., the DON stated that LVN B should not leave any medication on top of the medication cart unattended. The DON stated that she expected LVN B to have placed all Medications in the medication cart and locked the cart before administering medication to Resident #1. She said the medication cart was in the hallway, and the facility has dementia Residents who could have taken the medication, and it was not safe for the residents. The DON said if the resident who took the bottle of the medication had administered the medication to themselves, it could have a negative outcome because the medication was not prescribed for the resident. The DON said LVN B had a skill check off on medication storage, and she educated LVN B one-on-one yesterday on medication storage. The DON said the nurse managers monitor the nurses randomly.During an interview on 08/22/25 at 8:23 a.m., the Administrator said LVN B should lock the medication in the cart before leaving the cart to prevent any resident or unauthorized person from taking the drug or tampering with the medication. The Administrator said the nursing management team was supposed to make random checks on the nurses. Record review of the facility's policy on hazardous areas, devices and equipment, last revised July 2017 read in part, All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible .Identification of Hazards 1. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to: a. Equipment and devices that are left unattended or are malfunctioning .Record review of the facility policy on medication storage dated 2001MED-PASS, Inc. (Revised April 2007) read in part . the facility shall store all drugs and biologicals in a safe, secured and orderly manner.Record review of the facility's policy on Infection Control (Revised dated 06-08-21) read in part . Policy. This communities' infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The objective of our infection control policies and practices are to: a. Prevent, defect, investigate, and control infections in the community. B. Monitor infections in community for appropriateness and any trends that occur. C. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors and the public.

Based on observation, interview, and record review the facility failed to ensure the resident environment remained free of accident hazards as possible, and each resident received adequate supervision to prevent elopement for one of twenty-one residents (Resident #1) reviewed for accident hazards and supervision. -The facility failed to ensure Resident #1 had adequate supervision on 8/16/2024 which allowed her to elope from the facility. She was not found until 8/17/24 when she was admitted to the emergency room with complaints of heat exhaustion and weakness. The noncompliance was identified as past noncompliance and the Administrator was given the IJ Template on 8/29/24 at 2:23 pm. The IJ began on 8/16/2024 and ended on 8/18/2024. The facility had corrected the noncompliance before the investigation began on 8/18/2024. These failures could place residents at risk of serious injury or harm. Findings include: Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year-old woman admitted on [DATE]. The face sheet documented her diagnoses included schizophrenia (is a serious mental health condition that affects how people think, feel and behave), cognitive communication deficit (difficulty with communication that is affected by disruption of cognitive process), bipolar disorder (mental health condition that causes extreme mood swings), blindness right eye. Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS score of 03 indicating severe cognitive impairment. The MDS documented she had no potential indicators of behaviors affecting others, or rejection of care. Per the MDS, Resident #1 did not have wandering behaviors daily during the review period. The MDS documented she required supervision or assistance with all ADL's. Record review of Resident #1's Care plan initiated on date 4/18/2024 revealed her risk for wandering and risk of elopement, with her having a wander guard. The care plan included a focus on her interventions including identifying triggers for wandering/eloping, implement toileting program, monitor resident frequently, reorientate to surroundings/environment. Record review of Resident #1' s nurse's note dated 8/16/2024@ 23:21 revealed she could not be found in her room, the facility was searched and she was not found. The resident was last seen at 6:30 pm during dinner as reported by the CNA C. Code pink for missing person was initiated. Other staff began searching outside the facility and some staff began driving around the neighborhood. Around 9:00 pm the RN A reported to the Administrator and Director of Nurse that resident was not found. Administrator and Director of Nurse began to search. RN A notified the family, 911 and Houston Police Department (HPD) around 9:30 pm. HPD arrived within minutes and necessary information to file a missing person was given to HPD. Search areas included gas station, bus stops, homeless spots in the area, hospitals called and visited, Metro bus station center notified. Record review of Resident #1' s nurse's note dated 8/17/2024@ 18:46 revealed DON visited the resident in the hospital after being notified by the police she was at the hospital. Resident was asleep and the hospital nurse reported the resident was stable and receiving IV fluids, no injuries were noted or reported during admission full body assessment. Record review of Resident #1' s elopement risk assessment dated [DATE] revealed she was an elopement risk of 2.0. Record review of Resident #1' s elopement risk assessment dated [DATE] revealed she was an elopement risk of 5.0. Record review of Resident #1' s elopement risk assessment dated [DATE] revealed she was an elopement risk of 2.0. Record review of Resident #1' s elopement risk assessment dated [DATE] revealed she was an elopement risk of 8.0. Record review of Resident #1' s elopement risk assessment dated [DATE] revealed she was an elopement risk of 14.0. Record review of hospital records dated 8/19/2024 revealed she was received in Emergency Dept 8/17/24 via ambulance, with complaints of heat exhaustion, weakness, had anklet on, was poor historian was A&Ox2. She received X-Ray of chest \- Impression: no acute abnormality. Complete Blood Count (CBC) has no acute findings. Pre-hospital Fingerstick blood glucose 181 Wording to https://www.wunderground.com/ the temperature 8/16/2024 between 6:00 pm -12:00 midnight was 96-84 degrees Fahrenheit Wording to https://www.wunderground.com/ the temperature 8/17/2024 between -12:00 midnight -12:00 noon was 84-94 degrees Fahrenheit Interview on 8/18/24 2:05 pm with Administrator, said his primary duties were to manage the overall operation of the facility. The Administrator said on 8/16/2024 he received a report Resident #1 was not found. The Administrator stated somewhere between 6:30 pm and 8:00 pm when the CNA C reported the resident had not eaten dinner and was not in the bathroom. CNA C reported to RN A that resident was not in her room. Search ensued. Resident was wearing wander guard. Administrator called the HPD at 9:30 to report resident missing, also called medical director, physician, family, ombudsman. Administrator and DON went to local hospital and gave information to hospital staff with resident #1 name and date of birth, with facility phone number. The Emergency Medical Services (EMS) found Resident #1 wandering on the street, she was well dressed, did not look homeless, and was taken to hospital for evaluation. Resident remains there. The facility has tested all wander guard system are currently testing daily for 30 days. When the resident #1 arrives from the hospital her wander guard would be tested to assure that it is functioning properly. Administrator stated he did not know how resident left the building, stated it could have been a staff, a resident accidentally pressing an emergency door release button on the wall or recent power outages that may have released the alarm system throughout the facility which released all the doors allowing her to elope. The Administrator said facility has had so many power outages or surges that he has the energy company alerts on his phone. The Administrator said Resident #1 often wants to go home or wants to visit her family member, but she cannot due to her diagnoses and needs. Administrator said after the incident, all residents were assessed for an elopement risk, monitoring of all resident with wander guards are being checked every shift, and Resident #1 will be provided with a room in the memory care side when she returns. Observation on 8/18/2024 at 2:50 pm revealed the exterior doors on the 100 and 200 halls were locked and unable to be opened without using the push bar. The doors had a keypad near them to allow exit. Both doors had a sign that said an alarm would sound if they were opened without the code. Interview on 8/18/24 4:00 PM with DON, she reports the administrator called her around 8:00 pm on 8/16/2024 stating that he was on the way to the facility. It was reported to her that CNA C had given resident #1 the dinner tray around 6:30 pm resident #1 at the time of receiving the tray was on her way to the restroom. CNA C went back to see if Resident #1 had started eating and saw that the tray had not been touched. CNA C went back to resident #1's room about 20 minutes later to pick up trays and saw that Resident #1 was not there and the tray had been untouched. CNA C went to the smoking area, looked in the dining room, reported to her charge nurse, RN A the resident could not be found. RN A then notified over the speaker code yellow and all staff started searching for resident. RN A notified administrator . RN A and 2 CNA's drove around the neighborhood, RN A called the police and gave them picture with pertinent information. RN A also called family, doctor and medical director. DON started searching the field in the back of the building and inspected the ditch, church schoolyard, facility van, bus stops. The administrator searched from Hwy. 6 to facility and DON search from facility to Beltway 8 by car. Administrator called metro police, administrator went to two local hospitals to inform them of resident missing. DON and administrator then searched the facility again. Police were notified and missing report was given. DON states the police called her on 8/17/2024 around 3:00 PM that resident had been found at Hosptial. Hospital nurse gave report regarding Resident#1 she was unharmed, however, was dehydrated, was receiving IV fluids, Chest X ray and urinalysis performed. DON stated she went to see resident in the hospital. DON states when the resident comes back from hospital she will be placed in the secure unit. DON reports testing of the residence that have wander guards are tested at each of the doors 8/16/24 and 8/17/24. Staff are continuing to test each shift all doors and wander guards. Management staff testing doors and wander guards daily. All residents have been reassessed for elopement risk. Interview on 8/28/24 at 4:19 pm with LVN B. She stated she was working the 6:00 AM to 6:00 PM shift on 08/16/2024 on the B station which is 200 hall. LVN B reports between 5:00 PM and 6:00 PM she went to the dining room to assist with feeding residents and checking menus. LVN B visualized Resident#1 in her room prior to going to the dining room at around 5:30 PM. Resident#1 was sitting on her bed. During shift she monitored the resident's wander guard and noticed that it was blinking green meaning the battery was good. She said CNA C stayed on the 200 hall monitoring residents that did not go to the dining room. LVN B stated at around 6:30pm she gave report to RN A the oncoming nurse for 6P to 6A shift. Around 6:30 pm, CNA C asked where Resident #1 was. At that time the search began in the facility in the smoking area, closets, bathrooms. LVN B got into her car and started driving around local roads. LVN B stated she searched for two-three hours. Facility was being searched and the outside parking lot and field area. LVN B did not recall having heard any alarms during her shift and did leave the facility between 9:00 pm and 10:30 pm, the police, administrator, DON was present at that time. LVN B stated she has never had a resident elope during her career in this facility, LVN B stated she sees the maintenance manager checking doors. She also checked residents with the wander guard during her shift. CNA's and nurses check daily. LVN B stated when the wander guard flashes green and is close to the door the alarm system is working. Interview on 8/28/24 at 4:37 pm with CNA C. She typically works the 2:00 PM to 10:00 PM shift. CNA C stated resident's wander guards were checked daily to see if the green light flashes when the resident gets close to the door by staff. On 8/16/2024 CNA C stated she saw Resident # 1 in her room when she brought dinner tray and again when passing trays. Resident #1 was going into her restroom. When CNA C went to pick up dinner tray CNA C stated around 7:00 PM she noticed resident wasn't present. CNA C started checked the room, bathroom, common areas and didn't see Resident #1 and reported to RN A. CNA C reported all staff started searching. CNA C stated the administrator and DON got to the facility around 8:00 PM, the police showed up around 10:00 PM. CNA C stated she was informed on the 17th when she arrived for her shift that resident was safe. Interview on 8/28/24 at 4:51 with CMA. CMA stated she was working station B on 8/16/2024, approximately 5:30 pm to 6:00 pm and gave Resident #1 medications and a banana. When she left Resident #1 ' s room, resident was eating the banana. CMA stated she was told by a nurse around 8:30 to 9:00 PM that resident was missing, and CMA stated she started searching the parking lot, walked around the building, other staff searched by car. CMA stated she saw administrator and DON around 9:30 pm, the police were there between 9:30pm and 10:00pm, CMA stated she left around 10:00 PM. She said she felt bad when she found out Resident #1 was missing. She does not know how Resident #1 could have gone missing. Interview on 8/28/24 at 5:50 pm via telephone with RN A. RN A reported he received shift report at 6:00 PM on 8/16/2024 and did see Resident #1 at that time, he reported CNA C also saw Resident #1 around 6:30 PM when she was setting up the table for the resident to eat, and that Resident #1 was going toward the restroom. RN A reported when CNA C went to pick up the tray she noted that Resident #1 was not present. RN A stated he did not hear any alarms go off between 6:30 PM and 8:00 PM. He called a code yellow after realizing resident was not in the facility and got into his car and drove around the neighborhood. RN A reported he called administrator, family, physician, medical director and police. RN A stated when he spoke with Resident #1 ' s, family member and she wanted to know why he was calling. RN A reported he explained the current situation and the family member stated she had not seen Resident #1. RN A reported he kept the family member informed during the search he called her around 8:00 pm, 12:00 PM and 6:00am. RN A stated he felt horrible, when he realized Resident #1 couldn't be found. RN A stated he found out Resident #1 was at the hospital on 8/17/2024 by text. RN A stated all staff members knew what to do, were very concerned about residents welfare, had no idea how Resident #1 left the facility. Observation on 8/18/24 at 4:30 pm with administrator the wander guard alarm at the nurse station, it is a grey box with 2 blue boxes that will show which exit is being breached. Monitored the functionality of wander guard and proximity which alarm goes off appropriately. Observed staff monitoring and walking toward door that alarmed. 8/19/24 Upon entry to facility, the front door alarm went off -noted resident with wander guard close to entrance. Within 30 seconds noted 3 staff members going to front door to assess if resident was close to or outside the door. Interview on 8/28/24 at 9:30 am with Administrator, stated he had outside vendor install new sensor at the front door, the front door had been enhanced with an additional motion guard along with wander guard alarm sensitivity increased. Administrator stated each device has its own power source so no interference can occur. Administrator stated all the alarms are being monitored and tested daily by him and the maintenance director, stated they are adjusting the sensitivity and all systems are working well. The Administrator said the staff have been provided training to ensure that any time the electricity as to go out the staff immediately check and reset the doors. Interview on 8/28/24 at 10:00 am with DON, she stated she was notified by the Hospital at on 8/17/24 at 3 pm resident was there and having tests provided to her. She stated the resident told the nurse resident was looking for her family member and was found close to I 45 near downtown under a bridge at 1:00 pm by EMS. EMS provide care, then took her to hospital. The nurse in emergency department called the police and found the resident was missing person from the facility. She states training has continued, immediate response from her team when the alarm sounds continues to be her expectation. Interview on 8/28/24 at 10:30 am with Maintenance manager. States all of the wander guard alarms we're functioning and are currently functioning. He monitors them the weekly. Observed his binder with weekly door monitoring checks to include 8/16/24. Maintenance manager stated he did not know how resident could have left the building, however, there have been a lot of power outages and power surges since the hurricane. Maintenance manager stated outside vendor has added new sensor on the front door. Maintenance manager stated the front door has had an additional sensor and he is monitoring the sensitivity and adjusting it for distance. Front door, laundry door, side door by nurse station are all with key code pad a resident could leave without sounding the alarm These doors all have functioning wonder guard alarms and key code pad combination. He states he will continue to observe and adjust sensitivity for the next 30 days, then go back to monitoring weekly. Observation on 8/28/2024 at 11:55 am front door and side door at nurse station B were tested and alarm did sound appropriately. Observation on 8/28/2024 at 12:00 pm revealed the exterior doors on the 100 and 200 halls were locked and unable to be opened without using the push bar. The doors had a keypad near them to allow exit. Both doors had a sign that said an alarm would sound if they were opened without the code. Observation on 8/28/2024 at 12:10 pm Elopement binder from nurses station A,B and C to include Missing Resident Profile with resident face sheet, name, height, weight, race, color of eyes, identifying marks, device used, language, mental condition, name of friends or relatives, per their Elopement Risk Assessment Policy. Interview on 8/28/24 at 1:05 pm with family member. She stated she was not concerned at this time with the facility, feels like they keep resident safe, have been attentive to her needs since she was admitted . Interviews 8/28/24 with LVN B, CNA C, CMA, RN A reporting they were given in-services regarding elopement and could describe in detail the process for all alarms on doors, supervision of all residents. Record review of the facility's Provider Investigation Report (PIR) dated 8/17/2024 for Intake ID 525841 revealed Resident #1 had exited the facility between 6:50 pm and 8:00pm on 8/16/2024. Search of building and surrounding area started immediately. Family, physician, medical director and police contacted. Police were given photograph and other identifying information. Administrator and DON joined in search of gas stations restaurants in local businesses. Transit Authority contacted by administrator and photograph and other identifying information provided to them. Administrator also visited local hospital emergency room between 11 and midnight. Facility staff continued to search the neighborhood and local hospitals into the morning. Resident located and was undergoing assessment at hospital. No preliminary injuries reported. Staffing in-serviced on the elopement policy, elopement binder, wander guard use. 100% Elopement assessment completed on 8/17/24. All wander guards in use assessed 100% operation. Record review of the facility's invoice dated 8/20/2024 revealed the alarm servicing contractor made an inspection of wandering system and adjust as needed. Added external power supply and added a door extender to increase the detection range of the front door. Made adjustments to the gain of the existing units including the side door with LC 1200 Door Extender. Doors are fully functional. Record review of the facility's in-service documentation dated 7/19/2024 revealed the staff who attended were instructed on resident elopement responses, and the facility environment. The documentation was signed thirty-three staff members. Per the documentation, the in-service covered the facility's elopement policies. Record review of the facility's in-service documentation dated 8/16/2024 revealed the staff who attended were instructed on resident elopement responses, and the facility environment. The documentation was signed thirty-eight staff members. Per the documentation, the in-service covered the facility's elopement policies. Record review of the facility's in-service documentation dated 8/17/2024 revealed the staff who attended were instructed on resident elopement responses, and the facility environment. The documentation was signed thirty-six staff members. Per the documentation, the in-service covered the facility's elopement policies. Record review of the facility's in-service documentation dated 8/17/2024 revealed the staff who attended were instructed on resident abuse and neglect. The documentation was signed by twenty-seven staff including LVN's, CNA's, housekeeping staff, dietary staff, therapy staff, social services staff, and activities staff. Per the documentation, the in-service covered the facility's elopement policies. The documentation was signed by thirty-six staff members. Per the documentation, the in-service covered the facility's elopement policies. Record review of the facility's in-service documentation dated 8/18/2024 revealed the staff who attended were instructed on resident elopement responses, and the facility environment. The documentation was signed by twenty staff members. Per the documentation, the in-service covered the facility's elopement policies. Record review of the facility's in-service documentation dated 8/27/2024 revealed the staff who attended were instructed on resident elopement responses, and the facility environment. The documentation was signed by twenty-three staff members. Per the documentation, the in-service covered the facility's elopement policies. Record review of the facility's Elopement Risk Assessment policy effective 11/01/2019 revealed a policy statement which read the community will assess all patients/residents for elopement potential in order to provide a safe and comfortable living environment. Record review of the facility's Elopement Policy policy effective 11/01/2019 revealed a policy statement which read To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing. Elopement drill will be held quarterly. Procedure 1. Once it has been established that a patient/resident is missing, the following staff members are notified immediately: the charge nurse, Executive Director of Operations, Director of Clinical Operations and social service designee, responsible party and the primary care physician. Complete the missing resident profile make note of the outside temperature. 2. The director of clinical operation or designee organizes and institutes an immediate and thorough search of the center and surrounding grounds. Conduct a head count of each unit. Including but not limited to a search of the area outside the nearest exit to the patient's/resident's room or exit where he/she was last seen, and the entire unit where the patient/resident resides or was last scene, the remainder of the facility, all rooms, closets - including storage facilities - bathrooms and grounds, extending beyond the fence line. Check all offices and any locked doors to ensure none were left unlocked. 3. The entire search process of the facility and grounds, from the time the patient/resident is missing, should be completed within 30 minutes. 4. If the search fails to locate the missing patient/resident within two hours from the time the patient/resident is found to be missing, the Administrator and or designee contacts the appropriate community agencies (local law enforcement) and update the patient's/ resident's legal representative. Staff will provide the police with all physical identifying information including but not limited to physical appearance, height, weight, age, sex, and clothing. If known. 5. The search is continued period two staff members searched the surrounding streets by car for a two (2) mile radius around the facility. 6. When the patient slash resident is located, the nurse completes a head to toe assessment. The social service designee assesses the patient/resident for emotional distress. The charge nurse reports any findings to the Director of Clinical Operations. The Director of Clinical Operations notifies the Executive Director of Operations or designee and notifies the appropriate community agencies, attending physician and patient's resident's legal representative. 7. If a resident is not located during the search of the facility, facility grounds, and immediate vicinity, and there are circumstances that place the residence health, safety, and or welfare at risk, a report to HSC must be made as soon as the facility becomes aware the resident is missing and cannot be located. Examples include, but are not limited to: -a resident requires medication that, if not taken as scheduled, place the resident at risk of serious illness or death or both; -extreme weather conditions exposed to the resident to potential freezing, heat prostration, or drowning from flooding; -a resident is confused or otherwise incapable of assessing potential danger; -there is a suspicion of foul play

32422 Based on observations, interviews, and record review, the facility failed to immediately consult with the physician and notify the resident representative when the resident experienced a change in condition for 1 of 5 residents (Resident #72) reviewed for a change of condition. The facility failed to notify the physician regarding Resident #72's missed urologist appointments on 3/14/2024 and 5/23/24, and failed to communicate Resident #72's changing skin condition of the groin and resident's report of pain until around 06/10/2024, at which time the penis split measured 8 cm length by 1 cm width by .4 cm depth and appeared red and raw. On 6/28/24 at 5:44PM an Immediate Jeopardy (IJ) was identified and the template was presented to the Administrator and the Interim DON. While the IJ was removed 7/2/2024 at 3:45PM, the facility remained out of compliance at a scope of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. Findings: Record review of the facility facesheet dated 6/28/2024 revealed Resident #72 was a 58- year-old male admitted to the facility on [DATE] and readmitted on [DATE] and with diagnoses that included neuromuscular dysfunction of bladder (the nerves and muscles don't work together very well. As a result, the bladder may not fill or empty correctly.), unspecified and hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one?sided weakness, but without complete paralysis). Record review of Resident #72's care plan with dated 09/05/2023: Focus: Resident #72 had indwelling catheter and is at risk for increased Urinary Tract Infections diagnosis: Neurogenic bladder: Goal: Resident will be/remain free from catheter related trauma through review date, will show no sign/symptom of Urinary Infection through review date: Interventions: Catheter changed PRN change (Size 18FR), check Foley catheter placement, ensure Foley was secured via Velcro strap to reduce friction/pulling q shift, and monitor/record/report to MD for sign/symptom UTI, pain, burning blood-tinged urine, cloudiness, no output, deepening of urine color, increase pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. Record review of Resident #72's quarterly MDS dated [DATE], revealed a BIMS score of 9, indicating moderately impaired cognition. Record review of the weekly skin assessment from April 2024 to June 13, 2024, revealed no documentation for slit on penis. Record review of Resident # 72's physician orders for March revealed the following order: Urology Consult on 3/14/2024 and 3/30/2024. Physician orders for April included: order dated 04/29/2022 reflected Foley Catheter 18 FR 15 cc bulb to continuous drainage related to diagnosis and on 5/13/20220 reflected another physician's order for Foley catheter 18 FR 15cc bulb to continuous drainage related to (diagnosis renal disease with Hematuria), order with a start date of 4/30/2024 for a wound care consult; one time only for penal wound for 2 days. Physician orders for March 2024 to June 2024, revealed an order: every day and every night shift, monitor for open penial area and notify MD and NP of any change dated 5/2/2024. Record review of Resident #72's TAR (Treatment Administration Record) for May 2024 through June 2024 revealed orders to monitor every shift open penile area and notify MD/NP of any changes. Monitored area on every shift for skin integrity except on 5/13/2024 and 5/14/2024 on night shifts and 5/17/2024 during the day shift. Record review also revealed to monitor every shift the foley insertion site for redness, irritation every day and night shift for skin integrity, and monitor Foley Cath, stripe placement for redness, irritation every shift was provided on 6/28/2024, night shift and through 7/30/2024. Further review revealed the resident did not report pain. Record review of the weekly skin assessment for Resident #72 from April 2024 to June 13, 2024, revealed no documentation for slit on penis. NP notified, awaiting response. Treatment nurse provided care, notified family member. There was no assessment and measurement to opening in the penile area. Record review of Resident #72's progress notes revealed the physician was notified of the blood in the urine on 03/14/24 and 03/30/2024. Record review of progress notes dated 4/14/2024 revealed Resident #72 was documented to have blood in his urine. Record review of progress notes dated 4/30/2024 revealed the first documentation of Resident # 72 was observed to have opening in the penile area due to prolonged foley catheter use. Record review of nurse's progress note revealed on 5/2/24: MD in facility rounding on Resident #72. Documented Nurse follow-up with resident penile area opening with the MD. Resident MD said urologist consult will further evaluate. Resident #72 have urology consult appointment 5/23/24. Further review revealed there were no other NP notes addressing the issue with Resident #72's penis after 05/02/24 and the only physician visit noted was on 05/02/24. Record review of Resident #72's nurse's progress notes and multiple interviews with staff revealed Resident # 72 did not see the Urologist until 6/20/24 due to the Urologist office relocating and the facility was not aware. Record review of Resident 72's Urology consult dated 6/20/2024 revealed diagnoses that included Neurogenic Bladder (the name given to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord, or nerve problem), gross hematuria (when you can see the blood in your urine) and Hyperplasia of prostate (a noncancerous enlargement of the prostate gland) with lower urinary tract symptoms, and now has a penoscrotal hypospadias (in perineal hypospadias, the scrotum is abnormally divided and the urethral opening is located along the center of the divided sac). During an observation on 6/27/2024 at 10:22am during in-dwelling catheter and incontinent care, revealed Resident # 72 had a Velcro strap to his mid-thigh, not securing the catheter. Further observation revealed a slit to Resident #72's penis head to the scrotum. In an interview with Resident #72 at 6/27/2024 at 10:46am, he said that he had pain to the side of the penis and the foley catheter has always been rubbing and pulling on him and his slit grew over time. In an interview on 6/28/2024 at 8:39 am with the MDS Nurse, she said that Resident # 72 went to his urology appointment on May 25th, 2024, but for some reason it was rescheduled, so they did not see him that day. She said that they received the documentation from his urology appointment from 6/20/24 this morning and provided a copy. Observation of Resident #72 at 6/28/2024 at 3:15pm, the Velcro was at the knee of the resident and not securing the in-dwelling catheter. Measurement of the slit length was 8 centimeters, the width was 1 centimeter, and the depth was 0.4 centimeter. The area was pinkish. In an interview on 6/28/2024 at 2:32pm with the Treatment Nurse, she said she identified Resident #72's slit during a skin assessment around March or April 2024. She informed the DON, the MDS Nurse, the family representative, and the doctor. The doctor wrote an order for the resident to see a urologist and wait for their recommendations. The nurse said the resident's penis had a little opening, but no redness and the resident told her he was not in pain. The resident has never told the nurse he felt pain from the split. The nurse said she always made sure the resident had the catheter strap. She said since she noticed the split it has remained that way, although she has not measured the slit length. The nurse said she knew that there was a urology appointment scheduled but she did not know if he made it to that appointment. She never noticed blood in the urine and the resident never mentioned blood in the urine. Interview with the Administrator and Interim DON on 7/1/2024 at 4:12PM regarding failure to notify the physician, DON said the Medical Director is notified when his own residents have a change in condition while the Primary Physician is notified as soon as a change in condition is found. The Charge Nurse was responsible for notifying the physician. The Unit Managers are to follow-up to confirm that the Primary Physicians were notified in the facility's morning meetings. On 7/1/24 at 3:04PM called Resident #72's MD and left message with the answering service. In an interview with the MD (Medical Director) on 07/01/2024 at 3:22pm, he said he knew the resident and he was on dialysis. The MD has seen him at the facility. The facility called him about the blood in resident's urine and he does not remember how long ago it was. He said he remembered the call and that the resident was supposed to see a urologist. He doesn't know how long ago the resident was supposed to see the urologist. The MD said someone told him about the slit in the penis. He doesn't know if it was evaluated, but that the resident had a foley catheter and was referred to the urologist to get it repaired. The MD said all communication between the resident's NP and the physician, regarding the resident should be in PCC in the notes. He was informed of the resident's delayed urology consult last week and knew the resident was waiting to go but unsure if the appointment was delayed or cancelled. The MD knows the resident had gone to a urology appointment before and that a follow-up was scheduled. He stated all the appointment information should be in the nursing notes. The MD said he has a group practice, and an NP also sees the MD's patients. Changes in condition were reported to a resident's primary physician and the MD would be notified about his residents. The MD was also notified of significant changes in condition for other residents since he was also the Medical Director of this facility. At QA/QAPI meetings, the MD and the facility will discuss patient care at that time about all patients. The MD does not know how long the slit was, he did not see bleeding from the area last time he saw the resident. When asked if he knew how long the resident had the slit, the MD replied, If you have to put words in my mouth it would be three weeks, but he could not say for sure. The MD said he has seen the resident twice and that the NP has seen this patient as well. Record review of the policy and procedure entitled Change in Resident's Condition or Status dated read in part . Policy Statement- Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) Policy Interpretation and Implementation: The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): d. significant change in the resident's physical/emotional/mental condition, need to alter the resident's medical treatment significantly, refusal of treatment or medications two (2) or more consecutive times), need to transfer the resident to a hospital/treatment center. This was determined to be an Immediate Jeopardy (IJ) on 06/28/2024 at 5:44PM. The Administrator and Interim DON were notified. The Administrator was provided with the IJ template on 07/01/2024 at 4:35PM. The following plan of removal submitted by the facility was accepted on 7/2/2024 at 9:54 am. Plan of Removal Immediate Jeopardy[the facility] . On 7/1/2024 an incident survey was initiated at [the facility] . On 7/1/2024 the state surveyor provided an Immediate Jeopardy (IJ) Template notification that the regulatory services have determined that the condition at the facility constituted an immediate jeopardy to resident health and safety. The facility failed to notify the physician regarding Resident #72's missed urologist appointments and communicate Resident #72's changing skin condition of the groin. F580 - Notify of Changes (Injury/Decline/Room) Immediate Action: o Resident #72's physician was notified of the missed appointment on 5/23/24 on 7/1/24 by the Director of Clinical services. o Resident #72's head to toe assessment was completed by the Treatment Nurse and ADCO on 6/28/24. The weekly skin assessment was updated to show the measurement and description of the split. o All residents with appointments were reviewed, only 1 missed appointment for 7/1/24 due to the Doctor's office not accepting Resident#1's insurance. His physician was notified. The Social worker with his Nurse practitioner was locating another MD that takes resident's insurance. No changes with resident's condition. Facilities Plan to ensure compliance quickly: o The treatment Nurse was provided with 1:1 training notifying the Physician on changes in the skin and updating care plan by the Director of Nursing and was completed on 6/28/24. o The Director of Nursing/Designee initiated an in-service to all charge Nurses on reporting alteration of skin integrity to physician to be completed on 7/2/24. All charge Nurse's will be provided with an in-service prior to the beginning of their shift. o Daily focused rounds will be completed by Nurse management daily on all residents with foley catheter to ensure they have leg strap on, and to identify any irritation and trauma to the penis. If there was any to ensure Physician notification was completed, and the new order received. Nurse managers were in-serviced by the Director of Nursing, completed on 7/1/24. o The Medical Director was notified of the Immediate Jeopardy on 7/1/2024. The medical Director reviewed change of condition/notification of physician policies and made no changes to the policy, this was completed 7/1/24. o The current practice of making outside appointment was reviewed by the IDT, it was determined that the social worker / Designee will oversee making appointment, validating insurance, and appointment before resident goes to the appointment. This will be validated by EDO/designee from the resident's progress note. The physician will be notified of any missed appointments, and the follow-up will be completed. The staff were in-serviced by the Director of Nursing, completed on 7/1/24. o The Social worker/Designee was educated by the Administrator on 7/1/24 to make future urology appointments and discuss with the IDT if they were having any difficulty in getting timely appointments for further direction and to notify the physician of any missed appointments. Monitoring/Observation/Interviews/Record Review: Record review of Resident #72's pain level assessment on 06/29/2024 revealed a pain level of 0. Observation and interview on 6/30/2024 at 11:00 am with Resident #72 was sitting in wheelchair eating a snack. He was well-groomed with no odors. Resident #72 said he is feeling okay but wondered why it took the facility so long to address his catheter. He said he was now afraid of an infection from his stoma to g-tube. Resident #72 raised his shirt at that time and a small pea-sized area was observed in what appeared to be a white cream. Resident #72 consented for the DON to come assess him with another staff member. He was then transported back to his room. The DON later came and said that the white substance was not an infection but a cream that they used to treat the stoma called theravox, which was confirmed by viewing the container and conducting a record review of Resident #72's physician orders. In an interview with the Administrator and the DON on 06/30/2024 at 9:38AM, the DON said that Resident #72's doctor told the nurses he will send his paperwork, he did not return from his 06/20/2024 appointment with it. The Administrator and the DON said they were not aware of this situation regarding the facility not following up after the Urologist appointment. The Administrator started on 06/03/2024 and the DON started 05/16/2024 and that they were not aware the follow-up doctor's visit system was broken. They believed the SW was assigned to run the system. The DON said if a resident missed an appointment, it could have caused a delay in care. She also found out that nurses were calling the Urologist's office but not documenting it. Now the facility will send the resident with an envelope to their visit, make sure the doctor's office returns documents, and items needing follow-up back with the resident. If not, the charge nurse will contact the office. The monitoring system will include the DON, the ADON, the Unit Managers, and the SW. In an interview with the SW on 06/30/2024 at 10:33AM, he said that he used to make specialist appointments, and now nursing will assist him with paperwork and documentation. He said that appointments were to be documented in the electronic medical records. The nursing staff will be in charge of managing the communication and will follow-up with the doctor's office. The appointments and changes in condition would be discussed at the morning meetings, and if there were any issues or concerns, he would let the DON and the ADON know. In an interview with RN A on 07/02/2024 at 12:09PM, she said that she was in-serviced on reporting changes in condition to the DON and MD. In an interview with LVN M on 07/02/2024 at 1:51PM, she was in-serviced on foley catheter care, pain management, and scheduling and documenting appointments for residents. In an interview with CNA M on 07/02/2024 at 1:51pm, she said she was in-serviced on foley catheter care for residents. In an interview on 7/1/2024 at 2:40 pm and 7/2/2024 at 1:42 pm with the Social Worker, he acknowledged in-services on notification of changes in condition to the physician, arranging and follow-up processes to ensure resident appointments were coordinated with the physician to include arranging transportation, communication to confirm location of appointment, and communication with the ADON, the DON, and the nursing staff. Documentation of physician appointments and follow-up to ensure the resident's appointment was completed. In an interview on 07/02/2024 at 2:04PM, Social Worker was in-serviced on making appointments and reporting changes in condition to the ADON, the DON, and the MD, including missed appointments. Interview with LVN N on 07/02/2024 at 2:08PM, he was in-serviced on scheduling and documenting appointments. In an interview with the treatment nurse on 07/02/2024 at 2:15PM, she was in-serviced on appointments and notifying the MD and the DON with changes in condition. In an interview with LVN B on 07/02/2024 at 1:38PM, she was in-serviced on scheduling and following up with residents' appointments and notifying physicians with changes in condition. In an interview with RN C on 07/02/2024, she said she was in-serviced regarding documenting, confirming, and following up with appointments. Record review of in-services, all staff completed the following: Record review of policies/procedures, in-services provided 6/28/2024 to 7/2/2024 Policy: Skin Management: Prevention and Treatment of Wounds Effective: 11/01/2019 Last Revised: 10/06/2022 Catheter Policy: Indwelling, straight, Supra-Pubic and external, dated effective 4/20/2021. Social Worker/Designee in-service on documentation of appointments. Pain Assessment. Department Head, Nurse Management Appointment In-service. Wound Care Nurse Competencies. Wound Care one on one-disciplinary action form. Cath and Foley Care/securing catheter, skin assessment. The Administrator and Interim DON was informed the Immediate Jeopardy was removed on 07/02/2024 at 3:45PM. The facility remained out of compliance at a severity level of 2 and a scope of E due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 4 residents (Resident #72 and #54) reviewed for quality of care. 1. The facility failed to assess, follow-up with treatment, update the care-plan, obtain new order due to a change in resident # 72's skin condition of the groin and resident's report of pain, at which time the penis split measured 8 cm length by 1 cm width by .4 cm depth and appeared red and raw, and failed to ensure that Resident #72's indwelling catheter (drains urine from your bladder into a bag outside your body) had a securement device to anchor catheter. 2. The facility failed to ensure that CNA B changed her gloves and perform hand hygiene while providing indwelling catheter and incontinent care to Resident #72. On 6/28/24 at 5:44PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 6/30/2024 at 12:27 pm, the facility remained out of compliance at a scope of isolated and a severity of harm with potential for more than the minimal harm that was not an immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. 3. The facility failed to ensure CNA G and CNA H did not place foley bag on Resident #54's bed during foley and incontinent care. These failures could affect residents in delay of appropriate medical treatment leading to pain, discomfort, and death. Findings included: Resident #72 Record review of a facility face sheet dated 6/26/2024 indicated Resident # 72 was a [AGE] year-old male and admitted on [DATE] and was readmitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one?sided weakness, but without complete paralysis), obstructive and reflux uropathy (the urine backs up into the kidney and cannot drain through the urinary tract), chronic kidney disease, major depressive disorder, neurogenic bladder (nerves that communicate between the bladder and spinal cord and brain malfunction and cause symptoms such as dribbling urine, loss of feeling the bladder is full and being unable to control urine), muscle wasting and atrophy (wasting away of tissue or organ). Record review of a Quarterly MDS assessment dated [DATE] indicated Resident #72 had a BIMS score of 09 indicating moderately impaired cognition, and he required an indwelling catheter. Record review of a comprehensive care plan dated 09/05/23 indicated Resident #72 was at risk for complications related to Foley catheter and goal will be/remain free from catheter-related trauma through review date. Interventions: Catheter changed PRN (size 18 FR), check Foley catheter placement, ensure Foley was secured via Velcro to provide catheter care every shift. Record review of Resident #72's care plan with dated 09/05/2023: Focus: Resident #72 had indwelling catheter and is at risk for increased Urinary Tract Infections diagnosis: Neurogenic bladder: Goal: Resident will be/remain free from catheter related trauma through review date, will show no sign/symptom of Urinary Infection through review date: Interventions: Catheter changed PRN change (Size 18FR), check Foley catheter placement, ensure Foley was secured via Velcro strap to reduce friction/pulling q shift, and monitor/record/report to MD for sign/symptom UTI, pain, burning blood-tinged urine, cloudiness, no output, deepening of urine color, increase pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. Record review of the weekly skin assessment from April 2024 to June 13, 2024, revealed no documentation for slit on penis. Record review of Resident # 72's physician orders for March revealed that he had orders for a Urology Consult on 3/14/2024 and 3/30/2024. Record review Physician's order dated 04/29/2022 reflected Foley Catheter 18 FR 15 cc bulb to continuous drainage related to diagnosis and on 5/13/20220 reflected another physician's order for Foley catheter 18 FR 15cc bulb to continuous drainage related to (diagnosis renal disease with Hematuria). Record review of Resident # 72's physician orders for March revealed that he had orders for a Urology Consult on 3/14/2024 and 3/30/2024. Record review of Resident # 72 doctor's progress notes on 3/30/2024 revealed Please schedule urology consult SPT placement to avoid Foley related hematuria on 3/14/24 and UROLOGY CONSULT TO RULE OUT HEMATURIA. Record review of Resident #72's skin assessment sheets from February 2024 to June 2024 revealed there were no skin assessments identifying the split in the penile area. Record review of nurse's progress notes dated 4/14/2024 revealed Resident #72 was documented to have blood in his urine. A progress note dated 4/30/2024 revealed Resident #72 was observed to have opening in the penile area due to prolonged Foley catheter use. NP notified, awaiting response. Treatment nurse provided care, notified family member. There was no assessment and measurement to opening in the penile area. Record review of nurse's progress note revealed on 5/2/24: MD (medical doctor in facility rounding on Resident #72. Documented Nurse follow-up with resident penile area opening with the MD. Resident MD said urologist consult will further evaluate. Resident #72 have urology consult appointment 5/23/24. Further review revealed there were no other NP notes addressing the issue with Resident #72's penis after 05/02/24 and the only physician visit noted was on 05/02/24. Record review of Resident #72's physician order included: start date of 4/30/2024 for a wound care consult, one time only for penal wound for 2 days; start date of 5/2/2024 revealed an order for every day and every night shift, monitor for open penial area and notify MD and NP of any change. Record review of Resident #72's TAR (Treatment Administration Record) for May 2024 through June 2024 revealed orders to monitor every shift open penile area and notified MD/NP of any changes. were performed. Monitored area on every shift for skin integrity except on 5/13/2024 and 5/14/2024 on night shifts and 5/17/2024 during the day shift. Record review also revealed treatment to monitor every shift the foley insertion site for redness, irritation every day and night shift for skin integrity, and monitor Foley Cath, stripe placement for redness, irritation every shift was was provided on 6/28/2024, night shift and through 7/30/2024. Record review revealed Resident # 72 did not see the Urologist until 6/20/24 due to the Urologist office relocating and the facility was not aware. Record review of Resident 72's Urology consult dated 6/20/2024 revealed diagnosis that includedwere Neurogenic Bladder (t,he name given to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord, or nerve problem), gross hematuria (when you can see the blood in your urine) and Hyperplasia of prostate (a noncancerous enlargement of the prostate gland) with lower urinary tract symptoms, .managed with Foley catheter but has caused and urethral breakdown now has a penoscrotal hypospadias (in perineal hypospadias, the scrotum is abnormally divided and the urethral opening is located along the center of the divided sac). During an interview on 6/25/24 at 9:55 am, CNA B said that when care was provided to a resident with a catheter, she made sure the catheter was not pulled but did not check for a securement device. She said the nurses were responsible for placing the securement device. She said a catheter that was not secure could come out or cause pain. During an interview on 6/25/24 at 1:11 pm, LVN A said she had been at the facility for 4 years. She said that residents with an indwelling catheter should be checked every shift and a securement device should be in place to prevent discomfort and dislodgment. She said she had received competency training on indwelling catheters and care. During an observation and interview on 06/26/24 at 9:45 am, Resident # 72 was observed with an indwelling catheter with no securement device for the catheter. Resident # 27 said there was a pulling feeling in his private area at times. During an interview on 6/26/24 at 10:43 am, the DON said the charge nurses were responsible for checking residents with catheters each shift and each resident with a catheter should have a securement device. She said she was responsible for all nursing oversight and training and nurses had been trained on catheter assessment and ensuring a securement device was in place. She said if a catheter was not secure it could cause abrasions and become dislodged. During an interview with the DON regarding Resident #72 on 6/27/24 at 4:10 PM the DON was not sure why Resident #72 did not see a Urologist on 3/14/24, 3/30/24, and 5/2/24. She stated she would check on chart and call the Urologist's office. During an observation of indwelling catheter care on 6/27/24 at 10:22 AM, Resident #72 was transferred from the wheelchair to the bed by C.NA B and MA D assisting. Resident #72 had Velcro strap on, that did not secure the catheter, the strap was on the resident mid-thigh. Incontinent care done by C.NA B. She did not wash her hands before donning clean gloves. C.NA B used wet wipes to clean the Foley catheter twice. Resident #72's penis head was slit from the base to the scrotum and was red and raw. C.NA B did not change gloves when they repositioned Resident #72 to the left side. The resident had a moderate amount of bowel movement. C.NA B picked up a clean brief and placed it on the bed. C.NA picked up wet wipes and cleaned the BM, folding the wipes in half twice, once after each wipe. Using the same gloves, C.NA B picked up the clean brief and placed it on the resident, pulled up the pant without securing the indwelling catheter. Observation of Resident #72 on 6/28/2024 at 3:15pm, the Velcro was at the knee of the resident and not securing the in-dwelling catheter. Measurement of the slit length was 8 centimeters, the width was 1 centimeter, and the depth was 0.4 centimeter. The area was pinkish. During an interview on 06/27/24 at 10:43 AM, Resident #72 was observed with an indwelling catheter with securement device (Velcro) not securing the catheter. Resident # 72 said the foley catheter has always been rubbing and pulling on him and his slit grew over time. He said it was very painful. During an interview on 06/27/24 at 10:50 AM, CNA B said that when care was provided to a resident with a catheter, she made sure the catheter was not pulled but did not check for a securement device. She said the nurses were responsible for placing the securement device. She said a catheter that was not secure could come out or cause pain. She said she forgot to wash her hands and change gloves. She said she has been working with the facility for 1 year and did have the skills check off done. She said that the resident had not complained of pain before and she knew to report to the charge nurse when any resident complained of pain. During an interview on 6/27/24 at 11:00 AM, LVN A said she had been at the facility for 1 year. She said that residents with an indwelling catheter should be checked every shift and a securement device should be in place to prevent discomfort and dislodgment. She said she had received competency training on indwelling catheters and care. During an interview on 6/27/24 at 11:43 AM, the DON said the charge nurses were responsible for checking residents with catheters each shift and each resident with a catheter should have a securement device. She said she was responsible for all nursing oversight and training and nurses had been trained on catheter assessment and ensuring a securement device was in place. She said if a catheter was not secure it could cause abrasions and become dislodged. On 6/28/24 at 7:45AM, the DON said she had sent the facility marketing director to the urologist office to pick up the results. In an interview on 6/28/2024 at 8:39 am with the MDS Nurse, she said that Resident # 72 went to his urology appointment on May 25th, 2024, but for some reason it was rescheduled, so they did not see him that day. She said that they received the documentation from his urology appointment from 6/20/24 this morning and provided a copy. In an interview on 6/28/24 at 11:37 AM RN A said the nurses changed catheters monthly or as needed when there was a leak. She said she was aware of the slit to Resident #72's penis when she changed the catheter a month or 2 months ago. She stated the resident had a urologist appointment on 5/23/24 and she thought the treatment nurse did the slit measurement. She cannot remember the length and width of the slit to the penis. RN A said the nurses secured the Velcro to the catheter to avoid it pulling and trauma. In an interview on 6/28/2024 at 2:32pm with the treatment nurse, she said she identified the split during a skin assessment around March or April 2024. She informed the DON, the MDS Nurse, the family representative, and the doctor. The doctor wrote an order for the resident to see a urologist and wait for their recommendations. The nurse said the resident's penis had a little opening, but no redness and the resident told her he was not in pain then. Resident #72 has never told the nurse he felt pain from the slit. The treatment nurse said she always made sure that Resident #72 had the catheter strap. She said since she noticed the slit it has remained that way, although she has not measured the slit length. The nurse said she knew that there was a urology appointment scheduled but she did not know if Resident #72 made it to that appointment. She never noticed blood in the urine and the resident never mentioned blood in the urine. In an interview on 6/28/2024 at 3:20pm with the treatment nurse, after measuring she stated she did not know the slit was that long. In an interview with the DON on 6/28/24 at 3:30 PM, regarding resident urologist consult from 3/14/24 3/30/24 for hematuria, consult for slit on penis on 4/30/24 and 5/2/24. DON said she would check for the results because there no result on the PCC. At 4:30 PM on 6/27/24, DON said she would be calling the urologist office for the result. DON said she did not get any respond from the doctor's order and the results were not documented in the progress notes and she just found out Resident #72 visited the urologist on 6/20/24 and there was no result om the chart. In an interview with the DON on 06/28/2024 at 4:30 PM, the DON stated he was made aware by the CNA involved about the infection control issue during incontinent care. The DON said every staff should wash their hands before and after every care. He said gloves should be changed and the hands should be sanitized after cleaning the resident's buttocks or the resident's front part before touching the any clean items. He said not washing the hands, not changing the gloves, and not sanitizing the hands in between changing of gloves could result to cross contamination and infection. The DON also added if the brief had fallen to the floor, it should not be used anymore for a simple reason that it was already dirty. The DON said the expectation was for the staff to remember to wash their hands and change their gloves when transitioning from a dirty area to a clean area, sanitize their hand when changing their gloves, and not to use items that had fallen to the floor. The DON said he already did a one-on-one in-service with CNA D but would do an infection control in-service for all the staff. He concluded that he would continually remind the staff to be attentive to the procedures for infection control and that he would personally monitor infection control. On 7/1/24 at 3:04PM called the MD left message on answering service. Interview with the MD (Medical Director) on 07/01/2024 at 3:22pm, he said he knew the resident and he is on dialysis. MD has seen him at the facility. The facility called him about the blood in resident's urine and he does not remember how long ago it was. He said he remembered the call and that the resident was supposed to see a urologist. He doesn't know how long the resident was supposed to see the urologist. The MD said someone told him about the slit in the penis. He doesn't know if it was evaluated, but that the resident had a foley catheter and was referred to the urologist to get it repaired. The MD said all communications between the resident's NP, the physician regarding the resident should be in PCC in the notes. He was informed of the resident's delayed urology consult last week and knew the resident was waiting to know but unsure if the appointment was delayed or cancelled. The MD knows the resident had gone to a urology appointment before and that a follow-up was scheduled. All the appointment information should be in the nursing notes. The MD said he has a group practice, and an NP also sees the MD's patients. Changes in conditions are reported to a resident's PCP and the MD gets notified about his residents. The MD is also notified of significant changes in condition for other residents since he is also the Medical Director of this facility. At QA/QAPI meetings, the MD and the facility will discuss patient care at that time about all patients. The MD does not know how long the slit is, he did not see bleeding from the area last time he saw the resident. When asked if he knew how long the resident had the slit, the MD replied, If you have to put words in my mouth it would be three weeks, but he could not say for sure. The MD said he has seen the resident twice and that the NP has seen this patient as well. The result from the urologist dated 6/20/24 presented to the state surveyor on 6/28/24 at 8:20 AM. Consult 6/20/24: Reason for visit: Blood in urine, Progress Notes: Assessment/Plan, Problem List Items Addressed This Visit: Visit Diagnoses: Neurogenic bladder-Primary, gross hematuria, hyperplasia of prostate with lower urinary tract symptoms (LUTS). 1. Neurogenic bladder/urinary retention - from CVA but still makes urine - managed with Foley catheter but has caused urethral breakdown now has a penoscrotal hypospadias. -Discussed risks and benefits of changing to a suprapubic tube and he wants to proceed 2. Penoscrotal hypospadias - due to urethral 3. Hematuria - resolved, obtain Cysto Observation on 6/28/24 at 3:10 PM revealed Resident #72 was back from dialysis and was sitting on the wheelchair. She was propelled by staff to resident #72's room for a skin assessment. CNA A and CNA B transferred Resident #72 to bed and the Velcro was on the resident's knee, not securing the catheter. The treatment Nurse undid the brief then picked up the penis measuring the slit. The length was 8 cm by 1cm width by 0.4cm depth, red and raw. The treatment nurse stated while measuring the slit that she did not know it was that bad and it was her first time measuring it. This was determined to be an Immediate Jeopardy (IJ) on 6/28/24 at 5:45PM. The Administrator and the DON were notified The Administrator was provided with the IJ template via email on 6/28/2024 at 5:56PM. The following plan of removal was submitted by the facility and was accepted on 6/29/2024 at 10:14AM. Immediate Jeopardy (the facility) On 6/28/2024 an incident survey was initiated at. On 6/28/2024 the state surveyor provided an Immediate Jeopardy (IJ) Template notification that the regulatory services had determined that the condition at the facility constituted an immediate jeopardy to resident health and safety. The facility failed to assess, follow-up with treatment, update the care-plan, and obtain new order due to a change in resident # 72's skin condition of the groin to the physician. F690 Plan of Removal Immediate Action: o Resident #72 head to toe assessment was completed by Treatment Nurse and ADCO on 6/28/24. The weekly skin assessment was updated to show the measurements and description of the slit. o Resident #72 was assessed for pain by the ADCO on 6/28/24 which he denied having pain. o Resident #72's Physician was updated on the slit by the DCO on 6/28/24, and no new order received. Current monitoring orders were already in place and completed every shift. o Resident #72's care plan was updated on 6/28/24 to reflect the skin changes in the penis and intervention. o All residents with foley catheters were assessed to ensure no slit in the penis, there was a leg strap to anchor their Foley tubing on 6/28/24 by the ADCO. No concern was identified. o The care plan of all resident's with foley catheters was reviewed by the MDS Nurse on 6/28/24 to ensure the care plan was updated with no concerns noted. Facilities Plan to ensure compliance quickly: o The treatment Nurse was provided with 1:1 training on proper skin assessment including weekly measurement of the wound, documentation on weekly skin assessment, updating the Physician on changes in the skin, and updating care plan by the Director of Nursing and was completed on 6/28/24. The monitoring will be placed in the treatment sheet and reviewed during daily clinical meetings by the DCO/Designee. o The Director of Nursing/Designee initiated an in-service for all Nursing staff to ensure foley catheters were secured with the strap to resident's thigh. Report any trauma or irritation to the meatus to the charge Nurse and attending physician/NP when found. Inservice will be completed on 6/29/24. All staff members will be provided with in-service prior to the beginning of their shift. o Skin assessment competency was completed on the Treatment Nurse by the DCO on 6/28. o Daily focused rounds will be completed by Nurse management daily on all residents with foley catheter to ensure they have leg strap on, and to identify any irritation and trauma to the penis. If there was any to ensure Physician notification was completed and new order received. o The Medical Director was notified of the Immediate Jeopardy on 6/28/2024. o The current policies reviewed on Skin management by the Medical Director on 06-28-2024: Prevention and treatment of wounds, and catheter insertion, and maintenance with no changes to the current policy completed on 6/28/24. This practice will be reviewed monthly with the QA committee to ensure compliance in place. o The Social worker/Designee will be educated by the Administrator on 6/29/24 to make future urology appointments and discuss with the IDT if they were having any difficulty in getting timely appointment for further direction. The surveyors confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Observation and interview on 6/30/2024 at 11:00 am with Resident #72 was sitting in wheelchair eating a snack. He was well-groomed with no odors. Resident #72 said he is feeling okay but wondered why it took the facility so long to address his catheter. He said he was now afraid of an infection from his stoma to g-tube. Resident #72 raised his shirt at that time and a small pea-sized area was observed in what appeared to be a white cream. Resident #72 consented for the DON to come assess him with another staff member. He was then transported back to his room. The DON later came and said that the white substance was not an infection but a cream that they used to treat the stoma called theravox, which was confirmed by viewing the container and conducting a record review of Resident #72's physician orders. In an interview on 6/29/2024 at 10: 20 AM RN A said she had been working with the facility for 8 months 6:00 AM to 6:00 PM shift. She had in-services on incontinent care, indwelling catheter care, securing catheter, hanging foley bag below the bladder, and reporting any abnormalities to the charge nurse like skin irritation. If there were any changes in the site notify the NP and check indwelling catheter every shift. They were assessing catheter before daily but now every shift and for any slit to the penis they should document in the progress note. In an interview on 6/29/2024 at 10: 49 AM LVN A said she had been working with the facility for 1 year on the 6:00 AM to 2:00 PM shift. She had in-services on incontinent care, indwelling catheter placement, securing the catheter, and reporting any abnormalities to the doctor like skin irritation and document. In an interview on 6/29/2024 at 10: 56 AM RN B, (Weekend Supervisor) said she had been working with the facility for 2 years on the 9:00 AM to 6:00 PM shift. She had in-services on pain, skin assessment, indwelling catheter care, securing the catheter, reporting any abnormalities to the doctor, and SBAR like skin irritation and slit measure daily and document. In an interview on 6/29/2024 at 11: 26 AM RA A (Restorative Aide) said she had been working with the facility for 8 years, on the 6:00 AM to 2:00 PM shift. She had in-services on incontinent care, indwelling catheter care, securing the catheter, and reporting any abnormalities to the charge nurse like skin irritation. In an interview on 6/29/2024 at 11: 14 AM C.NA A said she had been working with the facility for 1 year on the, 6:00 AM to 2:00 PM shift. She had in-services on incontinent care, indwelling catheter care, securing the catheter, free of kinking, and reporting any abnormalities to the charge nurse like skin irritation. In an interview on 6/29/2024 at 11:18 AM MA C said she had been working with the facility for 7 years on the 7:00 AM to 8:30 PM shift (Friday, Saturday, & Sunday). She had in-services on incontinent care, indwelling catheter care, securing the catheter, and reporting any abnormalities to the charge nurse like skin irritation and document. In an interview on 6/29/2024 at 11: 26 AM C.NA B said she had been working with the facility for 1 year on the, 6:00 AM to 2:00 PM shift. She, had in-services on incontinent care, indwelling catheter care, securing the catheter, and reporting any abnormalities to the charge nurse like skin irritation. In an interview on 6/29/2024 at 8:20 PM LVN C said she had been working with the facility on the 6:00 PM to 10 PM shift. She had in-services on skin assessment, indwelling catheter care, securing the catheter, and reporting any abnormalities to the ADON, the DON, and the M.D. In an interview on 6/29/2024 at 8:27 PM, C.NA D said she had been working with the facility for 2 years on the 2:00 PM to 10 PM shift. She had in-services on incontinent care, indwelling catheter care, securing the catheter, and reporting any abnormalities to the charge nurse. In an interview with the Administrator and the DON on 06/30/2024 at 9:38AM, the DON said that Resident #74's doctor told the nurses he will send his paperwork, but he did not return from his 06/20/2024 appointment with it. The Administrator and the DON said they were not aware of this situation regarding the facility not following up after the Urologist appointment. The Administrator started on 06/03/2024 and the DON started 05/16/2024 and that they were not aware the follow-up doctor's visit system was broken. They believed the SW was assigned to run the system. The DON said if a resident missed an appointment, it could have caused a delay in care. She also found out that nurses were calling the Urologist's office but not documenting it. Now the facility will send the resident with an envelope to their visit, make sure the doctor's office returns documents, and items needing follow-up back with the resident. If not, the charge nurse will contact the office. The monitoring system will include the DON, the ADON, the Unit Managers, and the SW. In an interview with the SW on 06/30/2024 at 10:33AM, he said that he used to make specialist appointments, and now nursing will assist him with paperwork and documentation. He said that appointments were to be documented in the electronic medical records. The nursing staff will be in charge of managing the communication and will follow-up with the doctor's office. The appointments and changes in condition would be discussed at the morning meetings, and if there were any issues or concerns, he would let the DON and the ADON know. In an interview with CNA J on 06/30/2024 at 10:49AM, she said she worked the 6:00AM to 2:00PM shift. She had in-services on incontinent care, catheter care, pain management, and notifying the charge nurse of changes in condition with catheter and pain. In an interview with LVN K on 06/30/2024 at 10:58AM, she said she worked when she was called and had in-services on catheter care, documentation, documenting for changes in condition, and reporting them to the DON and MD. In an interview with CMA A on 06/30/2024 at 11:06am, she stated she worked the 7:00AM to 8:30PM shift. She had in-services on catheter care and reporting changes in condition to the charge nurse, ADON, DON and MD. In an interview with CMA B on 06/30/2024 at 11:12AM, she stated she worked when she was called. She had in-services on foley catheter, assessing pain, and reporting changes in condition to the nurse, ADON and DON. In an interview with LVN G on 06/30/2024 at 11:21AM, she stated was a Unit Manager from 8:00AM to 5:00PM. She was in-serviced on pain assessment, catheter care, and reporting changes in condition to the MD. In an interview with the ADON on 06/30/2024 at 11:30AM, she stated her shift was from 8:00AM to 5:00PM. She was in-serviced on pain management and reporting changes in condition to the DON and MD, and catheter care. In an interview with LVN H on 06/30/2024 at 11:37am, she was in-serviced on foley catheter, pain, appointments, and reporting changes in condition. She also was trained on scheduling and monitoring appointments. Interview with RN A on 07/02/2024 at 12:09PM, she said that she was in-serviced on reporting changes in condition to the DON and MD. Interview with LVN M on 07/02/2024 at 1:51PM, she was in-serviced on foley catheter care, pain management and scheduling and documenting appointments for residents. Interview with CNA M on 07/02/2024 at 1:51pm, she said she was in-service on foley catheter for residents. The Administrator and Interim DON was informed the Immediate Jeopardy was removed on 06/30/2024 at 12:27PM. The facility remained out of compliance at a severity level of 2 and a scope of E due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Resident #54 Record review of Resident #54's face sheet dated 06/27/24 revealed he was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #54 had diagnoses which included: diabetes mellitus (body do not produce enough insulin or cannot use it properly), hypertension (high or raised blood pressure), urinary tract infection (an illness in any part of the urinary tract), and neuromuscular dysfunction of the bladder (the nerves and muscles do not work together very well). Record review of Resident #54's quarterly MDS assessment dated [DATE] revealed a BIMS score of 11 of 15 indicated moderate impaired cognition. Further review revealed the resident had indwelling Foley. Record review of Resident #54's care plan dated 01/28/21 revealed resident had a Suprapubic Catheter and was at risk for increased urinary tract infections related to neuromuscular bladder dysfunction. Interventions: Check tubing for kinks each shift. Monitor for s/sx of discomfort on urination and frequency. Resident placed on EBP program due to him having a Suprapubic catheter. Record review of Resident #54's physician order dated June 2024 read in part . change indwelling F/C PRN, dislodgement/patency .as needed related to obstructive and reflux uropathy start date 06/07/24 . Record review of Resident #54's physician order da [TRUNCATED]

Based on observations, interviews, and record review, the facility failed to care for residents in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 2 of 5 residents (Resident #20, Resident #33, and Resident # 54), reviewed for resident rights. -CNA K was standing while feeding Resident #54 his breakfast on 06/25/24. -LVN B did not provide privacy when administering insulin to Resident #33 on 06/25/2024. -RN A did not provide privacy when administering Resident # 20 G-tube medications on 06/25/2024. This failure placed residents at risk for feeling embarrased, disrespected and diminished quality of life. The findings were: Record review of Resident #54's face sheet dated 06/25/24 revealed a [AGE] year-old male admitted to the NF on 05/08/2017. Resident diagnoses included the following: Parkinson's Disease (disorder that affects movement, often including tremors) without dyskinesia (unwanted or involuntary movement), muscle weakness, dysphagia (difficulty swallowing), major depression, age related physical debility, and attention-deficit hyperactivity disorder (not being able to focus). Record review of Resident #54's quarterly MDS dated [DATE] revealed that resident had a BIMS score of 3 indicating that resident cognition was severely impaired. Further review of the MDS section G reflected that resident was totally dependent and required full staff performance. Record review of Resident #54's Physician Order Summary Report reflected the following order: -Dated 05/11/2024 Carb Controlled diet pureed texture, regular consistency. Record review of Resident #54's Comprehensive Care Plan dated 10/03/2019 and revised on 11/20/2023 reflected that resident was being care planned for requiring assistance with all ADL's self-care performance deficit r/t disease processes. The interventions included eating: resident being totally dependent on skilled nurses for nutritional intake. Observation on 06/25/24 at 9:30AM revealed during breakfast on Station A, CNA K standing on Resident #54's right side feeding resident his breakfast. In an interview on 06/25/24 at 10:00AM CNA K said she had been working at the NF for approximately 2 months. CNA K said the reason she was standing while feeding Resident #54 was because she did not have a chair to sit on. CNA K said she was taught in CNA school to sit whenever feeding a resident but had forgotten the reason why she should be sitting instead of standing when feeding a resident. In an interview on 06/25/24 at 11:55AM LVN B (on Station A) said she worked the 6AM-6PM shift. LVN B said when a resident was being fed, the staff should be sitting while feeding the resident. LVN B said this was done to provide the resident with dignity. In an interview on 06/25/24 at 11:05AM the DON said she had been working at the NF for 5 weeks. The DON said whenever she had to assist with feeding a resident, she would sit to feed the resident. The DON said she would have to review the NF policy because it depended on the resident if they wanted the staff to sit while feeding them. Resident # 33 Record review of Resident #33's face sheet revealed a 63-year- old male admitted to the NF on 05/03/2023 with diagnoses that included the following: hemiplegia (muscle weakness or partial paralysis on one side of the body) and hemiparesis (paralysis that affects only one side of the body) following cerebrovascular (decrease in blood flow to the brain) disease affecting the right dominant side, and type two diabetes mellitus (too much sugar in blood). Record review of Resident #33's quarterly MDS dated [DATE] revealed that resident had a BIMS score of 2 indicating that resident cognition was severely impaired. Record review of Resident #33's Comprehensive Care Plan revised 11/15/2023 revealed that resident was care planned for diabetes mellitus with intervention that included to administer insulin as ordered. Record review of Resident #33's Physician Order Summary Report reflected the following order: -Dated 05/23/2024 Humalog (fast acting insulin to treat diabetes) subcutaneous inject 10 units before meals for dm (diabetes mellitus), if blood sugar was below 150 do not give insulin. Observation on 06/25/24 at 11:49AM revealed LVN B entering Resident #33's room to take the residents blood sugar. LVN B did not close Resident #33's door or pull the resident privacy curtain. LVN B continued to care for the resident by taking resident's blood sugar. Resident blood sugar was 272 requiring 10 units of Humalog subcutaneously. LVN B administered 10 units of Humalog subq to resident's left lower abdomen (belly or stomach region). In an interview on 06/25/24 at 12:00PM with LVN B she said she forgot to close Resident #33's door and pull the resident privacy curtain when administering the insulin. Resident #20 Record review of Resident #20's face sheet revealed a 51-year- old male admitted to the NF on 03/19/2023 with diagnoses that included the following: cerebral infarction (decrease blood flow to the brain), dysphagia (difficulty swallowing), gastrostomy (surgical procedure that creates an opening in the stomach to deliver food), aphasia (language disorder that affects a person's ability to communicate), and hemiplegia (muscle weakness or partial paralysis on one side of the body) and hemiparesis (paralysis that affects only one side of the body) following cerebral infarction. Record review of Resident # 20's MDS annual assessment 04/29/2024 reflected that resident had a BIMS score of 1 indicating that resident cognition was severely impaired. Record review of Resident #20's Physician Orders reflected the following: -Dated 04/26/2023 flush with 30ml (water) before and after medication pass with 5 ml between each medication. Record review of Resident #20's Comprehensive Care Plan dated 10/28/2023 and revised 04/29/2024 reflected the following: -Resident #20 required tube feeding r/t dysphagia with an intervention that included resident was dependent with tube feeding and water flushes. Observation on 06/25/24 at 4:10PM of medication administration for Resident #20 via gastrostomy tube by RN A. When RN A entered resident's room to administer resident medications, she did not close the door, nor did she pull Resident 20's privacy curtain. Resident #20 was sitting up in his specialized wheelchair watching a movie on his laptop. Resident #20 had a G-tube with a dressing at the site. RN A proceeded to check the resident's G-tube placement by raising the resident's shirt to auscultate (listen) resident's abdomen (stomach). When RN A was done, she continued with checking the G-tube for any residual. RN A proceeded to administer the resident's medication via G-tube by gravity. In an interview on 06/25/24 at 4:30PM RN A said whenever providing care for a resident, she was supposed to provide the resident with privacy by closing the door or pulling the curtain. RN A said she became nervous and forgot to provide privacy for Resident #20. In an interview on 06/25/24 at 12:07PM the DON said whenever the staff provide care for the resident's they were supposed to provide privacy for the residents. Record review of the NF policy on Meal Service dated 04/2022 revealed in part: .The dining experience will enhance the resident's quality of life .The staff member does not stand, when feeding or assisting the resident with eating. Staff converse with the residents during mealtime . Record review of the NF policy on Resident Rights revised December 2016 revealed in part: .Employees shall treat all residents with kindness, respect, and dignity .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence, be treated with respect, kindness, and dignity .privacy and confidentiality .

Based observations, interviews, 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 one (Resident #72) of four residents observed for infection control. The facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 3 of 5 staff (DHK, LSA, and CNA B) observed for infection control. 1.The facility failed to ensure that CNA B changed his gloves and perform hand hygiene while providing indwelling catheter and incontinent care to Resident #72. 2.The facility failed to ensure DHK and LS A followed proper infection control procedure in the laundry room, This failure could place the residents at risk of cross-contamination and development of infection. Finding included: Record review of a facility face sheet dated 6/26/2024 indicated Resident # 72 was a [AGE] year-old male and admitted on [DATE] and was readmitted on [DATE] with diagnoses of hemiplegia and hemiparesis following a cerebral infarction affecting left dominant side, obstructive and reflux uropathy, chronic kidney disease, major depressive disorder, neurogenic bladder (dysfunction affecting bladder control), and muscle waiting and atrophy. Record review of a comprehensive care plan dated 09/05/23 indicated Resident #72 was always incontinent for bowel and bladder. Review of Resident #72's Comprehensive Care Plan dated 09/05/2023 reflected resident had an ADL self-care performance deficit related to CVA (cerebrovascular disease: stroke) and one of the interventions was for two staff to assist with ADLs with needed assistance. Record review of a Quarterly MDS assessment dated [DATE] indicated Resident #72 had a BIMS score of 09 indicating moderately impaired cognition and he required an indwelling catheter. Observation of indwelling catheter/continence care on 6/27/24 at 10:22 AM, Resident #72 was being transferred from his wheelchair to his bed by C.NA B and MA D. Incontinent care done by C.NA B. She did not wash her hands before donning clean gloves. C.NA B used wet wipes to clean the Foley catheter twice. Resident #72's penis head was slit from the base to the scrotum and was red and raw. C.NA B did not change gloves when they repositioned Resident #72 to the left side. The resident had a moderate amount of bowel movement. C.NA B picked up a clean brief and placed it on the bed. C.NA picked up wet wipes and cleaned the BM, folding the wipes in half twice, once after each wipe. Using the same gloves, C.NA B picked up the clean brief and placed it on the resident, pulled up the pant without securing the indwelling catheter. In an interview with Resident #72 on 6/27/24 at 10:43 AM about the indwelling catheter, he said it was pulling and rubbing on his skin. He said it was very painful and he had a slit now. In an interview with MA D on 6/27/24 at 10:46 AM, she said CNA did a good job only she did not change gloves and she used the same gloves throughout the procedure. She was supposed to change gloves from soiled to dirty or use hand sanitizer. In an interview with CNA B on 6/27/24 at 10:50 AM she said she forgot to wash her hands and change gloves. She said she has been working with the facility for 1 year and did have the skills check off done. She said that the resident had not complained of pain before and she knew to report to the charge nurse when any resident complained of pain. In an interview with the DON on 06/28/2024 at 4:30 PM, the DON stated he was made aware by the CNA involved about the infection control issue during incontinent care. The DON said every staff should wash their hands before and after every care. He said gloves should be changed and the hands should be sanitized after cleaning the resident's buttocks or the resident's front part before touching the any clean items. He said not washing the hands, not changing the gloves, and not sanitizing the hands in between changing of gloves could result to cross contamination and infection. The DON also added if the brief had fallen to the floor, it should not be used anymore for a simple reason that it was already dirty. The DON said the expectation was for the staff to remember to wash their hands and change their gloves when transitioning from a dirty area to a clean area, sanitize their hand when changing their gloves, and not to use items that had fallen to the floor. The DON said he already did a one-on-one in-service with CNA D but would do an infection control in-service for all the staff. He concluded that he would continually remind the staff to be attentive to the procedures for infection control and that he would personally monitor infection control. Record review of the facility's policy, Hand Hygiene Infection Control Prevention and Control Program revealed Policy: This facility considers hand hygiene the primary means to prevent the spread of infections . b. Before and after direct contact with residents .h. Before moving from a contaminated body site to a clean body site during resident care . i. After contact with a resident's intact skin . j. After contact with blood or bodily fluids . m. After removing gloves . hand hygiene is the final step. During an observation on 06/26/24 at 12:49 p.m., revealed the clean side of the laundry room, which had a clean table for folding clean linen, had the following personal items on the table: two white portion cups with white sauce, one white bowel of fruit, one black plastic spoon, one black comb, OXI cleaner, and they were touching the clean folded linen. The following items: one leg boot, 4 socks, 2 blankets, and three pillowcases were on the floor under the clean rack in the clean area. There were three-yard black plastic bags filled with clean clothes in the dirty section of the laundry room, a white basket with 20 hangers laid sideways on the floor, and 5 hangers on the floor under a rack. There was a full-size rack with clean clothes in the dirty section of the laundry room, one orange sweat jacket with a hoodie, and an orange shirt was on the floor under the rack. The hand-washing soap dispenser on the dirty section of the laundry was broken. During an interview on 06/26/24 at 1:00 p.m., DHK said the staff was not supposed to have their items on the folding table because it was an infection control issue and the staff could transfer their germs to the clean clothes. DHK said the clean clothes should not be stored on the floor because the floor was dirty, and the clothes were contaminated with the germs on the floor. DHK said clean clothes should not be stored in the dirty area or on the floor because of cross-contamination. DHK said the clean donated clothes were stored on the floor in the dirty section of the laundry because there was no storage space. DHK said the soap dispenser had been broken since he started working (05/20/24), and there was no hand sanitizer in the laundry room. DHK said the laundry aide would go out to the hallway restroom and wash her hands after she loaded dirty linens in the washer, which was an infection control issue. During an interview on 04/26/24 at 1:30 p.m., LS A said the soap dispenser had been broken for about two days, and she had been going to the visitor's restroom in the hallway and washing her hands. LS A said it was an infection control issue when staff placed their items on the clean folding table where clean linens were placed because the germs from the staff items could be transferred to the resident. LS A said the resident could get sick because the linens may have been contaminated with germs from the staff's personal items. LS A said she had an in-service on infection control, and the housekeeping director monitored the laundry aide. During an observation and interview on 06/26/24 at 1:34 p.m., the Administrator said he could see the hand-washing soap broken. The Administrator said the laundry aide should not go to the restroom to wash her hands because it was an infection control issue. The Administrator stated LS A left one area to another area to wash her dirty hands, and she could have transferred the germs to the area where she went and washed her hands. The Administrator said LS A could have contaminated her hands on her way back to the clean area in the laundry room and could have transferred the germs to the clean linens, which was an infection control issue. The Administrator said clean linens should not be stored in dirty areas, and no clothes should be on the floor or staff personal items on the clean table for clean linen for infection control reasons. Record review of the facility policy on laundry and bedding, soiled dated 2001 MED-PASS, Inc. (Revised October 2018) read in part . soiled laundry/bedding shall be handled, .processed according to best practices for infection prevention and control .transport #6 . clean linens are stored separately, away from soiled linens, at all times . 36918 During an observation on 06/26/24 at 12:49 p.m., revealed the clean side of the laundry room, which had a clean table for folding clean linen, had the following personal items on the table: two white portion cups with white sauce, one white bowel of fruit, one black plastic spoon, one black comb, OXI cleaner, and they were touching the clean folded linen. The following items: one leg boot, 4 socks, 2 blankets, and three pillowcases were on the floor under the clean rack in the clean area. There were three-yard black plastic bags filled with clean clothes in the dirty section of the laundry room, a white basket with 20 hangers laid sideways on the floor, and 5 hangers on the floor under a rack. There was a full-size rack with clean clothes in the dirty section of the laundry room, one orange sweat jacket with a hoodie, and an orange shirt was on the floor under the rack. The hand-washing soap dispenser on the dirty section of the laundry was broken. During an interview on 06/26/24 at 1:00 p.m., DHK said the staff was not supposed to have their items on the folding table because it was an infection control issue and the staff could transfer their germs to the clean clothes. DHK said the clean clothes should not be stored on the floor because the floor was dirty, and the clothes were contaminated with the germs on the floor. DHK said clean clothes should not be stored in the dirty area or on the floor because of cross-contamination. DHK said the clean donated clothes were stored on the floor in the dirty section of the laundry because there was no storage space. DHK said the soap dispenser had been broken since he started working (05/20/24), and there was no hand sanitizer in the laundry room. DHK said the laundry aide would go out to the hallway restroom and wash her hands after she loaded dirty linens in the washer, which was an infection control issue. During an interview on 04/26/24 at 1:30 p.m., LS A said the soap dispenser had been broken for about two days, and she had been going to the visitor's restroom in the hallway and washing her hands. LS A said it was an infection control issue when staff placed their items on the clean folding table where clean linens were placed because the germs from the staff items could be transferred to the resident. LS A said the resident could get sick because the linens may have been contaminated with germs from the staff's personal items. LS A said she had an in- service on infection control, and the housekeeping director monitored the laundry aide. During an observation and interview on 06/26/24 at 1:34 p.m., the Administrator said he could see the hand-washing soap broken. The Administrator said the laundry aide should not go to the restroom to wash her hands because it was an infection control issue. The Administrator stated LS A left one area to another area to wash her dirty hands, and she could have transferred the germs to the area where she went and washed her hands. The Administrator said LS A could have contaminated her hands on her way back to the clean area in the laundry room and could have transferred the germs to the clean linens, which was an infection control issue. The Administrator said clean linens should not be stored in dirty areas, and no clothes should be on the floor or staff personal items on the clean table for clean linen for infection control reasons. Record review of the facility policy on laundry and bedding, soiled dated 2001 MED-PASS, Inc. (Revised October 2018) read in part . soiled laundry/bedding shall be handled, .processed according to best practices for infection prevention and control .transport #6 . clean linens are stored separately, away from soiled linens, at all times .

Based on observation, interview and record review the facility failed to dispose of garbage and refuse properly for dumpster A and Dumpster B of 2 dumpster reviewed for Food and nutrition services. -The facility failed to ensure dumpster A and dumpster B's lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings included: Observation on 06-26-24 at 1:15 pm, revealed the facility's dumpster area, had 2 commercial -size dumpsters (dumpster A and dumpster B) 3/4 full of garbage and the doors were open. In an interview on 06-26-24 at 3:45 pm, with the Food Service Manager, she stated that the dumpster doors must always be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. She further stated that housekeeping, and nursing also discard their waste garbage in the dumpster. It was the responsibility of staff from dietary, nursing and housekeeping for ensuring the food waste will properly be removed and disposed for from the community. Record review of facility's Policies and Procedures on waste disposal dated 11/ 2023 revealed that food waste will be properly removed and disposed for from the community to ensure the food safety for the residents. Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests. Outside dumpster provided by garbage pickup services will be kept closed and free of surrounding litter.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure expired foods were discarded. 2. The facility failed to ensure foods were dated as opened/preparation discarded after 72 hours. 3. The facility failed to thaw frozen Fish Filet These failures could place residents who ate food from the kitchen at risk of food borne illness and disease. Findings Included: Observation of the facility kitchen on [DATE] at 8:15 AM revealed the following. 1. 2 tubs Plastic Container of Cottage Cheese in the walk in cooler with manufacturer expiration date of [DATE]. 2. A Plastic container of Shredded Cheese in the walk in cooler with no date opened and no use by date. 3. A Plastic container of Sliced American Cheese in the walk in cooler with no date opened and no use by date. 4. A Plastic Container of frozen fish fillet submerged in water in the kitchen sink with water temperature of 71.8 degrees F and Fish Filet with a 66.4 degrees Fahrenheit. The fish temperature is in the danger zone ( 140degrees F or higher to 41degrees or lower.) 5. Scoop left in the ice maker bin equipment in the kitchen. In an interview with the Dietary Food Service Manager on [DATE] at 8:25 AM ; she stated the leftover food stored in the refrigerator should have been used or discarded prior to use by date, she further stated that the proper thawing of frozen food water should be running with a temperature of 70 or below degrees Fahrenheit and the Fish should have at temperature of 41 degrees or lower. Record review of facility's policies and procedures for Food Safety for Residents dated ,d+[DATE] read in part .potentially hazardous leftover foods are properly covered, labeled, dated, and refrigerated immediately. They are discarded after 72 hours unless otherwise indicated. Scoops should not be left in food containers or bins.

Based on interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' physical, mental, and psychosocial needs for 1 of 1 resident (Resident #72) reviewed for anticoagulants. The facility did not develop and implement a comprehensive person-centered care plan to address Resident #72's use of anticoagulants. There was no documentation in his care plan of measurable objectives, interventions, or timeframes for how staff would meet his needs. This failure affected 1 resident and has the potential to affect residents who use anticoagulants by not having his needs met and putting him at risk of being inappropriately cared for. Findings include: Record review of the facility face dated 6/28/2024 revealed Resident #72 was a 58- year-old male admitted to the facility on [DATE] and readmitted on [DATE] and with diagnoses that included anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), unspecified and hemiplegia and hemiparesis following cerebral infarction affecting left dominant side(paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one?sided weakness, but without complete paralysis). Record review of Resident #72's care plan, no date provided revealed there were no care plans to address anticoagulants. Record review of Resident #72's quarterly MDS dated [DATE] in section N-Medications revealed that Resident #72 received anticoagulants. Record review of Resident #72's physician orders for June 2024 for Apixaban Oral Tablet 5 MG (Apixaban):Give 1 tablet orally every 12 hours for anticoagulant with a start date of 4/17/2024 and discontinue date of 7/1/2024. Record Review of Resident #72's Medication Administration Record for April 17, 2024, to June 30,2024 revealed that Resident #72 was administered Apixaban 5mg at 8:00 am and 8:00 pm. July 1, 2024, Resident #72 was administered Apixaban 5mg at 8:00 am. Interview on 6/26/2024 with the MDS Coordinator, she said that there used to be another MDS Coordinator along with her and she had recently taken the responsibility for completing all of the care plans, she said that Resident #72 should have had a care plan for anticoagulants. She said the care plan is important because it showed how to provide care to a resident. She said that the facility had access to the Corporate MDS staff and the DON for monitoring the process as well. She said that the facility used the RAI Manual and they also had a comprehensive care plan policy. Record review of the facility policy and procedure entitled Comprehensive Care Plan dated: Effective: 1/20/2021, Last Revised: 4/25/2021 read in part .every resident will have an individualized interdisciplinary plan of care in place. A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of Admission. The Interdisciplinary Team will continue to develop the plan in conjunction with the RAI (MDS 3.0) and CAAS, completing and conducting Comprehensive Care Plan Meeting and Reviews by day 21 after Admission. The Care Plan is revised every quarter, significant change of condition, Annual or as the resident condition changes on an individualized basis. The Care Plan process is an ongoing review process.

Based on observation, record review, and interview, the facility failed to ensure residents received adequate supervision and assisted device to prevent accidents for 1 of 22 residents (CR #1) reviewed for accidents. -The facility failed to intervene by putting interventions in place when CR #1 began having choking episode during eating on [DATE]. -The facility failed to in-service staff on the s/s of silent aspiration and choking. -The facility failed to monitor CR #1 during meals after she had a choking episode on [DATE]. CR #1 experienced another choking episode on [DATE] and had to be transferred to the hospital via 911services. CR #1 passed away at the hospital on [DATE]. This failure could place residents at risk for choking/silent aspiration that could lead to death. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 1:07PM. While the IJ was removed on [DATE] at 12:24PM, the facility remained out of compliance at a scope of isolated and a severity of harm because all staff had not been trained on the importance of monitoring residents with dysphagia to prevent choking/ silent t aspiration. Findings: CR #1 Record review of CR #1's face sheet dated [DATE] revealed an 83year old female admitted to the NF originally on [DATE] and again on [DATE] with diagnoses that included the following: Alzheimer's Disease with late onset, dysphagia (difficulty swallowing) diagnosed on [DATE], heart disease, and cerebral infarction (disrupted blood flow to the brain). Record review of CR #1's MDS dated [DATE] reflected BIMS score 00 indicating resident cognition was severely impaired. Further review section K (swallowing/Nutrition Status) reflected that CR #1 had no s/s of possible swallowing disorder. Further review of the MDS section GG reflected that CR #1 required setup or clean-up assistance. Record review of CR #1's Physician Order Summary Report for the month of [DATE] included the following orders: -Dated [DATE] carb controlled no added salt mechanical soft texture, regular consistency. -Dated [DATE] may crush meds/open capsule every 12 hours for safety. -Dated [DATE] SLP evaluation. -Dated [DATE] Comprehensive swallow consult including MBSS (procedure to determine whether food or liquid is entering a person's lungs) to assess aspiration risk, r/o silent aspiration, determine least restrictive diet texture, assess esophageal function and physician consult for dysphagia include appropriate nutritional status. Record review of Screening Tool done by the NF Rehab Director on [DATE] reflected in part: .DON referred PT for ST services for dysphagia management. No s/s of swallow impairment noted at this time however ST to complete eval and schedule MBSS to r/o silent aspiration . Record review of CR #1 Speech Therapy note dated [DATE] recommended thin liquids and mechanical soft/ground textures, puree (creamy paste) consistencies. Record review of CR #1's Care Plan updated [DATE] did not reflect that CR #1 was being care planned for dysphagia. Record review of CR #1's Nursing Progress Notes dated [DATE] documented by RN B at 19:55 (8:55PM) reflected in part: .CR #1 was wheeled from the dining room to the nurse station by CNA at about 5:30PM with no sign of distress or discomfort. At about 5:45PM, CNA call out that resident was unresponsive on the wheelchair by the nursing station. Code blue activated, CPR done, oxygen connected, AED used, 911called. 911 arrived and took over the resident resuscitation. 911 later transferred the resident to hospital for further management, family member was notified of resident condition. NP also notified . Interview on [DATE] at 2:00PM the DON said he incident regarding CR #1 happened around 6:00PM or a little after on [DATE] but could not remember the exact time. The DON said CNA A was standing in the hallway calling for help. The DON said when she arrived at the scene, she observed CR #1 had been placed on the floor by staff members. The DON said the nurses had already initiated CPR and that she began to assist with the CODE ensuring that 911 services had been called. The DON said CR #1 had a weak pulse and was not breathing. The DON said CR #1 was not choking and believed that CR #1 had experienced a mini stroke. Interview on [DATE] at 2:11PM the Administrator said the NF had called the hospital where CR #1 was transferred to. The Administrator said the hospital informed that CR #1 had to be intubated and think placed on placed on a ventilator. Interview on [DATE] at 2:40PM with the MDS Nurse said she had been working at the NF for almost a month. The MDS Nurse said she was not aware that CR #1 was not being care planned for dysphagia. Interview on [DATE] at 3:06PM with CNA A said she worked at the NF full time on the 2PM-10PM shift. CNA A said the time was around 5:30PM-6:00PM on [DATE] when CR #1 was being wheeled from the Dining Room by another CNA (who name she could not recall). CNA A said CR #1 was placed facing the nurse station sitting in w/c. CNA A said CR #1 did not have any front teeth and therefore was unable to chew food well and could not swallow good. CNA A said at one time, CR #1 was on a puree diet and was later upgraded to a mech soft diet. CNA A said on [DATE] CR #1 choked off her food while feeding her in bed during dinner time. CNA A said CR #1 was eating potato soup. CNA A said she tried to help CR #1 when she started choking but was unsuccessful and therefore called LVN W who never came to CR #1's room. CNA A said the oncoming nurse LVN B came to the room and just looked at CR #1. CNA A said it was CNA I that helped CR #1 by pulling CR #1 forward in bed. CNA A said the food came up which was some potatoes and other undigested food. CNA A said CR #1 appeared to be okay after the choking incident on [DATE]. CNA A said she told LVN W and LVN B that CR #1's diet needed to be changed. CNA A said she also told the DON that CR #1 had experienced choking on [DATE]. CNA A said she had informed the DON on [DATE] at 7:30PM and that the DON was preparing to leave the NF to go home. CNA A said RN E told her that it was a chain of command for CR #1 to be assessed by the Speech Therapist. CNA A said RN E said the ADON had to be informed. CNA A said RN E told her that she would notify the ADON. CNA A said she went to the Speech Therapist on [DATE] in the evening and told him about resident choking episode on [DATE]. CNA A said the Speech Therapist told her that he would need an order. CNA A said she had informed the Administrator verbally on [DATE] and the Administrator told her to write a statement. CNA A said she wrote a statement at 11:34AM on [DATE] and send to the Administrator via e-mail regarding CR #1's choking incident on [DATE]. CNA A said she did not want the surveyor to say anything to the Administrator because she did not want to lose her job. CNA A said she went to the kitchen on [DATE] and told them what to give CR #1. CNA A did not elaborate on the exact food she told the kitchen to serve CR #1 but told them to give CR #1 soft texture foods that did not require CR #1 to chew a lot. CNA A said the kitchen gave CR #1 a mechanical soft diet. CNA A said [DATE] at 5:30PM or 6:00pm at the nurse station she saw CR #1 leaning to her side drooling at the mouth with food in her mouth. CNA A said nurse LVN C was trying to get the food out of CR #1's mouth. CNA said LVN C began to hit CR #1 in back, but CR #1 was not responding. CNA A said herself and LVN C transferred CR #1 on the floor and at this time CR #1 was completely unresponsive. CNA A said she started screaming for help and 911 was called. CNA A said after that she did not know what took place next because she went to see if 911 had arrived so she could direct them to the hall CR #1 was residing on. Interview on [DATE] at 3:45PM CNA I said she worked the first shift 6AM-2PM mainly but did work over sometimes on the evening shift. CNA I said the first time she observed CR #1 choking was on [DATE] after 5:50PM. CNA I said she believed that it was CNA A that called her to come and assist with CR #1 choking episode on [DATE]. CNA I said CNA A was standing in the hallway calling for help. CNA I said there was a new nurse caring for CR #1 who name she could not recall. CNA I said CR #1 was choking when she entered her room. CNA I said she immediately pulled CR #1 forward in bed trying to relieve the choking. CNA I said the food did come up and that the new nurse was just standing on the side of CR #1's bed looking. CNA I said they continued to let CR #1 sit up in bed and they continued to monitor CR #1 for any further choking. CNA I said CNA A said she was going to report the incident. CNA I said CR #1 appeared to be okay for the remainder of the shift. CNA I said the next morning when she returned to work, she told RN E that CR #1 needed to be gotten out of bed for her meals due to the choking episode on [DATE] and RN E agreed. Interview on [DATE] at 4:33PM CNA H said she worked from 2PM-10PM full time. CNA H said on [DATE] she was assigned to CR #1. CNA H said CR #1 was in the Dining Room sitting at the table of residents that needed to be fed. CNA H said CR #1 was able to feed herself just had to help her at times. CNA H said CR #1 was served for dinner chopped sausage in a bun, beets, and potato fries. CNA H said CR #1 was always choking or coughing when eating her food and that her choking was silent with her eyes watering. CNA H said in the past, she told this to LVN W and RN E. CNA H said RN E said nothing was wrong and just patted CR #1 on her back. CNA H said after dinner on [DATE], she pushed CR #1 in her w/c back to the nurse station. CNA H said as they were leaving the dining room, CR #1 took a bite of her hot dog bun and her beets. CNA H said when she arrived at the nurse station with CR #1, LVN C was at the nurse station. CNA H said later she heard CNA A and CNA D saying CR #1 was choking. CNA H said CR #1 was lowered to the floor from the w/c. CNA H said LVN C told her to call 911. CNA H said when 911 arrived, they suctioned CR #1 mouth, and food came out of CR #1's mouth. Interview on [DATE] at 5:19PM via phone LVN B said she worked the 6PM-6AM shift PRN. LVN B said the last time she worked at the NF was on [DATE] and [DATE]. LVN B said CR #1 did not have any issues with chocking. LVN B said CNA A was feeding CR #1 in bed on [DATE]. LVN B said CR #1 was being fed soup along with some type of salad with chunks of chicken chopped up in it. LVN B said CR #1 was not choking, but just not tolerating the texture of the food. LVN B said CR #1 had tea or apple juice as a beverage. LVN B said she heard CNA A calling for help and when she arrived to CR #1's room, CR #1 was able to follow commands and did spit the food out. LVN B said CNA A was in a complete uproar and got overly excited. LVN B said the incident was mentioned to the DON who came on the unit. LVN B said the DON said she would take care of the matter. LVN B said she did not call the physician on [DATE] because the DON said she would take care of it. Interview on [DATE] at 5:52PM the DON said it was CNA A that came to her on [DATE] around 8:00PM telling her that CR #1 was having difficulty swallowing. The DON said she put an order in on [DATE] for CR #1 to be evaluated by the Speech Therapist but did not call the NP or the physician. The DON said she told the NP when she was at the facility on [DATE] and the NP said that was good that she put an order in for CR #1 to be assessed by the Speech Therapist. The DON said she had not in-serviced the Nursing staff on silent aspiration/choking. The DON said the s/s of silent aspiration were pocketing food, difficulty in breathing, increase heart rate, and change in skin color. Further interview with the DON revealed that she was not aware that CR #1was not being care planned for dysphagia. The DON said herself and the Regional MDS Nurse was responsible in ensuring all residents had a comprehensive care plan and updated whenever there was a change in a resident condition. The DON said the reason she did not call the physician when told that resident had choked on her diet was because she got ahead of herself and just wrote the order. The DON said the physician should have been notified first before she put an order in for CR #1 to be evaluated by Speech Therapist because that was the normal process. Interview on [DATE] at 12:25PM LVN C said she worked the 6PM-6AM shift. LVN C said on [DATE] the incident happened before her shift started. LVN C said the staff were bringing the residents back from the dining room after eating dinner. LVN C said CNA A asked if CR #1 was choking and the time was around 5:30PM. LVN C said she observed CR #1 choking. LVN C said she removed food from CR #1's mouth and performed the Heimlich maneuver but was unsuccessful. LVN C said her and a CNA name she could not remember transferred CR #1 from her w/c to the floor and told another staff to call 911. LVN C said she initiated CPR. LVN C said at this time, CR #1 was not breathing. LVN C said CR #1's primary care nurse at the time was RN E. LVN C said she never suction CR #1 because she could not see any food after removing food out of her mouth initially. LVN C said when EMS arrived, they had to intubate CR #1 and that was when she saw EMS suctioning food from CR #1's mouth. LVN C said when EMS transferred CR #1 to the hospital, she was not breathing, and her pulse was weak. LVN C said CR #1 did not have any teeth. LVN C said when the staff assisted CR #1 from the dining room to the nurse station, CR #1 had food in her mouth because she pulled out of CR #1's mouth what appeared to be oranges and beets. LVN C said she never received in-service on silent aspiration/choking but because she was also a Respiratory Therapist and that she knew the signs and symptoms of silent aspiration/ chocking. Interview on [DATE] at 11:45AM RN E said she was CR #1's primary care nurse on the day CR #1 coded. RN E said no one had told her that CR #1 had been choking on her food. RN E said CR #1 was able to feed herself just had to be monitored. RN E said she was the nurse assigned to the dining room during dinner time on [DATE]. RN E said she was going around monitoring the residents and that CR #1 ate her dinner like she normally done. RN E said CR #1 was on mechanical soft diet. RN E said she could not recall exactly what CR #1 had on her dinner plate on [DATE], but believed it was some meat inside of bread. RN E said CR #1 fed herself for dinner. RN E said when CR #1 was removed from the dining room, she did not know if resident was still eating or pocketing food in her mouth. RN E said she was the only nurse in the dining room along with ,d+[DATE] CNA's. RN E said she was supervising over 40 residents in the dining room at dinner time on [DATE]. RN E said during her supervision, she was supposed to be assessing for signs and symptoms of choking and that it would be nice if the facility had more than one nurse in the dining room to help supervise the residents. Interview on [DATE] at 9:46AM the NP said she was at the NF and saw CR #1 but could not remember the exact date. The NP said CR #1 appeared okay. The NP said the NF never informed her that CR #1 experienced a choking incident on [DATE]. The NP said she later received a text from RN E on [DATE] informing that CR #1 was unresponsive and 911 had to be called. The NP said the DON's mistake was putting an order in without consulting her first. The NP said had she informed her when the incident happened, she would have put interventions in place such as changing resident diet and given further orders to assess resident swallowing to prevent resident from aspirating. Interview via phone on [DATE] at 11:08AM the Speech Therapist said he was told by the Director of Rehab that CR #1 had a choking incident on [DATE] and was in need of an assessment. The Speech Therapist said he did a swallow assessment on CR #1 on [DATE] at 7:15AM. The Speech Therapist said he gave CR #1 crackers and thin liquids. The Speech Therapist said he did not identify any concerns, but because there were concerns, he recommended that CR #1 be further evaluated by doing a MBSS (a procedure done to determine whether food or liquid is entering a person's lungs). The Speech Therapist said he put the order in on [DATE]. The Speech Therapist said he did not at the time of CR #1's assessment recommend changing CR #1's diet because he did not see any issues and he used his own clinical judgement. The Speech Therapist said no one from the Nursing Department informed him verbally about CR #1 had experienced on [DATE] choking when eating her dinner. Interview [DATE] at 2:30PM the ADON said she was the ADON for Station B. The ADON said she had been working at the facility for a little over a month. The ADON said none of the nurses or CNA's had informed her that CR #1 was choking on her food. The ADON said if they had, she would have called the doctor or NP to get an order for a swallow evaluation and notified the family. Interview on [DATE] at 1:10PM the DON said during meal services, the dining room was supposed to be staffed with 8 staff members that consisted of 2 nurses, 4 CNA's, and 2 Department heads to monitor the residents while eating. Interview [DATE] at 1:13PM Interview with CNA N said she had taken care of CR #1 and noticed CR #1 would pocket her food at times. CNA N said she did report these happenings to RN E. Interview via phone on [DATE] at 1:34PM with CR #1 Primary Care Physician said the NF never notified her that CR #1 had a choking episode on [DATE]. The PCP said CR #1 was on a mechanical soft diet and was at high risk for choking. The PCP said had the facility notified her of CR #1 choking episode on [DATE], she could have given prophylactic orders that consisted of the following: place resident on NPO or a liquid diet, ordered a MBSS, placed resident on antibiotics, and started breathing treatments because resident may have aspirated on [DATE] that could lead to pneumonia. Interview on [DATE] at 2:30PM LVN W said no one ever told her that CR #1 was choking on her food. LVN W said whenever she worked at the NF from 6AM-6PM, she assisted in the Dining Room. LVN W said CR #1 sat on the feeder table but was able to feed herself. LVN W said CR #1 ate her food really slow and you could not rush her. LVN W said she never observed CR #1 choking when she ate her food or drank beverages. Record review of the NF policy on Incident and Accident dated [DATE] reflected in part: .Accident and incidents involving residents shall be investigated and reported to the Administrator .complete an incident/accident report when staff is aware that an incident occurred. Review incident at daily clinical meeting . The facility Administrator and DON were notified on [DATE] at 1:07PM that an IJ situation had been identified due to the above failures. The IJ templated was provided. The following plan of removal was submitted by [DATE] and accepted on [DATE] at 4:54PM. PLAN of REMOVAL Date: [DATE] The facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents. The facility failed to notify the Physician when resident had a choking episode on [DATE]. The facility failed to intervene by putting interventions in place when CR #1 began having choking episode during eating on [DATE]. The facility failed to in-service staff on the s/s of silent aspiration and choking. The facility failed to monitor CR#1 who had a choking episode on [DATE]. What corrective actions have been implemented for the identified residents? On [DATE] resident CR#1 involved in failed practice was discharged to the hospital per MD orders on [DATE]. On [DATE] the facility Director of Clinical Services/designee reviewed all residents with a diagnosis of dysphagia and updated resident care: completed [DATE]. On [DATE] at 4:00pm the Facility Administrator notified the Medical Director, and the attending physician of failed practice. In-services provided to DCO. On [DATE] the following in-service was provided to the Director of Clinical Services (DCO) by the Regional Director of Clinical services (RDCO) 3. Notifying the Physician Immediately of Change of Condition Occurs and Obtaining Orders from the Physician before treating the Resident. 4. Ensure monitoring during and after meal intake is put in place while waiting on speech therapy to screen/ evaluate resident and to ensure monitoring is conducted and documented on the TAR by the License Nurse. DCO/designee will check the 24 hour report to ensure documentation is correct and necessary is in place. Will be discussed in morning clinical meetings. 5. On notifying resident's responsible party on changes of condition and new intervention that was put in place, completion date [DATE]. In-services provided to Licensed Nurses On [DATE] the DCO initiated in-services for facility charge Nurses on the following III. Complete assessment when there is a change of condition noted during meal service and document using SBAR assessment, to document on the TARS by the License monitoring of meal and follow up with a progress note for follow of any concerns completion date: [DATE]. IV. To notify resident's attending physician of the change and obtain order for therapy screenings/evaluations needed completion date [DATE]. V. Aspiration precaution on resident with difficulty in swallowing that includes pocketing food, Charge Nurses to monitor resident during meal intake. Charge Nurses to ensure resident's meal is provided according to order. Charge Nurses to ensure resident's mouth is brushed post meal intake to remove left over food from the mouth. Charge Nurses to ensure residents are provided with fluids in between meals. Charge Nurses to ensure residents are provided with meal intake small bite at a time. Charge Nurses to notify MD of increase difficulty with swallowing for possible texture change, completion date [DATE]. VI. Charge Nurses to notify resident's RP of texture change and change of condition, as changes are made, no revisions needed completion date [DATE]. VII. On [DATE] The Director of Clinical Services/Designee in-serviced license Nurses on auditing crash cart ensuring items are present has listed per documented worksheet: completion date [DATE]. VIII. 1:1 in-service conducted with LVN B by the DCS regarding physician notification completion date [DATE] CNA education provided are below. On [DATE] The C N A's in-service on Aspiration precautions; choking, secretions from the mouth pocketing food not swallowing and notification to the License Nurse immediately completion date [DATE]. C N A 's in-service on notifying License Nurses concerning change in conditions and documentation in POC documentation. completion date [DATE] Therapy in-service listed below. The SLP was in-service by the facility administrator to ensure referrals made on resident's swallowing concerns are addressed and recommendations are reviewed with license Nurses and communicated with resident's attending physician: Completion date [DATE]. The facility administrator provided in-service to Therapy Director on completion of Therapy screen documentation with recommendations noted on screening tool. Completion date [DATE] Validation/Monitoring The DCS/Designee reviewed residents' last SLP referrals no corrections as of [DATE]. Facility IDT reviewed policy/procedure of aspiration, swallowing precautions, therapy referrals, no revisions needed. Completion date [DATE]. On [DATE] the Director of Clinical Services/designee reviewed all residents with a diagnosis of dysphagia and updated resident care: completion date [DATE]. What does the facility need to change immediately to keep residents safe and ensure it does not happen again. D. The DCN/Designees will review all changes in condition and therapy referral in daily clinical meetings and ensure follow is completed timely, staff monitoring is in place, the RP/MD is notified of changes and new recommendation if followed. Completed [DATE]. E. The Director of Clinical Services will ensure Licensed Nurses notify the Physician Immediately of Change of Condition Occurs and Obtaining Orders from the Physician before Treating the Resident completed: [DATE]. F. Newly hired nurses will be in-serviced by the Director of Nursing or designee on immediately notifying the attending physician of residents change of conditions, obtaining orders for therapy screening and evaluations as needed, signs and symptoms of Aspiration Precautions, residents with diagnosis of Dysphagia care plan interventions, checking facility crash carts daily to ensure items needed are available on the cart and document results with correction if needed. G. Facility License Nurses and Certified Nursing Assistants will be in-service on the training courses listed in the plan before the start of their next shift. Quality Assurance An Ad Hoc Quality Assurance and Performance Improvement review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan. The surveyor confirmed the plan of removal had been implemented sufficiently to remove IJ by the following: Interview on [DATE] at 11:25AM with RN E said she worked on Station B 6AM-6PM. RN E said she had just received in-service on checking crash cart, signs and symptoms of choking and silent aspiration which were the following: grasping at the neck, apprehension, coughing and noisy breathing. RN E said she would intervene by giving several back blows between the shoulders to try and clear the resident airway. RN E said if this was unsuccessful, she would perform the Heimlich maneuver. RN E said if the resident became un-responsive, she would call for help and start CPR. RN E said some s/s of silent aspiration were the resident being unable to speak, tearing of the eyes, drooling of the mouth, and skin color. RN E said all were a change in condition and that she would notify the physician as well as the RP and make sure resident care plan got updated. Observation on [DATE] at 11:35AM revealed on Station B across from the nurse station was residents sitting in their w/c's dressed in street clothing with no concerns identified. Interview on [DATE] at 11:42AM with CNA F on Station B said that she worked the morning shift 6AM-2PM. CNA F said she had received in-service on what to do if a resident began to choke while eating. The CNA said she would call for help and began to try and clear the resident airway by providing the Heimlich maneuver. The CNA said some s/s/ of silent aspiration was resident having difficulty breathing, change in their facial appearance and skin color. The CNA said if she observed a resident having difficulty swallowing their food or pocketing their food, she would notify the nurse right away so that the resident could be assessed. The CNA said she was in-service to notify the nurse whenever she noticed a change in resident condition. Interview on [DATE] at 11:50AM with CNA Y said she worked the 6AM-2PM full time. CNA Y said she had been in-serviced on notifying the nurse when resident had a change in condition, s/s of silent aspiration were discoloration in the face, change in facial expression, and difficulty breathing. CNA Y said if the resident was choking, she would give them the Heimlich maneuver to try and help the resident clear the air way. CNA Y said she had been in-serviced to review the resident POC in the computer. Interview on [DATE] at 11:58AM with Wound Care Nurse said she worked at the NF Monday through Friday and did assist with monitoring the residents during mealtimes. The Wound Care Nurse said she had been in-serviced on choking and how to apply the Heimlich maneuver. The Wound Care Nurse said if the resident became unresponsive, CPR had to be initiated immediately and call 911. The Wound Care Nurse said s/s of silent aspiration were drooling at the mouth, skin discoloration of the face, difficulty breathing, and perspiring. The Wound Care Nurse said the physician and the RP had to be notified immediately when a resident experience a change in condition and the care plan had to be updated. Interview on [DATE] at 12:07PM with CMA K said she worked the Memory Care Unit and worked the morning and evening shift. CMA K said she had been in-serviced on choking and silent aspiration. CMA K said s/s of silent aspiration was drooling at the mouth, perspiring, difficulty breathing, and change in skin color. CMA K said if a resident was choking, she would call for the nurse and apply several back blows, if that was unsuccessful, she would do the Heimlich maneuver. CMA K said the incident must be reported to the nurse immediately as any change in condition. CMA K said when feeding a resident, she had to feed them slowly being careful to offer them fluids in between eating. Interview on [DATE] at 12:14PM with CNA L said she worked the Memory Care Unit 6Am-2PM and been in-serviced on reviewing the resident plan of care in POC, monitoring the residents for choking or s/s of silent aspiration and that all changes in condition were to be reported to nurse. CNA L said resident had to observed closely during mealtimes and if they notice a resident choking call the nurse immediately and do the Heimlich maneuver to dislodge what was blocking the resident airway. CNA L said the s/s of silent aspiration was drooling at the mouth, difficulty breathing, bulging of the eyes, change in skin color, and grabbing their neck. CNA L said the incident had to be reported to the nurse so that the nurse could call the doctor as well and the family. Interview on [DATE] at 12:20PM with RN M said she worked the 6AM-6PM shift and had been in-serviced on notifying the physician whenever a resident experience a change in condition. RN M said she had been in-serviced on the s/s of silent aspiration (drooling at the mouth, difficulty breathing, change in the color of resident skin) and choking. RN M said if a resident experienced this, the doctor had to be notified right away to get an order for a swallow evaluation and possible diet change. RN M said the resident care plan also had to be updated and the RP notified. Observation on [DATE] at 12:32PM in the Dining Room of lunch being provided to the residents revealed over 6 staff members being present one being the Wound Care Nurse. There were no concerns identified. Observation on [DATE] at 1:05Pm in the MCU of the residents eating their lunch with staff members being present. There were no concerns identified. Interview on [DATE] at 1:13PM with CNA N said she normally worked the morning shift. CNA N said she had been in-serviced on when a resident was choking to give the Heimlich maneuver. CNA N said s/s of silent aspiration was difficulty breathing, watering of the eyes, drooling at the mouth, and possible reaching for their throat. CNA N said she would try and clear resident airway by giving thrust in the back and then proceed with the Heimlich maneuver. CNA N said she would notify the nurse on all changes in a resident condition. CNA N said she was in-serviced to review resident care plan. Interview on [DATE] at 2:38PM with LVN O said he was in orientation and was hired to be a Unit Manager. LVN O said he had received in-service on checking the crash cart, choking that if the resident was choking to perform the Heimlich maneuver. LVN O said if the resident lost consciousness, he would have someone call [TRUNCATED]

Based on interview and record review, the facility failed to develop and implement comprehensive care plans that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 22 residents (CR #1) reviewed for care plans. - The facility failed to ensure CR #1 had a Comprehensive Care Plan to address her diagnosis of dysphagia (difficulty swallowing). -The facility failed to have interventions in place when CR #1 experienced a choking episode on [DATE]. On [DATE] CR #1 experienced another choking episode and was transferred to the hospital. - CR #1 passed away on [DATE] at the hospital. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 1:07PM. While the IJ was removed on [DATE] at 5:17PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of harm because all staff had not been trained on the importance of all residents having a comprehensive care plan that is updated when a resident experience a change in condition. This failure placed residents at risk for not receiving comprehensive care to address their diagnoses and medical needs. Findings: Record review of CR #1's face sheet dated [DATE] revealed an 83year old female admitted to the NF originally on [DATE] and again on [DATE] with diagnoses that included the following: Alzheimer's Disease with late onset, dysphagia (difficulty swallowing) diagnosed on diagnosed on [DATE], heart disease, and cerebral infarction (disrupted blood flow to the brain). Record review of CR #1's MDS dated [DATE] reflected BIMS score 00 indicating resident cognition was severely impaired. Further review section K (swallowing/Nutrition Status) reflected that CR #1 had no s/s of possible swallowing disorder. Record review of CR #1's Physician Order Summary Report for the month of [DATE] included the following orders: -Dated [DATE] carb controlled no added salt mechanical soft texture, regular consistency. -Dated [DATE] may crush meds/open capsule every 12 hours for safety. -Dated [DATE] Comprehensive swallow consult including MBSS to assess aspiration risk, r/o silent aspiration, determine least restrictive diet texture, assess esophageal function and physician consult for dysphagia include appropriate nutritional status. Record review of CR #1 Speech Therapy note dated [DATE] recommended thin liquids and mechanical soft/ground textures, puree (creamy paste) consistencies. Record review of CR #1's Care Plan updated [DATE] did not reflect that CR #1 was being care planned for dysphagia. Record review of CR #1's Nursing Progress Notes did not have any documentation of CR #1 experiencing a choking episode on [DATE]. Record review of CR #1's Nursing Progress Notes dated [DATE] documented by RN B at 19:55 (8:55PM) reflected in part: .CR #1 was wheeled from the dining room to the nurse station by CNA at about 5:30PM with no sign of distress or discomfort. At about 5:45PM, CNA call out that resident was unresponsive on the wheelchair by the nursing station. Code blue activated, CPR done, oxygen connected, AED used, 911called. 911 arrived and took over the resident resuscitation. 911 later transferred the resident to hospital for further management, family member was notified of resident condition. NP also notified . Interview on [DATE] at 2:11PM the Administrator said the NF called the hospital and that the hospital said resident had to be intubated and placed on a ventilator. Interview on [DATE] at 3:06PM with CNA A, said she worked at the NF full time on the 2PM-10PM shift. CNA A said the time was around 5:30PM-6:00PM on [DATE] when CR #1 was being wheeled from the Dining Room by another CNA whose name, she could not recall. CNA A said CR #1 was placed in her w/c facing the nurse station. CNA A said CR #1 did not have any front teeth and therefore was unable to chew food well and could not swallow good. CNA A said at one time, CR #1 was on a puree diet and was later upgraded to a mech soft diet. CNA A said on [DATE] CR #1 choked off her food while feeding her in bed during dinner time. CNA A said CR #1 was eating potato soup. CNA A said she tried to help CR #1 when she started choking but was unsuccessful and therefore called LVN W who never came to CR #1's room. CNA A said the oncoming nurse LVN B came to the room and just looked at CR #1. CNA A said it was CNA I that helped by pulling CR #1 forward in bed and began to give hand thrust to CR #1's back. CNA A said the food came up which was some potatoes and other undigested food. CNA A said CR #1 appeared to be okay after that incident. CNA A said she told LVN W and LVN B that CR #1's diet needed to be changed. CNA A said she also told the DON that CR #1 experienced choking on [DATE]. CNA A said she had informed the DON on [DATE] at 7:30PM when the DON was preparing to leave the NF to go home. CNA A said RN E told her that it was a chain of command for CR #1 to be assessed by the Speech Therapist. CNA A said RN E said the ADON also had to be notified. CNA A said she also informed the Speech Therapist who said that he would need an order to assess CR #1. CNA A said RN E told her that she would notify the ADON. CNA A said she went to the Speech Therapist on [DATE] in the evening and told him about CR #1 choking episode on [DATE]. CNA A said the Speech Therapist told her that he would need an order to assess CR #1. CNA A said she had informed the Administrator verbally on [DATE] regarding CR #1's choking episode on [DATE]. CNA A said the Administrator told her to write a statement. CNA A said she wrote a statement at 11:34AM on [DATE] and send to the Administrator via e-mail of CR #1's choking incident on [DATE]. CNA A said she did not want the surveyor to say anything to the Administrator because she did not want to lose her job. CNA A said she went to the kitchen on [DATE] and told them what food to give CR #1. CNA A did not elaborate on the exact food she told them to give CR #1 but told them to give CR #1 soft texture foods that did not require CR #1 to chew a lot. CNA A said the kitchen gave CR #1 a mechanical soft diet. CNA A said the kitchen gave CR #1 a mechanical soft diet. CNA A said [DATE] at 5:30PM or 6:00pm at the nurse station she saw CR #1 leaning to her side drooling at the mouth with food in her mouth. CNA A said LVN C was trying to get the food out of CR #1's mouth. CNA A said LVN C began to hit CR #1 in her back, but CR #1 was not responding. CNA A said herself and LVN C transferred CR #1 on the floor and at this time CR #1 was completely unresponsive. CNA A said she started screaming for help and 911 was called. CNA A said after that she did not know what took place next because she went to see if 911 had arrived so she could direct them to the hall CR #1 was residing on. Interview on [DATE] at 5:19PM via phone LVN B, said she worked the 6PM-6AM shift PRN. LVN B said the last time she worked at the NF was on [DATE] and [DATE]. LVN B said CR #1 did not have any issues with chocking. LVN B said CNA A was feeding CR #1 in bed on [DATE]. LVN B said CR #1 was being fed soup along with some type of salad with chunks of chicken chopped up in it. LVN B said CR #1 was not choking, but just not tolerating the texture of the food. LVN B said CR #1 had tea or apple juice as a beverage. LVN B said she heard CNA A calling for help and when she arrived to CR #1's room, CR #1 was able to follow commands and did spit the food out. LVN B said CNA A was in a complete uproar and got overly excited. LVN B said the incident was mentioned to the DON who came on the unit. LVN B said the DON said she would take care of the matter. LVN B said she did not call the physician because the DON said she would take care of it. Interview on [DATE] at 2:40PM with the MDS Nurse said she had been working at the NF for almost a month. The MDS Nurse said she was not aware that CR #1 was not being care planned for dysphagia. The MDS Nurse said she had not reviewed CR #1's care plan because she had not been working for the facility long. The MDS Nurse said if she had known that CR #1 was not being care planned for a having a diagnosis of dysphagia, she would have care planned CR #1 for dysphagia. Interview on [DATE] at 5:52PM with the DON, said it was CNA A that came to her on [DATE] around 8:00PM telling her that CR #1 was having difficulty swallowing. The DON said she put an order in on [DATE] for CR #1 to be evaluated by the Speech Therapist. The DON said she had not in-serviced the Nursing staff on silent aspiration/choking. The DON said the s/s of silent aspiration were pocketing food, difficulty in breathing, increase heart rate, and change in skin color. The DON revealed that she was unaware that CR #1 was not being care planned for dysphagia and that CR #1 should have been care planned for dysphagia. The DON said it was herself and the Regional MDS Nurse that were responsible for ensuring that all resident's had a comprehensive care and that the care plan was being updated whenever there was change in a resident condition. Record review of the NF policy for Care Planning-Interdisciplinary Team revised [DATE] reflected in part: .Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident .A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS) .The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not necessarily limited to the following personnel: The resident's attending physician, registered nurse who has the responsibility for the resident, Dietary Manager/Dietician, Social Services, Activity Director, Therapist (speech, occupational, recreational, etc.), Director of Nursing, charge nurse, nursing assistant, and others as appropriate or necessary . The facility Administrator and DON were notified on [DATE] at 1:07PM that an IJ situation had been identified due to the above failures. The IJ templated was provided to the Administrator. The following plan of removal was accepted on [DATE] at 4:54PM. PLAN of REMOVAL Date: [DATE] The facility failed to ensure a CR#1 had a Comprehensive Care Plan to address her diagnosis of dysphagia (difficulty swallowing). The facility failed to care plan CR#1 for dysphagia (difficulty swallowing). What corrective actions have been implemented for the identified resident. On [DATE] at 4:00pm the Facility Administrator notified the Medical Director, and the attending physician of failed practice. The care plans were updated for residents with a diagnosis of Dysphagia and at risk for aspiration by the CRC's and Completion date [DATE], completed by the CRC, ADON's. The Care Plan Policy and procedure was reviewed on [DATE] policy concerning care planning was reviewed no changes to current policy needed CRC's educated by RCRC (Regional Clinical Reimbursement Coordinator), training completed on [DATE]. The DCO is responsible for to make sure care plans are completed in the absence of the CRC. DCO in-serviced on [DATE]. The person responsible CRC's and DCO. The Charge Nurse will communicate changes in the clinical meetings and updates will be reviewed at that time. Address change in conditions in the morning meeting and update the care plan as needed. System reviewed no changes needed reviewed on [DATE] and completed on [DATE]. In-services provided to CRC's (Clinical Reimbursement Coordinators) on [DATE] and completed on [DATE] concerning diagnosis of Dysphagia and residents at risk for aspiration. Validation/Monitoring The CRC's to review residents with swallowing difficulty and completion of care plan during morning meeting. Completion date [DATE] CRC's will ensure a comprehensive care plan is completed by day 21 of the admission per RAI manual. The CRC's was educated on Rules and Regulations of Care planning according to the RAI manual upon hire on [DATE] Regional Clinical Reimbursement Coordinator completed in-service on [DATE]. Will be implemented by CRC's to obtain order listing report daily to ensure items listed are care plan timely if needed. Order listing reviewed daily by CRC's trained on [DATE] and completed on [DATE] on order listing auditing. What does the facility need to change immediately to keep residents safe and ensure it does not happen again. A. The Director of Nursing/designee will ensure residents with a diagnosis of Dysphagia order listing to be obtained to audit residents with diagnosis of Dysphagia have a care plan completed for Dysphagia and at risk for Aspiration. The audit was initiated on [DATE] and completed on [DATE]. Care plans updated. B. Facility License Nurses and Certified Nursing Assistants receive in-service training as new care plans are implemented and tasks initiated on the Kardex. The facility Nurses and Nurses Aides were educated on [DATE] and completed on [DATE] by the Director of Nursing/designee. C. All Charge Nurses and Nurse Aides will be in-serviced on the plan before the start of the next shift. Quality Assurance An Ad Hoc Quality Assurance and Performance Improvement review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan. ______________________________________________________________________ The surveyors confirmed the plan of removal had been implemented sufficiently to remove IJ by the following: Note: Due to initial IJ being called on [DATE] at 3:16PM, the NF had begun the process in in-servicing staff on notification of change in a resident condition by [DATE], therefore the surveyors began the monitoring process as follow: Interview on [DATE] at 11:25AM with RN E said she worked on Station B 6AM-6PM. RN E said she had just received in-service on making sure that resident care plans were comprehensive addressing the resident diagnosis and updated when a resident condition changed. Interview on [DATE] at 11:42AM with CNA F on Station B said that she worked the morning shift 6AM-2PM. CNA F said she had received in-service on notify the nurse whenever she noticed a change in resident condition so that the nurse could assessed the resident. Interview on [DATE] at 11:50AM with CNA Y said she worked the 6AM-2PM full time. CNA Y said she had been in-serviced on notifying the nurse when resident have a change in condition. CNA Y said she had been in-serviced to review the resident POC in the computer. Interview on [DATE] at 11:58AM with Wound Care Nurse said she worked at the NF Monday through Friday and did assist with monitoring the residents during mealtimes. The Wound Care Nurse said she had been in-serviced on choking and how to apply the Heimlich maneuver. The Wound Care Nurse said if the resident became unresponsive, CPR had to be initiated immediately and call 911. The Wound Care Nurse said s/s of silent aspiration were drooling at the mouth, skin discoloration of the face, difficulty breathing, and perspiring. The Wound Care Nurse said the physician and the RP had to be notified immediately when a resident experience a change in condition and the care plan had to be updated. Interview on [DATE] at 12:07PM with CMA K said she worked the Memory Care Unit and worked the morning and evening shift. CMA K said she had been in-serviced on choking and silent aspiration. CMA K said s/s of silent aspiration was drooling at the mouth, perspiring, difficulty breathing, and change in skin color. CMA K said if a resident was choking, she would call for the nurse and apply several back blows, if that was unsuccessful, she would do the Heimlich maneuver. CMA K said the incident must be reported to the nurse immediately as any change in condition. CMA K said when feeding a resident, she had to feed them slowly being careful to offer then fluids in between eating. Interview on [DATE] at 12:14PM with CNA L said she worked the Memory Care Unity 6Am-2PM and been in-serviced on reviewing the resident plan of care in POC, monitoring the residents for choking or s/s of silent aspiration and that all changes in condition were to be reported to nurse. CNA L said resident had to observed closely during mealtimes and if notice a resident choking call the nurse immediately and do the Heimlich maneuver. CNA L said s/s of silent aspiration was drooling at the mouth, difficulty breathing, bulging of the eyes, change in skin color, and grabbing their neck. CNA L said the incident had to be reported to the nurse so that the nurse could call the doctor as well and the family. Interview on [DATE] at 12:20PM with RN M said she worked the 6AM-6PM shift and had been in-serviced on notifying the physician whenever a resident experience a change in condition. RN M said she had been in-serviced on the s/s of silent aspiration (drooling at the mouth, difficulty breathing, change in the color of resident skin) and choking. RN M said if a resident experienced this, the doctor had to be notified right away to get an order for a swallow evaluation and possible diet change. RN M said the resident care plan also had to be updated and the RP notified. Interview on [DATE] at 1:13PM with CNA N said she normally worked the morning shift. CNA N said she had been in-serviced on when a resident was choking to give the Heimlich maneuver. CNA N said s/s of silent aspiration was difficulty breathing, watering of the eyes, drooling at the mouth, and possible reaching for their throat. CNA N said she would try and clear resident airway by giving thrust in the back and then proceed with the Heimlich maneuver. CNA N said she would notify the nurse on all changes in a resident condition. CNA N said she was in-serviced to review resident care plan. Interview on [DATE] at 2:38PM with LVN O said he was in orientation and was hired to be a Unit Manager. LVN O said he had received in-service on checking the crash cart, if a resident was choking to perform the Heimlich maneuver. LVN O said if the resident lost consciousness, he would have someone call 911 and he would start CPR right away. LVN O said some s/s of silent aspiration were the following: short of breath, wheezing, eyes bulging, perspiring, trying to clear their throat, drooling at the mouth, pocketing food. LVN O said the doctor had to be notified in both incidents as well as the RP. LVN O said resident care plan also had to be updated regarding the incident. Interview on [DATE] at 2:47PM with CNA I said she worked the morning and evening shifts and had been in-serviced on how to do the Heimlich maneuver, chest thrust if a resident was choking. CNA I said the nurse had to be notified of all changes in a resident condition. CNA I said she was in-serviced on recognizing some s/s of silent aspiration (change in a resident facial expression, drooling at the mouth, wheezing or difficulty breathing). CNA I said she was in-serviced that when having to feed a resident, to take her time and feed them slowly being aware to provide resident their beverage between feeding during meal service. CNA I said she was also in-serviced to review resident care plan in POC. Interview on [DATE] at 8:00PM with CNA P via phone said he worked the night shift 10PM-6AM. CNA P said he had been in-serviced in the following: POC regarding the resident plan of care, choking and how to apply the Heimlich maneuver, back blows and chest thrust, and reporting change in condition. CNA P said the nurse had to be notified if he witnessed a resident choking. CNA P said he was also in-serviced on silent aspiration. Interview on [DATE] at 8:08PM with CNA J said she worked the night shift 10PM-6AM. CNA J said she received in-service on silent aspiration and choking, checking resident care plan in POC, and when feeding the resident to feed slowly observing for and signs of choking and reporting to the nurse immediately all changes in a resident condition. CNA J said she had received in-service on resident plan of care that could be found in the computer. Interview on [DATE] at 10:30AM with LVN Q said he worked the 6AM-6PM shift and received in-service making sure a resident care plan was updated when there was a change in condition, notifying the doctor and the RP if the resident experience a change in condition, how to intervene if a resident experience choking, if the resident lose consciousness call for help and began CPR, the s/s of silent aspirations, and checking the crash cart each shift. Interview on [DATE] at 5:00AM with LVN S said she worked the 6:00PM to 6:00AM shift. LVN S said she had been in-serviced on choking and silent aspiration, the importance of notifying the physician when a resident experience a change in condition and making sure resident care plan was updated. Interview on [DATE] at 9:14PM with LVN R said they worked the night shift 6PM-6AM. LVN R said they had been in-serviced on s/s of silent aspiration and choking and to notify the doctor and the RP. LVN R said they were also in-serviced on making sure that the resident care plan was updated whenever a resident experience a change in condition and checking the crash cart. Interview on [DATE] at 11:25AM with CNA T said she worked the 6am to 2pm shift on the MCU. CNA T said she had been in-serviced on choking, performing the Heimlich maneuver, abuse and neglect, s/s of silent aspiration, reporting to the nurse when she observed a change in resident, and reviewing the resident plan of care in POC. Interview on [DATE] at 11:32AM with the ADON said she was in-serviced on choking/silent aspiration, notifying the doctor and RP when there was a change in resident condition, updating the care plan right away when a resident have a change in condition. Interview on [DATE] at 2:11PM with MDS Nurse said she was in-serviced on care planning on how and what to care plan to ensure that each resident care plan was individualized and personalized. MDS Nurse said she was also in-serviced on care planning for dysphagia, updating the resident care plan when a change in condition has occurred, notify the physician of the change, s/s of silent aspiration. Interview on [DATE] at 2:18PM CNA U work 6AM-2PM received in-service on different techniques to open a resident airway when choking which were back and chest thrust, and Heimlich maneuver, s/s of silent aspiration and to report to the nurse all changes in a resident condition. Interview on [DATE] at 2:30PM with LVN W said she worked the 6AM-6PM shift. LVN W said she had been in-serviced on abuse and neglect, choking, checking the crash cart each shift, notifying the physician if a resident experience a change in condition, and updating the care plan when there was a change in resident condition. Interview on [DATE] at 4:28PM with CNA V said she worked the 2PM-10PM shift. CNA V said the NF had in serviced her on choking and s/s of silent aspiration (discoloration of the face, difficulty in breathing, and drooling of the mouth). CNA V said if a resident was choking, she would perform the Heimlich or thrust resident on the back. CNA V said she was in-serviced to let the nurse know if she witnesses this and to always look in POC for resident plan of care, and when feeding resident to feeding resident slowing making sure resident was not choking. CNA V said she was also informed to use any recommended utensil when feeding a resident that was high risk for choking. Interview on [DATE] at 4:38PM with RN X said he worked the 6AM-6PM shift full time on Station C. RN X said he had received in-service on the following: s/s of silent aspiration (resident unable to speak, eyes watering, discoloration of skin to the face, drooling from the mouth, difficulty breathing). RN X said he would apply the Heimlich maneuver if a resident was choking and if the resident loss consciousness, he would have to begin CPR signaling someone else to call 911. RN X said if a resident experience the above, it was considered a change in condition and therefore, the physician as well as the RP had to be notified and the residents care plan had to be updated. Interview on [DATE] at 9:02AM with CMA AA said she worked the morning shift 7AM-8:30PM. CMA AA said she had been in-serviced on choking and aspiration. CMA AA said if a resident started choking, she would call for help and immediately apply one of the following, Heimlich maneuver, chest or back blows. CMA AA said some s/s of silent aspiration were drooling of the mouth, difficulty breathing, wheezing, discoloring of the skin, and unable to speak). CMA AA said she would inform the nurse for resident change in condition. CMA AA aid when feeding a resident, she had to observed for any of these signs especially residents with swallowing issues. Interview on [DATE] at 9:33 with CNA BB said she worked the morning shift and had been in-service on choking and silent aspiration. CNA BB said a resident that may have aspirated she would observe for the following: possible wheezing or difficulty breathing, drooling at the mouth. CNA BB said if she observed this, she could either give the resident back thrust, chest thrust or the Heimlich to try and clear the resident airway and have someone to call for 911. CNA BB said she would also tell the nurse right away. CNA BB said she was in-serviced on checking the POC for residents she provided care for. CNA BB said she was instructed when feeding a resident to feed resident slowing one bite at a time to prevent choking. CNA BB said if she noticed a resident not tolerating diet texture, she had to notify the nurse immediately because that was a change in the resident condition. Interview on [DATE] at 11:27AM with LVN BB said she worked at the NF PRN on the night shift. LVN BB said she had been in-serviced on abuse and neglect, checking crash cart each shift, updating a resident care plan when there had been a change in resident condition, notifying the physician and the RP when resident experience a change in condition, choking and aspiration precautions, and recognizing the signs of silent aspiration (drooling at the mouth, difficulty breathing, discoloration of the skin). Interview on [DATE] at 11:32AM with LVN C said she worked the night shift and had been in-serviced choking, silent aspiration and how to intervene by doing the Heimlich maneuver, back blows or chest thrust, notifying the doctor whenever resident have a change in condition and the RP. LVN C said the care plan had to be updated when a resident has a change in condition. Interview on [DATE] at 12:17PM with RN CC said he was the NF Weekend Supervisor. RN CC said he had received the following in-services: choking and silent aspiration, abuse /neglect, notifying the physician and RP when a resident has a change in condition, and updating the care plan when there was a change in a resident condition. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 4:54PM. The facility remained out of compliance at a severity level of isolated and a scope of harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to immediately consult with the physician and notify the resident representative when the resident experienced a change in condition for 1 of 22 residents (CR #1) reviewed for a change of condition: -The facility failed to immediately inform CR#1's physician after a change in condition. -The facility failed to notify the Physician when CR #1 had a choking episode on [DATE] and experienced a change in condition. -The facility failed to notify CR #1's RP when she experienced a change in condition - CR #1 passed away on [DATE] at the hospital. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 12:54 PM. While the IJ was removed on [DATE] at 12:24PM, the facility remained out of compliance at a scope of isolated and a severity of harm with potential for more than the minimal harm that is not an immediate jeopardy because all staff had been trained on to notify the physician when a resident experience a change in condition. These failures could affect residents in delay of appropriate medical treatment leading to death. Findings included: Record review of CR #1's face sheet dated [DATE] revealed an 83year old female admitted to the NF originally on [DATE] and again on [DATE] with diagnoses that included the following: Alzheimer's Disease (disease that destroys memory) with late onset, dysphagia (difficulty swallowing) diagnosed [DATE], heart disease, and cerebral infarction (disrupted blood flow to the brain). Record review of CR #1's MDS dated [DATE] reflected BIMS score 00 indicating resident cognition was severely impaired. Further review of section K (swallowing/Nutrition Status) reflected that CR #1 had no s/s of possible swallowing disorder. Further review of the MDS section GG reflected that CR #1 required setup or clean-up assistance. Record review of CR #1's Physician Order Summary Report for the month of [DATE] included the following orders: -Dated [DATE] carb controlled no added salt mechanical soft texture, regular consistency. -Dated [DATE] may crush meds/open capsule every 12 hours for safety. -Dated [DATE] SLP evaluation. -Dated [DATE] Comprehensive swallow consult including MBSS to assess aspiration risk, r/o silent aspiration, determine least restrictive diet texture, assess esophageal function and physician consult for dysphagia include appropriate nutritional status. Record review of the Screening Tool done by the NF Rehab Director on [DATE] reflected in part: .DON referred PT for ST services for dysphagia management. No s/s of swallow impairment noted at this time however ST to complete eval and schedule MBSS to r/o silent aspiration . Record review of CR #1's Speech Therapy note dated [DATE] recommended thin liquids and mechanical soft/ground textures, puree (creamy paste) consistencies. Record review of CR #1's Care Plan updated [DATE] did not reflect that CR #1 was being care planned for dysphagia. Record review of CR #1's Nursing Progress Notes dated [DATE] documented by RN B at 19:55 (8:55PM) reflected in part: .CR #1 was wheeled from the dining room to the nurse station by CNA at about 5:30PM with no sign of distress or discomfort. At about 5:45PM, CNA call out that resident was unresponsive on the wheelchair by the nursing station. Code blue activated, CPR done, oxygen connected, AED used, 911called. 911 arrived and took over the resident resuscitation. 911 later transferred the resident to hospital for further management, family member was notified of resident condition. NP also notified . Record review of CR #1's INTERACT Change in Condition dated [DATE]at 19:17 (7:17PM) reflected in part: NO pulse, no respirations2.This condition, symptom or sign has occurred before: H 1. Yes 2. No 3. Unknown3.Other relevant information: HResident was noticed by a CNA/Nurse in the Hallway drooling by mouth, and choking on food. Quickly, resident was assisted to the floor, a sweep of the mouth, the Heimlich maneuver given, nausea and vomiting small amount of food.4.Summarize your observations, evaluation and recommendations: HPt lost consciousness, with no pulse and no respiration. Signaled to call 911 and CPR began, oral suctioning required and AED utilized although no shock required. 1845 EMT arrived assisting with CODE. ET Tube placed with moderate suctioning and IV NS started in right arm. Pt regained pulse but Medic continued to give breaths per Ambu bag. Pt transported to Hospital. MD, DON, Administrator and daughter notified.5.Have you reviewed and acknowledged Interview on [DATE] at 2:00PM, the DON said the incident happened on [DATE] around 6:00PM or a little after could not remember the exact time. The DON said CNA A was standing in the hallway calling for help. The DON said when she arrived at the scene, she observed CR #1 had been placed on the floor by staff members. The DON said the nurses had already initiated CPR and that she began to assist with the CODE ensuring that 911 services had been called. The DON said CR #1 had a weak pulse and was not breathing. The DON said CR #1 was not choking and believed that CR #1 had experienced a mini stroke. Interview on [DATE] at 2:11PM, the Administrator said the NF had called the hospital where CR #1 was transferred to and that the hospital informed that CR #1 had to be intubated and placed on a ventilator. Interview on [DATE] at 2:16PM, the RP said he was not notified by the NF that CR #1 had choking episode on [DATE]. Further interview with the RP said he was not notified on [DATE] when CR #1 experienced a change in condition. Interview on [DATE] at 3:06PM, with CNA A said she worked at the NF full time on the 2PM-10PM shift. CNA A said the time was around 5:30PM-6:00PM on [DATE] when CR #1 was being wheeled from the Dining Room by another CNA who's name, she could not recall. CNA A said CR #1 was placed across facing the nurse station. CNA A said CR #1 did not have any front teeth and therefore was unable to chew food well and could not swallow good. CNA A said at one time, CR #1 was on a puree diet, was later upgraded to a mech soft diet. CNA A said on [DATE] CR #1 choked off her food while feeding her in bed during dinner time. CNA A said CR #1 was eating potato soup. CNA A said she tried to help CR #1 when she started choking but was unsuccessful and therefore called LVN W who never came to CR #1's room. CNA A said the oncoming nurse LVN B came to the room and just looked at CR #1. CNA A said it was CNA I that helped by pulling CR #1 forward in bed and began to give hand thrust to CR #1's back. CNA A said the food came up which was some potatoes and other undigested food. CNA A said CR #1 appeared to be okay after that incident. CNA A said she told LVN W and LVN B that CR #1's diet needed to be changed. CNA A said she also told the DON as well that CR #1 had experienced choking on [DATE]. CNA A said she had informed the DON on [DATE] at 7:30PM and that the DON was preparing to leave the NF to go home. CNA A said RN E told her that it was a chain of commands for CR #1 to be assessed by the Speech Therapist which was to inform the ADON. CNA A said she also informed the Speech Therapist who said that he would need an order to assess CR #1. CNA A said RN E told her that she would notify the ADON. CNA A said she went to the Speech Therapist on [DATE] in the evening and told him about CR #1's choking episode on [DATE]. CNA A said the Speech Therapist told her that he would need an order. CNA A said she had informed the Administrator verbally on [DATE] and the Administrator told her to write a statement. CNA A said she wrote a statement at 11:34AM on [DATE] and send it to the Administrator via e-mail regarding CR #1's choking incident on [DATE]. CNA A said she did not want the surveyor to say anything to the Administrator because she did not want to lose her job. CNA A said she went to the kitchen on [DATE] and told them what food to give CR #1. CNA A did not elaborate on the exact food she told them to give CR #1 but told them to give CR #1 soft texture foods that did not require CR #1 to chew a lot. CNA A said the kitchen gave CR #1 a mechanical soft diet. CNA A said on [DATE] at 5:30PM or 6:00PM at the nurse station saw CR #1 leaning to her side drooling at the mouth with food in her mouth. CNA A said nurse LVN C was trying to get the food out of CR #1's mouth. CNA A said LVN C began to hit CR #1 in the back, but CR #1 was not responding. CNA A said herself and LVN C transferred CR #1 on the floor and at this time CR #1 was completely unresponsive. CNA A said she started screaming for help and 911 was called. CNA A said after that she did not know what took place next because she went to see if 911 had arrived so she could direct them to the hall CR #1 was residing on. Interview on [DATE] at 3:45PM CNA I said she worked the first shift 6AM-2PM mainly but did work over sometimes on the evening shift. CNA I said the first time she observed CR #1 choking was on [DATE] after 5:50PM. CNA I said she believed that it was CNA A that called her to come and assist with CR #1's choking episode on [DATE]. CNA I said CNA A was standing in the hallway calling for help. CNA I said there was a new nurse caring for CR #1 who's name she could not recall. CNA I said CR #1 was choking when she entered her room. CNA I said she immediately pulled CR #1 forward in bed trying to relieve the choking. CNA I said the food did come up and that the new nurse was just standing on the side of CR #1's bed looking. CNA I said they continued to let CR #1 sit up in bed and they continued to monitor CR #1 for any further choking. CNA I said CNA A said she was going to report the incident. CNA I said CR #1 appeared to be okay for the remainder of the shift. CNA I said the next morning when she returned to work, she told RN E that CR #1 needed to be gotten out of bed for her meals due to the choking episode on [DATE] and RN E agreed. Interview on [DATE] at 5:19PM via phone LVN B said she worked the 6PM-6AM shift PRN. LVN B said the last time she worked at the NF was on [DATE] and [DATE]. LVN B said CR #1 did not have any issues with chocking. LVN B said CNA A was feeding CR #1 in bed on [DATE]. LVN B said CR #1 was being fed soup along with some type of salad with chunks of chicken chopped up in it. LVN B said CR #1 was not choking, but just not tolerating the texture of the food. LVN B said CR #1 had tea or apple juice as a beverage. LVN B said she heard CNA A calling for help and when she arrived to CR #1's room, CR #1 was able to follow commands and did spit the food out. LVN B said CNA A was in a complete uproar and got overly excited. LVN B said the incident was mentioned to the DON who came on the unit. LVN B said the DON said she would take care of the matter. LVN B said she did not call the physician because the DON said she would take care of it. Interview on [DATE] at 5:52PM, the DON said it was CNA A that came to her on [DATE] around 8:00PM telling her that CR #1 was having difficulty swallowing. The DON said she put an order in on [DATE] for CR #1 to be evaluated by the Speech Therapist but did not call the NP or the physician. The DON said she told the NP when she was at the facility on [DATE] and the NP said that was good. The DON said she had not in-serviced the Nursing staff on silent aspiration/choking. The DON said the s/s of silent aspiration were pocketing food, difficulty in breathing, increase heart rate, and change in skin color. Further interview with the DON said the reason she did not call the physician when told that resident had choked on her diet was because she got ahead of herself and just wrote the order. The DON said the physician should have been notified first before she put an order in for CR #1 to be evaluated by Speech Therapist because that was the normal process. Interview on [DATE] at 12:25PM with LVN C, said she worked the 6p-6a shift. LVN C said on [DATE] the incident happened before her shift started. LVN C said the staff were bringing the residents back from the dining Room after eating dinner. LVN C said CNA A asked if CR #1 was choking. LVN C said the time was around 5:30PM. LVN C said she observed CR #1 choking and not breathing. LVN C said her and a CNA (name she could not remember) transferred resident to the floor after removing food from resident mouth and performing the Heimlich maneuver which was unsuccessful. LVN C said CPR was initiated. LVN C said during this time she told a staff member to call 911. Record review of the NF's policy on Change in a Resident's Condition or Status revised [DATE] revealed in part: .Our facility shall promptly notify the resident, his or her attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition . The facility Administrator and DON were notified on [DATE] at 3:16PM that an IJ situation had been identified due to the above failures. The IJ templated was provided to the Administrator on [DATE]. Interview on [DATE] at 11:45AM RN E said she worked the 6:00AM-6PM and that she was not aware of CR #1 choking on her food. Interview on [DATE] at 9:46AM, the NP said she was at the NF and saw CR #1 but could not remember the exact date. The NP said CR #1 was fine. The NP said the NF never informed her that CR #1 experienced a choking incident on [DATE]. The NP said she later received a text from RN E on [DATE] informing that CR #1 was unresponsive and 911 had to be called. The NP said the DON's mistake was putting an order in without consulting her first. The NP said had she informed her when the incident happened, she would have put interventions in place such as changing the resident's diet and given further orders to assess resident swallowing to prevent resident from aspirating. Further interview on [DATE] at 11:58AM, with the DON she said when a resident experiences a change in condition the staff were supposed to notify the physician immediately. The DON said she told the primary care nurse LVN B to notify the physician on [DATE]. The DON said if the nurse was unable to get in contact with CR #1's physician, the next step would be to notify the Medical Director. Attempted interview via phone on [DATE] at 12:19PM with the NF Medical Director was unsuccessful. The Medical Director was left a voicemail with a call back number. Interview on [DATE] at 2:30PM with the ADON said she had been working at the facility for a little over a month. The ADON said none of the nurses or CNA's had informed her that CR #1 choked on her food. The ADON said if they had, she would have called the doctor or NP to get an order for a swallow evaluation and notified the family. Interview on [DATE] at 1:13PM, CNA N said she had taken care of CR #1 in the past and had observed CR #1 pocketing her food in her mouth at times. CNA N said she did report these happenings to RN E. Interview on [DATE] at 1:34PM with CR #1's primary care doctor via phone said the NF never notified her that CR #1 had a choking episode on [DATE]. The Doctor said CR #1 was on a mechanical soft diet and was high risk for choking. The Dr. said if the facility had notified her of resident choking episode on [DATE], she could have given prophylactic orders that consisted of the following: place CR #1 on NPO or liquid diet until a barium swallow test was done, placed CR #1 on antibiotics, and started breathing treatments. The doctor said CR #1 may have aspirated on [DATE] and that these would have been the measures she would have considered because aspiration could lead to pneumonia. Interview on [DATE] at 3:22PM via phone CNA D said she worked at the NF PRN. CNA D said CR #1 had a choking episode on a Sunday prior to the incident on [DATE]. CNA D said the nurse on duty was RN E. CNA D said she notified RN E but did not know what she had done about it. Interview on [DATE] at 2:30PM LVN W said no one ever told her that CR #1 was choking on her food. Further interview on [DATE] at 12:12PM the DON said she believed the reason the NF received an IJ was because of the facility failing to follow-up with the physician immediately when CR#1 experienced a choking episode on [DATE]. The following plan of removal was accepted on [DATE] at 7:22PM. PLAN OF REMOVAL Date: [DATE] The facility failed to immediately inform CR #1's physician after a change in condition. The facility failed to notify the Physician when resident had a choking episode on [DATE]. What corrective actions have been implemented for the identified residents? On [DATE] resident CR#1 involved in failed practice was discharged to the hospital per MD orders on [DATE]. On [DATE] at 4:00pm the Facility Administrator notified the Medical Director, and the attending physician of failed practice. Change of condition policy/ Procedure was reviewed by IDT, no changes were made: Completed [DATE] The DCO completed audit of all residents with change of condition in the last 30 days, the physicians were notified of all changes: Completed [DATE] In-services provided to DCO. On [DATE] the following in-service was provided to the Director of Clinical Services (DCO) by the Regional Director of Clinical services (RDCO) 1. Notifying the Physician Immediately of Change of Condition Occurs and Obtaining Orders from the Physician before treating the Resident. 2. On notifying resident's responsible party on changes of condition and new intervention that was put in place, completion date [DATE]. In-services provided to Licensed Nurses On [DATE] the DCO initiated in-services for facility charge Nurses on the following: I. Change of condition in relation to swallowing/aspiration difficulties or choking episode, and to notify resident's attending physician of these changes immediately completion date [DATE]. II. 1:1 in-service conducted with LVN B by the DCS regarding physician notification completion date [DATE] CNA education provided are below. C N A 's in-service on notifying License Nurses concerning change in conditions and documentation in POC documentation. completion date [DATE] Nursing staff will be in-service on the plan before the start of their shift. Validation/Monitoring The DCS/Designee reviewed residents' last SLP referrals no corrections as of [DATE]. Facility IDT reviewed policy/procedure of aspiration, swallowing precautions, therapy referrals, no revisions needed. Completion date [DATE]. What does the facility need to change immediately to keep residents safe and ensure it does not happen again. A. The DCN/Designees will review all changes in condition and therapy referral in daily clinical meetings and ensure follow is completed timely, staff monitoring is in place, the RP/MD is notified of changes and new recommendation if followed. Completed [DATE]. B. The Director of Clinical Services will ensure Licensed Nurses notify the Physician Immediately of Change of Condition Occurs and Obtaining Orders from the Physician before Treating the Resident completed: [DATE]. C. Newly hired nurses will be in-serviced by the Director of Nursing or designee on immediately notifying the attending physician of residents change of conditions, obtaining orders for therapy screening and evaluations as needed. Quality Assurance An Ad Hoc Quality Assurance and Performance Improvement review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan. ________________________________________________________________________________________________ The surveyors confirmed the plan of removal had been implemented sufficiently to remove IJ by the following: Note: Due to initial IJ being called on [DATE] at 3:16PM, the NF had begun the process in in-servicing staff on notification of change in a resident condition by [DATE], therefore the surveyors began the monitoring process as follow: Interview on [DATE] at 11:25AM with RN E said she worked on Station B 6AM-6PM. RN E said she had just received in-service on notify the physician as well as the RP when a resident experience a change in condition. Observation on [DATE] at 11:35AM of Station B across from the nurse station revealed residents sitting in their w/c's dressed in street clothing with no concerns identified. Interview on [DATE] at 11:42AM with CNA F on Station B said that she worked the morning shift 6AM-2PM. CNA F said she had received in-service on what to do if a resident began to choke while eating. The CNA said she would call for help and would begin to try and clear the resident airway by providing the Heimlich maneuver. The CNA said some s/s/ of silent aspiration was resident having difficulty breathing, change in their facial appearance and skin color. The CNA said if she observed a resident having difficulty swallowing their food or pocketing their food, she would notify the nurse right away so that the resident could be assessed. The CNA said she was in-serviced to notify the nurse whenever she noticed a change in resident condition. Interview on [DATE] at 11:50AM with CNA Y said she worked the 6AM-2PM full time. CNA Y said she had been in-serviced on notifying the nurse when residents had a change in condition, s/s of silent aspiration were discoloration in the face, change in facial expression, and difficulty breathing. CNA Y said if the resident was choking, she would give them the Heimlich maneuver to try and help the resident clear the air way. CNA Y said she had been in-serviced to review the resident POC in the computer. Interview on [DATE] at 11:58AM with the Wound Care Nurse said she worked at the NF Monday through Friday and did assist with monitoring the residents during mealtimes. The Wound Care Nurse said she had been in-serviced on choking and how to apply the Heimlich maneuver. The Wound Care Nurse said if the resident became unresponsive, CPR had to be initiated immediately and call 911. The Wound Care Nurse said s/s of silent aspiration were drooling at the mouth, skin discoloration of the face, difficulty breathing, and perspiring. The Wound Care Nurse said the physician and the RP had to be notified immediately when a resident experiences a change in condition and the care plan had to be updated. Interview on [DATE] at 12:07PM with CMA K said she worked the Memory Care Unit and worked the morning and evening shift. CMA K said she had been in-serviced on choking and silent aspiration. CMA K said s/s of silent aspiration was drooling at the mouth, perspiring, difficulty breathing, and change in skin color. CMA K said if a resident was choking, she would call for the nurse and apply several back blows, if that was unsuccessful, she would do the Heimlich maneuver. CMA K said the incident must be reported to the nurse immediately as any change in condition. CMA K said when feeding a resident, she had to feed them slowly being careful to offer them fluids in between eating. Interview on [DATE] at 12:14PM with CNA L said she worked the Memory Care Unit 6AM-2PM and been in-serviced reviewing the resident plan of care in POC, monitoring the residents for choking or s/s of silent aspiration and that all changes in condition were to be reported to the nurse. CNA L said resident had to observed closely during mealtimes and if notice a resident choking call the nurse immediately and do the Heimlich maneuver to held dislodge what was blocking the resident airway. CNA L said s/s of silent aspiration was drool at the mouth, difficulty breathing, bulging of the eyes, change in skin color, and grabbing their neck. CNA L said the incident had to be reported to the nurse so that the nurse could call the doctor as well as the family. Interview on [DATE] at 12:20PM with RN M said she worked the 6AM-6PM shift and had been in-serviced on notifying the physician whenever a resident experience a change in condition. RN M said she had been in-serviced on the s/s of silent aspiration (drooling at the mouth, difficulty breathing, change in the color of resident skin) and choking. RN M said if a resident experienced this, the doctor had to be notified right away to get an order for a swallow evaluation and possible diet change. RN M said the resident care plan also had to be updated and the RP notified. Observation on [DATE] at 12:32PM in the Dining Room revealed lunch being provided to the residents with over 6 staff members being present, one being the Wound Care Nurse. There were no concerns identified. Observation on [DATE] at 1:05Pm in the MCU revealed the residents eating their lunch with staff members being present. There were no concerns identified. Interview on [DATE] at 1:13PM with CNA N said she normally worked the morning shift. CNA N said she had been in-serviced on when a resident was choking to give the Heimlich maneuver. CNA N said s/s of silent aspiration was difficulty breathing, watering of the eyes, drooling at the mouth, and possible reaching for their throat. CNA N said she would try and clear resident airway by giving thrust in the back and then proceed with the Heimlich maneuver. CNA N said she would notify the nurse on all changes in a resident condition. CNA N said she was in-serviced to review the resident care plan. Interview on [DATE] at 2:38PM with LVN O said he was in orientation and was hired to be a Unit Manager. LVN O said he had received in-service on checking the crash cart, that if the resident was choking to perform the Heimlich maneuver. LVN O said if the resident lost consciousness, he would have someone call 911 and he would start CPR right away. LVN O said some s/s of silent aspiration were the following: short of breath, wheezing, eyes bulging, perspiring, trying to clear their throat, drooling at the mouth, pocketing food. LVN O said the doctor had to notified in both incidents as well as the RP. LVN O said resident care also had to be updated regarding the incident. Interview on [DATE] at 2:47PM with CNA I said she worked the morning and evening shifts and had been in-serviced on how to do the Heimlich maneuver, chest thrust if a resident was choking. CNA I said the nurse had to be notified of all changes in a resident condition. CNA I said she was in-serviced on recognizing some s/s of silent aspiration (change in a resident facial expression, drooling at the mouth, wheezing or difficulty breathing). CNA I said she was in-serviced that when having to feed a resident, to take her time and feed them slowing being aware to provide resident their beverage between feeding during meal service. CNA I said she was also in-serviced to review resident care plan in POC. Interview on [DATE] at 8:00PM with CNA P via phone said he worked the night shift 10PM-6AM. CNA P said he had been in-serviced in the following: POC regarding the resident plan of care, choking and how to apply the Heimlich maneuver, back blows and chest thrust, and reporting change in condition. CNA P said the nurse had to be notified if he witnessed a resident choking. CNA P said he was also in-serviced on silent aspiration. Interview on [DATE] at 8:08PM with CNA J said she worked the night shift 10PM-6AM. CNA J said she received in-service on silent aspiration and choking, checking resident care plan in POC, and when feeding the resident to feed slowly observing for signs of choking and reporting to the nurse immediately all changes in a resident condition. CNA J said she had received in-service on resident plan of care that could be found in the computer. Interview on [DATE] at 5:00AM with LVN S said she worked the 6:00PM to 6:00AM shift. LVN S said she had been in-serviced on choking and silent aspiration, the importance of notifying the physician when a resident experience a change in condition and making sure resident care plan was updated. Interview on [DATE] at 9:14PM with LVN R said they worked the night shift 6PM-6AM. LVN R said they had been in-serviced on s/s of silent aspiration, choking and to notify the doctor and the RP. LVN R said they were also in-serviced on making sure that the resident care plan was updated whenever a resident experience a change in condition and checking the crash cart. Interview on [DATE] at 10:30AM with LVN Q said he worked the 6AM-6PM shift and received in-service making sure a resident care plan was updated when there was a change in condition, notifying the doctor and the RP if the resident experience a change in condition, how to intervene if a resident experience choking, if the resident lose consciousness call for help and began CPR, the s/s of silent aspirations, and checking the crash cart each shift. Interview on [DATE] at 11:25AM with CNA T said she worked the 6am to 2pm shift on the MCU. CNA T said she had been in-serviced on choking, performing the Heimlich maneuver, abuse and neglect, s/s of silent aspiration, reporting to the nurse when she observed a change in resident, and reviewing the resident plan of care in POC. [DATE] at 11:32AM Interview with the ADON said she was in-serviced on choking/silent aspiration, notifying the doctor and RP when there was a change in resident condition, updating the care plan right away when a resident have a change in condition. Interview on [DATE] at 2:11PM with the MDS Nurse said she was in-serviced on care planning on how and what to care plan to ensure that each resident care plan was individualized and personalized. The MDS Nurse said she was also in-serviced on care planning for dysphagia, updating the resident care plan when a change in condition has occurred, notifying the physician of the change, s/s of silent aspiration. Interview on [DATE] at 2:18PM CNA U said they worked 6AM-2PM received in-service on different techniques to open a resident airway when choking which were back and chest thrust, and Heimlich maneuver, s/s of silent aspiration and to report to the nurse all changes in a resident condition. Interview on [DATE] at 2:30PM with LVN W said she worked the 6AM-6PM shift. LVN W said she had been in-serviced on abuse and neglect, choking, checking the crash cart each shift, notifying the physician if a resident experience a change in condition, and updating the care plan when there was a change in resident condition. Interview on [DATE] at 4:28PM with CNA V said she worked the 2PM-10PM shift. CNA V said the NF had in serviced her on choking and s/s of silent aspiration (discoloration of the face, difficulty in breathing, and drooling of the mouth). CNA V said if a resident was choking, she would perform the Heimlich or thrust resident on the back. CNA V said she was in-serviced to let the nurse know if she witnesses this and to always look in POC for resident plan of care, and when feeding resident to feeding resident slowing making sure resident was not choking. CNA V said she was also informed to use any recommended utensil when feeding a resident that was high risk for choking. Interview on [DATE] at 4:38PM with RN X said he worked the 6AM-6PM shift full time on Station C. RN X said he had received in-service on the following: s/s of silent aspiration (resident unable to speak, eyes watering, discoloration of skin to the face, drooling from the mouth, difficulty breathing). RN X said he would apply the Heimlich maneuver if a resident was choking and if the resident loss consciousness, he would have to begin CPR signaling someone else to call 911. RN X said if a resident experience the above, it was considered a change in condition and therefore, the physician as well as the RP had to be not [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accidents and hazards as is possible for 22 of 22 residents reviewed for accidents and hazards. 1. CNA B and CNA C engaged in a verbal and physical altercation in the presence of at least two residents, Resident #2, and Resident #3 on 1/18/24 at approximately 6:00 a.m. 2. CNA C left a loaded firearm unattended inside her personal bag in an unsecured cabinet under the nurse's station desk located directly across from a resident TV area for an undetermined amount of days/time. 3. CNA C pointed a loaded firearm at CNA B and discharged the gun outside in the air approximately one yard from resident-occupied rooms on 1/18/24. An Immediate Jeopardy (IJ) was identified on 02/07/2024 at 9:40 a.m. The IJ template was provided to the facility on [DATE] at 9:40 a.m. While the IJ was removed on 02/08/2024 , the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed all residents at risk possibly being seriously harmed/injured or killed by an unsecured firearm or stray bullet. Findings included: Observation of the nurse's station on the 100 Hall on 01/22/2024 at 11:00 a.m. revealed the entrance to the nurse's station was directly across from a resident television area. There were open areas underneath the desk with shelves. There were bags, purses, and jackets on the shelves. No staff were observed at the nurse's station at that time. There were three residents in wheelchairs sitting in the television area. In an interview with the DON on 01/22/2024 at 9:30 a.m., she stated on 01/18/2024, LVN V called her and said two staff members (CNA B and CNA C) were having an altercation. She could not recall what time LVN V called her, but it was at the start of the 6:00 a.m. - 2:00 p.m. shift. The DON said she told LVN V to get replacement staff and send CNA B and CNA C home. The DON said LVN called her again that morning and said there were gun shots fired outside. The DON said the MDS Nurse called the police after she heard gunshots. The DON said there had not been any prior altercations between the two staff that she knew of. She said CNA C was just hired in December 2023. She said CNA C had not complained about any prior incidents with any other staff. She said their corporate staff were involved in the investigation. She said CNA D tried to separate the two staff when they were fighting. She said all three staff were suspended pending the investigation, but CNA D returned to work on Sunday, 01/21/2024. She said the MDS Nurse was currently in the hospital having emergency surgery. She said the nurses did 12-hour shifts from 6:00 a.m. - 6:00 p.m. and 6:00 p.m. - 6:00 a.m. She said RN A was the night shift nurse and she also witnessed the altercation. In an interview with the Administrator on 01/22/2024 at 10:22 a.m., he stated on 01/18/2024, he received a call from a nurse at about 7:15 a.m. He said he could not recall what nurse called him, but the nurse said the Medical Records Coordinator said CNA C had a gun and fired shots in the air. The Administrator said CNA C texted him at 8:11 a.m. after the incident and said the other staff jumped her. He said he sent her a text saying she brought a weapon into the facility when signs were posted everywhere saying it was a felony and then discharged it unsafely. He said CNA C texted back saying she figured he would say that and that it was not a felony to protect herself The Administrator said the police came and did an investigation, but as of Friday, 01/19/2024, they had not found CNA C or arrested her. He said CNA C texted that she rode the bus to work, and the gun was in her bag. The Administrator said he did not know where CNA C's bag was stored inside the facility. He said CNA C told him she brought the gun for safety reasons because she rode the bus at night. He said this was the first time he heard about any incident between CNA B and CNA C. The Administrator said CNA C never told him what the argument was about, but he heard during the investigation that the argument was about an unsafe transfer. He said CNA C transferred Resident #2, who was a two-person transfer, alone and CNA B told her how to do it the right way. The Administrator said Resident #2 told him CNA B was very calm when she approached CNA C and told her how to transfer him the right way. The Administrator said that was when things escalated, and CNA D tried to stop CNA C from going outside to mess with CNA B, who was outside smoking. He said RN A, MDS Nurse, and CNA D all tried to stop CNA C from bothering CNA B outside. He said CNA C went outside and that was when everybody heard guns shots. The Administrator said nobody went outside with CNA C. He said from his understanding, there was a short amount of time when CNA C went outside and when gunshots were heard. He said from his understanding, there was not a physical altercation inside the building because some people said it was physical, and some said it was not. He said CNA C told the VP of Operations she was being bullied, but there were no reports of that to him. He said CNA C never reported being bullied before this incident. He said he always did in-services about staff getting along and workplace violence as part of their ongoing training. He said there were no prior issues with staff having altercations that he knew of. He said staff had lockers available to them outside in the courtyard and in the staff breakroom. He said staff could bring their own locks to secure their personal belongings. He said he did not know if CNA C had a locker or not. The Administrator said he implemented a new rule that staff could only bring clear bags into the facility. He said he also contracted to have security in the building 24-hours daily and in-serviced staff. He said there were always signs posted at every entrance and exit about not bringing guns into the building, but he posted more signs. In a telephone interview with CNA C on 01/22/2024 at 10:45 a.m., she stated she took responsibility for what she did because they (the Administrator and VP of Operations) told her having weapon on the premises was a felony. She said she only had the gun because she rode the bus at night to and from school. She stated she worked the 6:00 a.m. - 2:00 p.m. shift, but on 01/18/2024, she arrived early and clocked in at 5:45 a.m. She said she got Resident #2 up because he wanted to get up. She said she gave him a bed bath and transferred him safely with a Hoyer Lift to his wheelchair. She said RN A went to Resident #2's room because he was rambling and going on (she did not say what Resident #2 was rambling about). She said RN A said, Oh, you got him up, it was not time to get him up and you were not supposed to get him up by yourself. She said she was still in Resident #2's room and was leaving out right at 6:00 a.m. when CNA B approached her and was very aggressive about it. She said CNA B told her, I don't know what you think you are doing, but this is a two-person assist and you are going to get yourself fired. CNA C said she did not know what CNA B's problem was because she came down the hallway with her hands up like she was going to hit her. CNA C said CNA B swung at her and she backed up and asked CNA B not to do that. She said CNA B told her RN A asked her to come talk to her. She said she asked CNA B why she was so mad, and CNA B said she was done talking and was about to burst her upside her head. CNA C said she previously observed CNA B get Resident #2 up unassisted and CNA B said, I don't care what you thought you saw. CNA C said CNA B kept pushing and chest butting her. CNA C said she was walking away when CNA D grabbed her hand and said, Don't run up behind CNA B like that. CNA C said she told the rest of the staff she was leaving and showed them her bus pass. She said while CNA D held her, CNA B punched her on left side of her face. She said nobody let her leave. She said CNA B said, You about to go outside and get your ass whooped. CNA C said there were 3 - 4 people standing outside with CNA B and they were bullying her, so she pulled her gun out and shot into the air. She said she did not know the names of the other staff who were outside with CNA B. She said she called the Administrator and the VP of Operations after the incident. She said her car was broken, so she had to ride the bus. She said she went to class from 5:00 p.m. - 9:00 p.m. and she stored her bag behind the nurse's station, under the cabinet where there was an open area. She said that was where all the staff kept their things. She said she left her bag with the gun inside on the bottom shelf, next to the computer and chair on hall 100. She said her weapon was not exposed. She said RN A was there when CNA B hit her in the face. She said CNA B and another staff were already outside when she tried to leave the building and CNA D held her back and would not let her leave. She said she did not know if CNA D made it outside before her, but she saw some people at the door yapping their mouth (yelling at her and bullying her). She said she went out the side door of the building and was in the middle of the parking lot when she fired the shot in the air. She said she did not aim the gun at anybody, and she did not try to hurt anybody. She said the other staff were nowhere near her when she fired the shot. She said the other staff were more than 200 - 300 ft. away from her. She said the Medical Records Coordinator heard her telling the other staff to get off her. She said she told the Medical Records Coordinator and another CNA that she was being bullied by CNA B. She said during the week prior to the incident, she was mistreated by some African staff and CNA B defended her, so she did not understand why CNA B hit her in the face. She said she never reported to the Administrator or other management staff that she was being bullied. She said 01/18/2024 was the first day she brought her gun inside the building. She said she had never gone inside the building with a bag before because she previously had her car. She said her car broke down a couple of weeks before the incident. She said she never noticed or paid attention to the posted signs that said she could not bring a gun inside the building. She said she did not know she could not have the gun to protect herself. She said none of the residents had access to it because it was behind nurse station under the open cabinet. In an interview with the Medical Records Coordinator on 01/22/2024 at 11:15 a.m., she stated days before the incident on 01/1/2024, CNA C told her some other staff were messing with her and the nurses were always hostile to her. She said she told CNA C file a grievance because the Administrator had an open-door policy. She said CNA C told her that on Saturday, 01/13/2024, some nurses got her into the medication room and got in her face. She said CNA C told her that on the day of the incidents, CNA C came and told her she could not get Resident #2 up or change him by herself even though she previously observed CNA C transfer him alone. The Medical Records Coordinator said RN A told CNA B to go and tell CNA C she could not transfer Resident #2 alone. She said the two staff had a verbal and physical altercation in the residents' room. She said Resident #2 told her CNA C hit CNA B first. She said CNA C told her CNA B hit her first. She said CNA C and CNA B never had any disagreements. She said CNA D told her (Medical Records Coordinator) that CNA C said she had a gun and she had 'something for them' if this (when the nurses cornered her in the medication room and got into her face) happened again. She said CNA C told CNA D she had a gun possibly days before the shooting incident. She said CNA B was a smoker and usually went out to the patio in the courtyard to smoke, but on 01/18/2024, CNA B called CNA out and said, Come outside if you got something for me. The Medical Records Coordinator said she was at the table in the front of the building and saw people running. She said she heard staff saying, No! Let my purse go, let me go! and She got a gun! She said by the time she got to the side of the building: CNA C was already gone. She said she did not hear the gun shot. She said the incident occurred around 6:00 a.m., so of course residents were up at that time and roaming around the building. She said none of the residents were outside. She said CNA D was outside when CNA C shot the gun. She said CNA D tried to keep CNA C from leaving with her purse because she knew the gun was in there. She said CNA C's bag was probably behind the nurse station, but staff were supposed to keep their belongings in the lockers. In a telephone interview with CNA B on 01/22/2024 at 11:35 a.m., she stated she worked the 6:00 a.m. - 2:00 p.m. shift and there had not been any other incidents or animosity between her and CNA C. She said the two of them usually got along. She said on 01/18/2024, she had just gotten to work when RN A asked her to talk to CNA C because she got Resident #2 up way too early and she transferred him alone. She said RN A told her CNA C would not listen to her. She said she and CNA D went to the room and saw CNA C in there. She said she asked CNA C to come to the door and then told her RN A asked her to go and talk to her because Resident #2 was a two-person transfer. She said CNA C got mad and clapped her hands saying she was tired of people telling her what to do. CNA B said she told CNA C she was just trying to keep her from getting in trouble. CNA B said she walked away and told RN A it was too early for this. CNA B said the altercation was only verbal and never got physical. CNA B said they went to the nurse's station and continued arguing back and forth. She said RN A and CNA D were there trying to separate them. She said she tried to go outside and smoke to diffuse the situation, but it was brought up that CNA C had a gun. CNA B said CNA D knew CNA C had a gun. She said CNA D said, Don't let her get her purse! CNA B said at that time, CNA C was going for her purse behind the nurse's station desk. She said CNA D said, Don't let her get it because she got a gun! and CNA C said, And Do (meaning she did have a gun). CNA B said she was getting her stuff to go smoke and CNA B walked up on her back (walked closely behind her). She said as she walked down the hall to go smoke, the other staff were still in the building. She said once she got outside, she could see CNA C walking towards her thru the glass door. She said she saw CNA C's bag under left arm and her right hand was inside the bag. She said when CNA C walked outside, she was talking and pointed the gun at her as soon as she got outside. She said she heard CNA C ranting and raving that she was tired of people telling her what to do. She said when CNA C pointed the gun at her, she (CNA C) was about one or two feet away from the building and about three feet away from her. She said CNA C stood right by residents' windows. She said the police found the bullet shell next to building where she shot the gun. She said after CNA C pointed the gun at her, she backed up and pointed it in the air and fired. She said she did not know CNA C had a gun in building before the incident. She said she previously heard CNA C say they would not catch her like that again. She said CNA C was referring to an incident with some other nurses who attacked her. She said CNA C never reported that incident, but other staff knew because she was upset about it. She said CNA C told her the nurses were in her face and talking loudly because she gave a resident the wrong food tray. In an interview with LVN V on 01/22/2024 at 12:20 p.m., she stated on 01/18/2024, she had the on-call phone and RN A called her to say there were two staff at the nurse's station fighting. She said she asked RN A what the situation was, and RN A said she and other staff pulled them apart and they walked out of the building. She said she called the DON, and the DON said the staff had to write a statement and leave the building. She said when she called CNA B and told her she needed to leave, CNA B went off on her (got very angry). She said CNA B told her she would not give her a statement. In a telephone interview with the VP of Operations on 01/22/2024 at 12:40 p.m., she stated she was first notified of the incident the morning of 01/18/2024, when the Administrator called her. She said she told the Administrator to interview staff who witnessed the incident and call the police. She said when she arrived at the facility on 01/18/2024, they started safe survey interviews with all residents on the 100 hall, where the staff fought and on the 200 hall, where the staff was when she shot the gun. She said they talked to all staff who worked that day and sent a mass email to each resident's RP and family about the incident. She said they held a resident council meeting and staff meeting where they offered counseling to anybody who needed it. She said they contracted to have security in building because they were not aware if the shooter was arrested. She said CNA C called her when she was on her way to the building and she and CNA B did not have any incidents before that morning. She said CNA C told her that she and CNA B were cool because there was a previous incident where some nurses were trying to discipline her, and CNA B took up for her. CNA C said the incident started when she transferred a resident. She said CNA C told her CNA B said she did it incorrectly, but she previously observed CNA B transfer the resident that same way. She said CNA C told her CNA B said she never saw her do it that way, then they got into it (had a verbal altercation). She said CNA C told her CNA D was in between them and pulled her back while CNA B landed a lick (hit her) and RN A jumped in to get them apart. She said CNA C told her CNA B left, saying she did not have time for that while CNA D and RN A held her back. She said CNA C told her she told RN A and CNA D she was getting her bag and bus pass so she could leave for the day, and they eventually let her go. She said CNA C told her she proceeded out of the building thru the same door CNA B left from so she could walk towards the bus stop. She said CNA C told her she had the gun for her protection. She said she told CNA C it was a felony to go into a skilled nursing facility with a gun and the corporate office called the police. She said CNA C told her she had also called the police herself because they were trying to jump her. She said CNA C said there was a lot of staff outside, but after speaking to staff, they found that nobody else said they were outside. She said the other staff were inside trying to keep CNA C from going outside and nobody was outside trying to jump her. She said CNA D went outside after CNA C. She said the police had already gone to building by the time she arrived, and the shell was found in the parking lot. She said they completed staff education and counselors were going to talk to those who expressed uneasiness about the incident. She said none of the residents stated they were disturbed. She said Resident #2 and Resident #3, who were in the room where the incident started, did not have concerns. She said they had psych (psychiatric) services see both residents to make sure. She said they in-serviced all staff that if you see something, say something. She said they also educated staff on anger management, reporting, abuse/neglect, and having a gun in the facility. Observation and interview with Resident #2 on 01/22/2024 beginning at 1:30 p.m., revealed he was a larger male who self-ambulated in an electric wheelchair by using his chin to maneuver the controls. Resident #2 could not move his limbs. He stated CNA C was in his room getting him dressed the day of the incident. He said he usually got up at 7:00 a.m., but it was 6:00 a.m. when CNA C got him up. He said CNA C got frustrated and he got frustrated. He said when CNA B came, she was really calm. He said he heard CNA B say, I don't know how you did things where you came from, but around here, this is how we do it. He said the staff were arguing in the hallway but then things got physical when CNA C hit CNA B first. He said CNA C's arm went from down low and then down on CNA B's shoulder, like a windmill. He said the staff went down to the nurse's station, so he could not see anything after that, and he did not know how it ended. He said CNA D came up and stood beside them and did not get involved at all. Resident #2 said he was already in his chair during the incident, but the chair was not on. He said he was upset because CNA C said she was going to go get other residents up, and he told her she could not abandon him like that. He stated he felt safe at the facility, and he did not have any concerns because it was two girls fighting. In an interview with CNA D on 01/22/2024 at 1:40 p.m., she stated she worked the 6:00 a.m. - 2:00 p.m. shift. She stated there were no prior incidents between CNA B and CNA C that she knew of. She said CNA C told her she had an issue with some of the nurses because she got into it (had verbal altercations) with them the weekend before the gun incident about a wrong food tray. She said CNA C told her that she and the nurses argued, it got heated, and they went into the MDS office where they yelled in her face. She said CNA C received a verbal warning, but she felt she should not have gotten anything. She said CNA C said they were going to stop playing with her (stop harassing her), but she never said she was bringing a gun to the facility. She said she heard CNA B and CNA C arguing down the hall. She said the argument was about getting a resident up because CNA C said she saw other staff do it that way and she was tired of people telling her how to do her job. She said CNA C said she had gotten Resident #2 up safely so what did it matter. She said she saw both of their hands going up in each other's face and they were fanning each other's hands down. She said she told them to stop because they would lose their jobs. She said CNA C said, You stole me (hit me), oh no bitch, you stole me! She said she and RN A got between them, but they were going around them. She said CNA C said, I got something for you. She said CNA B had already gone outside and invited CNA C to go meet her outside. She said CNA C got her stuff, but they tried to keep her inside. She said CNA C said, I got something for this bitch. She said CNA C's bag was in the open area under the desk at the nurse's station. She said she and the MDS Nurse were standing at the door trying to calm CNA C down. She said the MDS Nurse said she would call the police if they fought. She said they tried to keep CNA C from going outside, but once she went outside, she instantly started digging in her purse and she came out of the purse with something. She said she and the MDS Nurse were right at the door with CNA C. She said she heard CNA B say, Oh you gone point the gun at me! She said CNA C then raised the gun and shot in the air. She said CNA C was on the sidewalk, near resident rooms when she shot the gun. She said CNA C was about a yard from the building and she was about a yard from CNA B. She said CNA C said, Ya'll bitches gone stop playing with me. She said CNA C said she quit and the MDS Nurse said, We already knew that. She said CNA C could have gone out the front door to catch the bus instead of going out the side door. She said the residents were getting up at that time. In an interview with Resident #3 on 01/22/2024 at 2:17 p.m., he stated the incident started in his room and then went to the nurse's station. He said he did not know how it started, but he saw one hit the other. He said one staff swung her hand back, but he did not know if she meant to hit the other staff, or if she just landed one accidentally. He said after that, he went outside and saw two police officers at the facility. Her stated he still felt safe in the facility. In a telephone interview with RN A on 01/23/2024 at 12:52 p.m., she stated she was waiting for her relief on 01/18/2024 when she CNA C went and got her because she was having issues with Resident #2's wheelchair. She said when she went to the room, she told CNA C she was not sure how to work the wheelchair, but she would get someone who knew. She said she noticed Resident #2 was already in his chair, so she asked CNA C how she got him in there. She said CNA C said she transferred him by herself. She said she told CNA C it was not safe for her to do that, but she said she could do it that way. She said she told CNA C she needed to get someone else to help her with Resident #2. She said she went to find someone to help control Resident #2's wheelchair and saw CNA B with CNA D in front of the nurse's station. She said she told CNA B that CNA C had already gotten the resident up by herself and that she needed help with the controller on Resident #2's wheelchair. She said CNA B went to the room and then she heard some sounds coming from down the hall. She said she heard someone say, Stop fighting. She said the staff were very close together and one hit the other, but she did not know who hit who first. She said CNA B left the building because she was upset, and they tried to calm CNA C down and told her she could not go outside because CNA B was still out there. She said CNA C kept yelling that she had to get out. She said CNA C took her backpack and left the building. She said by that time, she went out of the building and heard the gunshot. She said she did not go to the door with the other staff. She said she did not hear anybody say anything about a gun while they were inside the building. In a follow-up interview with the Medical Records Coordinator on 01/24/2024 at 10:15 a.m., she stated after CNA C got into an altercation with the nurses when they were all in her face, CNA D said she (CNA C) told her, I am not gone worry about it because I got something for them. She said after the shooting incident, CNA C called her and said of course she had a gun because she went to school at night on the bus. She said when she went outside after the shooting incident, she heard CNA B tell CNA D, You been knew she had a gun? Why didn't you tell me? The Medical Records Coordinator said CNA D said she already knew CNA C had a gun in the building. Record review of the facility's 'Workplace Violence policy, revised 01/2022 revealed, The facility seeks to provide a safe workplace for all team members and has Zero Tolerance toward any type of workplace violence committed by or against team members. Team members are prohibited from making threats or engaging in violent activities. This list of behaviors, while not inclusive, provides examples of conduct that is prohibited. Causing physical injury to another person; Making threatening remarks; Aggressive or hostile behavior that creates a reasonable fear of injury to another person or subjects another individual to emotional distress; . Possession of a weapon while on facility property or while on facility business; . Any potentially dangerous situations must be reported immediately to a supervisor . Threats, threatening conduct, or any other acts of aggression or violence in the workplace will not be tolerated. Any team members determined to have committed such acts will be subject to disciplinary action, up to and including termination . Record review of the facility's policy on Firearms and Other Weapons revised 01/2022 revealed, All applicants, associates, contractors, subcontractors, or any other persons are prohibited from using or possessing (whether concealed or not) any weapons while on company premises, engaged in company business, or at company-related activities. The company follows state and federal laws regarding concealed weapons, and to the extent this policy conflicts with any such law, the applicable law governs. Record review of In-Service Training Report dated 01/18/2024 revealed all nursing staff were educated by the DON on safe transfers, including Hoyer Lifts and two-person transfers. Record review of In-Service Training Report dated 01/18/2024 revealed all nursing staff were educated by RN A on reviewing each resident's Kardex (a quick reference for nurses to write, organize, and easily reference key patient information that shapes their nursing care plan) on the plan of care and requesting assistance before providing care. Record review of In-Service Training Report dated 01/18/2024 revealed all nursing staff were educated by the physical therapy department regarding Resident #2's motorized wheelchair, including operation, drive mode, tilting, chin joystick, and recharging. Record review of In-Service Training Report dated 01/18/2024 revealed all facility staff were educated by the SW regarding workplace violence and reporting incidents of bullying, harassment, and retaliation and possession of a weapon. Record review of In-Service Training Report dated 01/18/2024 revealed all facility staff were educated by the SW regarding Abuse and Neglect. This was determined to be an Immediate Jeopardy (IJ) on 02/07/2024 at 9:40 a.m. The DON was notified. The DON was provided with the IJ template on 02/07/2024 at 9:40 a.m. A Plan of Removal was requested at that time. The following Plan of Removal submitted by the facility was accepted on 02/08/2024 at 11:52 a.m. : The facility failed to ensure that resident environment remained free of accidents and hazards. 1. Immediate Action Taken * Identified staff were immediately suspended on 1/18/24 and police notified on 1/18/24. The residents that were located near were assessed by the Social Worker and Licensed Nurse to be offered the opportunity to have grief counseling by Psych Services to monitor for Post Traumatic Stress completed on 1/18/2024. * On 2/7/24 the social worker and Director of Nurses (DON), started education with all staff on the company policy for workplace violence, Use of clear bag policy at the community, and abuse and neglect, completed on 2/7/24. Employees that missed the in-service will not be allowed to work until this education has been completed. * The company will purchase clear bags for all employees to carry personal belongings into the facility in-service initiated on 1/19/24 and completed on 1/22/24. Clear bag policy was posted all over the community on 2/7/24. * The social worker and Director of Nursing initiated in- serviced to all staff on handguns prohibition policy, this will be completed on 2/8/24, all staff not available for the in-service will not be allowed to work until the in-service is completed with them. * An In-service by the Social Worker and corporate HR was started on 1/18/2024 to also provide grief counseling information from the employee through the employee's insurance company. This counseling was an immediate offer and is still available. There is no completion date because it is ongoing. Completed 1/18/2024 and ongoing. 2. Identification of Residents Affected or Likely to be Affected: * On 1/18/2024 the DON and Social Worker completed the audit for any resident who was near and wanted therapy. We identified no residents that wanted therapy. An audit was completed on 1/18/2024. 3. Actions to Prevent Occurrence/Recurrence: * The Social Worker and DON will validate daily x 10 days, that there are no residents that suffered stress due to the incident. * Any new licensed nurse hired by the facility will receive education upon hire on: o Education on Workplace Violence will be given to all new employees upon hire. o Staff that missed the initial training will have to be in-serviced on workplace violenc [TRUNCATED]

Based on record review and interview, 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 resident's choices for 1 of 10 residents (CR #1) reviewed for Quality of Care. 1.The facility failed to immediately transfer CR #1, who was cognitively impaired and received Eliquis (an anticoagulant/blood thinner) when CR #1 went to the hospital after an unwitnessed fall on 09/22/2023 at 4:55 a.m. and sustaining a head injury. CR #1 was transferred to the hospital via non-emergency transportation service as a replacement for 911 emergency services. An Immediate Jeopardy (IJ) was identified on 01/18/2024 at 10:49 a.m. The IJ template was provided to the facility on [DATE] at 10:49 a.m. While the IJ was removed on 01/19/2024, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. 2.The facility failed to assess CR #1 in her primary language of Spanish when she sustained a head injury on 09/22/2023. These failures placed residents on anticoagulant therapy who experience falls with injuries at risk of progression of the injury, prolonged pain, excessive bleeding, intracranial hemorrhage, and possible death. Findings included: Record review of CR #1's face sheet dated 01/17/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. CR #1's diagnoses included: Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), unspecified dementia (dementia without a specific diagnosis), epilepsy (brain condition that causes recurring seizures) and epileptic syndromes (a type of epilepsy identified by a specific seizure type), abnormality of gait (unusual walking pattern), heart failure (a chronic condition in which the heart does not pump blood as well as it should), dysphagia-oropharyngeal phase (reduced ability to feel food, liquid, or saliva that remains in the mouth or throat after swallowing), cognitive communication deficit (deficits which result in difficulty with thinking and how someone uses language), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), vascular dementia (brain damage caused by multiple strokes that causes memory loss in older adults), essential hypertension (abnormally high blood pressure that is not the result of a medical condition), and joint pain (physical discomfort where two or more bones meet to form a joint). CR #1 was discharged from the facility on 09/28/2023. Record review of CR #1's quarterly MDS assessment dated [DATE] revealed she was Hispanic or Latino; her preferred language was Spanish and she needed/wanted an interpreter to communicate with a doctor or health care staff; she had a BIMS score of 00 (severe cognitive impairment); she required extensive physical assistance from at least one staff for bed mobility, locomotion, dressing, eating, toilet use, and personal hygiene and she was totally dependent on staff for transfers and bathing; she was wheelchair bound; she was always incontinent of bowel and bladder; she was prescribed anticoagulant medication; and she received hospice services. Record review of CR #1's care plan updated on 09/25/2023 revealed the following areas of concern: * The resident was at risk for increased falls and fractures as evidence by confusion and incontinence. Goals included: The resident will be free of falls through the review date. Interventions included: Anticipate and meet the resident's needs. Be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. * The resident had a communication problem related to dementia and language barrier; speaks Spanish. Spanish speaking however nonsensical due to dementia majority of the time. Communication effective with simple basic terms. Goals included: The resident will maintain current level of communication function by next review. Interventions included: Anticipate and meet needs. Monitor/document/report PRN any changes in: ability to communicate, potential contributing factors for communication problems, potential for improvement. Speak on an adult level, speaking clearly and slower than normal. The resident is able to communicate by: gestures, translator (Spanish). * Resident at Risk for Falls as evidenced by: Cognitive Impairment. Goals included: Dignity will be maintained. Resident will not experience falls or injuries from falls throughout the review date. Interventions included: Assure lighting is adequate and areas are free of clutter. Encourage resident to ask for assistance of staff. Ensure call light is in reach and answer promptly. Therapy to evaluate and treat per orders. * 9/22/23 I have had an actual fall with minor laceration to forehead related to poor balance, unsteady gait. Goals included: The resident's (Specify: injured areas [no injuries were noted] ) will resolve without complication by review date. Interventions included: 9/22/23 Clean the forehead laceration with wound cleanser, pat dry and apply dry dressing. 9/22/23 Continue interventions on the at-risk plan. 9/22/23 Give PRN Tylenol per physician order for pain. 9/22/23 Neuro-checks x 72 hours per facility protocol. 9/25/23 Neuro-checks x 72 hours per facility protocol. 9/22/23 PT consult for strength and mobility. 9/22/23 Send resident to ER for CT scan without contrast. 9/25/23 Check range of motion every shift daily. 9/25/23 For no apparent acute injury, determine and address causative factors of the fall. 9/25/23 Monitor/document /report PRN x 72h to MD for signs and symptoms: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Further review of CR #1's care plan revealed no documentation of a care area, goal, or interventions related to CR #1's anticoagulant therapy. Record review of CR #1's Nursing Progress Notes for March 2023 revealed the following: On 03/07/2023, the SW (no longer employed at the facility) wrote, SW met with resident in the common area of Station C to complete a quarterly social service assessment . SW utilized an interpreter to assist with the assessments, as resident is Spanish speaking . Record review of CR #1's physician's orders for September 2023 revealed the following orders: * Admit to hospice with diagnosis: Alzheimer's Disease. Order date - 05/28/2023. * Eliquis Oral Tablet 5 MG. Give 1 tablet by mouth two times a day for DVT (blood clot) until 10/17/2023. Order date - 04/17/2023. End date - 10/17/2023. * Acetaminophen Oral Tablet. Give 2 tablets by mouth every 4 hours as needed for pain. Order date - 04/18/2023. Record review of CR #1's MAR for September 2023 revealed: * Acetaminophen Oral Tablet. Give 2 tablets by mouth every 4 hours as needed for pain. There was no documentation to show this medication was administered in September 2023. * Eliquis Oral Tablet 5 MG. Give 1 tablet by mouth two times a day for DVT until 10/17/2023. This medication was administered daily as prescribed (except for the 8:00 a.m. dose on 09/22/2023) for the month of September 2023 until she was discharged on [DATE]. Record review of drugwatch.com's article, Eliquis revised 10/15/2023 and written by a board-certified patient advocate revealed Eliquis was a powerful blood thinner prescribed to prevent strokes and potentially fatal clots. The article stated doctors prescribed Eliquis to people after knee or hip replacement surgery to prevent deep vein thrombosis (DVT) which was when blood clots formed in veins deep in the body. The article stated Eliquis' effects lasted for at least 24 hours after the last dose, according to the drugs label. The label stated serious and potentially life-threatening bleeding was the most severe side effect. Record review of the undated Eliquis medication guide on Eliquis.bmscustomerconnect.com, revealed Eliquis can cause bleeding which can be serious and rarely may lead to death. Record review of premierneurologycenter.com's undated article , Blood Thinners and Head Injuries: What You Need to Know revealed, . Blood thinners are medications that help prevent blood clots from forming, however they can increase the risk of delayed intracranial hemorrhage (bleeding with the skull) after a head injury. Therefore, if you are taking a blood thinner, it is important to be aware of the risks associated with head injuries. If you experience a bump, blow, or jolt to the head, it is important to seek medical attention right away. Even if you do not feel any symptoms after the injury, it is still important to be evaluated by a doctor . Record review of CR #1's Nursing Progress Notes for September 2023 revealed the following: On 09/22/2023, RN A wrote, 4:55 a.m. - Upon rounds, resident was observed lying on her right side on the left side of her floor mat by the window with bed on the lowest position, upon assessment, resident was observed with laceration on her forehead area, resident was alert and awake, small blood was seen on the handle of her dresser which appears that she bump her head on the dresser handle, bed was moved away from the dresser, resident was assisted to her bed, area was cleaned with wound cleanser, pat dry with dry dressing applied, PRN Tylenol administered for possible pain and was well tolerated. Hospice Nurse notified of the situation and gave a phone order for resident to be sent to ER for CT scan of the head, order noted and carried out, report given to ER nurse, RP made aware, DON and Administrator made aware. Non-emergency transportation service notified, and resident was picked up via stretcher by 2 EMS alert and awake, no s/s of distress noted, no active bleeding noted on her forehead area, dressing intact, respirations even and unlabored. NP also made aware Record review of CR #1's Pain Tool completed by RN A and dated 09/22/2023 revealed, A. Location - For each site listed, describe type of pain (stabbing, burning, sharp, dull, throbbing), duration and frequency and whether it is continuous or intermittent in the description box. Site: 1) Top of Scalp. Description: Laceration to forehead area (no further description was detailed in the description box). B. Current Pain Level. 1. Faces Scale: Hurts a Little Bit . C. What Makes the Pain Better? 1. What makes the pain better? Forehead area cleaned with wound cleanser and pat dry and dry dressing applied, bleeding stopped, PRN Tylenol administered for possible pain with good effect . Record review of CR #1's incident report completed by RN A and dated 09/22/2023 revealed, . Injuries Observed at Time of Incident: Laceration. Injury Location: Top of Scalp. Level of Pain: 3 ( . Negative Vocalization: Score 0 [None], Facial Expression: Score 1 [Sad, Frightened, Frown], Body Language: Score 1 [Tensed, Distressed Pacing], Consolability: Score 1 [Distracted or Reassured by Voice or Touch]. Mental Status: Oriented to Person . Predisposing Physiological Factors: Confused . Record review of CR #1's fall assessment completed by RN A and dated 09/22/2023 revealed, Score: 55 . History Of Falling: Has Resident ever fallen before? Yes. Secondary Diagnosis. Does the resident have more than one diagnosis on the chart? Yes . Scoring: High Risk: 45 and higher . Record review of CR #1's Neuro Assessment completed by RN A and dated 09/22/2023 revealed: 1. Q15 (4:55 a.m.) - . 4. Glascow Coma Score (a clinical scale used to reliably measure a person's level of consciousness after a brain injury. The scale assesses a person based on their ability to perform eye movements, speak, and move their body) . B. Best Verbal Response: 5. Oriented . 6. Obeys Commands. 5. Other Neurological Abnormalities . B. Headache: 2. No . Further review of CR #1's Neuro assessment dated [DATE] revealed neurological assessments were also conducted at 5:10 a.m., 5:25 a.m., 5:40 a.m., and 6:10 a.m. with the same exact documentation as the 4:55 a.m. assessment. Record review of CR #1's Transfer Form completed by RN A, dated 09/22/2023 revealed, . 5. Primary Language: Spanish .2. Transfer/Discharge Details: Sent to hospital. Date: 09/22/2023, 6:41 (a.m.) . Reason: Fall . 4. Pain. 1. Most Recent Pain Level: 3 - Date: 09/22/2023 at 7:43 (a.m.). 2. Pain Location. Site: Top of Scalp. Laceration to forehead area. 3. Most Recent Pain Medication. Orders: Acetaminophen Oral Tablet. Last Administered: 05/20/2023 at 2:08 p.m. Risk Alerts: Other Risks 12. A. Anticoagulation. 12b. Specify medication used: Eliquis. 12c. Specify reason for use: blood thinner. 13. Are there any additional risks present: b. Falls, i. Seizures . Record review of CR #1's Ambulance Transport Run Report dated 09/22/2023 revealed she was transported to a local acute care hospital ER via non-emergency transportation service. The document read, . Arrived at Scene: 6:31 (a.m.) Left Scene: 6:42 (a.m.) Destination: 6:57 (a.m.) . Got dispatched to an [AGE] year-old Hispanic female with chief complaint of fall. Upon arrival, patient is confused but able to talk. Patient is Spanish speaking only . Nurse believes her head bumped the drawer of nightstand. Patient taking blood thinner. Patient condition is stable . Record review of CR #1's hospital records dated 09/22/2023 revealed she arrived at the hospital'sER on [DATE] at 6:57 a.m. and was discharged on [DATE] at 11:49 a.m. The document read in part, . Glascow Coma . Best Verbal Response: Confused . Diagnosis: Acute head injury, dementia, fall, forehead laceration . ED Triage Information . Tracking Acuity: 3 - Urgent . Trauma Indication: Yes . History of Present Illness: The patient presents following a fall out of bed. The location where the incident occurred was at a nursing home. Location: scalp. Forehead. The character of symptoms is bleeding. Risk factors consist of anemia, bed bound and vascular dementia. The patient is an [AGE] year-old female with a past medical history of vascular dementia, anemia and is bed bound. Presents to the ED via EMS from her nursing home for evaluation s/p unwitnessed fall. Per EMS the patient was found at 5 a.m. after falling from bed and hitting her head on a dresser at bedside. EMS reports that the patient is on blood thinners and is confused at baseline. Injury is sustained to the forehead and scalp. No other symptoms or complaints reported at this time. Limited HPI secondary to patient's clinical condition . Trauma Brain without contrast CT - 09/22/2023. Impression: 1. No acute intracranial process. No intracranial hemorrhage, edema, or skull fracture. 2. Stable chronic changes. 3. Laceration of the superior scalp, superficial . Her laceration inspected, irrigated, closed with staples . Problems Addressed: Patient presents with a problem that potentially represents a highly morbid condition with a possible threat to life or bodily function . Description/repair: Laceration 3 cm in length. Face: forehead. Shape: irregular. Depth: subcutaneous . Skin closure: 3 staples . Record review of CR #1's progress notes for September 2023 revealed: On 09/22/2023 at 12:27 p.m., LVN E wrote, Back from hospital ER via stretcher accompanied by 2 attendants. Resident was awake, alert. Laceration with 3 staples and dry blood remained visible to forehead. Neuro checks in progress and WNL . In an interview with CR #1's family member on 01/17/2024 at 8:15 a.m., she stated CR #1 passed away in November 2023. She stated she missed three calls from the facility on 09/22/2023, so she called the hospice nurse. The family member said the facility failed to assess the seriousness of CR #1's injury and did not send her out for two hours. She stated CR #1 was transferred to another facility after the incident. She said CR #1 did not speak English, but she could understand it. She stated CR #1's dementia had progressed, so she really could not voice her needs. In an interview with the DON on 01/17/2024 at 11:23 a.m., she stated she thought CR #1 had a fall and went out to the hospital but returned the same day. She said after the fall, CR #1's RP requested her to transfer to a sister facility. She said CR #1 was on hospice. The DON stated if a resident experienced a fall and hit their head with swelling or anything, the staff automatically sent them out for a CT scan just to be on the safe side. She said the staff would call hospice because some hospice residents were still full code (no DNR). The DON said if the fall incident occurred at 4:55 a.m., the nurse would start neurological assessments immediately but whether or not 911 was called to transport the resident depended on the nurse's assessment. The DON said if a resident had a bleeding laceration, they should be sent out 911, but it depended on what the nurse assessed. She said the risk of failing to immediately transport someone on a blood thinner who experienced a fall with head injury would have been possible internal bleeding, which may not have been assessed. She said there was no active bleeding, but since CR #1 was on Eliquis. there may have been internal bleeding that the nurse was not able to see. She stated the facility did not have a policy on quality of care or any policy specific to CR #1's incident. In an interview with the Administrator on 01/17/2024 at 12:15 p.m., he stated he thought the 6:41 a.m. transfer time documented on CR #1's transfer form dated 09/22/2023 was a documentation error. He said he thought CR #1 was sent out to the hospital before that time. He said the facility's nurses would not send a resident out right away unless they were profusely bleeding. He said there were no changes to CR #1's level of consciousness and she was not actively bleeding, so there could have been some delay in transferring her to the ER. He said he thought the nurse applied pressure to CR #1's wound and it was stable. In a telephone interview with Hospice RN on 01/17/2024 at 1:20 p.m., she stated she could not recall what time the facility called her, but if the fall happened at 4 a.m., she must have been the on-call nurse. She said she could not recall if the facility nurse called her before or after they sent CR #1 out to the ER after she fell and hit her head. She stated the details of the incident would be in her notes. In a follow-up telephone interview with Hospice RN on 01/17/2024 at 1:40 p.m., she stated RN A called her at 5:00 a.m. on 9/22/23 and said CR #1 struck her head on the bed, but she initially denied there was a fall. Hospice RN said RN A eventually said an aide told her CR #1 did fall and hit her head on the dresser. Hospice RN said RN A told her CR #1 sustained a laceration to her head and was bleeding. She said CR #1 was sent out for evaluation and CT for a subdural hematoma (a pool of blood between the brain and its outermost covering). She said RN A told her she had already called EMS. In a telephone interview with RN A on 01/17/2024 at 2:26 p.m., she stated she recalled CR #1, who was on hospice. She stated CR #1 was alert, but only spoke Spanish, so she could not understand her. RN A said on the night CR #1 fell , she was asleep until she (RN A) made her final rounds for the night. RN A said she worked from 6:00 p.m. - 6:00 a.m. She said when she walked into CR #1's room, she was on the floor mat. RN A said CR #1's bed was very low to the ground, so it appeared she rolled out of bed or something. She said she saw that CR #1's face had blood and the bottom drawer of the dresser had a blood stain on it. RN A said CR #1's face was positioned near the dresser area. She said the laceration was like a line that resembled the dresser drawer handle. RN A said she cleaned CR #1's wound and she was still alert and talking (in Spanish). She said she rounded every two hours and the laceration appeared to be fresh like the fall had just happened. RN A said CR #1 could not really communicate with her, but she cleaned the wound and saw the line from the laceration. She said she called hospice and spoke with the nurse. RN A said she told Hospice RN that CR #1 needed to go to the hospital, so she gave the order to send CR #1 to the ER. She said the incident happened at the end of her shift. She said as soon as she wiped the blood from CR #1's laceration, the bleeding stopped so she covered it with a dry dressing. RN A said she knew CR #1 had to go to hospital because it was their policy. She said she called their non-emergency transportation company, and they came almost immediately. She said CR #1 left the building while she (RN A) was still in the building. RN A said she knew CR #1 was on Eliquis. She said she knew CR #1 had to go to the hospital but spoke to the hospice nurse before she called the transportation company. She stated the hospice nurse never mentioned calling 911. RN A said the ETA for the transportation company was soon because they were in the area. In a follow up telephone interview with RN A on 01/23/2024 at 12:52 p.m., she stated CR #1 could speak some English, but mostly Spanish. She said CR #1 could say, Yes in English and could say, Poquito ('a little' in Spanish) when she was in pain. RN A said when she conducted a ROM assessment on CR #1, there was no sign of pain, but when she felt around the laceration area, CR #1 jerked a little and said, Poquito. RN A said CR #1 was speaking in Spanish the morning she fell , and none of the staff could speak Spanish to her. She said she gave CR #1 Tylenol, if she was not mistaken. She said the Tylenol administration was probably not on CR #1's MAR, but she thought she gave it to her. In an interview with CR #1's NP on 01/17/2024 at 3:45 p.m., she stated she did not recall CR #1's fall in September 2023. She stated if a resident was cognitively impaired, confused, and had a communication barrier experienced a fall with a head injury and was on Eliquis, it did not necessarily mean the nurse should have called 911. She stated CR #1 was on hospice and usually, hospice patients did not go to the hospital unless the hospice agency said to send them out. She said if a resident hit their head and was bleeding, they would send the resident out for a CT to ensure there were no injuries. CR #1's NP said if CR #1 had a head injury that was bleeding and there was a two-hour delay in getting her to the hospital, you would have to be very careful, but if she was not actively bleeding and there was just a skin laceration, the situation was not urgent to her. She said if a resident had a brain bleed for two hours, that would be an emergency. She said CR #1 was in a low bed, so she could not say for sure if there was a possibility for her to have sustained a brain bleed as a result of the fall. The NP said it depended on how hard CR #1 hit her head. She said a normal person would have had altered mental status if they had a brain bleed, but CR #1 was already confused. In another telephone interview with Hospice RN on 01/18/2024, at 9:40 a.m., she stated she ordered RN A to send CR #1 out after the fall to evaluate for subdural hematoma because she could have had a brain bleed. She stated going out to the hospital was not usually recommended for residents on hospice unless their family wanted it. Hospice RN said, CR #1 could have had a brain bleed and being on a blood thinner would have exacerbated that condition. She said typically, a family would not treat a brain bleed if the resident was on hospice. She said if a resident was not on hospice, a two-hour delay would not be appropriate for this situation. She said CR #1 could not speak any English at all. She said she took over as CR #1's primary hospice nurse after she experienced the fall in September 2023 and followed her to the other facility (after she was discharged from the facility). She said CR #1 had dementia, so even when she spoke Spanish, she could not communicate her needs. In an interview with the Administrator, VP of Operations and Regional Nurse on 01/18/2024 at 10:50 a.m., the VP of Operations stated she was previously the administrator at the facility, and she recalled that CR #1 could speak some English. The Regional Nurse stated she was previously the DON at the facility and CR #1 did speak some English and was able to communicate some although she was selective who she spoke English to. The Administrator, who was also an RN stated Eliquis acted different from blood thinners like Coumadin. The Administrator said doctors prescribed Eliquis because it controlled the blood/bleeding better. The Administrator said CR #1 could speak some English and they sent her to the hospital for evaluation. The Administrator said it was not an emergency because staff were monitoring CR #1 during the time she was in the facility, and she was stable. In an interview with CNA C on 01/22/2024, at 1:40 p.m., she stated she cared for CR #1 a few times and she only spoke Spanish. In an interview with LVN E on 01/23/2024 at 12:30 p.m., she stated she cared for CR #1 while she was there and every one-in-a while, CR #1 would say thank you in English. LVN E said CR #1 spoke some English before she declined a few months before she left the facility, but after the decline, she only spoke Spanish. In an interview with MA F on 01/23/204 at 12:30 p.m., she stated she administered CR #1's medications when she was at the facility. She stated she recalled that CR #1 required total care and did not speak any English. She said CR #1 only spoke Spanish. Record review of the facility's Change in Condition policy dated 11/01/2019 revealed, Communities will use the facility's definition for a Change in Condition. It will be the policy that once the nurse has notified the physician for a change in condition the resident/patient will be monitored for 1 hour until the physician has responded. The monitoring will include vital signs, pulse ox, and finger stick blood sugar if a diabetic (one time only). A physical assessment should be completed relative to the symptoms present and a pain assessment . If the resident/patient condition appears emergent, Transfer to local ER may occur without physician order. Record review of the facility's Incident and Accident policy dated 03/01/2017 revealed, 3. Licensed nurse will complete a fall investigation report after every fall to include vital signs, pain assessment, and environmental assessment . A head-to-toe assessment must be completed at the time of the incident . 10. All residents are at risk for falls. A risk assessment will be conducted on admission and the findings of that assessment will be included in the plan of care . 12. A fall is defined as unintentionally coming to rest on the floor, ground or lower level . b. a resident found on the floor is considered to have fallen . 13. A neurological check form is to be completed for any fall involving the head or any unwitnessed fall . This was determined to be an Immediate Jeopardy (IJ) on 01/18/2024 at 10:49 a.m. The Administrator, VP of Operations, and the Regional Nurse were notified. The Administrator, VP of Operations, and Regional Nurse were provided with the IJ template on 01/18/2024 at 10:49 a.m. A Plan of Removal was requested at that time. The following Plan of Removal submitted by the facility was accepted on 01/18/2024 at 3:09 p.m.: 1. Immediate Action Taken * Resident was discharged to another facility. * On 1/18/2024 the Director of Nurses (DON) or designee, started education with all license nurse on the guidelines for sending out residents via 911emergency services that are on anticoagulant therapy. This will guide the clinical team on ensuring that each resident receives emergency care immediately, and services in the event of a unwitnessed fall when a resident is on anticoagulant therapy. This education will be completed at 3:00 pm on 1/19/2024, and no license nurse will be allowed to work until this education has been completed. * An In-service by the Social Worker was started on 1/18/2024 on the use of the language line and the communication charts. This education will be completed on 1/19/2024. * An in-service initiated on 1/18/2024 by the DON for licensed nurses on proper assessment of a resident with fall with injury to include language barriers. To be completed by 1/19/2024 * The below policies were reviewed on 1/18/2024 and there are no changes to current policy. o Falls (Incident and Accident) to include witnessed and unwitnessed falls * Anticoagulation therapy information pamphlets o Communication * Using Language Line for Non-English-Speaking Residents. 2. Identification of Residents Affected or Likely to be Affected: * On 1/18/2024 the DON completed the audit for any resident who was on anticoagulant therapy. We identified 8 residents on anticoagulant. An audit was completed on 1/18/2024 by the DON and Assistant Director of Nurses (ADON) on resident with falls within the past 72 hours to validate that no other residents failed to receive emergency care, that were on anticoagulant therapy. This is to be completed by 1/18/2024. * Licensed nurses will use the resident clinical records (Medical Administration Records), to identify residents on anticoagulants. If resident is on anticoagulant, they will immediately be transferred to Higher Level of Care (Hospital) via 911 emergency. 3.Actions to Prevent Occurrence/Recurrence: * The DON/Designee will validate daily x 30 days, that the Incident and Accidents are reviewed daily during morning meeting to ensure no delays in services. * Any new licensed nurse hired by the facility will receive education upon hire on: o Education on the guidelines for sending out residents that are on anticoagulant therapy. o The use of the language line and the communication charts. o Proper assessments with a resident with a fall with injury to include language barriers. On 1/18/2024 the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to failure to provide treatment and care in accordance with professional standards of practice and reviewed plan to sustain compliance. Monitoring of the plan of removal included the following: Record review of In-Service Training Report dated 01/18/2024 revealed all facility staff were educated on Falls and on Anticoagulant or Blood Thinner by the DON. The document read in part, If a resident has a fall and is on anticoagulants or blood thinners, then send out 911 for evaluation. Record review of undated facility document, Are Coumadin and Eliquis the Same Thing? revealed the document was included in the in-service dated 01/18/2024 regarding falls and residents on blood thinners. The document explained the difference between Coumadin and Eliquis, including their indications, side effects, drug interactions, and how they should be taken. Record review of In-Service Training Report dated 01/18/2024 revealed all licensed nurses were educated by the DON regarding proper assessment of residents with language barriers who experience falls with injuries and how to identify residents on anticoagulant therapy. Record review of In-Service Training Report dated 01/18/2024 revealed all facility staff were educated on Residents with Language Barriers [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible, and each resident received adequate supervision and assistance devices to prevent accidents for 5 of 15 residents (Residents #321, #80, #34, #43, and #53) reviewed for accidents and supervision. 1. The facility failed to ensure the memory care courtyard gate was locked. Resident #321 left the courtyard through the unlocked gate, after being left unsupervised by the MA A, and was headed toward the front of the facility. 2. The facility failed to train staff to monitor the memory care courtyard gates to ensure they were locked. 3. The facility failed to ensure Resident #80 (a resident with quadriplegia and the inability to hold his own cigarette without staff assistance), Resident #34, Resident #43 and Resident #53 were supervised during smoke breaks. An Immediate Jeopardy (IJ) situation was identified on 4/20/2023 at 4:18 p.m. While the IJ was removed on 04/22/2023, the facility remained out of compliance at a scope of a pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents identified as elopement risk at risk for serious injury or death and placed residents who smoke at risk of injury, burns, and hospitalization due to risk of fire. Findings include: 1. Record review of Resident #321's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. He had diagnoses which included other symptoms and signs which involved cognitive functions and awareness (learning and problem-solving), basal cell carcinoma of skin of nose (a type of skin cancer), hypertension (high blood pressure), and type 2 diabetes (an insufficient production of insulin, causing high blood sugar.). Record review of Resident #321's, undated, care plan revealed he was an elopement risk/wanderer and was at risk for possible injury related to impaired safety awareness and diagnosis of dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Interventions were to 3. distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books. 4. Provide structured activities: toileting, walking inside and outside, reorientation strategies, including signs, pictures and memory boxes. Record review of Resident #321's Elopement Assessment, dated 4/13/23 written by LVN O, revealed he was at low risk for elopement. Record review of Resident #321's Progress Notes, dated 4/14/23, written by LVN L, read in part, .after dinner, standing near the exit door, stated where is the door to get out, that he [Resident #321] needs to get out, Resident has history of wandering, Resident was redirected . Record review of Resident #321's History and Physical, dated 4/17/23, written by NP, revealed he had a history of agitation with dementia and was at risk for elopement. He was transferred to this facility on 4/13/23 for a secured unit. In an observation and interview on 4/19/23 at 2:18 p.m. in Resident #36's room, revealed Resident #321 walked by the window on the outside of the building, headed toward the front of the building. The State Surveyor immediately alerted the Administrator, Director of Environmental Services, and Maintenance Director, who were present in Resident #36's room. The Director of Environmental Services ran to the window and then left the room quickly. The Director of Environmental Services opened the exterior door near the laundry room with Resident #321 next to her and said look who I found. She escorted Resident #321 back inside the facility and walked him to the memory care unit. In an interview on 4/19/23 at 2:20 p.m. with MA A on the memory care unit, she said she was outside monitoring Resident #321 in the memory care courtyard. She said she did not tell anyone she left the resident outside. She said when she looked back outside Resident #321 was not there, and no other staff were outside. She said the courtyard gate was opened and she was surprised because it was always locked. She said she did not check the gate earlier to ensure it was locked because it was always locked. In an observation on 4/19/23 at 2:23 p.m. the memory care courtyard gate was opened. An additional opened gate near the laundry room was observed. There was a third opened gate at the front of the facility near the dumpster. Beyond the front opened gate was the busy main street where cars were passing by. In an observation and interview on 4/19/23 at 2:25 p.m. with Plant Operations Assistant who was outside of the building between the gate near the laundry room and the gate located near the front of the facility by the dumpster. He said the front gate and housekeeping (laundry) gate were normally unlocked until 4 p.m. He said the gate by memory care was locked and had to be locked at all times. In an interview on 4/19/23 at 2:29 p.m., the Director of Environmental Services said when she left out of the building she found Resident #321 at the housekeeping (laundry) gate. In an interview on 4/19/23 at 2:43 p.m., the Administrator said it was the first time he saw the memory care courtyard gate opened. He said he would put a sign on the door (to indicate the gate needed to be closed at all times). In an interview on 4/19/23 at 3:06 p.m., MA A said she did not know much about Resident #321 because she only administered medication to him. She said she was unsure if he was an elopement risk but that could be a reason why he was in the memory care. She said at the time of the incident she was outside with him but went inside to ask someone to take her place while she went to the restroom. She said when she looked back outside, she did not see Resident #321. She said she did not know the memory care courtyard gate was opened because it was always locked. She checked the gate and started to look for him. She said she ran back to the nursing station to alert the nurse the resident was not in the courtyard. She said staff were normally always outside with the residents and said they were trained to always stay with the residents. She said she was not trained on ensuring the gates were locked and was unsure if a code was used to lock the gate. She said the maintenance staff normally checked the gates because memory care staff did not have access to the gates. In an interview on 4/19/23 at 3:15 p.m. CNA LL, who worked in the memory care secured unit, said she was not trained on checking the courtyard gates and said the gates were permanently locked. In an interview on 4/19/23 at 3:19 p.m. CNA Y, who worked in the memory care secured unit, said at the time of the incident Resident #321 was agitated and wanted to go outside. MA A went out to the back courtyard with Resident #321, and then opened the door to go use the restroom. She said since she started working at the facility 5 years ago, the two courtyard gates were always closed. She said she did not know the code to the gates and the residents were free to move around. She said no one knew the gates were opened because they did not open them at all, no one used them, and it was permanently locked. She said they were trained on checking their surroundings and checking the inside doors of the memory care. She said the problem today was maintenance staff did not alert them the gate was open. In an interview on 4/19/23 at 3:58 p.m., the DON said Resident #321 was a new resident with dementia and who was an elopement risk. She said she was informed, MA A was outside with Resident #321 but left him unattended to use the restroom and did not know the gate was opened. She said staff had to be outside to monitor the residents to ensure there were no incidents such as falls or altercations. She said the gates were not normally opened, especially the memory care units because of the yard. She said maintenance staff sometimes checked to ensure the gates were locked but pest control might have been the person to leave the gate opened. She said there was no sign on the gate to instruct people to shut the door behind them. She said if there was no sign, someone could leave it open. She said staff were not trained specifically on monitoring the courtyard gates but were trained to ensure a safe and secure environment. She said the risk of leaving a resident unsupervised with an unlocked gate could result in the resident eloping or sustaining an accident. If not supervised appropriately they could elope or have an incident fall or accident. In an interview on 4/19/23 at 4:16 p.m., the Director of Plant Operations said the memory care courtyard gate had a magnet lock and it required a code to get in and out. He said pest control staff put black boxes for rats outside and left the gate opened. He said there was no sign on the gate to instruct to make sure the gate was locked so no one tried to get out. He said the facility did not monitor the closed gates because no one was supposed to walk out of those gates. In a telephone interview on 4/19/23 at 4:30 p.m., the Pest Control staff said when he was at the facility this morning, he went through the memory care courtyard gate because it was already opened. He said memory care staff normally let him into the secure unit in the building because he did not have the access codes to the gate. In an interview on 4/19/23 at 4:38 p.m., the DON said when she walked outside of the building to assess the situation at the time of the incident (on 4/19/23 at 2:18 p.m.) all gates were opened. In an interview on 4/19/23 at 4:39 p.m., the Administrator said Resident #321 admitted to the facility the other day (4/13/23) because he was wandering. He said no one was aware the side courtyard gate was opened, and no one was assigned to ensure the gates were locked and closed. He said there were a few things that could have happened to cause the gate to be left open, which included pest control staff and the fire alarm test. He said the fire alarm was tested earlier (with a life safety code surveyor and maintenance staff) but it did not resonate with him (Administrator) to go and check the gate. He said staff normally watched the gates during a fire alarm test but an announcement was made in the facility that it was a test. He said the gate was normally locked because it was a means for the secure unit residents to freely move around in the courtyard. He said all three gates (memory care, laundry, and front gate) should have never been left opened at the same time. He said he expected staff to supervise residents in the memory care courtyard and ensure they were ok if the resident was outside for an extended period of around 5 - 10 minutes. He said he did not expect staff to sit outside with the residents. He said there was a potential for Resident #321 to have gotten out of the facility. In an interview on 4/19/23 at 4:45 p.m., a copy of the facility's policies were requested from the Administrator on supervision of memory care residents and fire alarm tests. These policies were not provided prior to exit. In an observation and interview on 4/20/23 at 11:44 a.m. revealed Resident #321 was in his room looking out of the window. He said he did not remember if he went outside yesterday and he did not try to leave the facility. He said he was in the facility too long and did not want to be there anymore. In a telephone interview on 4/20/23 at 12:07 p.m., the Director of Environmental Services said on the day of the incident, 4/19/23, she found Resident #321 by the opened outside laundry gate headed toward the street. She said the front gate was cracked opened. 2. Record review of Resident #80's face sheet revealed a [AGE] year-old male who was readmitted to the facility on [DATE]. He had diagnoses which included quadriplegia (a form of paralysis that affects all four limbs), lack of coordination, and contracture of muscle (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen). Record review of Resident #80's quarterly MDS assessment, dated 4/19/23, revealed a BIMS score of 13 out of 15, which indicated intact cognition. He was totally dependent on two staff for transfers and toilet use. He required extensive assistance of one staff for bed mobility, dressing, and personal hygiene. Record review of Resident #80's care plan, revised on 1/8/23, revealed he was a smoker. He required a protective apron and assistance while smoking. Interventions included: Resident utilizes the assistance of nursing staff to assist in smoking and holding cigarette, Resident will participate in supervised smoke breaks. Record review of Resident #80's safe smoking assessment dated [DATE] written by RN A revealed he required direct supervision while smoking. He could not independently light smoking materials safely, he could not extinguish smoking materials or dispose of ashes or other tobacco-related residue appropriately, and he could not use his hands to self-smoke. 3. Record review of Resident #34's face sheet revealed a [AGE] year-old female who was readmitted to the facility on [DATE]. She had diagnoses which included alcohol dependence with alcohol-induced persisting dementia (a group of symptoms that affects memory, thinking and interferes with daily life), symptoms and signs involving cognitive functions following cerebral infarction (stroke), need for assistance with personal care, and intracranial injury (a head injury causing damage to the brain by external force or mechanism. It causes long term complications or deatha) with loss of consciousness. Record review of Resident #34's quarterly MDS assessment, dated 2/21/23, revealed a BIMS score of 15 out of 15, which indicated intact cognition. She was independent with ADLs. Record review of Resident #34's, undated, care plan revealed she was a smoker. Her interventions included: resident will participate in supervised smoke breaks. Record review of Resident #34's Safe Smoking Assessment, dated 4/29/22, written by LVN Y, revealed she required direct supervision while smoking. The assessment indicated the resident shook or had tremors while smoking and indicated the resident had a past accident/incident with smoking materials. 4. Record review of Resident #43's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. He had diagnoses which included cerebral infarction (stroke), lack of coordination, weakness, need for assistance with personal care, and nicotine dependence. Record review of Resident #43's quarterly MDS assessment, dated 1/18/23, revealed a BIMS score of 13 out of 15, which indicated intact cognition. He required limited to extensive assistance with ADL care. Record review of Resident #43's care plan, revised on 1/26/23, revealed he enjoyed smoking. His interventions were to participate in supervised smoke breaks. Record review of Resident #43's Safe Smoking Assessment, dated 4/6/23, written by RN A, revealed he required direct supervision while smoking. The assessment indicated the resident had finger dexterity problems. 5. Record review of Resident #53's face sheet revealed a [AGE] year-old male who was readmitted to the facility on [DATE]. He had diagnoses which included dementia (a group of symptoms that affects memory, thinking and interferes with daily life), muscle weakness, lack of coordination, and hypertension (high blood pressure). Record review of Resident #53's quarterly MDS assessment, dated 2/20/23, revealed a BIMS score of 15 out of 15, which indicated intact cognition. He was independent with toilet use, eating, and transfers. He required limited assistance with bed mobility, dressing and personal hygiene. Record review of Resident #53's care plan revised on 1/8/23 revealed he was a smoker. His interventions were to participate in supervised smoke breaks. Record review of Resident #53's Safe Smoking Assessment, dated 3/10/23, written by RN A, revealed the resident required direct supervision while smoking. In an observation and interview on 4/18/23 at 10:41 a.m. revealed Residents #80, #34, #43 and #53 were observed smoking unsupervised outside in the courtyard. There were no facility staff present in the courtyard with the residents or in the common area located inside of the building where the smoking area could be seen. Resident #80 was wearing a protective smoking apron and had a cigarette in his mouth. Resident #80 said there were no staff out in the courtyard with them now. Resident #53 said a staff member normally supervised them, but a lady filled in today and told the residents she had to go back to work on the floor. In an observation and interview on 4/18/23 at 10:50 a.m. revealed CNA V opened the door to the courtyard where the residents were smoking and asked Resident #80 if he was ok. CNA V said the facility had designated smoking assignments and said he thought the laundry aide was supposed to supervise the residents. CNA V left the area. In an observation and interview on 4/18/23 at 10:53 a.m., the DON and State Surveyor entered the smoking area in the courtyard. The residents were no longer smoking. Resident #53 told the DON a staff member had to leave them outside smoking by themselves. The DON said she did not see any staff outside with the residents. She said the staff member should have stayed with the residents to finish watching them smoke. In an interview on 4/18/23 at 11:12 a.m., the laundry aide said she was the staff who took the residents out for their smoke break on 4/18/23 at 10:30 a.m. She said she gave the residents the cigarettes and left because she was behind on the laundry. She said the residents were still smoking when she left. She said she reported it to her manager, the Director of Environmental Services. She said the residents needed supervision per policy. She said Resident #80 had no use of his arms and she had to ensure he did not injure himself. She said she was previously instructed to light the cigarettes and stay with the residents if it was not busy. If she was busy, she was instructed to light the cigarettes and leave the residents. In an observation and interview on 4/20/23 at 1:07 p.m., Resident #80 said when he smoked, the cigarette sat in his mouth the whole time and he blew out like normal. Resident #80 said he could not raise a cigarette to his mouth. He said on 4/18/23 Resident #34 removed the cigarette from his mouth when he was done smoking. He said Resident #34 normally placed his smoking apron on and removed it but said staff would also put his apron on. He said earlier this year (unknown date) while smoking his cigarette fell on his neck and down his shirt and burned a hole in the shirt. He said he was wearing a smoking apron at that time. There was no record of this incident in the resident's medical record. Resident #80 said staff normally supervised their smoke breaks. In an interview on 4/20/23 at 1:54 p.m., Resident #34 said she normally assisted Resident #80 with the smoking apron because he was paralyzed. She said she would also light Resident #80's cigarette and discard it when he finished because he could not take it out on his own. She said staff normally supervised their smoke breaks. In an interview on 4/21/23 at 9:58 a.m., the Director of Environmental Services said the laundry aide did not notify her she needed to leave the residents to return to work. She said the laundry aide was trained on smoking procedures and knew she was supposed to stay with the residents the entire time. She said Resident #80 had to wear a smoking vest and needed someone to place the cigarette in his mouth and remove it. In an interview on 4/21/23 at 10:51 a.m., Resident #80 said he did not report the previous smoking incident (from early 2023) to staff. In an interview on 4/21/23 at 11:51 a.m., the DON said during resident smoke breaks she expected staff to stay and supervise the residents until they were finished with everything for safety reasons. She said Resident #80 required total assistance with smoking and staff had to light and remove his cigarette. She said staff should assist and remove Resident #80's apron, not residents. She said residents should not put the apron on Resident #80 because they may not know how to put it on appropriately. She said the Administrator was responsible for the smoking program and ensured staff were following facility policy. She said she was not aware of the prior smoking incident (from early 2023) with Resident #80. In an interview on 4/21/23 at 11:02 a.m., the Administrator said the laundry aide left the residents smoking unsupervised (on 4/18/23) at the 10:30 a.m. smoke break because she was busy. He said staff should not leave the residents unsupervised while smoking and the residents could be at risk for burns. He said Resident #80 should be protected from burns because he wore a smoking apron. He said Resident #80 manipulated the cigarette with his mouth and if he were to drop an ash, it was designed to fall on the apron. He said Resident #80 could not use his hands and did not know how he would remove the cigarette if staff were not present. He said he was not aware of the previous smoking incident, which involved Resident #80, where the cigarette fell and burned his shirt. He said staff were supposed to put the apron on Resident #80. He said residents should not light the cigarettes or assist other residents with the apron to ensure it was properly placed. The Administrator said all staff were in serviced on the smoking policy and what to do while supervising residents on smoke breaks 6 months ago. The Administrator said staff were aware of the resident's smoking needs by the care plan and from the residents who could verbalize their smoking needs. He said no one monitored the smoke breaks to ensure proper supervision. Record review of the facility's Smoking policy, dated 3/1/17, read in part, .accommodate residents who desire to smoke . by taking reasonable precautions, providing a safe environment for them . Procedure . 8. IDT will develop an individualized plan for safe storage, use of smoking materials, assistance and required supervision for resident who smoke This was determined to be an Immediate Jeopardy (IJ) on 4/20/2023 at 4:18 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 04/20/2023 at 4:18 p.m. The following Plan of Removal (POR) submitted by the facility was accepted on 4/22/2023 at 11:35 p.m. and the POR revealed: April 22, 2023 Plan of Removal F Tag 689 Accident Hazards The following actions have taken place immediately to remove the deficient practice. 1. The resident that was outside was immediately placed back in the secure unit on 4.19.2023, family guardian and physician notified by nurse on 4.19.23 no new orders given. The medication Aide was counseled 1:1 by Director of Nurses, and suspension for failure to follow facility policy on monitoring residents. 4.19.23 Resident was reassessed for elopement on 4.19.23 by the charge nurse. The care plan was updated to show that the attempted to elope on 4.21.23 by MDS coordinator. The staff that was suspended will have to complete 1 Sheet on elopement and attend the mandatory in-service on Elopement, Monitoring, Supervision, and Fire Drills by the Administrator prior to returning to work. Scheduled for 4.24.23. 2. Wander Guards of the 8 residents were reevaluated by the Maintenance Director to ensure they are working properly on 4.20.23. They were all functioning properly. The 8 residents were taken to the front door and the alarm went off to indicate the wander alarm device was functioning properly. The resident that attempted to elope did not have a wander guard on and there is no wander guard system in the secure unit. The residents on the secure unit will have supervised out times in the single access courtyard in the secure area that staff will be assigned by charge nurse daily. If the staff member has to leave for some reason, the staff member will call the receptionist and have them to send some to relieve them. 3. The clinical staff on-site will be in-serviced on monitoring the gate closure during and after a fire alarm has been activated or in the event of a power failure by the Administrator. During environmental rounds the Administrator and the Director of Maintenance will ensure the gates are functioning and intact weekly. The in-service will show that after the alarm sound they are to physically go and shake the gate to ensure that it is closed, and the locking mechanism is activated. Prior to training the gate was checked by Maintenance Director and Total Fire and Safety and a sensor was replaced on the door 4.20.23. A pre and posttest, for all Nursing staff will complete training. Those not being able to attend the training will not be allowed to work until training is completed. Completed by 4.22.23. 4. Staff will be trained on the monitoring of the residents in the secure unit and smoking areas. Residents that are outside or in the building will not be left alone or unsupervised. This training is conducted by the Administrator on 4.21.23. System change is that there will be scheduled times that the residents will be able to go into the courtyard and supervision will be mandatory, Completed 4.21.23. 5. All Licensed Staff will be in-serviced with return demonstration on the measure to ensure that the gate will be locked before and after the fire alarm sounds by the Administrator. The staff members that are not at work will be required to take the training from the Maintenance Director prior to coming back to work. Completed by 4.21.23 6. An elopement assessment will be completed on all residents in the secure unit and the 5 residents with wander guards in place and the elopement binder updated. Completed by the Director of Nurses and Nursing Management by 4.21.23. 7. Signage was posted by the Maintenance Director above the one keypad to make sure contract personnel close the gate if used. The Maintenance Director and the Administrator will ensure that the signage remains intact during the weekly environmental round. Completed by 4.20.23 8. All staff will be in-serviced by the Administrator on the current company policy for Elopement, Fire Drills, and simulations, and Memory Care Education Announcement, by the Administrator: Code PINK, which signals that an Elopement Drill Procedure is in progress. 1. An immediate and thorough search of the center and surrounding grounds. Including but not limited to a search of the area outside the nearest exit to the patient's/resident's room or the exit where he/she was last seen, and the entire unit where the patient/resident resides or was last seen, the remainder of the facility (all rooms, closets - including storage areas - and bathrooms) and grounds, extending beyond the fence line. 2. The entire search process of the facility and grounds, from the time the patient/resident is missing. 3. If the search fails to locate the missing patient/resident within (30) thirty minutes from the time the patient/resident is found to be missing, then the Administrator and/or designee places a mock telephone call to the appropriate community agencies (Police, Local Health Department), Administration, the patient's/resident's legal representative and attending physician. 4. The search is continued. Two staff members search the surrounding streets by car for a two (2) mile radius around the facility. By Administrator completed by 4/20/2023. 9. All Facility doors will be checked by Maintenance Director to ensure that the exit magnets are functioning properly. The Maintenance Director and the Administrator will check the doors weekly during environmental rounds and report and negative findings to the QAA. Completed by 4.20.23 10. Risk of elopement assessments, care plans and interventions reviewed and or revised for all residents at risk of wandering or elopement by Director of Nurses and Assistant Director of Nurses. Completed by Director of Nurses and Nursing Administration by 4.22.23 11. Resident #80 When made aware that the residents were outside smoking unsupervised another housekeeping staff member went to supervise the residents on 4.18.23. Resident was assessed by Licensed Nurse on 4.21.23 to see if there were any injuries or burns none were noted. The family and Nurse Practitioner were notified in regards to the resident being left unsupervised during smoke break by Administrator on 4.21.23 no new orders were given by NP. The staff that left the residents unattended was given a written 1:1 counseling on 4.18.23 on the smoking policy and not leaving the residents unattended during smoke breaks. Completed 4.18.23. The residents smoking items will be stored in a tackle box on the A nursing unit. The policy was reviewed by the IDT on 4.18.2023 and found not updates needed. The facility has always mandated that a resident smoking items be keep or maintained by the staff at the facility. 12. All Staff were in-serviced on smoking and residents being left unsupervised on 4.18.23, 4.19.23, 4.20.23, 4.21.23 by the Administrator. A copy of the smoking times and a copy of the policy was placed in the smoking area by the Maintenance Director on 4.21.23. The resident smoking assessments were completed by Social Services Completed on 4.21.23 and no changes to current smoking arrangements for identified residents. 13. Change is the facility will hire a smoking hospitality aide immediately and train them on the policy and smoking of the residents. We will use current schedule of departments to smoke the residents until the smoking aide is hired and trained. We will hire 2 persons to fulfill this role so that it will provide 7 days a week coverage. Residents that smoke on the secure unit will be escorted to the smoke area and monitored by the assigned staff from the secure unit on 4.20.23. The assigned staff will take the residents back once they have completed the smoke break. If the staff member has to leave for some reason, the staff member will call the receptionist and have them to send someone to relieve them. 14. A meeting is scheduled for 4.22.23 with the residents by the Administrator and Activities Director and they were informed that at no time should they place any smoke apron on one another, light another's cigarette, or extinguish another resident's cigarette. Completed 4.22.23. 15. At smoking times, the Administrator and Department heads will be making rounds in the smoking area daily starting 4.19.23 to ensure that the residents are supervised by departmental staff during the assigned smoking times. Any deficiency will be corrected by the department manager staying and to monitor and disciplinary actions up to termination for the assigned staff member leaving the residents unsupervised. Plan to Ensure Compliance Medical Director confirmed receipt of IJ on 4.20.23 1. An Ad hoc QAPI was completed by the IDT on 4.19.23. The QAPI included smoking and monitoring compliance by staff. 2. Wander guard system will be checked daily by Maintenance Director to start 4.20.23. Smoking monitoring compliance rounds will be completed by Departmental Managers daily and by the Manager on Duty on the weekends. 3. On Weekends and holidays the Doors will be checked by the facility department managers that serve as manager on duty each day and documented on manager log. This training will be done by the Administrator on 4.21.23 4.All staff must complete an in-service prior to working next shift and will be added to new hire orientation. Those staff not at work or could not make the general orientations will have to complete the assigned course in SNF Clinic as well as take the in-service by the Administrator or Maintenance Director. The Administrator or Designee will ensure that all staff have completed all of the above in-services and trainings before returning to work. In-servicing of

Based on observation, interview and record review, the facility failed to ensure 1 of 3 residents (Resident #3) reviewed for pressure ulcers received care to prevent pressure ulcers and necessary treatment and services, consistent with professional standards of practice, to promote healing, in that: - Resident #3 was noted to have a wound on her sacrum by CNA R on 01/22/22, but no wound assessment, wound care or treatment was provided to the resident until 01/26/22. - The facility nursing staff assessed Resident #3 to have no skin abnormalities on 01/21/22 but on 01/26/22 was later assessed to have two stage 3 pressure ulcers - full thickness skin loss potentially extending into subcutaneous tissue layers. This failure caused a resident to develop pressure ulcers and could place other residents at risk of development or worsening of pressure ulcers. Findings included: Record review of Resident #3's undated face sheet revealed a [AGE] year-old female who was admitted into the facility initially on 10/29/2014, and was diagnosed with protein-calorie malnutrition, abnormal weight loss and dysphagia. Record review of Resident #3's Braden scale for predicting pressure ulcer risk, dated 02/08/2022, revealed resident was categorized to have a moderate risk for developing pressure ulcers with a score of 14, with 18 being the highest risk score. Record review of Resident #3's care plan, dated 02/24/2022, revealed the resident was at risk for skin breakdown/pressure ulcers due to incontinence and immobility. The goal was for the resident to maintain or develop intact skin with the invention of inspecting skin morning and evenings and during showers or ADL care, also, to document each incident of skin problems to prevent further occurrences. Record review of Resident #3's MDS, dated [DATE], revealed the resident had an incomplete BIMS score, indicating assessment of cognition level was unable to be done or the resident was rarely/never understood, and was a two+ person assist for bed mobility and transfers. Record review of Resident #3's weekly skin assessments revealed the resident was noted to not have any skin issues on 01/07/22, 01/14/22, and 01/21/22. Record review of Resident #3's skin monitoring/shower review sheets revealed on 01/22/22, the resident was noted to have a wound on sacrum by CNA R. This review was signed off by an unidentified nurse. Record review of Resident #3's nurses notes revealed no notes were written concerning resident skin condition from 01/21/22 to 01/25/22. Record review of Resident #3's weekly wound assessment, dated 01/26/22, revealed a new stage 3 pressure wound on her coccyx measuring 0.4cm by 0.5cm by 0.1cm with an open wound bed with moderate, clear exudate. Treatments for this wound included calcium alginate, daily wound treatment and low air loss mattress. The resident's physician and family member were notified on this date. Record review of Resident #3's weekly wound assessment, dated 01/26/22, revealed a new stage 3 pressure wound on her sacrum measuring 3.1cm by 4.2cm by 0.1cm with an open wound bed with moderate, clear exudate. treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's physician and family member were notified on this date. In an interview with the Wound Care Nurse on 02/24/2022 at 10:54AM, she stated she was the main wound care and treatment nurse that stages the wounds during assessments. Other nurses' duties for wound care are to document on resident skin discoloration, open skin, redness and any change of conditions should be notified to her. She stated the date 01/26/2022 was when she was made aware of Resident #3's wounds. She stated wounds can happen overnight, especially with the resident not getting adequate nutrition or is experiencing a decline. She stated she does not go through the shower sheets but they usually verbally report to her if there are resident skin concerns. She stated she could not remember if she was notified about Resident #3's wound by another nursing staff or if she caught it during routine weekly assessments. She stated she was unaware of the note on the wound on sacrum made on Resident #3's skin shower sheet, dated 01/22/22 but based on the timing of the documentation, there was a delay in treatment if no assessment was done on that day. She stated the consequences of not documenting and communicating skin concerns could lead to possible neglect of the health of the resident. A phone interview was attempted with CNA R on 02/24/22 at 12:16PM. Both attempts failed. In an interview with the CNA M on 02/24/22 at 11:34AM, she stated she had given Resident #3 a shower and if she were to see any skin issues such as redness, or marks, she would notify her charge nurse because she knew it could have the potential of developing into a wound. She stated sometime in January, date unknown, she remembered notifying a charge nurse, likely LVN R but she was not sure, about seeing a red mark on her butt and got the nurse to assess it. She stated there was no open skin at that time but the charge nurse applied A&D ointment and said it was okay. She said the charge nurse thanked her for letting her see it and walk out of the room, she did not know if anything was done afterwards about it. In an interview with CNA D on 02/24/22 at 11:45AM, she stated, she had worked with Resident #3 and gave the resident a bed bath, date unknown. She stated remember while doing her bed bath at one point, the resident's back looked red on the middle part of her back and on the side of her cheek, but there was no sore on it. She stated she notified her charge nurse, unsure which nurse, and put A&D ointment on the resident. She stated she forgot to note anything on her shower sheet indicating the redness and where it was located. She said it slipped her mind to do it but generally it was supposed to be done. In an interview with LVN R on 02/24/22 at 1:50PM, she said she did not sign off on any of the shower sheets from 01/18 /22 - 01/25/22. When asked if she was expected to sign it, she said sometimes the sheets can go unsigned for up to two days because they rushed and dropped it in the resident's room, so she and nurses will sign it later based on seeing if it appears as if the resident had a bath. She said around the time the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she went to look at the patient and saw no broken skin but it just looked like she was laying on her side too long. At the moment she remembers applying A&D ointment and as she came out of the room, she saw the Wound Care Nurse and notified her at that time about the redness. She stated she did not document her findings because the Wound Care Nurse is usually good about following up on the resident's skin conditions. She said she was unaware of the shower sheet written on 1/22/22 that noted the wound on Resident #3's sacrum. She said based on the time the note was made and the assessment was documented 1/26/22, she recognized there was a delay in communication. She said she remembered on a Monday, 01/24/22 she had said to herself how come no one said that this woman's butt is red . Oh, so nobody said anything throughout the weekend? She stated the expectation of CNAs were to report skin abnormalities to her. She stated that she, as the charge nurse, she was supposed to notify the physician and family and the wound nurse all verbally or over the phone, but she did not document it because she would only take full responsibility of assessing and documenting skin concerns unless the Wound Care Nurse was not in the building at the time. She said in the nursing field if she did not write it down it meant she did not do it. In an interview with the DON on 02/24/22 at 4:00PM, she stated nursing care to prevent skin breakdown includes turning, more frequent changes, use of cream A&D and zinc ointment. She said Resident #3 used to get up but resident stopped eating because she was grinding her teeth and could no longer open her mouth, and as a result, she had peg tube placed in February 2022. She stated due to Resident #3's decline with weight loss, the bony areas become more prominent placing her at risk for skin breakdown. She said redness of the skin is usually the first sign for skin breakdown and if CNAs saw it, they are expected to document on the shower sheet and notify the nurse, the nurse is expected to notify the doctor and who would place a standing order for wound care. She stated the nurses are responsible for noting skin concerns and if the skin is open, the nurse should notify the doctor, and put in an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she was not notified of resident having red skin before the Resident #3's was diagnosed with stage 3 wounds. She said the nurse on duty at the time the wound was first noted should have had the order placed that day and dress the wound herself. She stated the Wound Care Nurse wound be responsible for re-assessing the wounds with measurements and provided additional treatments if necessary. She stated based on the timing from which the wound was first noted on the shower sheet to when the wounds were assessed, there was a delay in the provision of care or care the was not being documented at all. She said the implication of not documenting the development of a wound and relying on wound care to make all assessments is a delay in treatment. Observation of Resident #3's wound care on 02/25/22 at 11:09AM, one sacral wound 8 by 5 cm with eschar tissue in the center and white skin on the edges of the wound. Record review of the facility's policy on Skin Management System, undated, stated, . Routine weekly checks will be completed on the Skin observation Tool on every resident; if skin is intact it will be noted as such. If a new pressure sore is noted, a Weekly Wound Observation Form will be started CNA's will note any alteration in skin integrity during care in [EHR] and reported to the Charge Nurse . Keep open lines of communication with physicians, families, and residents regarding status of wounds.

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 in following CDC guidelines for COVID-19 for 4 of 6 residents (Resident #1, #3, #4, and #5) reviewed for infection control. The facility failed to implement interventions to prevent the potential spread of COVID-19 when it failed to screen staff appropriately upon entering the facility. The facility failed to ensure staff who were experiencing symptoms of COVID-19 were not allowed to work. The facility failed to ensure staff who began experiencing symptoms of COVID-19 while working were immediately sent home . The facility failed to trace possible contact of both resident and staff who were exposed to positive staff. The facility failed to quarantine residents who were readmitted from the hospital and failed to quarantine residents who received [MEDICAL TREATMENT] outside the facility. The facility failed to have appropriate PPE readily available for staff when entering quarantine rooms. An Immediate Jeopardy (IJ) was identified on 5/13/2020. While the IJ was lowered on 5/16/20, the facility remained out of compliance at a scope of pattern and severity of actual harm that is not immediate jeopardy while they continued to monitor their plan of removal. These failures could affect all residents in the facility and placed them at risk of contracting COVID-19 resulting in possible serious illness or death. Findings Include: Record review of provider investigation report dated 5/10/20 revealed LVN A tested positive for COVID-19. Several addendums were made throughout the investigation beginning 5/13/20 to include a total of 7 positive staff members and 8 positive residents. Record review of LVN A's timesheet revealed she worked on 5/4 from 7 am to 2:26 pm, 5/5 from 7:05 am to 3:12 pm, and 5/7 from 6:51 am to 3:14 pm. Record review of LVN A's screening checklist dated 5/4/20 revealed she did not indicate any symptoms related to COVID-19 on the form. Her temperature was recorded as 96.9 degrees Fahrenheit. Record review of LVN A's screening checklist dated 5/5/20 revealed she did not indicate any symptoms related to COVID-19 on the form. Her temperature was recorded as 97.1 degrees Fahrenheit. Record review of LVN A's screening checklist dated 5/7/20 revealed she did not indicate any symptoms related to COVID-19 on the form. Her temperature was recorded as 96.8 degrees Fahrenheit. During a telephone interview on 5/11/20 at 9:35 am, LVN A said she started having a cough and headache around 5/4 but did not tell anyone or indicate it on her screening when entering the facility. She said she had an itchy throat on 5/6, called in, and got tested for COVID-19 to rule it out. She said she spoke with the Scheduler and told her she was not feeling well. She said she did not remember if she told the Scheduler the symptoms she was having and did not tell anyone she was tested because she did not like people in (her) business. She said she went to work on 5/7 because she did not believe she had COVID-19 and again did not indicate symptoms on the screening. She said she received results on 5/9 that she was positive and informed the facility. She said she did not remember if she spoke with the DON. She said she was to report if a test was positive. During an interview on 5/11/20 at 10:00am, the DON was asked about LVN A the DON said she talked with LVN A at the end of shift 5/7 and was told she was having a sore throat and cough. When asked why LVN A was allowed to return to work after calling in on 5/6 she said she was not aware LVN A called in. During an interview on 5/15/20 at 3:00 pm, the Scheduler said she was over clinical records, central supply, and staffing but also a nurse. She said she had been the on-call manager for the past 3 weeks. She said when a staff member calls in she asked what their symptoms were then notify the DON and Administrator. She said they were having multiple call-outs on the same hall with similar symptoms. She said LVN A called out on one day for personal reasons then again two days later due to a cough, fever, and sore throat. She said she last worked on Unit B on the 12th since LVN A was out. Observation on 5/11/20 at 8:25 am revealed residents scattered throughout the facility. Some residents were sitting outside of their rooms, while most of them were inside their rooms. There was a group of 5 residents sitting near the nursing station not [MEDICATION NAME] social distancing. Most residents were observed wearing surgical masks. Resident #1 Record review of Resident #1's face sheet dated 5/11/20 revealed a [AGE] year-old female admitted to the facility on [DATE] with a recent readmitted d of 5/6/20. Her [DIAGNOSES REDACTED]. Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. She required extensive assistance of two people for all ADLs except for eating. Record review of Resident #1's COVID-19 test dated 4/28/20 revealed the test was negative and verified on 4/29/20. Observation and interview on 5/11/20 at 8:25 am during a tour with the Administrator and DON. When asked where quarantined residents rooms were located, the DON said Unit B (hallway 200). There was one resident room located on 200 hallway (Unit B) with PPE outside of the room. The DON said the room belonged to Resident #3 who was recently readmitted from the hospital and on 14-day quarantine. When asked if there were any other residents on quarantine the DON said Resident #1. Further observation of Resident #1's room at that time revealed no PPE outside of the door or indication that she was on isolation. Resident #1 was not inside her room. The DON said she was out at [MEDICAL TREATMENT]. The DON said those were the only residents she knew of that were on quarantine. During an interview on 5/11/20 at 10:00 am, the DON said if a resident tested negative twice for COVID-19 while in the hospital they were readmitted without any isolation precautions. She said if a resident tested negative once, they were readmitted on 14-day quarantine on droplet precautions. She said staff were required to wear a face mask, gown, and gloves in rooms with residents on droplet precautions. She said the facility had N-95 masks, but they had not issued out any to staff yet. She said most staff on Unit B had face shields. When asked what type of isolation precautions Resident #1 was on the DON said she should be on droplet precautions. When informed there was no PPE outside of her room the DON said We talked about it this morning. It's there now. She said all residents were being screened every shift and none currently had symptoms related to COVID-19. Record review of Resident #1's physician orders [REDACTED].>- [MEDICAL TREATMENT] on Mondays, Wednesdays, and Fridays ordered on [DATE] - Droplet precautions ordered 5/12/20. Observation and interview on 5/13/20 at 10:57 am revealed Resident #1 wearing a mask, being pushed into the facility by two transportation workers. Her room was located on the 200 hallway. Observation and interview on 5/11/20 at 1:35 pm revealed CNA A walking on the 200 hallway wearing gloves. He turned around and went down the hallway and removed them and put them in his hand. His cloth mask was observed covering his mouth, but not his nose. When asked why he was wearing gloves on the hallway he said he normally did not wear them on the hallway, but he was rushing and forgot to take them off. He adjusted his mask to cover his nose. Observation and interview on 5/11/20 at 1:40 pm, the DON was standing in the doorway talking with another staff members. Her mask was observed underneath her chin. She pulled the mask over her mouth and nose. She said residents on isolation/quarantine eat in their room using regular plates and silverware. When informed quarantined residents should be using disposable plates, utensils, and cups she nodded her head. Resident #4 Record review of Resident #4's face sheet dated 5/11/20 revealed a [AGE] year-old male admitted to the facility on [DATE] with a recent readmission date of [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #4's admission MDS dated [DATE] revealed a SAMS was conducted and he was coded as having moderately impaired cognition. Record review revealed he was totally dependent on one staff for most ADLs. Record review of Resident #4's nursing note dated 5/7/20 revealed he was readmitted to the facility from the hospital. Record review of Resident #4's physician orders [REDACTED]. Observation on 5/11/20 at 10:28 am revealed Resident #4's room located on the 100 hallway. He shared a room with one other resident. There were no indications that the residents were on isolation precautions and there was no PPE located outside of the room. Both Resident #4 and his roommate were asleep in their beds. During an interview on 5/11/20 at 11:30 am, the DON said Resident #4 was not on isolation precautions because He went to the emergency room and came back. When they go to the emergency room and come back we don't typically isolate. She further said the resident was not isolated because he was not admitted to the hospital. Record review of Resident #4's clinical chart on 5/13/20 revealed no COVID-19 testing results. Record review of testing results of COVID-19 dated 5/14/20 revealed Resident #4 was positive for COVID-19. Resident #5 Record review of Resident #5' face sheet dated 5/15/20 revealed a [AGE] year-old male admitted to the facility on [DATE] with a recent readmission date of [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #5' quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating in-tact cognition. Record review revealed he required extensive assistance of one staff for most ADLs. Record review of Resident #5' Hospital to Post-Acute Care Facility Transfer COVID- 19 assessment dated [DATE] revealed he was tested on [DATE] and had a negative result. His primary [DIAGNOSES REDACTED]. Record review of Resident #5' physician orders [REDACTED]. Observation on 5/11/20 at 10:30 am revealed Resident #5' name and roommate's name outside the door located on the 100 hallway. Neither residents were in the room. There was no PPE located outside of the room or a sign indicating the residents inside were on isolation. Residents were somewhere in the facility. During an interview on 5/11/20 at 11:30 am, the DON said she was not aware residents on [MEDICAL TREATMENT] should be on quarantine. The Don was asked what was the criteria for quarantine, she said Residents admitted /readmitted from the hospital should be quarantined . Observation and interview on 5/13/20 at 8:42 am, the receptionist was observed putting masks into brown bags. She was not wearing a mask. When approached she said the mask wouldn't stay on. Observation and interview on 5/13/20 at 8:45 am revealed CNA B dragging a bag of dirty linen on the floor on the 200 hallway. When asked what training she received on infection control she said dirty linen was to be placed in a bag and taken to the laundry. She said the bag should not be dragged because the contents could get on the floor. She said they were also trained on washing hands before/after care and before/after donning gloves. Observation on 5/13/20 at 8:52 am revealed the following rooms with isolation precautions 202, 204, 206, 217, and 314. There were stop signs that said to see a nurse before entering with PPE located outside of the rooms. Observation and interview on 5/13/20 at 8:55 am revealed Housekeeping Aide inside room [ROOM NUMBER] cleaning with gloves on. She stepped out into the hallway, grabbed a broom and dustpan and began sweeping in front of the room. She put a wet floor sign down, took off the gloves, and threw them away in the housekeeping trash can. She put on new gloves without hand hygiene. An interview was attempted but she said she did not speak English. She was wearing a regular surgical mask. During an interview on 5/13/20 at 12:30 pm, Housekeeping Manager said he had been in the position for 2 years. He said he already was informed about the Housekeeping Aide wearing gloves in the hallway. He said he told the staff they should take their gloves off after leaving the room and wash their hands every time they go in and out of a room. He said the Housekeeping Aide should know better because she had been working in the facility for 7-8 years. When asked how he communicated with staff who did not speak English, he said he had to use a translator to communicate on his phone. When Housekeeping Manager was asked about training provided to Housekeeping Aide, he said staff are constantly being trained and she was aware of the proper protocol. Observation and interview on 5/13/20 at 9:05 am revealed CNA C put on gloves and enter room [ROOM NUMBER]. She was wearing a surgical mask. She exited the room, took off her gloves, and threw them away in the housekeeping trashcan. She said she worked in the facility for 1 year and 4 months. When asked what type of PPE is necessary when entering rooms with residents on isolation she said, it depends on the type of isolation. When asked what type of isolation the resident was on she said she did not know. She said, I just wanted to give him his medicine. She looked at the PPE outside of the door and said, I could have worn a gown. She said she passed medicine for the whole unit and there was only one other resident on isolation precautions (Resident #2 ) She said she was not sure what type of isolation precautions that resident was on either. When asked the proper procedure for throwing away gloves she said for residents on isolation they should be thrown away in a red biohazard bag. During an interview on 5/13/20 at 9:30 am, the DON said asymptomatic staff who have been tested can continue to work while test results were pending. She said if the staff is symptomatic they must wait until negative results are given to continue to work. She said there was no policy on this, they went by HHSC guidance. She said the two ADONs and herself were conducting ongoing infection control training. When asked when staff should gown up for residents on isolation she said, if they go inside the room. She said staff would have to ask the nurse what type of isolation residents are on. She said gloves were not to be worn in the hallway. They were to be removed while in the resident's room and hand hygiene should be performed immediately after. She said the Housekeeping Manager was trained on infection control who then would train his staff. She said no residents were currently displaying any symptoms. When asked her expectations on masks she said, All staff have to have on a mask at all times. Observation and interview on 5/13/20 at 10:54 am revealed an unidentified staff member walking inside the building. The Receptionist asked, Did you ask all the questions? Hospitality Aide said, No ma'am. The Receptionist said, You've got to ask all of them. Hospitality Aide said he had been doing the screening for a couple of weeks. A transportation company pulled up and got Resident #1 out of the back. They came into the facility and the Hospitality Aide asked the two transporters to sanitize their hands. He asked Do you have any of these symptoms? Have you traveled? He then took the temperatures of the transportation workers and allowed them to enter. The questionnaire was not provided to be completed. During an interview on 5/13/20 at 11:05 am, the Receptionist said the expectation was that masks be worn at all times by all staff. She said she took her mask off if she was doing something with her mouth, but the masks irritated her ears. Record review of Medication Aide F's timesheet revealed she worked 5/6 from 6:37 am to 8:37 pm and 5/7 6:40 am to 2:25 pm. Record review of the nursing schedule dated 5/13/20 revealed Medication Aide F was scheduled to be the medication aide for unit B. During a telephone interview on 5/13/20 at 11:50 am, Medication Aide F said she last worked on Thursday 5/7/2020 from 6:30 to 2 pm. She said shortly after clocking in she noticed her chest hurt while pushing the med cart and asked for relief around 7 am on 5/7/20 from the Scheduler. She said she also had diarrhea, vomiting, and heaviness in chest. She said she reached out to her physician because she thought it was her sinuses and was advised to get tested for COVID-19. She said she got tested on the 9th, but did not expect it was positive, because she did not know anyone else was positive in the facility. She said she got results back on 5/12 and they were positive. She said she sent an email to HR that she was getting tested said she would relay to the DON. She said she talked to the DON yesterday ( 5/12/20 ) and told her the test was positive. She said the DON told her she had to go through the protocol and test negative twice before returning to work. During an interview on 5/13/20 at 12:18 pm the Administrator and DON were present. When asked again if any new staff or residents had tested positive the Administrator said no. The Administrator said both ADONs left Monday and got tested due to not feeling well. He said the Activities Director was not feeling well and tested herself on 5/12 due to having a low-grade temperature and body aches. He said the MDS coordinator said she was feeling dizzy, headache, feeling sick today and left to get tested . When the DON was asked if she was aware of any new positive cases she said mhm mhm. When asked why Medication Aide F wasn't at work the DON said because she was being tested for COVID-19. When informed that Medication Aide F said she spoke with the DON about her positive results the day prior she said, She didn't talk to me. The Administrator said, I wasn't aware of her testing positive. The DON said, I know that she got tested on the 9th. During an interview on 5/15/20 at 3:00 pm, the Scheduler said Medication Aide F was sick in the facility on the 7th and was sent home around 12 pm. She said Medication Aide F never told her she was feeling sick or she would have sent her home immediately. She said she saw Medication Aide F trying to pass medications sitting down and asked her what was going on. She said She just wasn't looking right. When informed Medication Aide F's timesheet indicated she clocked out at 2:25 pm she said, She had to finish up on med pass and clean up the cart. She said she told the Administrator and DON that Med Aide F was sent home because she was sick. Record review of the Activities Director's timesheet revealed on 5/12/20 she clocked in at 7:52 am and clocked out on 7:57 am. Record review of the Activities Director's Screening Checklist dated 5/12/20 revealed no indicated symptoms related to COVID. Her temperature was recorded as 98.2. During a telephone interview on 5/13/20 at 12:40 pm, Activities Director said she last worked on Monday 5/11/2020 and felt fine. She said she woke up Tuesday morning feeling a little achy in her knees and shoulders. She said she never felt that before but thought maybe I could fight it off. She said she came to work and did the screening and her temperature was 98 degrees which was slightly higher than normal. She said something did not feel right and went to her car and called around to see if she could get tested . She said she did not want to expose the residents if she did have COVID-19, so she did not enter the building. She said she already had an appointment for 5/16 because The fact that I was exposed scared me. She said she spoke to the DON and the Administrator and told them she wasn't feeling well, and they advised her to go home. During an interview on 5/15/20 at 2:55 pm, the Administrator said the Activities Director called and said she wasn't going to go inside the building because she didn't feel well. When informed the Activities Director's timesheet indicated she clocked in he called the Activities Director and asked her if she came into the building on 5/12/20. He said, She came in, clocked in, and had somebody clock her out. He said he was under the impression she never came inside. When asked the protocol for calling in sick, the Administrator said the staff will call the on-call manager who would try to find a replacement. If the on-call manager was unable to find a replacement, the staff was expected to still come in. Record review of Center for Medicare and Medicaid Service (CMS) Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes (REVISED) 3/13/2020 revealed facilities should follow CDC guidelines for restricting access to health care workers. Implement active screening of residents and staff for fever and respiratory symptoms. Remind residents to practice social distancing and perform frequent hand hygiene. Screen all staff at the beginning of their shift for fever and respiratory symptoms. Actively take their temperature and document absence of shortness of breath, new or change in cough, and sore throat. If they are ill, have them put on a facemask and self-isolate at home. Provide instruction, before visitors enter the facility and residents' rooms, provide instruction on hand hygiene, limiting surfaces touched, and use of PPE according to current facility policy while in the resident's room. Individuals with fevers, other symptoms of COVID-19, or unable to demonstrate proper use of infection control techniques should be restricted from entry. Facilities should communicate through multiple means to inform individuals and non-essential health care personnel of the visitation restrictions, such as through signage at entrances/exits, letters, emails, phone calls, and recorded messages for receiving calls. Facilities should identify staff that work at multiple facilities (e.g., agency staff, regional or corporate staff, etc.) and actively screen and restrict them appropriately to ensure they do not place individuals in the facility at risk for COVID-19. Facilities should review and revise how they interact vendors and receiving supplies. Record review of the facility's COVID-19 Preparation Plan and Guidance dated 4/20/20 revealed for admissions/readmissions Identify and implement a designated area. This will be your quarantine area where all new admissions and/or readmissions will be quarantined for 14 days to ensure they are not suspected of having COVID-19 and are kept away from the general population. If a new admission and/or readmission has 2 negative COVID-19 tests prior to admission to our community, that will suffice as a COVID-19 negative resident and that resident does not need to be quarantined/isolated for 14 days. All residents in this quarantine area will be placed on droplet precautions and treated as if they are COVID-19 positive. The quarantine ideally would have a designated team member(s) to care for these residents so that cross contamination will not occur with the general population, but if that is not possible due to the community staffing patterns, the community will have to ensure infection control practices are well maintained between the quarantine hall and general population. At a minimum, the PPE required will be surgical face masks and gloves. Disposable isolation gowns will be used for high risk residents and who show symptoms and/or required procedures that would generate droplets on team members clothing. Washable hospital gowns can be used as a barrier when disposable isolation gowns are limited. Face shields will also be encouraged for team members working this quarantine area. Residents without symptoms for the duration of the 14 days will be relocated to a room within the general population after the 14-day quarantine after a discussion with the resident's physician. Record review of the facility's undated protocol for suspected resident with COVID-19 revealed the following: 1. Immediately put a regular facemask on resident. Transfer the patient to a private room. 2. Initiate droplet and contact isolation. 3. Contact Department of Health immediately. 4. Minimize traffic into the resident's room. A dedicated nurse should be assigned to the case. 5. Use dedicated equipment available in the room. 6. Limit resident movement outside the room. Avoid any unnecessary diagnostic tests. 7. No visitors allowed in the room. 8. Use disposable equipment whenever possible. If disposable equipment is not available, disinfect with viricidal agent after use. 9. In the case of a roommate of someone who tests positive for COVID-19, asymptomatic roommates are likely already exposed, so you can either move the roommate to a private room with droplet and contact precautions or allow them to stay in place if the risk of spreading [MEDICAL CONDITION] is greater by moving the roommate. 10. As long as the community can manage the resident, there is no need to transfer the resident to a hospital. Always consult with the resident's physician and alert him/her if you can't manage resident's respiratory status or if there are additional medical interventions that you can't provide at the community, including a negative pressure room. Record review of undated Texas Notifiable Conditions from the Texas Department of Health and Human Services revealed Report all confirmed and suspected cases. Record review revealed confirmed and suspected cases of COVID-19 were to be reported immediately. Record review of the facility's undated Infection Control Policy revealed It is the policy of this facility that standard precautions will be observed at this facility to prevent contact with blood or other potentially infectious materials. All blood or other potentially infections materials will be considered infectious regardless of the perceived health status of the source of the individual. This includes barrier protections for healthcare workers such as gloves, gowns, masks, and goggles when exposure to blood or body fluids, secretions and excretions, nonintact skin, or mucus membranes is anticipated. Also, now included in standard precautions are respiratory hygiene/cough etiquette and safe injection practices. Record review revealed physician order [REDACTED]. Determine necessary PPE. Add signage to door - 'Contact nurse prior to entering.' Cart will be placed outside resident room. Add isolation to care plan. These failures resulted in an Immediate Jeopardy (IJ). The facility Administrator and DON were notified of the IJ on 5/13/20 at 4:25 pm and a plan of removal (POR) was requested at that time. The IJ template was provided to the Administrator at that time. After several revisions, the Plan Of Removal (POR) was accepted on 5/15/2020 at 11:08am. The POR read in part: Inservice screening protocol. All assigned screeners will be re-trained on the screening process and will be given a competency to ensure they will follow all COVID-19 Infection Control protocols related to screening all employees, and visitors. Screeners will not be allowed to screen until they have been trained and completed the competency. All new screeners hired by the facility will be trained and provided the screening competency during the orientation process. Staff will be in serviced on how to complete screening questionnaire appropriately and accurately answer questions regarding COVID19 related symptoms that they may be experiencing or have experienced in the last 24 hours. Staff will be screened prior to starting their shift daily. All staff will be in serviced on symptoms of COVID-19 and to immediately report any symptoms noted to the Director of Clinical Operations or designee. Director of Clinical Operations or designee will immediately send staff member home and request that staff member be tested for COVID-19 and notify Director of Clinical Operations of results. Staff member will not be allowed to return to work pending results. Nursing administration staff will be in serviced that the on-call staff member or designee will report any team member that calls in sick to the Director of Clinical Operations and/or the Executive Director. The team member will be required to bring a written release to return to work from their MD. The Director of Clinical Operations will track the progress of the individual and ensure that they do not return without following the proper procedures. Inservice will be completed on 5/15/2020 Staff will be in serviced that anyone tested for COVID-19 outside of the community must immediately report to the Executive Director and/or the Director of Clinical Operations. Staff with symptoms will not be allowed to work pending results. The Director of Clinical Operations will follow the CDC's guidance on when to allow the team member to return to work, both test-based and non-test-based strategy. Inservice will be completed on 5/15/2020. Director of Clinical Operations or designee will trace any staff member and/or residents that have come into contact with any symptomatic individual or any who have tested positive by assessing the residents on the unit the person with symptoms worked on. Director of Clinical Operations or designee will review scheduled assignment that day to identify any staff that may have worked with the potentially affected persons. Daily screening will be completed, and full PPE will be utilized to prevent any further spreading of [MEDICAL CONDITION]. The MA and LVN are currently out on quarantine and will be in serviced upon return. On May 14th, 2020, the Regional Director of Clinical Operations in serviced the Director of Clinical Operations on COVID-19 infection control protocols to include staff with symptoms that are awaiting results are not allowed to return to work. Director of Clinical Operations will follow the CDC's guidance when to allow team members to return to work, both test-based and non-test-based strategy. Documentation of training will be kept in the Director of Clinical Operations employee file. The screener will report to the Executive Director of Operations and/or Director of Clinical Operations immediately at the time of screening of any individual that claims to have any s/s COVID-19and that individual will be not be allowed to enter community and we will provide further direction per telephone. Inservice staff that new admissions and readmissions will return on droplet precautions on the designated quarantine unit. The facility has designated Hall 300 (311-316) as the quarantine hall, which will house all new admission, all re-admission, any resident who goes out on pass to an appointment, or [MEDICAL TREATMENT], etc. Residents #1, #2, #3 and #4 were all relocated to Hall 300 and they will remain in quarantine for at least the next 14 days, and all will have the appropriate PPE located outside of the room. Resident #1 and #2 who go out to [MEDICAL TREATMENT], will remain on the quarantine hall indefinitely. Residents that were relocated to the quarantine hall had rooms deep cleaned on May 13th by housekeeping. We will use designated staff to the best of our ability. Education was provided on 5/13/20 by the Regional Vice President of Operations on the facility's policy and procedure on placing all new admissions and readmissions on the quarantine hall for at l (TRUNCATED)