Every finding on record at Focused Care at Midland

Based on interviews and record reviews, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 17 days of 90 days reviewed nursing services.The facility failed to have a registered nurse working on multiple dates when reviewed nursing staff coverage for the most recent 3 months, from May 2026 to July 2026.This failure could place residents at risk of not receiving advanced nursing skill of a registered nurse.Findings included:Record review of the Nursing Staffing Sheets for the last 3 months, from May 2026 to July 2026, revealed the following days with no RN coverage:May 2026: The following Nursing staffing sheets: Saturday 05/02/2026, Saturday 05/16/2026, Saturday 05/30/2026, and Sunday 05/31/2026, notated under 6 AM - 6 PM 'Nurse,' LVN Q and LVN R were listed; Under 6 PM - 6 AM 'Nurse,' LVN S and LVN T were listed.June 2026: The following Nursing staffing sheets: Monday 06/08/2026, Friday 06/12/2026, and Friday 06/26/2026, notated under 6 AM - 6 PM 'Nurse,' LVN Q and LVN R were listed; Under 6 PM - 6 AM 'Nurse,' LVN S and LVN T were listed.July 2026: The following Nursing staffing sheets: Monday 07/06/2026, Friday 07/10/2026, Saturday 07/11/2026, Sunday 07/12/2026, Monday 07/20/2026, Tuesday 07/21/2026, Saturday 07/25/2026 and Sunday 07/26/2026, it was notated under 6 AM - 6 PM 'Nurse,' LVN Q and LVN R were listed; Under 6 PM - 6 AM 'Nurse,' LVN S and LVN T were listed. Nursing Staffing Sheet 07/24/2026 Friday 07/24/2026 notated under 6 AM - 6 PM 'Nurse,' LVN Q and LVN R were listed, and; LVN U covering from 6 AM - 10 AM. Under 6 PM - 6 AM 'Nurse,' LVN S and LVN T were listed. In an interview and record review of the Nursing Facility policy on 08/12/2026 at 03:03 PM with the Regional Director of Clinical Operations, she stated the DON counted toward the RN coverage hours. She provided the Regulation and policy the Nursing Facility used in reference. Record review of the Nursing Facility's policy with no title, that read in part: The requirement for 8 consecutive hours of RN services can be met by any RN or multiples of RNs. The hours worked by the DON would be considered applicable towards the requirement.In an interview on 08/13/2026 at 11:51 AM with RN P, he stated it was important for a Nursing Facility to have a Registered Nurse on-site because a Registered Nurse had a broader scope of practice such as declaring time of death. RN P stated it was a safety concern for residents to have a Registered Nurse work daily, at least 8 hours a day.In an interview on 08/13/2026 on 07:08 PM with the Administrator, she stated she believed the DON covered the RN coverage hours. She stated the importance of having an RN on-site was because an RN had a broader scope of practice and responsibilities. The Administrator it could potentially place residents at risk but declined to elaborate on type of risk.Record review of the Nursing Facility's policy with no title, that read in part: The facility must designate a registered nurse (RN) to serve as the DON on a full-time basis. Additionally, the facility may permit the DON to serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. Under Probes related to the full-time DON requirements, it continued to read, If the facility's average daily census is greater than 60 residents, and the facility indicates that the DON does serve as the charge nurse, F727 must be cited at a minimum of scope and severity of F.CFR S 483.35(b)) requires skilled nursing facilities to have an RN on duty for at least 8 consecutive hours per day, 7 days a week.

Based on observation, interviews and record reviews, the facility failed to implement policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety for 4 (Resident #1, Resident #2, Resident #3 and Resident #4) out of 10 residents reviewed for smoking.The facility failed supervise Resident #44 and Resident #47 when smoking in the nursing facility's designated smoking area on 08/11/26.This failure could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment.Findings included:Record review of Resident #44's face-sheet dated 08/13/26 revealed a [AGE] year-old male resident with initial admission date 04/11/2022 and re-admission date 07/31/2026. Record review of Resident #44's history and physical dated 07/09/2026 revealed past medical history of: paraplegia (paralysis of the legs, causing loss of sensation or movement of the legs), and tobacco use. Record review of Resident #44's Quarterly MDS dated [DATE] revealed a BIMS of 7, indicating severe cognitive impairment. The Quarterly MDS revealed Resident #44 had an active diagnosis of tobacco use. Record review of Resident #44's care plan with revision date 08/07/26 revealed the resident was a smoker that included the following interventions: resident to smoke in designated smoking areas with access to appropriate smoking receptacles.Record review of Resident #44's smoking and safety assessment dated [DATE] revealed resident was a tobacco smoker. Record review of Resident #47's face-sheet dated 08/13/2026 revealed a [AGE] year-old female resident with an admission date 03/12/2026.Record review of Resident #47's history and physical dated 02/19/2026 revealed past medical history of tobacco use.Record review of Resident #47's Quarterly MDS assessment dated [DATE] revealed a BIMS of 7, indicating a severe cognitive impairment. The Quarterly MDS did not include Resident #47's tobacco use.Record review of Resident #47's care plan dated 04/23/2026, revealed it did not include the resident's smoking preference.Record review of Resident #47's electronic medical chart revealed there was no smoking assessment.Interview with the Nursing Facility Administrator and record review of a smokers list dated 05/21/26 provided by the Nursing Facility Administrator on 08/11/2026 at 3:00 PM, she stated it was the most recent list. The smokers list revealed a total of 33 residents including a handwritten name, Resident #7, admission date 06/26/2026. The smokers list did not include Resident #47.In an observation and interview on 08/11/2026 at 12:10 PM, Resident #47 was observed coming from the designated smoke area that was located in the back of the main dining room. Resident #47 was accompanied by their family member, and they stated they had just finished their smoke break. Resident #47 stated she was smoking outside in the smoking area with her family member alone and stated there was no staff present. Resident #47 stated she smoked at least daily, sometimes multiple times a day. In an observation on 08/11/2026 at 12:15 PM, a sign was posted outside of the door leading to the outside designated smoking area, which read: Smoking Schedule: 8:00 AM Kitchen Staff, 10:00 AM Activity Assistant, 1:00 PM Housekeeping staff, 2:30 PM Social Service, 4:30 PM Activity Director, 6:00 PM CNA, 7:30 PM CNA, All resident smoking must be supervised by staff. Residents are not permitted to carry or keep lighters in their possession under any circumstances. In an observation and interview on 08/11/2026 at 3:20 PM, Resident #44 was observed smoking a tobacco cigarette in the designated smoking area with no staff or other residents present. Resident #44 stated he smoked daily, and staff was not always present during his smoke breaks.In an interview on 08/12/2026 at 11:37 AM with the Social Worker, he stated residents were to smoke with supervision in the designated smoking area. The Social Worker stated the nursing staff were responsible for completing smoking assessments for residents and there was staff assigned for every smoking break. The Social Worker was unsure if only staff were to supervise residents, and stated residents did smoke with family or friends when visiting. The Social Worker stated the potential risks of a resident smoking unsupervised or without a smoking assessment included potential injury to the resident with burning themselves. In an interview on 08/13/2026 at 10:04 AM with CNA E, she stated all lighters and cigarettes were to be kept in the nurse's station in a locked box. CNA E stated only staff were were provide residents with a cigarette during scheduled smoke breaks. CNA E stated she was unsure who was responsible for conducting the smoke assessments on residents, but CNA and other staff were provided a smokers list containing a list of residents allowed to participate in the scheduled smoke breaks. CNA E stated she was unsure if family were allowed to supervise residents instead of staff supervising residents. CNA E stated the potential risk of residents smoking unsupervised or being allowed to smoke without a smoke assessment being completed included injury or burns.In an interview on 08/13/2026 at 11:42 AM with RN P, he stated the nurses were responsible for completing residents' smoking assessments during admission to the nursing facility or when the resident verbalizes desire to smoke. RN P stated residents were not allowed to smoke in the nursing facility smoking area until the resident had a smoking asessment complete due to potential risk of harming themselves. RN P stated it was important to accurately add resident information such as if the resident was a smoker so the staff could be aware of that preference. RN P stated staff also needed to be aware if the resident was able to smoke safely, which was done with a smoking assessment.In an interview and record review on 08/13/2026 at 1:36 PM with the MDS Nurse, he stated he reviewed Resident #47's documents and did not locate a smoking assessment, and he did not have Resident #47 noted as a smoker. The MDS Nurse stated he was unaware Resident #47 was a smoker and if he was aware he as the MDS nurse would be responsible for adding it into the resident's care plan and conduct a smoking assessment. The MDS Nurse stated the nurses were responsible for adding and assessing for the resident being a smoker during admission into the nursing facility, or as needed, such as the resident stating they want to smoke. The MDS Nurse stated the MDS and resident's plan of care were revised every 3 months or as needed for changes of conditions. The MDS Nurse stated a resident participating in smoking without having the smoking assessment could potentially burn themselves.In an interview on 08/13/2026 at 2:29 PM with the DON, she stated the nurses were responsible for completing a smoke assessment on all residents upon admission into the nursing facility. The DON stated residents were then reviewed for smoking during every quarter, or as needed. The DON stated residents needed smoking assessments so they could be determined whether they were safe to smoke. The DON stated the potential risk to residents smoking without a smoking assessment was a safety concern. The DON stated staff were assigned and expected to supervise residents during the residents' smoke breaks.In an interview on 08/13/2026 at 6:56 PM with the Administrator, she stated the Social Worker was responsible for completing the smoking assessment on residents when admitted into the nursing facility. The Administrator stated a smoke assessment could also be completed when a resident was observed smoking or if the resident reported wanting to smoke. The Administrator stated the potential risk for residents smoking without a smoking assessment included burning self or others. The Administrator stated staff were to monitor residents during the residents' smoking breaks and family was not able to supervise in replacement of staff.Record review of the nursing facility's Risk Management, Smoking policy, with revision date 06/11/2018, revealed in part: It is the policy of this facility to accommodate residents who desire to smoke by taking reasonable precautions, providing a safe environment for them, and protecting the non-smoking residents. It further revealed in part, under Procedure: 1. Residents and their families/responsible parties are informed of this policy prior to or during the admission process, Resident Council meetings and care conferences. 2. Smoking by residents is allowed outiside in designated, amked smoking area with following safely measures readily available . 6. Resident Smoking Assessment, the Licensed Nurse will assess residents who express a desire to smoke, upon admission, quarterly, annually and upon significant change of condition identification, and present it to the Interdisciplinary Team (IDT) for review . 8. IDT will develop an individualized plan for safe storage, use of smoking materials, assistance and required supervision for residents who smoke. this is a documented on the Resident Smoking Assessment, the resident's Plan of care, and discussed with the resident and Responsible Party at resident care conference meetings.

Based on interview and record review, the facility failed to ensure the quality assessment and assurance committee (QAA) consisted of the required members (Medical Director) for 2 of 3 quarterly QAA meetings reviewed. The facility failed to have the appropriate members (Medical Director) for their QAA committee meetings held on 05/14/2026 and 07/09/2026.This failure could place all 81 residents at risk for quality deficiencies being unidentified and no appropriate plans of actions developed or implemented. Findings included:Record review of Nursing Facility's Quality Assurance Performance Improvement meeting sign in sheets provided of the last of the last 3 months which revealed the Medical Director was not notated or signed in as an attendee on meetings dated 05/14/2026 and 07/09/2026.In an interview on 08/13/2026 at 1:35 PM, the MDS Nurse stated the Interdisciplinary Team (IDT) meet every month which was every second Thursday of the month. The MDS Nurse stated general topics discussed during the QAPI meetings were the Quality Measures compared to other facilities such as trends in Infections, or weight loss, for example. The MDS Nurse stated all department Supervisors or Directors, participated in the meeting. The MDS nurse stated the nursing facility had a Medical Director but stated he had not observed or was made aware of the Medical Director participating in the monthly QAPI meetings. This included the Medical Director participating over the phone or via Teams. The MDS Nurse stated that not having the Medical Director in the QAPI meeting could impose a potential risk of not providing guidance or answering arising questions that he could answer during the meetings.During an interview on 08/13/2026 at 2:26 PM with the DON, she stated the QAPI meeting was conducted every month and included all the Department Directors. The DON stated Quality Measures were compared to the National Quality measures during the meetings and that included general topics such as Urinary Tract Infections, Fall trends, and ADL improvements, for example. The DON stated the Medical Director did not participate in the monthly QAPI meetings, and she had not recalled when seeing the Medical Director last participate, which included participating via phone or Teams. The DON stated the facility did have a Medical Director. The DON stated the purpose of having the Medical Director participate in the QAPI meetings was for them as a Medical Director. The DON stated the Medical Director would have the opportunity to be aware of the Nursing Facility residents' needs and concerns during the QAPI meetings.During an interview on 08/13/2026 at 6:56 PM with the Administrator, she stated QAPI meetings were done once a month. The Administrator stated during the QAPI meetings their discussion included Falls or Urinary Tract Infections. She stated those Quality Measures were compared to the Regional and National level and then discussed. The Administrator stated the Medical did participate to all the QAPI meetings via Teams. The Administrator was provided the QAPI sign-in sheet and was asked to identify the Medical Director's signature for the QAPI attendee sign-in sheet for 05/14/2026 and 07/09/2026. The Administrator stated the Medical Director's signature was not noted on the QAPI attendee sign-in sheets for 05/14/2026 and 07/09/2026 and that meant the Medical Director did not participate in those meetings. The Administrator stated the purpose of the Medical Director participating in the monthly QAPI meetings included for them to be aware of the residents' medical needs and concerns, and provide medical guidance as needed.Record review of the Nursing Facility Quality Assurance and Performance Improvement policy dated with effective date 03/01/2017, read in part under Policy: This facility shall develop, implement, and maintain an ongoing, facility-wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve quality, and resolve identified problems. Under Procedure, it read in part: Authority 1. The ownder and/or governing board (body) of our facility shall be ultimately responsible for the QAPI Program. 2. The Administrator is responsible for assuring that this facility's QAPI Program complies with federal, state, and local regulatory agency requirements.CFR 483.75(G) Quality Assessment and Assurance CFR 483.75(G)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of: (i) the director of nursing services; (ii) The Medical Director or his/her designee; (iii) at least three members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role.

Based on observation, interview and record review the facility failed to ensure the therapeutic diet prescribed by the physician or his delegate were adhered to by the kitchen staff for 19 of 19 residents (Resident #13, #14, #23, #29, #30, #34, #37, #57, #62, #64, #72, #75, #78, #79, #83, #85, and #86) prescribed a mechanical soft and mechanical soft with ground meat diet. -The facility failed to serve food in the appropriate form on 08/11/2026 at 11:38 a.m. when [NAME] L blind poured milk into the food processor for the puree diets of Salisbury steak, rice, okra, and bread.-The facility failed to serve food in the appropriate form on 08/11/2026 at 12:00 p.m. when stewed okra that was not mechanically altered or reduced from its original size was served.-The facility failed to serve food in the appropriate form on 08/13/2026 at 12:00 p.m. when boiled broccoli that was not mechanically altered or reduced from its original size was served. These failures placed residents at risk for choking, aspiration, and decreased ability to consume the entirety of their vegetables served.Findings included: In an interview and observation on 08/11/2026 at 11:12 a.m. [NAME] L stated the okra was stewed and did not need to be chopped. She stated she knew this because it was common sense if a person can chew the okra or not and anything bigger than bite size needed to be mechanically chopped. She stated she did not know how many residents were on a mechanically altered diet. Amid the interview, [NAME] L left the kitchen to contact Dietary Aides N and O to participate in the interview and assist with answering questions she did not have the answers to (reference to number of residents on mechanically altered diet). During puree observation, [NAME] L was observed blind pouring milk from the gallon into the food processor for Salisbury steak, rice, okra, and bread. She stated she poured about half a cup into the food processor and stated she determined this was the amount she poured by guessing. She stated she was trained to perform puree preparation with this method by guessing and directly pouring milk into the food processor. In an observation on 08/11/2026 at approximately 11:45 a.m., stewed okra was served to residents on a mechanical diet with no alteration to the vegetable. The steam table did not have a separate compartment for mechanically altered stewed okra In an observation on 08/13/2026 at approximately 12:00 p.m., boiled broccoli was served to resident on a mechanical diet with no alteration to the vegetable. The steam table did not have a separate compartment for mechanically altered boiled broccoli. In an interview on 08/13/2026 at approximately 12:05 p.m., the Director of Food Services stated there was no mechanically altered broccoli and all the residents on regular diet and mechanical diet were served the same boiled broccoli. In an interview on 08/13/2026 at 1:07 p.m., [NAME] M stated he had not been trained on preparing therapeutic diets for residents on mechanical orders. He stated the recipe book should be looked at to review how to prepare the mechanical chop. He stated mechanical chopped was used when there was a diagnosis for swallowing complications and for a lack of teeth. He stated he did not know where to look for the actual size for a vegetable mechanically chopped. He stated that he did not know the dimensions for mechanical chopped broccoli. He stated therapeutic diets were reviewed by the cook, dietary manager, and nurse. He stated he checked the recipe menu every once in a while when he was uncertain how to prepare an item, with the last instance being last week. In an interview on 08/13/2026 at 1:37 p.m., the Director of Food Services stated she did have contact with the Dietitian and saw her once a month. She stated that therapeutic diets were provided by the Dietitian, Speech Language Pathologist, physician, and DON to the kitchen. She stated she had 20 to 22 residents on a mechanical altered diet. She stated that she did not know that the size of the vegetables needed to be for mechanical chopped diets. She stated it affected the residents because they could potentially choke by not receiving a diet they were supposed to be on. She stated there had not had a choking incident from residents on a mechanical diet. She stated that the cook and herself were responsible for ensuring the mechanical chopped dimensions were met. She stated that she was never trained or instructed on the proper serving for mechanical chopped food. She stated that the diets were reviewed every week and the nurse would review the plate and dietary orders to ensure they matched. She stated that herself, the cook, and the nurse were responsible for to ensuring the diet orders were followed. She stated the cook should not be blind pouring milk into the food processor because it altered the recipe. In an interview on 08/13/2026 at 3:25 p.m., ADON A stated she had reviewed meals and tickets to ensure the meal, diet, and name matched. She stated that the mechanical meals sometimes needed to be chopped up because they needed to be made smaller, because they were too big for residents to eat if they were on a mechanical diet. She stated if a resident was on mechanical soft/ground orders, the meal needed to be chopped into sizable portions. She stated the broccoli needed to be chopped up and the okra needed to be chopped to be smaller. She stated she would request the dietary department to make the pieces smaller or obtain a substitute. She stated she was not aware if nurses completed this on 08/11/2026 or on 08/13/2026. She stated that a resident was ordered mechanical soft ground based on dental needs, swallowing, dementia care, and individual needs. She stated it affected the resident because they might not be able to eat, could be embarrassed to attempt to eat, could miss out on nourishment, it could cause a choking hazard, breathing could cease, throat irritation could occur, and they could inhale into the lungs, which could create infections or result in a visit to the ER. She stated the nurse and dietary department were responsible for ensuring the therapeutic diet was correct. She stated the doctor would provide the orders for the diet on mechanical ground and it needed to be adhered to. She stated the Director of Food Services needed to make sure the cook prepared the meal in accordance to the mechanical order. She noted there was no choking throughout the facility on 08/11/2026 and 08/13/2026. She stated she did not recall the last in-service training for therapeutic diets but suspected it was within the past 3 months. In an interview on 08/13/2026 at 4:49 p.m., the Dietitian stated that vegetables should be steamed soft with nothing hard, and staff should make sure they were not large pieces. She stated that the okra needed to be dice size to the residents and broccoli needed to be chopped into more manageable sizes. She stated the cook should refer to the recipe guide for dimensions and extensions of how to prepare residents on mechanical diets. She stated that the dimensions required were about 1/4-inch sized portions. She stated this needed to be done for all mechanical diets unless there was an exception by the physician. She stated there was potential for choking, death, or aspiration if served full size broccoli florets or okra. She stated that the nurse usually reviewed the plate and the diet to ensure accuracy and safety for the residents. She stated if the vegetables bypassed by all the safety checks by the cook, Director of Food Services and nurse, then the resident would be at risk. She stated there were issues she observed with the puree process during her visit in the form of staff blind pouring milk into the food processor; she states she had educated the cooks to not do this and must measure and use appropriate liquids in the recipe guidelines. She stated that she provided training to staff at the beginning of 2025. She stated that they needed to use measurements for pouring into the puree and not use milk unless specified. In an interview on 08/13/2026 at 5:41 p.m., the Speech Language Pathologist stated she could prescribe mechanical diets if the resident had difficulty with swallowing. She stated the only time she requested a diet change was upon request for evaluation. She stated the evaluation included trials, and assessment to determine swallowing difficulty and severity, trials of liquids, textures, honey, textures, sip, cup sip, and straw sip, evaluating texture at baseline and reviewing baselines. She stated that the expectation was for the kitchen to make alterations to adhere to the diet she ordered for the mechanical soft texture residents. She stated it was expected for the kitchen to have separate sides appropriate for mechanical soft diets. She stated that it was recommended that for broccoli and okra, they cut into smaller pieces and steam it longer for mechanical diets. She stated that they needed to be adhered to because the resident might have difficulty chewing, could fatigue, and could have increased difficulty for choking and aspiration. She stated that the Director of Food Services and nurse were responsible for ensuring the therapeutic diet was adhered to. In an interview on 08/13/2026 at 7:35 p.m., the Administrator stated broccoli was about 2 inches in width and 3 inches in length, and stated it was not appropriate for the mechanical chopped residents. She stated it needed to be chopped smaller to match their diet order to ensure safety. She stated vegetables bigger than the recommended dimensions were hazards for a mechanical altered diet resident. She stated the Director of Food Services and cook needed to ensure the vegetables were properly chopped up. She stated that the resident could choke, lodge it further, go to the hospital, or die. She stated the therapeutic diets needed to be relayed to all staff members and followed at every meal. She stated the nurse could also review the plate to ensure it was safe for consumption for a resident on a mechanically altered diet. She stated that the recipe and dietary manual should be referenced, along with corporate support as needed. She stated the dietary orders came from the Speech Language Pathologist, dietitian, and doctor, and would be above a cook's judgment to alter. Record review of the facility's document titled, Diet type report dated 08/13/2026 revealed, 19 residents (Resident #13, #14, #23, #29, #30, #34, #37, #57, #62, #64, #72, #75, #78, #79, #83, #85, and #86) were on a mechanical diet. Record review of the facility's policy titled, Therapeutic Diets dated 10/2017 read in part: (policy) The residents treatment and plan of care and in accordance with his or her goals and preferences (policy interpretation and implementation close ( ( 1 ) diet will be determined in accordance with the residents informed choices preferences treatment goals and wishes. Diagnosis alone will not determine whether the resident is prescribed A therapeutic diet ( 3 ) diet order should match the terminology used by the food and nutrition services department ( 5 ) if a mechanically altered diet is ordered the provider will specify the texture modification . ( 7 ) the dietitian nursing staff and attending physician will regularly review the need for end resident acceptance of prescribed therapeutic diets Record review of the facility's recipe binder, from 2026 read in part: (Salisbury steak and gravy) (puree) . Place portions needed into a food processor. Process to fine texture for every 5 portions needed prepare a slurry with 1/4 cup thickener and 3/4 cup hot liquid (water or low sodium broth) . Insert me with a #8 scoop topped with one ounce gravy.(parslied rice) (puree) Until smooth. Add water ( 1 cup/ 5 servings) and dry milk ( 1 tablespoon/ 5 servings). Reheat to 165 F and serve with a #8 scoop. (Stewed Okra/tomatoes) (mechanical soft) Chop portions needed from regular prepared recipe. Reheat to 165 F and serve. (Soft and bite sized ; level 6) Chop cooked regular portions. Make sure all particles are no more than 15 mm x 15 mm (approximately 1/2 inch x 1/2 inch) in size. Reheat to 165 F and serve. (Minced and Moist; Level 5) No separate thin liquid prior to service. (4 mm, approximately 1/8 of an inch) use slot between 4 prongs to determine whether minced pieces are correct size. Reheat to 165 F and serve.(seas broccoli)(mechanical soft) chop portions prior to service. Reheat to 165 F and serve as above (soft and bite sized; level 6) Prior to cooking vegetables, chop or process and make sure all particles are no more than 15 mm x 15 mm (approximately 1/2 inch x 1/2 inch) in size. (mince and moist; level 5) Prior to cooking vegetables, chop or process and make sure all particles are no more than 4 mm x 4mm, approximately 1/8 of an inch. use slot between 4 prongs to determine whether minced pieces are correct size. Record review of the Dietary Manual dated 03/2026 read in part: (Mechanically altered/Textured modified diets, page 69)(Intended use) mechanically altered foods are available for residents with chewing and/or swallowing problems. The dysphagia textures are specifically for resident with swallowing problems and HPSI follows and recommends using the international dysphagia diet standardization initiative (IDDSI) framework. It is recommended that the Speech Language Pathologist (SLP) perform a screening procedure or assessment to determine which consistency should be ordered. (Recommendations, page 70). Vegetables should be soft cooked and tender in texture. Some cooked vegetables may need to be chopped. Fresh vegetables are acceptable if they are chopped fine as in coleslaw or tossed salad served with dressing The HPSI spreadsheets designate which fruits and vegetables should be chopped fine or diced. (IDDSI Soft and bite sized food, level 6, page 72) A texture used in the dietary management of dysphagia with the food texture to be prepared as soft, tender, and moist with no separate thin liquid. This texture is recommended to avoid mixed consistencies. The particle size of the food should be no greater than 1.5cm x 1.5cm for adults. To make sure the food is soft enough, press down on the fork until the thumbnail blanches to white, then lift the fork to see that the food is completely squashed and does not regain its shape. Biting is not required, but chewing is required. The diet does require the resident to have adequate tongue force to move the bolus to prevent aspiration. Gravy may be used to hold together the foods to pass the IDDSI testing methods (should be incorporated into food not poured on top) unless resident can tolerate mixed consistencies. (IDDSI Minced and Moist Food, Level 5, page 72) A texture used in the management of dysphagia with the food texture prepared as soft and moist but with no liquid leaking. Once prepared the size of the lumps should be approximately 4 mm in size for adults. The IDDSI avoids list notes to avoid food particle size greater than 4mm x 4 mm x 15 mm. Food must also pass the IDDSI Spoon Tilt Test - Sample holds its shape on the spoon and falls off fairly easily if the spoon is tilted or lightly flicked. Sample should not be firm. Biting is not required with this diet and only minimal chewing is needed. The foods are easily mashed with a fork and have no separate thin liquid. Gravy may be used to hold together the foods to pass the IDDSI testing methods (should be incorporated into food not poured on top) unless resident can tolerate mixed consistencies.

Based on record review and interviews, the facility failed to ensure the individual financial record was available to the residents through quarterly statements and upon request and practice accepted accounting principles of residents' funds for 3 of 5 residents (Resident #35, #36, and #77) reviewed for resident trust funds. The facility failed to ensure Resident #77 had signed the resident trust fund agreement and authorized himself as he had no financial POA and was his own responsible party. The facility failed to ensure Resident #35, #36, and #77 received trust fund statements from the business office at least quarterly and upon request. This failure placed residents at risk of not being involved in their financial decisions and account monitoring.Findings included: Resident #35 Record review of Resident #35's admission sheet dated 08/13/2026 revealed the resident was a [AGE] year-old male with an original admission date of 03/22/2024 and a readmission date of 08/28/2025. Record review of Resident #35's physical and health dated 03/03/2026 revealed the resident was diagnosed with Chronic Kidney disease, stage 4 (severe kidney damage that reflects kidneys are working at 15% to 29% at capacity resulting in waste build up in the blood) and aphasia (inability/impaired ability to understand or produce speech, as a result of brain disease or damage). Record review of Resident #35's quarterly MDS dated [DATE] revealed the resident had a BIMS of 11 with the significance being the resident had moderate cognitive impairment. Record review of Resident #35's care plan dated 06/16/2026 revealed the resident had a focus to address impaired cognitive function or impaired thought process with an intervention in the form to communicate with the resident regarding resident's capabilities and needs. Record review of Resident #35's resident trust fund agreement dated 08/01/2026 revealed the resident had authorized the facility to be his representative payee with an agreement to be provided with a detailed accounting of his funds on a quarterly basis. Resident #36 Record review of Resident #36's admission sheet dated 08/13/2026 revealed the resident was a [AGE] year-old male with an original admission date on 09/11/2024 and a readmission date on 10/25/2024. Record review of Resident #36's physical and health dated 07/21/2026 revealed the resident was diagnosed with bipolar disorder9 a mental health condition defined by at least one full manic [a psychological state of abnormally high energy, elevated or irritable mood, and extreme activity] episode that lasts for seven days or requires hospital care). Record review of Resident #36's quarterly MDS dated [DATE] revealed the resident had a BIMS of 12 with the significance being the resident was cognitively intact. Record review of Resident #36's care plan dated 06/16/2026 did not have focus areas or interventions in place for resident's cognition, decision-making, or finances. Record review of Resident #36's resident trust fund agreement dated 10/25/2024 revealed the resident had authorized the facility to be his representative payee with an agreement to be provided with a detailed accounting of his funds on a quarterly basis. Resident #77 Record review of Resident #77's admission sheet dated 08/13/2026 revealed the resident was an [AGE] year-old male with an admission date on 03/16/2026. Record review of Resident #77's documents on 08/13/2026 of his electronic database profile revealed the resident's family member did not have a financial POA for Resident #77. Record review of Resident #77's physical and health dated 04/29/2026 revealed the resident was diagnosed with Major Depressive Disorder (It causes a lasting sad or empty mood and a loss of joy in daily life for at least two weeks). Record review of Resident #77's quarterly MDS dated [DATE] revealed the resident had a BIMS of 6 with the significance being the resident had severe cognitive impairment Record review of Resident #77's care plan dated 05/06/2026 revealed the resident had a focus to address impaired cognitive function or impaired thought process with an intervention in the form to communicate with the resident regarding resident's capabilities and needs. Record review of Resident #77's resident trust fund agreement dated 03/30/2026 revealed the resident's family member had authorized the facility to be his representative payee with an agreement to be provided with a detailed accounting of his funds on a quarterly basis. In an interview on 08/11/2026 at 2:42 p.m., Resident #77 stated that his family member admitted him to the facility and that the facility was handling his money. He stated he never asked them to do so and that the facility used his Social Security number to obtain his checks. He stated he was missing $80 from his trust fund account. He stated he did not want the facility to control his money and wanted to handle it on his own, at his bank. In a follow-up on 08/12/2026 at 1:21 p.m., Resident #77 stated that he did not initially understand his Social Security checks were going to the trust fund at the facility instead of to his bank. He stated that his family did not have Power of Attorney over him and added, no one did. He stated he had never seen the statements regarding the money he had in the trust fund. He stated he still wanted his bank to handle his own money. He stated he had never seen the sample quarterly statement being provided. In an interview on 08/12/2026 at 2:22 p.m., Resident #35 stated he has never received a quarterly statement and had met with the [NAME] but had not been provided a statement within the past months. He stated he was his own responsible party and had never seen the sample quarterly statement being provided. He stated he did not have a paper resembling the sample quarterly trust fund statement in his personal belongings or drawers. In an interview on 08/12/2026 at 2:25 p.m., Resident #36 stated he had never received a statement for his trust fund and stated he was his own responsible party. He stated he had never seen the sample quarterly statement being provided. He stated he did not have a paper resembling the quarterly trust fund statement in his personal belongings or drawers. In an interview on 08/12/2026 at 1:28 p.m., the Receptionist stated she assisted with Medicaid pending applications and recertifications. She stated she handled petty cash disbursements, which required two witnesses and counting the money aloud to the resident. She stated she had not received any complaints or concerns from the Resident #77 regarding money. She stated he had not voiced concerns about his trust fund agreement with the facility. She stated she would bring any trust fund concerns to the [NAME]. She stated that the resident or POA needed to sign the trust fund agreement. She stated Resident #77 was confused sometimes but she had been able to have sound conversations with him and was not aware if he had a POA. In an interview on 08/12/2026 at 1:37 p.m., the [NAME] stated Resident #77 did not have a POA. She stated Resident #77 was legally responsible for making his own decisions. She stated that the regional [NAME] handled the trust fund contract, as she did not due to being out of office. She stated she spoke with Resident #77's family about the representative payee program upon her return. She stated the Resident #77 complained of fraud at his bank when he initially admitted to the facility, so she offered to handle his money so he would not have to carry cash around. She stated that Resident #77's Supplemental Security Income (SSI) was discontinued, and he now only received about $30 a month after Social Security and room and board expenses not covered by insurance. She stated she did not document the conversations and explanations of the services of the representative payee she had with Resident #77 or with his family members. She stated she did not know if the family member had been receiving the quarterly statements for the trust fund because they were sent out by corporate. She stated both Resident #77 and family members could receive the quarterly statement. She stated Resident #77 needed to be changed to be the priority for his own account since there is no POA in place. She stated that Resident #77's family assisted with decisions. She stated that the resident had the right to manage his own finances and for social services to assist with a POA if the decisions become drastic and unideal for a reasonable person. She stated it was a resident's right to manage the money and stated she followed up with the resident in March and April of 2026 about the agreement to see if they were notified about the payments and what was due at admission. She stated she needed to look to see when she explained the trust fund payee account based on the application permission portal. She stated that she could provide quarterly statements upon request to residents. She stated she was working on the representative payee status to change it back to his account and he will be his own representative payee and receive the quarterly statements. She stated that corporate was responsible for mailing out the quarterly statements. She stated that the [NAME] was responsible for ensuring the information was accurate and true on the trust fund agreement so that quarterly statements were sent to the proper place. In a follow-up interview with the [NAME] on 08/12/2026 at 2:59 p.m., she stated she delivered the mail usually but did not have a sign-off sheet for when she delivered the quarterly statements to the residents. In an interview on 08/13/2026 at 7:12 p.m., the Administrator stated that the residents should receive their quarterly statements once a month and stated it came from corporate. She stated the resident should receive the statement, or their POA. She stated there was no sign-off of delivery from the [NAME] to the resident when they received the letter and did not have a way to verify residents were receiving their quarterly statements. She stated the resident would be affected by not knowing how much money they had and would not be involved in their finances. She stated the [NAME] and Administrator were responsible for ensuring the resident's right to participate in finances was upheld. She stated that the resident should sign off on the document for a trust fund agreement if they were their own responsible party. She stated the resident should receive the statement if they were their own responsible party and there was no POA. Record review of the facility's policy titled, Resident Trust Fund and Policy and Procedure with a date of 03/19/2020 read in part: (Purpose) this resident trust account has been established to offer residents who desire the nursing home to provide banking and cash handling services for their personal funds with a means to do so. Participation is voluntary for the residents and may be started or ended at any time.(trust fund authorization) It is the right of a resident to manager their own funds, but if the resident or the responsible party chooses for the facility to manage the residents' funds - the resident trust fund authorization must be signed by the resident or responsible party, authorizing the management of the resident's funds. Although the resident or responsible party chooses the facility to manage the resident's funds, the resident or responsible party has the right to their financial affairs. (accounting and record keeping of personal funds).(3) individual financial records will be available to the resident by quarterly statements and upon request.

Based on interviews, observation, and record review, the facility failed to adhere to accepted professional standards and practices by protecting the residents right to privacy and confidentiality of personal medical records for 25 of 86 residents (Resident #2, #6, #9, #10, #11, #15, #17, #20, #21, #30, #34, #37, #50, #53, #56, #58, #65, #66, #67, #72, #75, #82, #83, #85, and #86) reviewed for privacy of medical records.-The facility failed from 08/11/2026 to 08/13/2026 to ensure the locked shredder box was not overflowing with disposed patient information.These failures place residents at risk to have their health protected information accessible to the public and jeopardize having conditions.Findings included: In an observation from 08/11/2026 to 08/13/2026 the secured shredder box located near the nurse's station was overflowing and had documents from residents that were retrievable from the opening, laying on top of the shredder, or on the floor in front of the box. Over the 3-day survey, 19 different residents protected health information was accessible with varying information to include: names, date of birth s, addresses, phone numbers, social security numbers, physicians, diagnoses, prescriptions, appointments, and treatments. The shredder box located in the medical record was additionally overflowing but no information was recovered from this location. The shredder box behind the Receptionist front desk and within the conference room appeared to be below half filled and papers disposed of in these locations were not accessible.In an interview on 08/12/2026 at 5:32 p.m., LVN Q stated that she protected patient information by locking the computer screen and not discussing it in areas that were inappropriate. She stated that she put physical copies that were of no use in the shredder in the nurses' hall, in the medication room, and in the lobby. She stated it was a lot of confidential information that was in the shredding box. She stated the information should not be accessible. She stated it could result in fraud, identity theft, and a breach of HIPAA. She stated that the DON and Administrator were responsible for ensuring that the shredder was emptied. She stated she had not received an in-service training on protecting health information in the past six months. She stated that everybody was responsible for protecting patient information. She stated she did not know the shredder near the nurse's station was overflowing. She stated that it appeared that staff were not aware of the shredder locations or too lazy to go to another shredder. She stated that she had not received an in-service training on locating the shredding locations. She stated that the DON was responsible for educating staff on shredder locations. In an interview on 08/12/2026 at 5:44 p.m., ADON B stated that she did not have any responsibilities for the shredders. She stated that the facility followed HIPAA guidelines, which included not logging in outside of work, protecting privacy, not sharing information with a third party if it was not needed for a resident, locking the computer when away, and disposing of physical papers in the shredder. She stated that the shredder was to properly destroy identifying information on documents. She stated it should not be accessible to anyone. She stated the shredders were located in the nursing station, the medical records room, and the front lobby. She stated that she had only provided information to new staff on locating the shredders. She stated she did not know who called the company to recover a full shredder box and empty it. She stated she was not aware of the shredder overflow until now and had not received any complaints from residents having their private information breached. She stated it did not appear that the staff were protecting residents' information and adhering to guidelines based on the paperwork that was retrieved on 19 different residents. In an interview on 08/12/2026 at 5:57 p.m., the DON stated her staff was trained to protect resident information by closing computer screens, not discussing information apart from necessity, and not leaving paper unattended. She stated the facility utilized shred boxes to discard physical copies. She stated the facility had four shred boxes. She stated she did not know who was responsible for contacting the contracted company for pick-up of overflowing boxes. She stated she had not received any reports on the overflowing shredder boxes. She stated it did not appear the information was being protected and stated everyone was responsible for protecting the residents' information. She stated that medical history, social security numbers, dates of birth, appointments, diagnoses, and prescriptions were visible from the documents obtained. She stated she had not conducted any HIPAA trainings or in-services. She stated there were no reports from residents of their medical information being released to unauthorized parties. She stated that ADON A or herself were responsible for entering refusal notes for Resident #19. She stated that the resident was on weekly weights but had refused. She stated the resident had been on weekly weights since 06/22/2026. She stated there were eight opportunities for the refusal documentation. She stated that it would appear that the facility was not doing anything for the Resident #19 regarding weight loss. She stated she did not remember the last in-service training for documentation provided to staff.In an interview on 08/13/2026 at 7:55 p.m., the Administrator stated that patient information was protected by making sure laptops were locked, not sharing passwords, and shredding documents. She stated the facility had four shredder boxes. She stated that the contractor came out once a month. She stated that the nurses' station shredder was full. She stated that herself, the DON, and the [NAME] were responsible for contacting the shredder company for pickup. She stated the information that was accessible involved prescriptions, Social Security numbers, names, dates of birth, diagnoses, providers, addresses, and phone numbers. She stated this information should not be accessible to anyone once it was placed in the shredder box. She stated she had not contacted the contractor to empty the boxes.Record review of the documents accessed from the shredder in front of the nurses station revealed it contained various information of 25 different residents to include: names, date of birth s, addresses, phone numbers, 1 social security number, prescriptions, diagnoses, treatments, physician's treating the resident, appointments, and orders for care.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for 1 of 1 facility reviewed for pest control. -The facility failed on 08/11/2026 to maintain an effected pest control as noted with mice droppings, flies, and gnats in the dry storage in the kitchen, more than 15 cockroaches caught on a glue board trap in the pantry in the dining room, and multiple sightings of alive cockroaches within residents' rooms and hallways. -The facility failed on 08/11/2026 to address pest access points as evident by a burrow entry point within the medication storage room, the exit door on D-hall was not seated flush with the door and doorway, and an exposed sewage within a room under construction. - The facility failed on 08/11/2026 to remove all food waste from the memory care unit halls and leaving food waste outside of the kitchen for pests to access. This failure could affect residents by potentially exposing them to pests causing physical/mental distress, unsanitary living conditions, health/infection risks, and loss of dignity.Findings included: In an observation and interview on 08/11/2026 at 9:00 a.m. with the Director of Food Services, it was observed there was a notable amount of flies and gnats flying around the dry storage area near the shelf with soy sauce, condiments, pasta, and flour. In the corner near the can storage was multiple droppings from mice. She stated there was rodents and insects throughout the whole building. In the pantry located outside the kitchen was a glue board trap intended for rodent and insect capturing pests with more than 15 cockroaches of varying age and size. In initial screening of residents on 08/11/2026 from 10:00 a.m. to 4:00 p.m. who were alert and oriented to participate in screening 11 of 24 residents sampled stated they had seen mice or cockroaches either in their room, in the halls, in the dining room or common areas throughout the facility. The consensus of how long pests had been present in the facility varied from 1-2 years depending on the resident's length of stay at the facility. Residents reported that a majority of the pest activity occurred at night. In an interview and observation on 08/11/2026 at 12:40 p.m., [NAME] L stated, did something run across your foot? regarding an observation being captured under the steam/preparation table. When asked, what runs across feet here she stated, usually a rodent. In a nighttime observation on 08/11/2026 from 9:45 p.m. to 11:00 p.m., 3 live cockroaches were spotted at 10:05 p.m. in C-Hall, at 10:32 p.m. in the F-Hall, and at 10:41 p.m. on A-Hall. At 10:01 p.m. food waste was observed on a cart outside the kitchen entry in the form of bread, Salisbury steak patty, okra, and tomatoes. At 10:18 p.m. a mouse burrow was located on the shelf within the medication storage room along with stick traps and bait boxes under the sink and behind the minifridge. At 10:25 p.m. a room at was under construction revealed the sewage outlet for the toilet was left uncovered along with demolition to the walls, baseboards, and crevices for pests to access but too small for human access. At 10:27 p.m. four sandwiches were located on a metal rack in the E-Hall. 14 various pest traps of glue board traps, bait boxes, spring traps, and multi-catch mouse traps were located throughout the facility to include: storage closets, corners, under residents beds, in the dining room, lounge rooms, and medication storage room. In an interview on 08/13/2026 at 9:21 a.m., Dietary Aide N stated that when she first started there were pests in the kitchen, but not anymore. She stated that there were mice running on the floor in the past, but it was better now. She stated that there were still some mice in the kitchen ceiling and it was being treated by pest control. She stated pests were not allowed to be in the kitchen because the food would be contaminated and the residents could get sick. She stated that the residents were more fragile and could have compromised immune systems that could not handle the bacteria pests carry. She stated that the dietary aide was responsible for ensuring all the plates were recovered and washed before end of shift. She stated that she asked the staff for plates and trays, but sometimes they did not bring them. She stated she did not tell anyone, including the nurses and CNAs, about not bringing the trays and cups back in a timely manner for sanitation. In an interview on 08/13/2026 at 9:59 a.m., Dietary Aide O stated she was in charge of ensuring that all the plates were clean and food was disposed of before leaving for the shift. She stated it was not okay for the trash from lunch to be left overnight until the next morning outside the kitchen. She stated she had entered in the morning and found plates outside the kitchen from the days before one to two times a week. She stated the CNAs were responsible for bringing the plates back from the hall after every meal. She stated that if she did not receive all the plates and cups, she would tell the manager. She stated she did not tell her boss that there were plates outside the kitchen in the morning of 08/12/2026. In an interview on 08/13/2026 at 11:40 a.m., CNA E stated that after the resident was done with the meal, they put the tray on the cart and took it back to the kitchen for food removal and to clean the trays and plates. She stated all plates and trays in the hall needed to be collected by the staff before the next meal or after two hours. She stated that food could not be left out because it could be eaten by a resident, a pest infestation could begin, or it could worsen the current mice and cockroach situation. She stated the CNAs and nurses were responsible for picking up hallway trays and returning them to the kitchen in a timely manner. She stated the nurse was responsible for ensuring the CNAs recover the trays and returning them to the kitchen before the next meal or after two hours. She stated she did not know when the last time was that she received an in-service training for meal recovery. In an interview on 08/13/2026 at 12:18 p.m., RN D stated she had seen mice and cockroaches throughout all the halls, especially at night. She stated this had been going on for one year and she saw at least one mouse and roach per shift she worked. She stated she had not reported it to anyone because everyone knew about it already. She stated that the pests were more active at night. She stated she did not know where they were coming from. She stated that leaving food out attracted pests. She stated it affected the residents because the residents would get scared and pests could carry diseases. She stated the management oversaw reporting all pest sightings to the pest control contractor. She stated all staff should notify the Administrator if there were mice and roaches in the building. She stated that CNAs and nurses picked up the trays from the residents' rooms and took them to the kitchen to be cleaned and put away. She stated that residents usually had an hour to two hours to eat their meal, then it needed to be returned. She stated it needed to be returned before the next meal. She stated it needed to be taken back so that they could be cleaned up and to safely dispose of the food. She stated she checked to see that trays were picked up room to room by the CNA after every meal that she worked. She stated that if the trays did not get back to the kitchen on time, then the kitchen would not be able to clean them before leaving. She stated no dishes should be left dirty overnight. She stated that if she found food after the kitchen staff had left, she would throw away the food because the patients might try to eat the food and it would attract more pests. In an interview on 08/13/2026 at 2:29 p.m., the Director of Food Services stated she had mice, cockroaches, and flies throughout the facility, and they were coming from openings in the floors, edges, and the ceiling. She stated she had been notified that there was activity in the kitchen ceiling. She stated it affected a resident's health but stated she could not explain how based on her limited clinical knowledge. She stated the food left out contributed to the mice infestation. She stated she had reported changes to corporate as needed and cooperated with the exterminator. She stated that everybody was responsible for reporting pest activity and logging it in the book for when they came out to inspect. She stated there had not been improvement and it was stagnant status with the current pests. She stated that the dishes took one to two hours to get back from the halls and another hour to wash. She stated the CNAs were responsible for returning all dishware and silverware back to the kitchen before the next meal and before 8:00 p.m. She stated that kitchen staff stayed until the end of all chores. She stated that there was a concern regarding not getting dishware and silverware back. She stated that plates with food should not be left outside the kitchen. She stated there was a pest problem and it would contribute to further consequences with pests. She stated that only kitchen staff had keys and would be able to access the kitchen. In an interview on 08/13/2026 at 4:17 p.m., the DON stated that there were roaches and mice in the facility. She stated she did not know where they originated from, where they were most active, and did not know any areas that were not affected. She stated it affected residents because it could be a nuisance, make them feel uneasy, they could lose belongings, or possibly receive a transmitted infection or disease; she denied any of the such as of lately. She stated that staff needed to log in to the pest control book for the last sighting and notify leadership. She stated pest control was coming twice a week. She stated the mice and roach presence had been ongoing since July 2025. She stated the contributing factors involved leaving crumbs behind, clutter, insecure openings to the outside, and staff practices of unsanitary conditions like leaving food outside of the kitchen overnight. In an interview on 08/13/2026 at 7:53 p.m., the Administrator stated it was not acceptable for food to be left outside the kitchen. She stated the food should be discarded and the plates washed. She stated it needed to be in the kitchen area so no one else would get it and attract more pests. She stated all staff were responsible for ensuring the cleanliness of the facility. On 08/13/2026 at 5:25 p.m. a pest policy was requested from the MDS nurse. He stated via text message, I asked regional [executive director of operations] he said we don't have one specifically for pest. Record review of the facility's pest control invoices from 06/02/2026 to 08/07/2026 read in part: (08/04/2026) checked the [bait] station in the kitchen ceiling. The bait had been completely consumed, confirming this remains the primary rodent activity area. (07/24/2026) During the kitchen inspection, I noticed fly activity beginning to increase. Performed a targeted fly wipe-down throughout the kitchen, dry storage, dining room. (07/21/2026) .[Administrator] requested that all resident rooms in F Hall be treated due to an increase in roach[sic] sightings in several rooms. Checked the [bait] station in the kitchen ceiling. Approximately half of the bait had been consumed, so the bait was replaced.Followed up on the rodent issue in the med[sic] room. Maintenance has repaired the hole beneath the sink but has not yet sealed the opening behind the mini refrigerator.if the remaining entry point is not repaired, it could lead to future rodent issues. (07/17/2026) Saw the exit door at the end of A hall had a gap that needs to be sealed. Invoices revealed the pest control has a frequency of facility visits every 3-7 days with scheduled and emergency visits.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 laundry areas reviewed for transmission-based precautions.The facility failed to ensure dirty linens did not enter through where clean linen was folded and stored creating a risk of cross-contamination. These failures could lead to the transmission of infection, infection, or illness. Findings included: In an observation and interview on 08/12/2026 at 11:25am, in the only laundry area on 08/12/2026 revealed bags of dirty linen entering through the designated clean folding and storage zone to reach the washing machines. The House keeping Manager stated that upper management was supposed to make another entrance on the opposite side of the laundry room so that there could be a clear separation from dirty linen entering the laundry room and clean linen that was being folded and stored. She stated that there was no risk to the resident as the dirty linen was being brought in bags and in the soiled linen bins. The Housekeeping Manager stated that there had to be a separation between dirty and clean linen to prevent cross contamination. She stated that it was her responsibility to ensure and oversee an orderly workflow when transporting and washing linens. In an interview on 08/13/2026 at 6:38pm with the Administrator she stated the laundry room was supposed to have 2 doors, one for incoming dirty linen and the other for outgoing clean linen. She stated this was to prevent cross contamination. She stated that the laundry room had only had one entrance since she took over being administrator about a year ago. She stated that the Director of Maintenance was supposed to open the entrance to the laundry room, but it had yet to get done. She stated that there was no risk to the resident because dirty linen was being transported in bags and sealed bins. Review of facility policy titled Infection Control revised on 10/25/22 read in part The objectives of our infection control policies and practices are to: maintain a safe , sanitary and comfortable environment for personnel, residents, visitors and the public .

Based on interview, observation, and record review the facility failed to make information on how to file a grievance or complaint available and to support anonymous submissions to the residents for 5 of 5 residents (confidential group interview) reviewed for grievances. The facility failed to ensure residents knew who the Grievance Official was, knew how to file a grievance, and that they had access to grievance forms. This failure placed residents at risk for being dependent on staff to assist with providing, filling, and submitting a grievance.Findings included: During a confidential group interview with 5 out of 5 residents present reported being dissatisfied with the handling of grievances. 5 out of 5 residents present stated that they did not know how to complete a grievance or who the grievance coordinator was. The residents stated they usually had to ask multiple staff members to provide them with a grievance form but would have to wait more the 45 minutes or would sometimes not be provided with the grievance form because the staff member they asked had forgotten their request. The residents stated the grievance form was only available from staff as there was no location where the forms could be accessed freely. The residents denied knowing if the grievance could be completed on a piece of paper other than the grievance form. The residents denied receiving a refresher on their right to file a grievance or explanation on how to file a grievance within the past 6 months. An observation of the facility made on 08/13/2026 at approximately 12:00 p.m. revealed there were not readily available grievance forms or submission boxes available throughout the facility or in its high traffic areas. In an interview on 08/13/2026 at 11:46 a.m., CNA E stated that any employee could take a grievance but did not know who was in charge of handling them. She stated that the grievance form was behind the nurses' station. She stated that it needed to be readily accessible for a resident to get and she added that the residents were not allowed in the nurses' station. She stated that she had never assisted a resident in completing the grievance form. She stated that she would give the grievance form to the Administrator. She stated that it was a resident's right to file a grievance and access the forms without assistance from staff. In an interview and observation on 08/13/2026 at 12:23 p.m., RN D stated that she did not know where the grievance form was and went around the nurse's station to attempt to locate the grievance form location. She stated that if a resident wanted a grievance form, they would need assistance because they were not allowed behind the nurses' station. She stated that she did not know if the grievance form needed to be readily available for all residents, family members, or visitors. She stated that the grievance form was for residents to complain. She stated that she did not know where the grievance forms were located and could not provide one during the interview. She stated she was not trained on assisting with grievance filing. She stated that she would take the grievance form back to the Administrator but did not know if she oversaw grievances. She stated that there was no other location or staff member who had the grievance forms. She was observed asking for assistance from ADON B and the DON on where to locate the grievance forms at the conclusion of the interview. In a brief interview on 08/13/2026 at 12:32 p.m., the Social Worker stated he was the grievance coordinator and only his office contained the grievance forms. In an observation on 08/13/2026 at 2:40 p.m. revealed a form holder was mounted to the wall outside the Social Worker's office that had not previously been there. In an interview on 08/13/2026 at 2:48 p.m., the Social Worker stated that he put up the grievance forms in a holder based on experience at another nursing facility following an earlier conversation. He stated that he ensured residents knew how to file a grievance upon admission by explaining the process to residents and family. He stated that he worked from 8:00 a.m. to 5:00 p.m., Monday through Friday. He stated that the grievance form would not be accessible prior to the form holder being installed outside his office outside of his business hours. He stated that an employee had to print out the grievance form for the resident in the event they wanted to file a grievance outside of his hours. He stated that it needed to always be readily accessible and available to the resident. He stated that it would affect a resident because there could be a barrier to submitting a grievance. He stated that he had received grievances in forms other than the grievance form. He stated that all staff were responsible for ensuring that the grievance forms were always available. He stated that it affected residents because there could be a barrier in getting information regarding the grievance to him. He stated that the grievance could not be relayed or addressed due to a lack of knowledge if the resident did not have access to the form. He stated that no residents had reported any concerns on how to submit a grievance or where to access a form. He stated that the grievance could be slid under the door after completion. He stated that he informed staff that he was the grievance coordinator and how to provide forms to residents but did not have documentation on this in service. In an interview on 08/13/2026 at 4:12 p.m., the DON stated that RN D had difficulty locating a grievance form and requested assistance from staff near the nurse's station. She stated that the grievance forms needed to be readily available to access without asking for all residents and family members. She provided the rationale that residents could obtain a copy during off-hours or if staff were unavailable to provide them a copy and stated that it was a resident's right. She stated that it was a requirement for the instructions to the grievance to be made available as well. She stated that the Social Worker oversaw the grievances and handled them. She stated that it affected residents because they would have to wait or rely on staff to provide it. She stated if a resident had to ask staff it would take away for the possible to anonymously submit a grievance as well. She stated that all staff were responsible for ensuring that the residents had free access to the grievance form. She noted that there were no complaints from residents on the grievance process. In an interview on 08/13/2026 at 7:17 p.m., the Administrator stated that a resident could access grievance forms from the Social Worker or any other staff member. She stated that it affected residents because they would have to wait and it would remove the anonymous aspect of it. She stated that the form might not be provided because staff could be busy. She stated that the resident would not be able to express what was going on if staff did not provide a grievance form. She stated that the form was a template which helped guide the residents on filling out the form. She stated that she was the grievance coordinator along with the Social Worker. She stated that the response and resolution varied, taking maybe about a day or two. She stated that she had received dissatisfaction with resolution in some instances and explained the resident rights and compliance with policies. She stated that she was not sure how the residents received education on completing the grievance and who submit it to. She stated that she had not provided training and in-services to staff on grievance filing. She stated that prior to today, the forms were only locatable in the Administrators office and Social Worker offices, where residents would not have exclusive access to. Record review of the facility's policy titled, Grievance dated 04/01/2017, revealed in part: our facility will assist residents, their representatives, other interested family members or resident advocates in filing grievances or complaints when such requests are made. The facility will make prompt efforts to resolve all grievances. (Procedure). (2) Upon admission, residents are provided with written information on how to file a grievance or complaint. A copy of our grievance/complaint procedures is posted on the resident bulletin board. (5) Staff members will offer to listen to the complaint/grievance and transcribe it or offer to allow the complainant to complete their own form. If a form is not readily available, the complainant may write to the complainant/grievance on any sheet of paper. (6) Grievances and/or complaints may be submitted orally or in writing. Record review of the facility's undated in service directed to All Staff on the subject of Resident Rights hosted by the DON revealed in part: Residents have the right to high quality, legally compliant care of: Dignity and respect; Freedom from abuse and restrains; Privacy and confidentiality; Participation in care; Personal property (to have personal belongings/clothing); to file grievances and complaints without fear and 18 signatures to include CNA E and the Social Worker.

Based on observation, interview, and record review, the facility failed to ensure the resident's environment was as free of accident hazards as possible for 2 of 8 residents (Residents #44 and #47) reviewed for accidents.The facility failed to provide supervision during Resident #44's smoking on 08/11/26.The facility failed to provide supervision during Resident #47's smoking on 08/11/2026 and 08/12/2026.This deficient practice could place residents at risk of harm or injury and contribute to avoidable accidents. Findings included:Record review of Resident #44's face-sheet dated 08/13/26 revealed a [AGE] year-old male resident with initial admission date 04/11/2022 and re-admission date 07/31/2026. Record review of Resident #44's history and physical dated 07/09/2026 revealed past medical history of: paraplegia (paralysis of the legs, causing loss of sensation or movement of the legs), and tobacco use. Record review of Resident #44's Quarterly MDS dated [DATE] revealed a BIMS of 7, indicating severe cognitive impairment. The Quarterly MDS revealed Resident #44 had an active diagnosis of tobacco use. Record review of Resident #44's care plan with revision date 08/07/26 revealed the resident was a smoker that included the following interventions: resident to smoke in designated smoking areas with access to appropriate smoking receptacles.Record review of Resident #44's smoking and safety assessment dated [DATE] revealed resident was a tobacco smoker. Record review of Resident #47's face-sheet dated 08/13/2026 revealed a [AGE] year-old female resident with an admission date 03/12/2026.Record review of Resident #47's history and physical dated 02/19/2026 revealed past medical history of tobacco use.Record review of Resident #47's Quarterly MDS assessment dated [DATE] revealed a BIMS of 7, indicating a severe cognitive impairment. The Quarterly MDS did not include Resident #47's tobacco use.Record review of Resident #47's care plan dated 04/23/2026, revealed it did not include the resident's smoking preference.Record review of Resident #47's electronic medical chart revealed there was no smoking assessment.Interview with the Nursing Facility Administrator and record review of a smokers list dated 05/21/26 provided by the Nursing Facility Administrator on 08/11/2026 at 3:00 PM, she stated it was the most recent list. The smokers list revealed a total of 33 residents including a handwritten name, Resident #7, admission date 06/26/2026. The smokers list did not include Resident #47.In an observation and interview on 08/11/2026 at 12:10 PM, Resident #47 was observed coming from the designated smoke area that was located in the back of the main dining room. Resident #47 was accompanied by their family member, and they stated they had just finished their smoke break. Resident #47 stated she was smoking outside in the smoking area with her family member alone and stated there was no staff present. Resident #47 stated she smoked at least daily, sometimes multiple times a day. In an observation on 08/11/2026 at 12:15 PM, a sign was posted outside of the door leading to the outside designated smoking area, which read: Smoking Schedule: 8:00 AM Kitchen Staff, 10:00 AM Activity Assistant, 1:00 PM Housekeeping staff, 2:30 PM Social Service, 4:30 PM Activity Director, 6:00 PM CNA, 7:30 PM CNA, All resident smoking must be supervised by staff. Residents are not permitted to carry or keep lighters in their possession under any circumstances. In an observation and interview on 08/11/2026 at 3:20 PM, Resident #44 was observed smoking a tobacco cigarette in the designated smoking area with no staff or other residents present. Resident #44 stated he smoked daily, and staff was not always present during his smoke breaks.In an observation on 08/12/2026 at 12 PM, Resident #47 was observed smoking a cigarrette in the scheduled smoking area with her family present. No staff were observed in the area.In an interview on 08/13/2026 at 10:04 AM with CNA E, she stated all lighters and cigarettes were to be kept in the nurse's station in a locked box. CNA E stated only staff were were provide residents with a cigarette during scheduled smoke breaks. CNA E stated she was unsure who was responsible for conducting the smoke assessments on residents, but CNAs and other staff were provided a smokers list containing a list of residents allowed to participate in the scheduled smoke breaks. CNA E stated she was unsure if family were allowed to supervise residents instead of staff supervising residents. CNA E stated the potential risk of residents smoking unsupervised or being allowed to smoke without a smoke assessment being completed included injury or burns.In an interview on 08/13/2026 at 11:42 AM with RN P, he stated the nurses were responsible for completing residents' smoking assessments during admission to the nursing facility or when the resident verbalizes desire to smoke. RN P stated residents were not allowed to smoke in the nursing facility smoking area until the resident had a smoking asessment complete due to potential risk of harming themselves. RN P stated it was important to accurately add resident information such as if the resident was a smoker so the staff could be aware of that preference. RN P stated staff also needed to be aware if the resident was able to smoke safely, which was done with a smoking assessment.In an interview and record review on 08/13/2026 at 1:36 PM with the MDS Nurse, he stated he reviewed Resident #47's documents and did not locate a smoking assessment and he did not have Resident #47 noted as a smoker. The MDS Nurse stated he was unaware Resident #47 was a smoker and if he was aware he as the MDS nurse would be responsible for adding it into the resident's care plan and conduct a smoking assessment. The MDS Nurse stated the nurses were responsible for adding and assessing for the resident being a smoker during admission into the Nursing Facility, or as needed, such as the resident stating they want to smoke. The MDS Nurse stated the MDS and resident's plan of care were revised every 3 months or as needed for changes of conditions. The MDS Nurse stated a resident participating in smoking without supervision could potentially burn themselves.In an interview on 08/13/2026 at 2:29 PM with the DON, she stated the nurses were responsible for completing a smoke assessment on all residents upon admission into the nursing facility. The DON stated residents were then reviewed for smoking during every quarter, or as needed. The DON stated residents needed smoking assessments so they could be determined whether they were safe to smoke. The DON stated potential risk to residents smoking without staff supervision was a safety concern.In an interview on 08/13/2026 at 6:56 PM with the Administrator, she stated the Social Worker was responsible for completing the smoke assessment on residents when admitted into the nursing facility. The Administrator stated only staff were to monitor residents during smoke breaks. The Administrator stated the potential risk for residents smoking without supervision included burning self or others.Record review of the nursing facility's Risk Management, Smoking policy, with revision date 06/11/2018, revealed in part: It is the policy of this facility to accommodate residents who desire to smoke by taking reasonable precautions, providing a safe environment for them, and protecting the non-smoking residents. It further revealed in part, under Procedure: 1. Residents and their families/responsible parties are informed of this policy prior to or during the admission process, Resident Council meetings and care conferences. 2. Smoking by residents is allowed outiside in designated, amked smoking area with following safely measures readily availbable . 6. Resident Smoking Assessment, the Licensed Nurse will assess residents who express a desire to smoke, upon admission, quarterly, annually and upon significant change of condition identification, and present it to the Interdisciplinary Team (IDT) for review . 8. IDT will develop an individualized plan for safe storage, use of smoking materials, assistance and required supervision for residents who smoke. This is a documented on the Resident Smoking Assessment, the resident's Plan of care, and discussed with the resident and Responsible Party at resident care conference meetings.

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 2 of 10 residents (Residents #11 and #77 ) reviewed for medication storage and failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, safe and secure storage of medications for 1 of 4 Med Aide carts checked for storage of medications. -The facility failed to ensure on 08/11/2026 at 2:58 p.m. to ensure Resident #77 did not have his scheduled prescription medication in a disposable cup on his nightstand. -The facility failed to ensure on 08/11/2026 at 9:50 p.m. to ensure a medication cart was locked. -The facility failed to ensure Resident #11's enteral feeding was properly labeled on 8/11/2026. -The facility failed to ensure a bottle of milk of magnesia stored in the medication cart was clean and free of dried drippings on 08/12/2026. This failure could place residents at risk of access to medications not approved for administration by their physician. Findings included: Resident #11 Record review of Resident #11's admission record dated 8/12/2026 revealed a [AGE] year-old male with an original admission date of 06/13/2026 and a re-admission date of 08/05/2026. Record review of Resident #11's Physician progress note dated 07/14/2026 revealed a diagnosis of gastrostomy status (an opening made through the skin of the belly directly into the stomach). Record review of Resident #11's Comprehensive MDS dated [DATE] revealed a BIMS score of 00 indicating severe cognitive impairment. Section K-Swallowing/ Nutrition Status indicated Resident #11 had a feeding tube on admission, and while a resident. Record review of Resident #11's physician orders dated 07/15/2026 revealed an active order for Nepro/CarbSteady Oral Liquid (Nutritional Supplements) to be given at 60 milliliters per hour via gastrostomy tube. Record review of Resident #11's care plan revised 07/10/2026 revealed the resident required tube feeding nova source on continuous feeding related to dysphagia (trouble swallowing). In an observation on 08/11/2026 at 11:10am revealed Resident #11's kangaroo bag was not labeled with the formula type, date, time hung and staff initials. Medication Cart: In an observation of B hall medication cart on 08/12/2026 at 9:36 am revealed a bottle of milk of magnesia with dried drippings on the top and sides of the bottle. In an interview on 08/12/2026 at 9:36am with Med Aide J, she stated that she was supposed to keep all medication bottles clean and free from drippings to prevent cross contamination and to keep it looking clean. She stated that she was to clean the bottle after every use. She stated that she was responsible for ensuring that the medication bottles that she used were cleaned after every use. She stated that she did not see a risk to the resident. In an interview on 08/13/2026 at 1:50pm with RN D, she stated enteral feedings were to be labeled by the nurse who hung it with the time, date and initials. She stated the risk to the resident would be infection if the feeding was not labeled and it ran for longer than 24 hours. She stated that the nurse administering the enteral feeding was responsible for ensuring the feeding was properly labeled. In an interview on 08/13/2026 at 2:17pm with the DON she stated medication bottles were to be kept clean and free from dried drippings to prevent cross contamination. She stated that there was no risk posed to residents. She stated that it was the nurses responsibility to ensure that the bottles were wiped down after every use. She stated tube feedings were supposed to be labeled with the date that it was hung and the time because the feedings were only good for 24 hours. She stated that the nurse was responsible for ensuring that the feedings were labeled with all the correct information. She stated that the risk to the resident would be infection if the feeding was allowed to run for longer than 24 hours because of lack of labeling. In an interview on 08/13/2026 at 6:38pm with the Administrator she stated tube feedings were supposed to be labeled with the date and time that it was hung. She stated that the nurse administering the feeding was responsible to ensure that it was properly labeled. She stated that the risk to the resident was exposure to bacteria if the feeding was not changed within the 24 hours due to staff not knowing when it was initially hung. She stated that medication carts were to be kept locked when not in use or when the medication aides or nurses walked away from the carts. She stated that residents were at risk of getting hold of medications that weren't theirs if the medication cart was unlocked, and medications could also go missing. She stated that it was the responsibility of the med aides and the nurses to ensure the carts were locked. She stated that when medication aides and nurses were administering medications to residents, they needed to stay with the resident until all medications were swallowed to ensure medication compliance. She stated that staff were not allowed to leave medications unattended at bedside. She stated that a risk would be other residents getting hold of the medications or the resident not properly taking the medications. She stated that it was the responsibility of the medication aide and nurses to ensure they were staying with the resident until medications were swallowed. She stated the medication bottles were to be wiped after every use to prevent cross contamination and preventing residents from getting ill off of possible bacteria that can grow on the dirty bottles. She stated that it was the nurse or medication aides responsibility to ensure the bottles were kept clean. On 08/12/2026 at 5:00pm the Policy for Medication Storage and Labeling was requested to Administrator, the policy was not provided to survey team by exit on 08/13/2026. Resident #77 Record review of Resident #77's admission sheet dated 08/13/2026 revealed the resident was an [AGE] year-old male with an admission date on 03/16/2026. Record review of Resident #77's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 6 with the significance being the resident had severe cognitive impairment. Under Section N – Medications revealed the resident was prescribed antidepressants, diuretic, antiplatelet, and anticonvulsant. Record review of Resident #77's care plan dated 05/06/2026 revealed the resident had a focus to address impaired cognitive function or impaired thought process related to dementia with an intervention in the form to communicate with the resident regarding resident's capabilities and needs. Another focus area identified the resident used antidepressants medication duloxetine with intervention to administer antidepressant medications as ordered by physician and monitor for reactions. Record review of Resident #77's physical and health dated 04/29/2026 revealed the resident was diagnosed with Major Depressive Disorder (It causes a lasting sad or empty mood and a loss of joy in daily life for at least two weeks), lower extremity edema (swelling in your legs, ankles, and feet caused by fluid trapped in your body tissues), essential hypertension (high blood pressure that has no clear, single medical cause), peripheral neuropathy (when nerves outside your brain and spinal cord get damaged), myopathy (diseases that affect the skeletal muscle fibers, causing the muscles to become weak, stiff, or cramped), gastroesophageal reflux disease (a chronic digestive condition where stomach acid frequently flows back into the tube connecting your mouth and stomach, irritating its lining). Under current medications revealed the resident was prescribed: acetaminophen 325 MG, Lactulose 10GM/15ML, Pantoprazole Sodium 40MG, Tamsulosin hydrochloride 0.4MG, Lisinopril-hydrochlorothiazide 10-12.5MG, Clopidogrel Bisulfate 75MG, Duloxetine hydrochloride 30MG, Ergocalciferol 1.25MG, Gabapentin 800MG. Record review of Resident #77'a Medication Administration Record dated 08/12/2026 revealed only MA's H and J were the most recent (from 08/02/2026 to 08/12/2026) staff members to dispense the scheduled medication located on Resident #77's nightstand. During an interview and observation on 08/11/2026 at 2:42 p.m., Resident #77 stated that he had medication on his nightstand and produced 16 pills of various sizes and colors divided amongst 2 small cups evenly. He stated he does not remember when he found the pills and does not know what the medications were. He stated he did not know which staff member provided the medications. Record review of the medication reconciliation by the DON provided on 08/11/2026 at approximately 4:00 p.m., revealed the medications pills were identified as: (1) Pantoprazole Sodium 40MG, (2) Tamsulosin hydrochloride 0.4MG, (3) Lisinopril-hydrochlorothiazide 10-12.5MG, (4) Clopidogrel Bisulfate 75MG, (5) Duloxetine hydrochloride 30MG, (6) Furosemide 40MG, (7) Gabapentin 300MG, (8) Potassium Chloride extended release 20MEQ; none of which were controlled substances. In an interview on 08/11/2026 at 4:00 p.m., LVN G stated she administered PRN medications, intravenous medications, and g tube medications as the nurse. She stated she stands by the residents to ensure that they take it. She stated that she needed to make sure that the residents were administered the medication because they could be pocketing it and potentially overdose. She was requested to meet in Resident #77's room to review for unattended medication. She stated she located 16 pills in dixie cups. She stated she rounds on residents when she was free, at the beginning and end of her shift. She stated she arrived today at 6 am and generally checked on the residents and not around the environment. She stated the CNAs round every two hours, and she had 2 CNAs that split the D hall. She stated MA H was the medication aide for the D hall. She stated she could not recall the last in service for medication administration because she was PRN at the facility. She stated she would discard the medication if there was any medication located in a resident's room and provide in-service to the aide right away. In an interview on 08/11/2026 at 4:10 p.m. MA H stated he oversaw B hall, D hall, and F hall and was working on 08/10/2026. He stated that he has been crushing medication for Resident #77 for the past couple of months and stated this was the resident's medication. He stated that he stands by the resident to ensure the medication was administered for every resident. He stated that MA J had worked the weekend. He stated that he usually administered medication in public settings and not in the resident's room. He stated the pills included gabapentin, Flomax, potassium, Plavix, possibly Lasix, Cymbalta, protonic, pantoprazole, and stated it was morning scheduled medication and were in both cups. He stated that all the medications were scheduled but no controlled substances. He stated the medication still posed a hazard to a resident if they were left unattended. He stated it affected residents because they did not have their medication administered for the day. He stated it would affect Resident #77's mood, bodily regulation, and cause reactions if someone other than Resident #77 self-administered the medication. He stated the last in service for medication administration was 3 months ago. He stated that the MA was responsible for ensuring medication was administered and not left at bedside. He stated that CNA and medication aide and housekeeper can conduct environment rounds and report it to the nurse immediately. In an interview on 08/12/2026 at 4:14 p.m. MA J stated she oversaw B hall, D hall, and F hall. She stated she worked 08/07/2026 to 08/09/2026. She stated she came in at 6 am and usually provided the medication to Resident #77 in the dining room. She stated Resident #77 received the medication whole. She stated she has never left medication unattended in his room. She stated it was not acceptable to leave medication unattended because they needed to verify that the medication was administered. She stated that another resident or someone who should not have it could access the medications. She stated she needed to notify the nurse of medication refusal, ask again, and dispose of the scheduled and narcotics. She stated she did not recall the last in-service for medication administration. She stated CNAs and MAs perform environmental checks to ensure there was no medication being pocketed or left at bedside. She stated the images of the 16 pills located appeared to be 2 day's worth of medication for Resident #77. She stated it did not appear staff were monitoring medication administration or completing environmental checks if 2 days' worth of medication went undiscovered. Unlocked Medication Cart: During a nighttime observation on 08/11/2026 at 9:50 p.m. it was observed that a medication cart locking bolt was extended out revealing the red tab on the side signifying it was unlocked and accessible. 2 residents were observed awake and walking around the nurse's station and front lobby. 5 CNAs and 2 nurses were observed in the common areas and hallways while the cart was unlocked. A follow-up at approximately 10:40 p.m. revealed the cart had been locked by the DON. In an interview on 08/11/2026 at 10:51 p.m. RN I stated she was not aware the medication cart was unlocked. She stated that she relieved MA H of the medication cart at 8:30/9PM. She stated that the exchange was to ensure the narcotics were accurate and nothing was missing. She stated it was a shared responsibility between the 2 evening nurses to share the medication carts and assist as needed with each other's cart. She stated the medication cart could have been unlocked for 50 minutes to 90 minutes. She stated it was not okay for the medication cart to be unlocked when unattended. She stated that it needed to be always locked to prevent staff and residents from accessing it. She stated that it affected residents because they could harm themselves by taking medication not prescribed for them. She stated medication could go missing which would result in not being able to provide scheduled medication required for the resident. She stated that the nurses and MAs were responsible for ensuring the med carts were locked. She stated there was no way for staff to verify if medication was missing besides counting during shift exchange. She stated the last in service for medication storage was within the last 6 months. In an interview on 08/13/2026 at 10:20 a.m., CNA K stated she sometimes worked D hall and went this past week as needed with bed making, activity notice and showers. She stated if they were not in the room or asleep she usually did not enter the room or complete an environment check. She stated if the resident was awake, she checked for pathway, ice water, she stated she does not ever check the top of the nightstand. She stated that unattended medication was harmful to the residents. She stated that environmental checks did not appear to be completed if there were pills from potentially 2 days left in Resident #77's room. She stated that MA and nurse were responsible for ensuring that the medication was administered. She stated all staff were responsible for conducting environmental checks for unattended medication. She stated she had never received training on discovering medication in a resident's room and what to do. She stated she would report to the nurse and med aid immediately if she located medication. she stated this needed to be done to remove hazards from the residents. She stated she has never received instruction on how to check an environment check from her supervisors. In an interview on 08/13/2026 at 3:48 p.m. the DON stated that staff did not administer medication for Resident #77 based on the discovery of 2 days' worth of medication. She stated that staff should be completing environmental checks in rooms, plain sight areas, restrooms and report any variants to the nurse. She stated the nursing department was responsible for ensuring medication was not left at bedside. She stated it affected the residents because if they didn't take it, they could experience negative effects in regard to their diagnosis. She stated she locked the medication cart on the evening of 08/11/2026 because it was not supposed to be unlocked when unattended. She stated that she locked the medication cart because the nurse was not immediately in front of it. She stated she did not know how long it was unlocked for. She stated she did not notice if a staff member was moving to close it prior to her action. She stated that the cart should be locked when it was not in use or passing medication. She stated this was done so no residents got into medications not intended for them. She stated she does not know if anything was missing and would only know if they needed something and it was not there anymore. She stated that the narcotics box was closed and locked with key when she closed it. She stated the last in services for medication storage and administration was in March 2026.

Based on interview, observation, and record review the facility failed to employ sufficient staff with appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 5 of 7 of dietary staff members reviewed for trainings and competencies. -The facility failed on 08/11/2026 to ensure [NAME] L, [NAME] M, Dietary Aide N, Dietary Aide O, and Director of Food Services were adhering to its facility policies for food storage, kitchen sanitization, therapeutic diets, preparation of foods, and outside food policy. -The facility failed on 08/12/2026 to ensure [NAME] L and [NAME] M were adhering to its facility policy for food storage and kitchen sanitization.-The facility failed on 08/13/2026 to ensure [NAME] L and Director of Food Services were adhering to its facility policies for therapeutic diets.-The facility failed on 08/13/2026 ensure dietary staff had received in service, training, and documented within the past 2 months of the new Director of Food Services taking position. This failure placed residents who received their meals from the kitchen at risk to exposure to foodborne illnesses based on the competency of staff.Findings included: In an observation on 08/11/2026 from 9:00 a.m. to 9:45 a.m. it was observed omelets and cheese were undated and unlabeled in the walk-in fridge, paint chipping in the fridge. Oven racks were located on the floor in the pantry as a storage place. Water was pooling throughout the kitchen with the origin of the water coming from the handwashing sink. In the chemical storage closet in the dining room, 2 containers of coffee grounds were located in the chemical storage where cleaning supplies and 2 cans of roach poison aerosol came in contact with the containers. Within the freezer located in the dining room, a shopping bag from a local grocery store was located with various foods opened and designated to be a resident's food by the Director of Food Services. In a follow-up observation on 08/11/2026 at 11:04 a.m. to 12:50 p.m. [NAME] L was observed not mechanically chopping okra (measured at 1-2 inches in width and over 0.5 an inch) being served and using the hand washing station and dishwasher to clean the food processor in between uses. [NAME] L was observed using tongs to dispose of a tray liner in the trash, pushed it further into the trash with the tongs, hit the tongs on the edge of the trash to remove residue, and proceeded to use the tongs to handle ready-to-eat food. [NAME] L was observed only by rinsing the food processor with hot water under the hand washing station and did not use soap, scrubbing, or sanitizing products. No hand washing was completed by [NAME] L, Dietary Aide N, Dietary Aide O, or the Director of Food Services after contaminating gloves, changing work tasks, exiting/returning into the kitchen, or touching unsanitary surfaces/handles during lunch service from 11:45 a.m. to 12:50 p.m. [NAME] L was observed capturing steam table temperatures without sanitizing the probe between use and only wiped the residue off with a cloth rag that was utilized to clean counter tops. [NAME] L captured the temperature of a puree Salisbury Steak to be at 131 degrees F and did not reheat the food item before serving on trays. Dietary Aide O was observed collecting outside prepared food from a resident that was partially eaten, reentered the kitchen, heated it in the kitchen microwave, and returned to the resident. Record review of the food temperature log revealed the dinner temperatures for 08/11/2026 had been recorded as completed with varying temperature ranges at 12:11 p.m.; dinner for 08/11/2026 had not been prepared or cooked yet to record these temperatures. In an observation on 08/12/2026 from 12:40 p.m. to 1:15 p.m. [NAME] M was observed thawing 2 10-pounds of ground beef within 24-inch by 12-inch by 6-inch deep pan of still water; the ground beef cylinders were larger than the container that was holding them and were hanging out the edge of the pan with only a portion of the ground bee being submerged under the water. In an observation on 08/13/2026 at 12:40 p.m. to 1:00 p.m., The Director of Food Services captured the temperature of the sample tray that measured all below 135 F (chicken fried steak at 107 F, mashed potatoes 129 F, broccoli 112 F), she utilized the same cloth rag to remove residue from the thermometer probe after temperatures were captured at the steam table and sample tray. [NAME] M and Director of Food Services provided boiled broccoli florets with stem (measured approximately 1-3 inches in width and 1.5-3 inches in length) to residents on mechanical diets. Residents on mechanical diet were observed throughout the dining room with some eating them one piece at a time; no choking present. In an interview and observation on 08/11/2026 at 11:12 a.m. [NAME] L stated she was trained to use the dishwasher, food processor, and wash supplies by her previous Director when she first started working at the facility approximately over a year ago. She stated I use whatever is available to get it done in reference to washing a large bake tray and food processor in the dishwasher. She stated she did not know how often the dietary staff received training or in services and added the last in-service was 2 months ago on labeling food, sanitation, and temperatures provided by the Director of Food Services. She stated the okra was stewed and did not need to be chopped. She stated she knew this because it was common sense if a person can chew the okra or not and anything bigger than bite size needed to be mechanically chopped. She stated she did not know how many residents were on a mechanically altered diet. Amid the interview, [NAME] L left the kitchen to contact Dietary Aides N and O to participate in the interview and assist with answering questions she did not have the answers to (reference to number of residents on mechanically altered diet). During puree observation, [NAME] L was observed blind pouring milk from the gallon into the food processor for Salisbury steak, rice, okra, and bread. She stated she poured about half a cup into the food processor and stated she determined this was the amount she poured by guessing. She stated she was trained to perform puree preparation with this method by guessing and directly pouring milk into the food processor. In a follow-up interview during 3-sink compartment observation on 08/12/2026 at 12:45 p.m., [NAME] L stated she did not know if the rinse water compartment needed to be filled and if dishes needed to be rested in there after washing utensils. She redacted her previous statement regarding training and stated the last in service was 3 months ago about food topics (unable to recall specifics) but nothing on dishwashing practices. She stated the 3-sink compartment was the only designated spot to wash cookware and it was not appropriate to wash anything besides resident cups, plates, and utensils in the dishwasher. She stated she practiced hand hygiene throughout the day whenever she touched unsanitary surfaces, returned from exiting the kitchen, changed gloves, after doing dishes and believed she washed her hands yesterday but was uncertain. She stated employees were responsible for washing their hands after being exposed to cross-contamination. She stated any staff member could instruct another staff member to wash their hands and should be practiced by all dietary staff. In an interview on 08/13/2026 at 9:34 a.m., Dietary Aide N stated that the last in-service/training she received was about a month ago. She stated that she felt she had enough training but would like more training regarding what to do if the trays came back late. She stated that she did not know the temperature for cold foods. She stated that she did not know the temperature for which hot foods needed to be served at. She stated that she did not know the process of thawing meats and vegetables. She stated that she only spoke Spanish and would receive instructions in English via Google Translate. She stated that she asked the Director of Food Services for instructions if she had questions. She stated did not know the process for handling outside food brought in by residents, family, or staff. In an interview on 08/13/2026 at 9:49 p.m., Dietary Aide O stated that she could not receive instructions in English, preferred Spanish. She stated the Director of Food Service would use translation apps to provide clarifications on instructions. She stated that the last in-service training for handwashing was five months ago. She stated that she did not remember the last in-service training for labeling and dating food. She stated that she did not remember when she received training for cross-contamination prevention. She stated that the last time she received training for dishwashing was a year ago from a coworker who used to work here. She stated that she did not know the temperature for which hot food needed to be served at but guessed it was 160 F. She stated that the temperature for cold food was about 40 F degrees. She stated that she did not know the temperature range for the danger zone of food. She stated that she did not know the parts per million solutions needed for the dishwasher. She stated the temperature for the dishwasher needed to be between 120 F to 200 F. She stated that she felt she had enough training to do dishwashing. She stated that the process to defrost meat was to leave it sitting in cold water without the water running over it. In an interview on 08/13/2026 at 1:25 p.m., [NAME] M stated that he received an in-service training last month on temperature, handwashing, and how to store food. He stated that he felt he had received enough education and training to perform his job. He stated that he would benefit from receiving more training. He stated that the ground beef was being thawed in a pan with lukewarm water in a 2 foot by 1 foot pan. He stated that only half of the ground beef was submerged under water, with the other half extended outside of the pan because it was too long for the pan. He provided the rationale was because the three-compartment sink was preoccupied and the big pans were dirty. He stated that he did not have enough equipment to safely complete his job. He stated that the normal way was to place it in the refrigerator for an all-day thaw. He stated that the middle sink would get the plunger to stop the water and still cool water would be utilized to thaw the meat. He stated the water did not need to be running and the meat did not need to be fully submerged. He stated that he knew this was the procedure based previous knowledge from other food handling jobs. He stated he had not received training or in service in the past 7 months on defrosting meat. In an interview on 08/13/2026 at 2:33 p.m., the Director of Food Services stated that she was working with staff on 1:1 needs to ensure that staff were competent and trained. She stated that she did not have access to the food policies and procedures from the facility and needed to ask the Administrator to print them out. She stated that she just provided the information that she knew from experience and added it was not enough to provide the services and training to the staff. She stated that if staff were not trained and competent, then the residents would not receive proper diets, prevention of cross-contamination, handling of outside food, and safe temperature and food handling procedures. She stated that she had 11 dietary employees and that she was responsible for educating and training staff as needed. She stated that she had not hosted any formal in-service training to her staff in the past 2 and half months. She stated that she did not know that the dimensions of the vegetable needed to meet the IDDSI guidelines for mechanically chopped diets. She stated that she was never trained or instructed on the proper serving for mechanically chopped food. In an interview on 08/13/2026 at 7:35 p.m., the Administrator stated that the kitchen staff were trained annually and the facility had some issues with the conditions of the kitchen and was doing better than it was. She stated that she assumed the dietary manager was providing formal in-services and documenting them but had not verified they were completed. She stated that any training provided to staff needed to be documented. She stated that if the staff was not properly trained, it affected how the residents' meal service, could result in an increase for foodborne illness, cross-contamination, safety, and comprehension on therapeutic diets. She stated that dietary staff should be trained during hire, every quarter, and as needed for any observed variant from policy and procedure. She stated that based on the kitchen findings and observations, it appeared staff were not properly trained in their field. An in-services and trainings policy was requested from the Administrator, who stated the facility did not have a policy in place on this topic. Record review of the facility's policy titled, Preparation of Foods dated 04/2022 read in part: (Policy) Food is to be prepared by methods that conserve nutritive value flavor and appearance. ( 2 ) all food will be prepared by methods that preserve nutritive value flavor and appearance with variety of color and will be attractively served at the proper temperature and in a from [sic] to meet the individual needs of the resident. ( 3 ) food is prepared in a sanitary manner with minimal handling utilizing HACCP guidelines. ( 4 ) Will be maintained in file or book accessible to the cooks. The cook is responsible for food preparation using those recipes which reflect the planned menu. ( 5 ) food will be cut chopped ground or pureed to meet individual needs of the resident and served according to menu. Record review of the facility's policy titled, Kitchen Sanitation dated 03/2026 read in part: (Policy) Free from spills to minimize the risk of cross contamination (procedure) ( 1 ) clean and sanitized food preparation areas and equipment after use ( 2 ) clean grills griddles vent hoods microwave ovens and similar cooking devices after use and as needed ( 5 ) clean clothes are stored to prevent cross contamination clothes being used for cleaning should be stored in a sanitizing solution bucket between use (7 ) the kitchen should remain free of pests. Record review of the facility's policy titled, Food Storage dated 04/11/2022 read in part: (Policy) . Processed prepared in compliance with Allstate federal and local laws and regulations. Food will be handled in a safe and sanitary method to prevent contamination and foodborne illness. (procedure) ( 1 ) food is delivered at the appropriate temperature and expected prior to storage for signs of contamination ( 5 ) Are animal foods such as eggs fish meat and poultry from ready to eat foods such as produce cooked and ready to eat foods are stored above raw foods including shell eggs in the refrigerator to prevent cross contamination ( 6 ) food removed from its original packaging will be labeled with the following ( a ) receive date ( b ) open date ( C ) contents in the package . ( 9 ) open package or leftover food is to be tightly wrapped or covered in airtight clean containers. It should be labeled dated with opened or used by date. Do not keep leftovers in the refrigerator for more than 7 days . ( 12 ) perishable food should not remain in the temperature danger zone ( 41-135 ) for longer than four hours. ( 14 ) frozen foods are thawed during the cooking process under refrigeration or by immersion under running water of a temperature of 70 F or lower ( 16) do not consume handle prepare or store food in areas with hazardous chemicals ( 19 ) safe food temperatures will be maintained at acceptable levels during food storage preparation holding service delivery cooling and reheating ( 22 ) food is cooked to at least 135 F. Reheat foods to an internal temperature of at least 165 F for at least 15 seconds ( 24 ) check food temperatures prior to meal service if the food temperatures are not within acceptable parameters the food is reheated or chilled to an appropriate temperature. ( 25 ) make certain the thermometer is clean and has been sanitized. Sanitized thermometer if food tested is between 41 F and 135 F or if visibly soiled. ( 26 ) food temperatures are taken and recorded at all meal times period . Record review of the facility's policy titled, Therapeutic Diets dated 10/2017 read in part: (policy) The residents treatment and plan of care and in accordance with his or her goals and preferences (policy interpretation and implementation close ( ( 1 ) diet will be determined in accordance with the residents informed choices preferences treatment goals and wishes. Diagnosis alone will not determine whether the resident is prescribed A therapeutic diet ( 3 ) diet order should match the terminology used by the food and nutrition services department ( 5 ) if a mechanically altered diet is ordered the provider will specify the texture modification . ( 7 ) the dietitian nursing staff and attending physician will regularly review the need for end resident acceptance of prescribed therapeutic diets Record review of the facility's policy titled, Food from Outside Sources dated 03/2021 read in part: (policy) residents may have outside sources The community was sure that proper steps are taken so that the food remains safe. (Procedure) ( 1 ) community team members will educate residents and/or family members on food brought in from outside the community on:. (b) proper reheating ( i ) community team to assist resident in reheating food to proper temperature (>165 F for 15 seconds) food to be reheated in designated area (in example Med room) opened food containers will not be able to be reheated in the kitchen to prevent cross contamination of food . ( 3 )If residents would like the food and nutrition services team to store their food item the following conditions must be met: ( a ) food is unopened ( b ) resident name is labeled on food product ( C ) receive date added ( d ) open date is added (once open) Record review of the Dieticians Sanitation Report dated 07/16/2026 revealed the kitchen and its staff were not meeting standards for: (main kitchen areas)Preparation tables, convection oven, range, shelves/racks, microwave, floors/baseboards, drains, (cold storage) walk-/reach-in cooler, walk-/reach-in freezer, shelves/racks, cooler/freezer seals (dish room) dish machine, 3-compartment sink, shelves/racks, floors/baseboards, drains. The overall score from the report was 70.5% with the expectation noted as 90% or greater. The notes entered by the Dietician read in part, . Still several areas that need to be replaced or repaired. Dish machine drain not draining. Standing water visible.

Based on interview, observation, and record review the facility failed to ensure food was at safe and appetizing temperatures for 1 of 1 kitchen reviewed for temperatures on sample trays. -The facility failed on 08/11/2026 at 12:08 p.m. to reheat the puree Salisbury steak when the temperature on the steam table before meal service read at 131 F.-The facility failed on 08/13/2026 at 12:40 p.m. failed to serve food to a resident at 135 F or higher on a sample tray (chicken fried steak at 107 F, mashed potatoes with gravy 129 F, broccoli 112 F). This failure placed residents at risk for experiencing poor dining experience and having their food at risk for developing food-borne illnesses.Findings included: In a confidential group interview 5 out of 5 residents complained about the temperature of the food served during meals. In an observation on 08/13/2026 at 12:04 p.m. the temperatures for meals on the steam table measured above 135 F (chicken fried steak at 158 F, mashed potatoes 152 F, broccoli 161 F, and gravy 166 F). The sample tray arrived at the conference room [ROOM NUMBER] minutes after leaving the kitchen for delivery to residents' rooms. In an interview on 08/13/2026 at 9:34 a.m., Dietary Aide N stated that she did not know the temperature for cold foods. She stated that she did not know the temperature for which hot foods needed to be served at. In an interview on 08/13/2026 at 9:49 p.m., Dietary Aide O stated that she did not know the temperature for hot food but guessed it was 160 F. She stated that the temperature for cold food was about 40 F. She stated that she did not know the temperature range for the danger zone of food. In an interview on 08/13/2026 at 1:15 p.m., [NAME] M stated that cooked hot foods needed to be between 135 F and 165 F and cold foods needed to be between 45 F and 55 F. He stated that the purpose was to ensure the food was cooked. He stated that the food would reach an improper temperature, develop organisms, and increase the pathogens of foodborne illness if left in the range between 55 F to 135 F. He stated that the cook monitored the temperature of the food and used the thermometer to obtain the accurate temperature. He stated he did not know to sanitize the probe every time between use. He stated that the temperature log needed to be completed when the temperature was measured and not ahead of time. He stated that filling out the temperature log ahead of time was falsifying documentation. In an interview on 08/13/2026 at 1:31 p.m., the Director of Food Services stated that the food should be at 145 F for a resident when they received their meals. She stated that it was not acceptable for a resident to receive food below 145 F. She stated it affected the residents because they could be upset that the food did not arrive hot, as it could affect their appetite. She stated that they sent out the trays at the correct temperature, but the CNAs were responsible for ensuring the tray reached them in a timely manner to maintain the temperature. She stated that she had only received complaints from one resident about the food temperature. She stated that the CNAs left the food sitting in the halls and did not send out the delivery. She stated that only the domes were used to keep the food plates warm. She stated that she had ordered a plate warmer, but it was backlogged under not necessary with no anticipated delivery date. She stated that the carts were not insulated and caused the plates to lose temperature. She stated that she had not provided an in-service or training for any food topics in the past 2 and a half months. She stated that wiping the thermometer with a cloth rag needed to be done even between use and added it was an unsanitary practice. She stated that single use alcohol wipes would need to be used, but the facility did not have any. She stated that staff needed to complete the temperature logs before serving the meal and not in advance. She stated doing so in advance constituted a falsification of documents. interview on 08/13/2026 at 7:45 p.m., The Administrator stated that the danger zone was between 41 F to 145 F. She stated she did not know what temperature residents needed to receive their food at. Record review of the facility's policy titled, Food Storage dated 04/11/2022 read in part: (Policy) . Processed prepared in compliance with Allstate federal and local laws and regulations. Food will be handled in a safe and sanitary method to prevent contamination and foodborne illness. (procedure). ( 12 ) perishable food should not remain in the temperature danger zone ( 41-135 ) for longer than four hours.( 19 ) safe food temperatures will be maintained at acceptable levels during food storage preparation holding service delivery cooling and reheating ( 22 ) food is cooked to at least 135 F. Reheat foods to an internal temperature of at least 165 F for at least 15 seconds ( 24 ) check food temperatures prior to meal service if the food temperatures are not within acceptable parameters the food is reheated or chilled to an appropriate temperature. ( 25 ) make certain the thermometer is clean and has been sanitized. Sanitized thermometer if food tested is between 41 F and 135 F or if visibly soiled. ( 26 ) food temperatures are taken and recorded at all meal times period

Based on the 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 and nutrition services. -The facility failed on 08/11/2026 at 9:00 a.m. to 9:45 a.m. to label and date omelets and cheese; failed to ensure the walk-in fridge did not have paint chipping from the walls surrounding the food; store oven racks off the floor; prevent the pooling of water throughout the preparation, cook, serve, and dishwashing area of the kitchen; separate food and chemical storage.-The facility failed on 08/11/2026 at 11:04 a.m. to 12:50 p.m. to ensure [NAME] L was properly washing and sanitizing the food processor between uses; ensure [NAME] L washer her hands after discarding waste; ensure [NAME] L washed tongs that had came in contact with the trash before reusing for served food; ensure that [NAME] L Dietary Aide N, Dietary Aide O, or the Director of Food Services had washed their hands after contaminating gloves, changing work tasks, exiting/returning into the kitchen, or touching unsanitary surfaces/handles; to properly reheat food that measured below 135 degrees F that had not been served from the steam table.-the facility failed on 08/11/2026 to accurately document meal temperatures.-The facility failed on 08/12/2026 at 12:40 p.m. to ensure [NAME] M was properly thawing 20 pounds of ground beef that was going to be served for dinner. This failure could place residents at risk of foodborne illness.Findings included: In an observation on 08/11/2026 from 9:00 a.m. to 9:45 a.m. it was observed omelets and cheese were undated and unlabeled in the walk-in fridge, paint chipping in the fridge, oven racks on the floor in the pantry, and pooling water throughout the kitchen deriving from the handwashing sink. 2 containers of coffee grounds were located in the chemical storage where cleaning supplies and 2 cans of roach poison aerosol came in contact with the container. Within the freezer, a shopping bag from a local grocery store was located with food unlabeled and opened and designated to be a resident's food by the Director of Food Services. At 11:04 a.m. to 12:50 a.m. [NAME] L was observed not mechanically chopping okra (measured at 1-2 inches in width and length and over 0.5 an inch in thickness) being served and using the hand washing station and dishwasher to clean the food processor in between uses. [NAME] L was observed using tongs to dispose of a tray liner in the trash, pushed it further into the trash with the tongs, hit the tongs on the edge of the trash to remove residue, and proceeded to use the tongs to handle ready-to-eat food. [NAME] L was observed only by rinsing the food processor with hot water under the hand washing station and did not use soap, scrubbing, or sanitizing products. No hand washing was observed from [NAME] L, Dietary Aide N, Dietary Aide O, or the Director of Food Services after contaminating gloves, changing work tasks, exiting/returning into the kitchen, or touching unsanitary surfaces/handles. [NAME] L was observed capturing steam table temperatures without sanitizing the probe between use and only wiped the residue off with a cloth rag that was utilized to clean counter tops. [NAME] L captured the temperature of a puree Salisbury Steak to be at 131 degrees F and did not reheat the food item before serving on trays. Record review of the food temperature log revealed the dinner temperatures had been captured in advance on 08/11/2026 at 12:11 p.m. while lunch was still being served. In an observation on 08/12/2026 from 12:40 p.m. to 1:15 p.m. [NAME] M was observed thawing 2 10-pounds of ground beef within 24-inch by 12-inch by 6-inch deep pan of still water; the ground beef cylinders were larger than the container that was holding them and were hanging out the edge of the pan with only a portion of the ground bee being submerged under the water. In an observation on 08/13/2026 at 12:40 p.m. to 1:00 p.m., The Director of Food Services captured the temperature of the sample tray that measured all below 135 F (chicken fried steak at 107 F, mashed potatoes 129 F, broccoli 112 F), she utilized the same cloth rag to remove residue from the thermometer probe after temperatures were captured at the steam table and sample tray. In an interview and observation on 08/11/2026 at 11:12 a.m. [NAME] L stated she was trained to use the dishwasher, food processor, and wash supplies by her previous Director when she first started working at the facility approximately over a year ago. She stated I use whatever is available to get it done in reference to washing a large bake tray and food processor in the dishwasher. She stated she did not know how often the dietary staff received training or in services and added the last in-service was 2 months ago on labeling food, sanitation, and temperatures provided by the Director of Food Services. In a follow-up interview during 3-sink compartment observation on 08/12/2026 at 12:45 p.m., [NAME] L stated she did not know if the rinse water compartment needed to be filled and if dishes needed to be rested in there after washing utensils. She redacted her previous statement regarding training and stated the last in service was 3 months ago about food topics (unable to recall specifics) but nothing on dishwashing practices. She stated the 3-sink compartment was the only designated spot to wash cookware and it was not appropriate to wash anything besides resident cups, plates, and utensils in the dishwasher. She stated she practiced hand hygiene throughout the day whenever she touched unsanitary surfaces, returned from exiting the kitchen, changed gloves, after doing dishes and believed she washed her hands yesterday but was uncertain. She stated employees were responsible for washing hands after being exposed to a cross-contamination practice but the Director of Food Services and coworkers In an interview on 08/13/2026 at 9:21 a.m., Dietary Aide N stated she had worked here for six months. She stated her responsibilities were to prepare the drinks, napkins, trays, organize tickets, put covers on items, and prepare snacks, sandwiches, and desserts. She stated that she needed to wash her hands every time she entered the kitchen, when she handled something dirty, when she touched anything besides the food or utensils, and when handling items. She stated it was obligatory to wash hands to prevent cross-contamination. She stated that items needed to be labeled and covered with the date, the use-by date, and the name of the item. She stated that everything needed to be labeled to ensure it was used at the right time and to prevent cross-contamination. In an interview on 08/13/2026 at 12:48 p.m., [NAME] M stated the ground beef was being thawed in a pan with lukewarm water in a 2x1 foot pan. He stated that only half of the ground beef was submerged under water, with the other half extended outside of the pan because it was too long for the pan, with the rationale because the three-compartment sink was preoccupied and the big pans were dirty. He stated he did not have enough equipment to safely complete his job. He stated that the normal way was to place it in the refrigerator for an all-day thaw. He stated the middle sink would get clogged and still used cool water to thaw meat. He stated that this was the procedure from previous knowledge and that he was not trained here in the past seven months on defrosting meat. He stated that this was safe if there were no punctures in the meat. He stated observation and theory were not acceptable and the meat could be contaminated and exposed. He stated a resident could get sick from eating contaminated food. He stated the cook and the manager were responsible for ensuring the food was cooked and stored in methods that prevented cross-contamination. He stated handwashing needed to be done when reentering the kitchen and when changing gloves. He stated gloved hands should not be used to grab any food because the food could be cross-contaminated. He stated the freezer needed racks to prevent cross-contamination, separate all the produce and items, and facilitate better ventilation to ensure everything was frozen. He stated food needed to be sealed and labeled every shift. He stated the other half needed to be labeled with the name, open date, and use-by date for everything in the kitchen pantry and freezer. He stated this kept the ingredients fresh and ensured bad ingredients were not served. He stated that the pipes were leaking and there might be a leak under the floor. He stated there was a spillage over the past weekend. He stated the kitchen had been leaking and dirty since he began working here seven months ago and stated the conditions were not safe for food handling and processing. In an interview on 08/13/2026 at 2:08 p.m., the Director of Food Services stated that the findings included issues with labeling, dry drippings, coffee, the condition underneath the sink, water, a lack of racks in the freezer, an unlabeled bag from a resident in the freezer, a sticky pad with roaches, and droppings in the pantry from the mice. She also noted the method of defrosting the ground beef, which had to be fully submerged under running cold water. She stated that staff needed to wash their hands between glove changes, when handling raw meats, and after touching anything unsanitary, such as handles, hair, faces, clothing, dirty rags, or dishware. She stated there had been no training for the three-compartment sink and that it was not acceptable for staff to use the dishwasher or the handwashing sink to wash dishes because it was not sanitary. She stated that soap, water, and a sanitizing solution needed to be used, that hot water alone was not sufficient, and that the food processor should not be used. She stated that residents could get sick because the food handling occurred in an unsanitary work environment. She stated she was responsible for ensuring that safe food handling procedures were completed, and noted that her ability to monitor this varied based on her meeting schedule. She stated that the snacks included sandwiches that were placed on ice. She stated it was not safe for a resident to eat those sandwiches, and added that a Memory Care Unit (MCU) resident would not be coherent enough to put the food on ice. In an over-the-phone interview on 08/13/2026 at 4:40 p.m., the Dietitian stated this was the first passing score the facility had received from the Registered Dietitian (RD). She stated that the kitchen needed a remodel and a larger three-compartment sink. She stated the competency of the staff required a lot of training and noted that staff members were reluctant to put hairnets on in the kitchen, but added that the dietary manager was making positive changes. She stated these standards were not appropriate and stated she instructed staff to clean upon opening the kitchen before beginning. She stated she had seen rats and mice in the building. She stated she had said she would report the conditions to the state to the regional director of dietary if they did not improve, and stated the quality of the food had improved. In an interview on 08/13/2026 at 7:45 p.m., the Administrator stated that these conditions presented a risk for cross-contamination, improper nutrition, choking, and a loss of appetite for the residents. She stated that the dietary department and leadership were responsible for ensuring food storage and safety were being practiced. She stated the procedure should be followed all the time and while the kitchen was open. She stated she would not accept the conditions as safe food handling. She stated that the danger zone was between 41 and 145 degrees. She stated she did not know the temperature at which residents should receive their food. Record review of the facility's policy titled, Kitchen Sanitation dated 03/2026 read in part: (Policy) Free from spills to minimize the risk of cross contamination (procedure) ( 1 ) clean and sanitized food preparation areas and equipment after use ( 2 ) clean grills griddles vent hoods microwave ovens and similar cooking devices after use and as needed ( 5 ) clean clothes are stored to prevent cross contamination clothes being used for cleaning should be stored in a sanitizing solution bucket between use (7 ) the kitchen should remain free of pests. Record review of the facility's policy titled, Food Storage dated 04/11/2022 read in part: (Policy) . Processed prepared in compliance with Allstate federal and local laws and regulations. Food will be handled in a safe and sanitary method to prevent contamination and foodborne illness. (procedure) ( 1 ) food is delivered at the appropriate temperature and expected prior to storage for signs of contamination ( 5 ) Are animal foods such as eggs fish meat and poultry from ready to eat foods such as produce cooked and ready to eat foods are stored above raw foods including shell eggs in the refrigerator to prevent cross contamination ( 6 ) food removed from its original packaging will be labeled with the following ( a ) receive date ( b ) open date ( C ) contents in the package . ( 9 ) open package or leftover food is to be tightly wrapped or covered in airtight clean containers. It should be labeled dated with opened or used by date. Do not keep leftovers in the refrigerator for more than 7 days . ( 12 ) perishable food should not remain in the temperature danger zone ( 41-135 ) for longer than four hours. ( 14 ) frozen foods are thawed during the cooking process under refrigeration or by immersion under running water of a temperature of 70 F or lower ( 16) do not consume handle prepare or store food in areas with hazardous chemicals ( 19 ) safe food temperatures will be maintained at acceptable levels during food storage preparation holding service delivery cooling and reheating ( 22 ) food is cooked to at least 135 F. Reheat foods to an internal temperature of at least 165 F for at least 15 seconds ( 24 ) check food temperatures prior to meal service if the food temperatures are not within acceptable parameters the food is reheated or chilled to an appropriate temperature. ( 25 ) make certain the thermometer is clean and has been sanitized. Sanitized thermometer if food tested is between 41 F and 135 F or if visibly soiled. ( 26 ) food temperatures are taken and recorded at all meal times period . Record review of the Dieticians Sanitation Report dated 07/16/2026 revealed the kitchen and its staff were not meeting standards for: (main kitchen areas)Preparation tables, convection oven, range, shelves/racks, microwave, floors/baseboards, drains, (cold storage) walk-/reach-in cooler, walk-/reach-in freezer, shelves/racks, cooler/freezer seals (dish room) dish machine, 3-compartment sink, shelves/racks, floors/baseboards, drains. The overall score from the report was 70.5% with the expectation noted as 90% or greater. The notes entered by the Dietician read in part, . Still several areas that need to be replaced or repaired. Dish machine drain not draining. Standing water visible.

Based on interview, observation, and record review the facility failed to adhere to their policy regarding use and storage of foods [NAME] to residents by family and other visitors to ensure the safe and sanitary storage, handling, and consumption for 1 of 1 kitchen reviewed for outside food handling. -The facility failed on 08/11/2026 at 9:31 a.m. to ensure a residents' food that was stored in the freezer in the dining room was labeled, dated, and properly sealed.-The facility failed on 08/11/2026 at 12:50 p.m. to ensure Dietary Aide O did not reheat Resident #44's partially eaten food that was from outside the facility in the kitchen microwave. These failures place residents at risk of exposure to cross contamination and food-borne illnesses for residents who receive their food from the kitchen.Findings included: In an interview and observation on 08/11/2026 at 9:31 a.m. during the initial kitchen tour with the Director of Food Services, a local grocery store bag with 4 separate food items that were undated, unlabeled, and unidentifiable to which resident it belonged to was located in the freezer in the dining room. She stated this food was not supposed to be there but since the freezer was in the dining room she stated she could not limit the residents from accessing it and placing items in the freezer. She stated she monitored and checked it whenever possible but did not have a routine for monitoring the freezer for resident's food. In an interview and observation on 08/11/2026 at 12:50 p.m. Dietary Aide O was observed bringing in a plate with Spanish rice and a protein on a paper plate with a foil cover from a resident in the dining room. Dietary [NAME] O returned to the kitchen microwave and placed the plate within and reheated it for approximately 1 minute. She stated that the plate was for a resident. She asked if it was okay to reheat it in the kitchen and was redirected to review policy and seek instruction from the Director of Food Services. Dietary Aide O exited the kitchen and was observed returning the plate to Resident #44. In an interview on 08/13/2026 at 9:40 a.m., Dietary Aide N stated that she did not know where to heat up food brought in by residents. She stated she would not let it into the kitchen because she did not know where it came from or how it was prepared. She stated she had never heated up food for a resident. She stated she had not received training or instruction on handling outside food from residents. She was provided the policy on outside food that was in English and clarified she understood very little of it and would need further clarification to understand what it said. In an interview on 08/13/2026 at 9:48 a.m., Dietary Aide O stated that she received a plate from a resident and took it to the kitchen microwave to reheat. She stated she did not know if it was acceptable to take outside food into the kitchen. She stated she did not know if there was a policy in place to handle this situation. She was provided the policy on outside food that was in English and did not understand it. She stated it caused cross-contamination for outside food to be heated in the kitchen. She stated the residents could become sick or die if the process was not upheld. In an interview on 08/13/2026 at 1:21 p.m., [NAME] M stated that he could not heat up outside food in the kitchen. He stated this was not allowed because food could be cross-contaminated. He stated that all dietary staff were responsible for ensuring outside food was not brought into the kitchen. He stated the breakroom microwave should be used in this event. He stated the Director of Food Services was responsible for ensuring the outside food policy was implemented and adhered to. He denied receiving training on the outside food service policy in the past seven months. In an interview on 08/13/2026 at 2:18 p.m., the Director of Food Services stated outside food should not be brought into the kitchen because of cross-contamination. She stated she was not aware of when the incident occurred and was later notified. She stated that there was no community microwave, but the residents food could be reheated in offices or the breakroom. She stated she had not provided an in-service or training to staff on the facility's outside food policy. In an interview on 08/13/2026 at 7:50 p.m., the Administrator stated that the facility did have an outside food policy. She stated the staff was not supposed to warm up food in the kitchen because of cross-contamination. She stated that staff should adhere to the policy at all times. She stated the Director of Food Services was responsible for ensuring outside food was not brought into the kitchen. Record review of the facilities policy titled, Food from Outside Sources dated 03/2021 read in part: (policy) residents may have outside sources The community was sure that proper steps are taken so that the food remains safe. (Procedure) ( 1 ) community team members will educate residents and/or family members on food brought in from outside the community on:. (b) proper reheating ( i ) community team to assist resident in reheating food to proper temperature (>165 F for 15 seconds) food to be reheated in designated area (in example Med room) opened food containers will not be able to be reheated in the kitchen to prevent cross contamination of food . ( 3 )If residents would like the food and nutrition services team to store their food item the following conditions must be met: ( a ) food is unopened ( b ) resident name is labeled on food product ( C ) receive date added ( d ) open date is added (once open)

Based on interviews, observation, and record review, the facility failed to not release information that was resident-identifiable to the public for 2 of 4 locked shredder boxes and to adhere to accepted professional standards and practices by maintaining complete and accurate documentation for 2 of 10 residents (Resident #5 and # 19) reviewed for documented care areas.The facility failed to ensure that a copy of a thorough internal investigation was maintained for a self-reported incident on 07/04/2026 involving misappropriation of property for Resident #5.The facility failed on 08/12/2026 to document Resident #19's weight for July and August and to enter a progress note for refusal.These failures place residents at risk to have their health protected information accessible to the public and jeopardize having conditions and treatments go undocumented and unreported. Resident #19 Record review of the resident's admission sheet dated 08/13/2026 revealed the resident was a [AGE] year-old female with an original admission date of 07/19/2024. Record review of the Residents Quarterly MDS dated [DATE] revealed under Section C – Cognitive patterns that the resident had a BIMS score of 6, with the significance being that the resident was severely cognitively impaired. Under Section E - Behavior the resident was coded for having physical behavioral symptoms directed towards others and verbal behavioral symptoms directed towards others for 1 to 3 days out of 7. Under Section K – Swallowing/Nutritional status under subsection height and weight the resident was measured at 62 inches in height and weighed 99 lbs. and the resident was coded for having lost 5% or more in the last month or loss of 10% or more in the last six months with no weight gain noted; the resident was not provided a specific diet for nutritional approaches as per the quarterly MDS. Under section N - Medications the resident was prescribed high risk drug classes in the form of antipsychotic, anti-anxiety, and antidepressants. Record review of the resident care plan dated 07/14/2026 revealed the resident was coded for being at risk for weights loss since 04/28/2025 and experienced significant weight loss on 11/10/2025 with an 11.3% weight loss in under 180 days. Interventions listed were to monitor for dietary intake and weigh weekly as ordered by the physician. Record review of the residents physical and health dated 05/19/2026 revealed the resident was diagnosed with Schizoaffective disorder (a chronic mental health condition defined by a combination of psychotic symptoms (like hallucinations or delusions) characteristic of schizophrenia and major mood disorder episodes (such as depression or mania)), myopathy (a general term for muscle diseases where the primary defect is located within the muscle fiber itself, rather than in the nerves supplying them), anxiety (common mental health conditions that cause ongoing, extreme fear, worry, or dread), Crohn's disease of both small and large intestine without complications () means there is active inflammation in multiple parts of the digestive tract, but no severe secondary events like blockages, fistulas[abnormal, tunnel-like passageways that connect two parts of the body], or abscesses [painful, localized collections of pus caused by an infection]), and Alzheimer's dementia early onset (a rare form of dementia that strikes people before age [AGE]). Record review of the resident's health account revealed under the weight log that the resident had not received a reweigh since 06/12/2026 and had an order from her physician to receive weekly weighs every Monday beginning on 06/17/2026. Review of the residents progress notes did not have any notations for attempts and refusals by nurses or CNAs. Record review of the facility's July and August paperback weight logs completed by CNA E, revealed she had written in refused for Resident #19. Resident #19 was unable to participate in an interview on 08/11/2026 at 10:18 a.m. and 08/12/2026 9:35 a.m. due to internal stimulation and loose association to what was being asked as observable by the residents verbal and physical aggression towards others. In an interview on 08/12/2026 at 3:45 p.m., CNA E stated that it usually took her three days to obtain all the weights of all the residents, typically by the 10th of every month. She stated she did have residents who refused weight checks, and she notified the DON. She stated that it needed to be documented in case the resident lost weight. She stated that weight loss could result in skin breakdown, fragility, and a loss of functionality. She stated that the DON had appointed her to complete weight checks. She stated that the facility verified the accuracy of the weights by taking her word for it and reviewing variants. She stated that she was unable to document in the facility's electronic databases for residents as a CNA. She stated she notified the ADON A, DON, and nurses if a resident refused to be weighed. She stated that she tried to measure Resident #19 weight all month long, but she would continuously refuse. She stated that the nurses would be responsible for documenting weight loss and refusals from Resident #19. She stated that it needed to be documented to show the facility's efforts to weigh Resident #19. In an interview on 08/12/2026 at 3:57 p.m., ADON A stated that she entered all the weights for the residents that were provided by CNA E. She stated that it was within the scope and practice of the CNAs to complete this task independently. She stated that CNA E would not be able to enter weights and progress notes into the facility's electronic database for residents. She stated that she verified the work by remeasuring as needed and if it was questionable finding. She stated a resident needed to be weighed monthly, and if they were on a weight loss program, it was weekly. She stated that she instructed CNA E to try three times and then notify her if a resident still refused and to notify the charge nurse. She stated that she was responsible for ensuring the refusal note was entered for Resident #19. She stated that it affected Resident #19 because no weight would be monitored and they would not know to keep an eye on it. She stated Resident #19 could experience muscle mass loss, a loss of the ability to be independent, and could be susceptible to injuries, disease, and skin breakdown. She stated it would depreciate their quality of life. She stated that nurses and CNAs were responsible for monitoring resident weights and documenting intake and output during meals. She stated that the nursing leadership was in charge of monitoring staff for task completions. She stated that she was made aware of Resident #19's refusal via a sheet log from CNA E. Resident #5 Record review of Resident #5's admission record dated 08/13/2026 revealed a [AGE] year-old male with an initial admission of 04/24/2026 and a readmission date of 06/29/2026. Record review of Resident #5's History and Physical dated 07/14/2026 revealed a diagnosis of Major depressive disorder, recurrent, severe with psychotic features (repeated episodes of deep depression combined with a loss of touch with reality, such as hearing voices or holding false beliefs). Record review of Resident #5's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 indicating intact cognitive function. Record review of Residents progress notes for the date of the incident involving misappropriation of property on 7/4/2026 revealed that there was no documentation regarding the incident. Record review of Resident #5's care plan revealed Resident #5 was at risk for financial loss due to a history of keeping cash on his person and not consistently storing personal funds in a secure location. Interventions included encouraging the resident to avoid carrying large amounts of cash on his person. In an interview on 08/13/2026 at 6:38pm with the Administrator she stated when there was an incident with allegations of abuse, neglect, or misappropriation of property, she was to initiate an internal investigation and report to the State Survey Agency. She stated that for the incident involving Resident #5, she collected staff statements and resident's statements and initiated an abuse and neglect Inservice. She stated that after conducting the internal investigation she collected the information and placed it in a yellow folder. She stated that when reporting to the State Survey Agency she submitted the 3613-A form. She stated that she did not know where she placed the folder due to having a lot of papers on her desk. She stated she was not sure if she threw them away accidentally. She stated that it was important for her to keep documentation to prove investigation was conducted and to be able to provide documentation upon request to the State Survey Agency. Review of the facility policy revised 01/01/2023 section on Compliance read in part . Upon notification of an allegation of physical or mental abuse, neglect or involuntary seclusion[sic], the facility will conduct interviews[sic] that include documented statement[sic] summaries from the alleged perpetrator[sic], the alleged victim, family members, visitors who may have made observations, roommate[sic] and any staff who worked prior to and during the time of the incident .

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 7 residents reviewed for care plans. The facility failed to include Resident #47's smoking preference in the care plan.This failure had the potential to affect residents by placing them at risk for unmet care needs.Findings included:Record review of Resident #47's face-sheet dated 08/13/2026 revealed a [AGE] year-old female resident with an admission date 03/12/2026.Record review of Resident #47's history and physical dated 02/19/2026 revealed past medical history of tobacco use.Record review of Resident #47's Quarterly MDS assessment dated [DATE] revealed a BIMS of 7, indicating a severe cognitive impairment. The Quarterly MDS did not include Resident #47's tobacco use.Record review of Resident #47's care plan dated 04/23/2026, revealed it did not include the resident's smoking preference.Record review of Resident #47's electronic medical chart revealed there was no smoking assessment.Interview with the Nursing Facility Administrator and record review of a smokers list dated 05/21/26 provided by the Nursing Facility Administrator on 08/11/2026 at 3:00 PM, she stated it was the most recent list. The smokers list revealed a total of 33 residents including a handwritten name, Resident #7, admission date 06/26/2026. The smokers list did not include Resident #47.In an observation and interview on 08/11/2026 at 12:10 PM, Resident #47 was observed coming from the designated smoke area that was located in the back of the main dining room. Resident #47 was accompanied by their family member, and they stated they had just finished their smoke break. Resident #47 stated she was smoking outside in the smoking area with her family member alone, and stated there was no staff present. Resident #47 stated she smoked at least daily, sometimes multiple times a day. In an interview on 08/13/2026 at 2:27 PM with the DON, she stated the nurses were responsible for residents' care plans. The DON stated the purpose of the care plan was to include and address all the resident's goals and interventions which the staff had access to. The DON stated the MDS Nurse was responsible for formulating the comprehensive care plan within 14 days of admission. The DON stated there were potential risks of not including resident information such as smoking into the care plan but did not elaborate.In an interview on 08/13/2026 at 6:56 PM with the Administrator, she stated care plans were completed by the IDT which included the MDS Nurse, and the DON. The Administrator stated it was completed by the nursing staff when the resident was admitted and reviewed quarterly by the MDS Nurse and the DON, or if there were any changes in condition. The Administrator stated the potential risk of not having information included in the residents' care plan meant the staff would potentially be aware of the residents' needs.Record review of the nursing facility's Comprehensive Care Plan policy, with revision date 04/25/2021, revealed 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 hourse of Admission. It continued to reveal in part, 1. A Registered Nurse will complete the baseline Care Plan in the RN's absence in the Clinical reimbursement role. An RN initiates all Care Plans. 2. To assure that the resident's immediate care needs are met and maintained, the baseline care plan will be developed with 48 hours of the residents' admission. It will be utilized until the Comprehensive Care Plan is developed. 3. The Comprehensive Care Plan is developed within 21 days of Admission.

Based on observations, interviews, and record review, the facility failed to provide the necessary services for residents who were unable to carry out ADLs to maintain good grooming and personal hygiene for 1 of 6 residents (Resident #2) reviewed for ADL care.The facility failed to ensure Resident #2's nail was trimmed on 08/11/2026.This failure could place residents at risk of loss of dignity, risk for infections, and a decreased quality of life.Record review of Resident #2's face-sheet dated 08/12/2026 revealed a [AGE] year-old female resident with an initial admission date 03/25/2025, and re-admission date 07/17/2026.Record review of Resident #2's history and physical 07/21/2026 revealed the following medical history: Quadriplegia (paralysis from the neck down, meaning the person cannot intentionally control or move the muscles affected); Major Depressive Disorder (a mental health condition that persist of sadness and loss of interest in daily activities for at least two weeks); and Anxiety (intense, excessive and persistent worry and fear, which affects daily life).Record review of Resident #2's Nursing Home PPS MDS dated [DATE] revealed the resident was unable to participate in a BIMS. Under Section GG- Functional Abilities, Resident #2 was noted to be completely dependent on all self-care activities including hygiene. Being completely dependent means the helper does all the effort to complete the task while the resident does none of the effort.Record review of Resident #2's Care Plan with revision date 04/15/2025 revealed Resident #2 required total assistance with one-person physical assist with personal and oral hygiene.Observation on 08/11/2026 at 11:04 AM revealed Resident #2 sitting in a recliner in her room. Resident #2 was unable to verbally participate or answer questions but was able to follow instructions. Resident #2 lifted her arms and showed her hands when asked about her nails. Resident #2's nails of her right and left hands were observed 3-5 millimeters long, and jagged.In an interview on 08/13/2026 at 10:04 AM with CNA E revealed the nursing aides, or CNAs, were responsible for offering residents basic nail care and grooming. CNA E stated nail care and grooming was offered during resident showers which was every other day, or as needed. CNA E stated long and jagged fingernails were a potential risk of injury as the resident could potentially scratch their skin.In an interview on 08/13/2026 at 11:37 AM with RN P, he stated CNAs 's were responsible for the residents ' basic nail care. RN P stated the CNAs 's were to offer residents nail care including trimming, during showers or as needed if the resident was observed with long nails. RN P stated the RNs 's were responsible for monitoring residents' nails at least weekly. RN P stated the potential risk for residents to have long and jagged fingernails, including scratching the skin. RN P stated that was also a potential infection control risk.In an interview on 08/13/2026 at 2:28 PM with the DON, she stated the CNAs were responsible for maintaining and providing residents with nail care during the residents' shower days. The DON stated residents' shower days were every other day. The DON stated the nurses on the floor were responsible for monitoring the residents' nails and ensuring nail care was provided or offered. The DON stated she was unsure how often the nurses were monitoring residents' nail care. The DON stated the potential risk for residents having long and jagged fingernails included skin tears.In an interview on 08/13/26 at 7:00 PM with the Administrator, she stated the CNAs were responsible for providing and maintaining the residents' fingernails trimmed and groomed. The Administrator the CNAs provided basic nail care services at least once a week. The Administrator stated the nurses were responsible for CNAs and ensuring residents' nails were being trimmed and groomed, at least weekly. The Administrator stated long and jagged fingernails were a potential risk of causing skin tears to residents.Record review of the nursing facility's Resident Rights Policy with revision date 12/2026, revealed in part under Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. A dignified existence.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 (Residents #74) of 6 residents observed for oxygen management. The facility failed to ensure Oxygen (O2) in use signage was posted on the doorways of Resident #74 to ensure smoking was prohibited. This failure could place residents at risk of receiving incorrect or inadequate oxygen support and decline in health and at risk of fire hazards by not posting oxygen signs outside the residents' rooms.Findings included: Record review of Resident #74's admission record dated 08/13/2026 revealed a [AGE] year-old male with an initial admission date of 08/02/2022 and a readmission date of 03/09/2026. Record review of Resident #74's Physician progress note dated 05/07/2026 revealed a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) (a group of progressive lung conditions that block airflow and cause severe breathing difficulty). Record review of Resident #74's Annual MDS assessment dated [DATE] revealed a BIMS score of 06 indicating severe cognitive impairment. Record review of Resident #74's physician orders dated 8/13/2026 revealed an active order for oxygen 2 liters to 4 liters to keep oxygen saturation above 92% as needed for shortness of breath. Record review of Resident #74's care plan revised on 08/12/2026 revealed Resident #74 had an ineffective breathing pattern related to COPD. Interventions were to administer oxygen as ordered. In an observation on 08/11/2026 at 10:26am of Resident #74's room, aan oxygen concentrator along with an oxygen cylinder was present in the room. There was no oxygen in use signage posted on the doorway. In an interview on 08/13/2026 at 10:04am with CNA E, she stated oxygen in use signs should be posted on the doorway when oxygen was in the room. She stated that it was the responsibility of the nurses to post the oxygen in use signs, but if any staff sees that there was oxygen in the room and no sign, then any staff can get a sign and post it. she stated that a risk was that oxygen was flammable and so other staff members or visitors were aware of oxygen in the room. In an interview on 08/13/2026 at 11:39am with RN P, he stated oxygen signs were to be posted in the doorway of rooms of residents who used oxygen. He stated that it was the responsibility of whomever initiated the oxygen to post the sign outside of the Residents' rooms. He stated the risk of not having the sign posted was possible injury because of flammable precautions and staff not being aware of oxygen in use. In an interview on 08/13/2026 at 2:17pm with the DON she stated the nurse was responsible for placing oxygen in use signs outside of the resident rooms. She stated the oxygen signs were placed so that staff and visitors were aware of oxygen in use. She stated there was no potential risk for the resident because no one smoked inside the facility. In an interview on 08/13/2026 at 6:38pm with the Administrator she stated the DON was responsible for putting up the oxygen signs when oxygen was in use. She stated that it was important for signage to be posted to let staff and visitors know that oxygen was in use. The risk would be the staff not knowing that the resident needed oxygen. Review of the facility policy titled It Takes a Minute to Save a Life, Respiratory section with an effective date of 04/2021 read in part . post no smoking sign on the outside of door to residents room .

Based on observation, interview, and record review, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 1 of 6 residents (Resident #13) reviewed for accommodation of needs. The facility failed to ensure resident call light was within reach for Resident #13 on 08/11/2026. This failure could place residents at risk of having their needs unmet when they were unable to contact staff.Findings included Record review of Resident #13's admission Record dated 8/13/2026 revealed a [AGE] year-old male with an original admission date of 10/21/2020 and a readmission date of 06/21/2023. Record review of Resident #13's History and Physical dated 02/17/2026 revealed a diagnosis of Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (complete paralysis or partial muscle weakness on one side of the body caused by stroke or blocked blood vessel in the brain). Record review of Resident #13's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 02 indicating severe cognitive impairment. Section GG- Functional Abilities indicated Resident #13 was dependent for toileting and hygiene. Record review of Resident #13's care plan with a revision date of 06/25/2026 revealed Resident #13's wish regarding bed placement will be met through next review; interventions indicated that Resident #13 preferred to have call light to be within reach. In an observation on 08/11/2026 at 10:19am revealed in Resident #13's room, the call light was observed to be on the floor not pinned to the bed while the resident was in bed. In an interview on 08/13/2026 at 10:53AM with Resident Care Provider C, she stated that the purpose of the call light was for residents to call for assistance when needed. She stated the call lights should be kept within reach of the resident when in bed in case they needed any help. She stated that the resident care providers were responsible for ensuring call lights were kept within reach and the charge nurse would oversee that call lights were in reach. She stated that a risk of the call light not being within reach would be falls or injuries. In an interview on 08/13/2026 at 11:37am with the RN, he stated the call light was for residents to get the attention of staff members. HE stated that it needed to be within reach of the resident. He stated that risks included delayed care and falls. He stated that it was the responsibility of the nurses and CNAs to ensure call lights were within reach. He stated that CNAs rounded at least every 10 min and nurses rounded every 2 hours to ensure call light placement and overall resident wellbeing. In an interview on 08/13/2026 at 2:17pm with the DON, she stated call lights were used for when residents needed assistance. She stated call lights were supposed to be kept within reach, pinned to the bed. She stated that it was everyone's responsibility to ensure call lights were within reach of the residents. The risks included delayed care and injuries if a resident were to get up and fall. In an interview on 08/13/2026 at 6:38pm with the Administrator, she stated call lights were for the residents to ask for assistance. She stated that it was everyone's responsibility to ensure call lights were within reach of the resident. She stated the risk would be a delay in care and risk of falls or injury. On 8/12/2026 at 5:00pm call light policy was requested from Administrator, the policy was not provided before exit on 8/13/2026.

Based on observations, interviews and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accidents and supervision, in that: Resident #1 eloped on 11/19/24 out of the facility and across a 35-mph street and was found at a school 0.8 miles away 2 hours later by police. An IJ was identified on 5/2/25. The IJ template was provided to the facility on [DATE] at 12:44 PM. While the IJ was removed on 5/2/2025 at 8:35 PM. The facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for more than minimal harm that is an immediate jeopardy due to facility's need to evaluate the plan of removal. This failure could place residents at risk of severe injury or even death. The Findings were: Review of Resident #1's Admission Record, dated 4/29/25, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of dementia with behavioral disturbance, brief psychotic disorder (had an episode of seeing things that were there or believing things that were completely irrational). Review of Resident #1 quarterly MDS Assessment prior to the incident, dated 2/24/25, revealed: He had a mental status of 6 of 15 (indicating severe cognitive status) There were no behaviors documented. He had no range of motion impairments. He could walk 150 feet with partial assistance. He was on an antidepressant. Review of Resident #1's care plan revealed: Initiated 4/13/23 Focus: Resident is an elopement risk/wanderer and is in secured unit being at risk for possible injury related to impaired safety awareness and diagnosis of dementia. Goal: Resident's safety will be maintained throughout the review date Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, televisions, or books. Provide structured activities: walking inside and outside, reorientation strategies, including signs, pictures, and memory boxes. Initiated 4/26/23: Focus: Resident resides in secure unit as is at risk for injury from wandering in an unsafe environment related to diagnosis of dementia as evidenced by impaired safety awareness. Resident is at risk for injury from others while residing in secure unit due to altered cognition. Goal: Dignity will be maintained, and resident will wander about unit without the occurrence of any occurrence of any injury over the next quarter. Interventions: Call by name when giving care, involve in care as much as possible. Resident #1's Elopement Assessment, dated 10/8/24 scored an 11 making him a high risk for elopement. There was no Incident/Accident report for the 11/19/24 elopement in the electronic record. Review of Resident #19's Nurse's Notes revealed no nurse's notes for 11/19/24. The next nurse's note was dated 11/21/24 and read: Nurse Practitioner rounded on resident today, no new orders noted/ After occurrence this week with resident escaping from facility lockdown unit. Review of the facility's investigation revealed on 11/19/24: Staff reported Resident #1 was missing at 6:00 p.m. RN A ordered a search of the facility and notified the Administrator and DON. Administrator and DON came to the facility. They notified the police. The Administrator drove through the neighborhood while the DON stayed at the facility. The facility completed the head count. Police found Resident #1 west of the facility 0.8 miles away at 8:45 p.m. Facility notified physician. Facility completed skin assessment with no injuries found to the resident. Facility changed the number to the doors to the secured units. Management began an Inservice to the staff about not allowing residents to follow people out the door. Review of the facility's investigation dated 11/25/24 revealed resident went out of secured unit behind a girl is what he is saying. Verification on Accuweather.com revealed the temperature was between 39- and 68-degrees Fahrenheit. Sunset was 5:45 p.m. Interview on 4/28/25 at 10:45 a.m. the Administrator stated Resident #1 made it to the school on {x} street. The also present DON stated the {x} school was about 3/4 a mile away. The Administrator stated that weekend the facility had a plumbing problem, and the facility was replacing plumbing, and Resident #1 followed the contract worker out the door. The DON stated Resident #1 crossed their street (30 mph) and walked down the other street (35 mph). The DON stated the police officer found Resident #1 at the school and the only thing wrong with him was his brief was full of poo. The DON stated the staff should have seen the elopement attempt coming and all the staff knew to keep the door shut. The DON said they told the workers in Spanish but did not know how much they understood. The DON said it did not matter the staff all knew. The DON said they did not have a staff member designated to watch the door because she assumed the staff would do their job. The DON said this time Resident #1 got out of the building by following someone out the door of the secured unit and then left out the front door. The DON said Resident #1 felt like he did not belong at the facility. Interview on 4/29/25 at 8:55 a.m the DON stated the facility did QA the situation and their added solution was there would be a dedicated person at the door while there was construction going on. Observation on 4/29/25 at 12:44 p.m. of the neighborhood revealed the road the facility was on was 30 mph . The road the resident went down was a four-lane divided road with a draw (long drainage ditch) between the two lanes, and the speed limit was 35mph. There were four stop signs between where the resident was found and the facility. There was a sidewalk. Interview on 4/29/25 at 11:45 a.m. the DON stated there was a lack of documentation on Resident #1 because her nurses did not like to document anything. The DON reviewed Resident #1's documentation and stated all she could find was the 11/21/24 nurses note documenting the NP visit. Interview on 4/29/25 at 1:00 p.m. the DON stated there was no incident-accident report for Resident #1's elopement on 11/19/24. The DON said it was missed and did not have an answer for why. The DON said the facility did do a skin check for Resident #1 when he returned and every 15-minute checks, but those would not be in his clinical record. The DON stated the physician was notified. The DON said Resident #1 was his own Responsible Party so there was no Responsible Party to notify. The DON stated at the time the facility was working off electronic 24-hour reports and new nurses were not putting in everything they needed to. The Administrator joined the conversation and admitted the lack of documentation was a staffing failure and Resident #1 now lived on the smaller of the two secured units where it would be harder for him to slip through the cracks. Interview on 4/29/25 at 5:47 p.m. the Administrator admitted she did not take statements from the night staff about what happened with Resident #1's elopement. She said she was just tired, relieved to have him back, and forgot. The Administrator said her investigation showed it happened around 5 p.m. Interview on 4/29/25 at 6:27 p.m. RN A stated she was a charge nurse the night Resident #1 got out, but she was not Resident #1's charge nurse. RN A stated she was getting shift change information from LVN B and MA C when a CNA came off the unit saying she could not find Resident #1. RN A said she could not remember which CNA it was. RN A said she directed the CNA to go check the rooms on the units. RN A said it was shift change so she and LVN D checked the outside of the building. RN A stated they came back in and told everyone what to do. RN A said she called the DON. RN A stated she directed everyone to do a room-to-room search to include checking bathrooms, and closets. RN A said she and LVN D did a head count and everyone else was accounted for. RN A stated the DON and Administrator came at that point. RN A stated she told the DON what she (RN A) told the staff to do up to that point. RN A said the DON and Administrator started the corporate protocols at that point, the DON called the police while the Administrator went to go search for the resident. RN A stated she did not remember when Resident #1 came back but he was ok. RN A said she did not know how Resident #1 got out the building because she was charge nurse over the other side of the building. RN A said nothing stood out as unusual when she got to the building that day. Interview on 4/30/25 at 9:18 a.m. CNA E said she worked the 6 a.m. - 6 p.m. shift. CNA E stated her memory of Resident #1 getting out of the building was fuzzy. CNA E stated she did not know if that was how Resident #1 got out or not, but she remembers there was a lot of construction going on at the unit that day. CNA E said she did not know Resident #1 had eloped until he was gone. CNA E stated Resident #1 got his breakfast and lunch trays and remembered checking on Resident #1 in his room when she did rounds. CNA E said she never asked Resident #1 how he got out. CNA said there was nothing else unusual about that day. CNA E said after the incident they had an in-service about making sure the door was closed, the door code was changed, and that Resident #1 room was changed. Interview on 4/30/25 at 10:19 a.m. CNA F said he worked 8 a.m. - 8 p.m. and he worked the day Resident #1 got out. CNA F said that day Resident #1 could not stay still. CNA F said there was maintenance going on in the unit so there were carts in and out. CNA F said people had to know to pull the door shut to make sure it closed, or the residents would follow people out. CNA F said since Resident #1 could no longer get through the fence he followed someone out the unit door. CNA F said Resident #1 did not move quickly, but if someone was pulling a cart behind them, Resident #1 would be able to follow. CNA F said he was surprised Resident #1 got 0.8 miles away before he was found since Resident #1 walked with the limp. CNA F said after the elopement they were told to watch the residents more, but CNA F did not know how since residents went outside on the patio as well. CNA F said the staffing pattern was two people on E hall and two people on F hall - which left one aide to do aide work and one person to watch the hallway and the patio to monitor residents. CNA F said he worked 8 a.m. to 8 p.m. to reduce some of the chaos that happened at shift change and worked the men's unit exclusively. CNA F stated since Resident #1 eloped the facility worked on the door magnets, changed the code, moved Resident #1 to another hall, in-serviced staff and told the staff to watch the residents more . Interview on 4/30/25 at 12:23 p.m. LVN B confirmed she was a charge nurse the day Resident #1 got out. LVN B stated she stayed after her shift after the CNA said Resident #1 was missing. LVN B said the aide came out of the unit asking if anyone saw Resident #1 and the staff were unable to find Resident #1. LVN B said she did not know what time that was, but she thought it was between 6 p.m. and 6:15 p.m. LVN B stated the staff checked the other unit the patio was attached to because you never know and then rechecked the hall Resident #1 lived on. LVN B said all staff were alerted to check the whole building. LVN B said it took an extra hour to hour and a half. LVN B said they were unsuccessful, after they checked the outside, she just left. LVN B said the next day she learned they found Resident #1 at a school. LVN B said no one told her how Resident #1 got out . LVN B said that day there were a lot of people in and out of the unit because there was construction going on. LVN B said they did not know if the construction workers left the door open. LVN B said it was unclear how he got out. LVN B said LVN D worked Resident #1's hall during the day. LVN B said she did not remember which night aide told them the resident was gone. Interview on 4/30/25 at 12:32 p.m. LVN D stated she was Resident #1's charge nurse. LVN D said no one reported to her Resident #1 was missing. LVN D stated CNA G's statement that documented she told a nurse Resident #1 was missing was false. LVN D said CNA G no longer worked at the facility. LVN D stated no one told her Resident #1 was gone. LVN D said CNA G may have told MA C. LVN D said she could not remember that day, but she knew he was there because she put her eyes on everyone before dinner, LVN D just could not recall if she saw him. LVN D said they called the Administrator twice that day but did not remember why. LVN D said there was an in-service about missing residents but could not remember anything else. Interview on 4/30/25 at 4:02 p.m. MA C stated he kind of remembered some of the incident of Resident #1's elopement. MA C said they were doing maintenance on Resident #1's side of the men's secured unit. MA C stated there were a lot of people going in and out. MA C said he thought Resident #1 just followed them out. MA C stated he could not remember what time it was. MA C he was not assigned to pass medications down that side of the building. MA C stated no one told him a resident was missing, if they did, he would search room to room and check the entire facility and then check with the Administrator to see what needs to be done. MA C stated he believed Resident#1 was gone a couple of hours. MA C said residents hung out on the patio area and the staff were responsible for keeping up with where the residents were, and it was difficult to keep up with the patio, the day room, and the resident's room plus being an aide. Interview on 5/1/25 at 10:29 a.m. the Regional RN Consultant stated she only checked care plans during the facility's mock survey. She stated the regional staff were supposed to check the care plans after an incident occurred. The Regional RN admitted she did not because she usually looked to see if there was an intervention put in place after the incident. The Regional RN Consultant stated after an Elopement she expected to see if the resident was checked for a UTI, were doors locked and/or alarming, making sure that the residents could not get out and if there was a system failure. The Regional RN stated she remembered the facility reported the incident occurred to the corporate staff, but they were not part of the plan of correction, and they were not part of monitoring the plan of correction. The Regional RN stated usually if the facility had a self-report, she would go over it. Interview on 5/1/25 at 1:00 p.m. Resident #1's physician stated the facility notified him of the elopement and the NP did an as needed visit the next day to verify there were no injuries. The physician reviewed Resident #1's notes and stated the only medication Resident #1 had ordered in the last 3 years was diphenhydramine so Resident #1 was medically stable. The physician stated he had not issues with how the units were being run. Observation on 5/1/25 at 4:22 p.m. revealed two maintenance worker bringing dirt into the patio area on the men's unit to level it out. One male resident was sunning himself on the ground, another resident came out to smoke. There was one of the employee's children intently staring at the open gate. Surveyor asked him if his job was to watch the gate, he shrugged, and continued to stare at the open gate. Interview on 5/2/25 at 10:10 a.m. the DON stated the facility was supposed to be doing head counts every day - that was the responsibility of the ADON who was no longer with the facility. The DON did not know when that stopped or why that stopped. The DON said after Resident #1's elopement the facility also changed the physical keypad to all the doors, changed the codes, secured the furniture to the patio so the furniture could not be moved for residents to climb over the fence, referred Resident #1 out to other facilities. The DON said she thought there were some in-services with maintenance department, but she could not remember - it was not her department, so she was not sure. Interview on 5/2/25 at 10:17 a.m. surveyor attempted to call the previous ADON and left a detailed message requesting a call back. Interview on 5/2/25 at 10:45 a.m. the DON stated, as a general rule Resident #1 wore a beige jacket he would not take off, a t-shirt and jeans. The DON said she did not remember exactly what Resident #1 wore on 11/19/24 except jeans because the officer was so mad about the poop falling out of it. The DON said she was unable to find any of the head count forms the previous ADON was responsible for monitoring. 5/2/25 at 11:54 the DON showed surveyor where the plumbers were working, and one of three rooms was Resident #1's. Review of the facility's investigation dated 11/20/24 revealed: The DON's statement revealed: I received a call that resident was not on the unit. We told the staff to check every room and every bathroom, closet and any place someone could be hiding and myself and the Administrator went down the street to look for him. Several staff came out to look for him and we called the police and spoke to an officer and gave a report of him missing. At about 8:45 p.m. an officer called the facility and said that he had found him and was bringing him back home. Resident arrived in the police car with no injuries to himself and returned to his room. When asked how he got out he said that he followed a girl out. We in-serviced staff on making sure no one is exiting the doors with you and that the doors are shut and locked before leaving. We did in-services on ensuring no on follows you out of the unit. He is back home with no injuries' and safe. We also notified the physician. Resident is his own responsible party. We started a head count and looked around the premises of the building and then started a search and called the police to get them to help us to look for him as well. Making sure no one is following you out of the doors and that they are secure before you walk away. Statement from Pest Control the Administrator called: Spoke with Pest Control and he said he thought he saw someone matching description out in parking lot around 5 or so. CNA F's statement revealed: He was here. I don't know what happened. CNA E's statement revealed: He was here at breakfast and lunch. Dinner hadn't been served when I left but I saw him. Dated 11/20/24 CNA G's statement revealed: I went to hand out dinner trays and I noticed he wasn't here and I told the nurse. We started checking everywhere. Dated 11/19/24 MA C written by the Administrator revealed: Spoke with MA C who just said Resident #1 was not here and we couldn't find him. He did not know how he could have gotten out. Administrator's statement dated 11/19/24 revealed: was notified about elopement of Resident #1. Called ADON and went and picked her up. Called Regional Director. Everyone was out looking. DON was in building looking everywhere. Called police to get more eyes out. We were driving around from about 6:40 p.m. until about 8:30 p.m. when we were notified he was back at the building. Police officer found him down by school. Asked him how he got out and he said he waited until he saw an opportunity and then walked out when no one was looking. It seems the door did not close after workers leaving the unit and he just followed them out. He said he was going to follow the water until he got somewhere else. Started in-service on making sure doors are closed when exiting and to watch closely when workers like construction or plumbers are on the unit. Review of in- services, dated 11/21/24, revealed the facility trained all departments on watching doors when construction was going on and always checking doors behind you when leaving. Review of the facility's QA minutes dated 12/12/24 revealed 11 staff discussed the incident and determined the fix was if there was ongoing construction all staff needed to know, and they needed to be at the door and contract staff needed to know they could not let anyone out with them. Review of the facility's Policy and Procedure on Elopement, effective 11/1/19 revealed: Policy: 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. Procedure: 1. Once it has been established that a patient/resident is missing, the following staff members are notified immediately: the charge nurse, Administrators, DON, and social service designee, responsible party and the primary care physician. Complete the missing resident profile. Make note of the outside temperature. 2. The DON or designee organizes and institutes an immediate and thorough search of the center and surrounding ground. Conduct a headcount 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 the exit 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 facilities' - bathrooms and grounds extending beyond the fence line. Check all offices and any locked door to ensure non 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 2 hours from the time patient/resident is found to 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. Two staff members search the surrounding streets by car for a two (2) mile radius around the facility. 6. When the patient/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 DON. The DON notified the Administrator or designee and notifies the appropriate community agencies, attending physician, and patient's/resident's legal representative. The Director of Clinical Operations, Regional [NAME] President of Operations and DON were notified of an IJ on 5/2/25/ at 12:44 p.m. and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal accepted on 5/2/2025 at 4:50 PM and included the following: Door codes changed on 5/02/2025 All residents will have a current Elopement Assessment done by the DON/ADON/Charge nurse to be completed by 5/2/25 Resident have updated Kardex for those identified at high risk for elopement based on updated elopement assessments, by the DON or designee by 5/2/25 Care plan audits completed by Regional [NAME] President of Operations/ Regional Director of Clinical Operations to reflect any changes in elopement status based on new assessments conducted by DON or Regional Director of Clinical Operations. By 5/2/25 In-service initiated on 5/2/25 for all staff on Elopement policy and procedure by DON. All staff will have this in-service prior to the start of their shift and will also be included in the orientation process with any newly hired staff. To be completed by 5/2/25. One to one in-service with DON by Regional [NAME] President of Operations regarding Elopement Policy and interventions to reduce risk of elopement with resident who are at risk or exit seeking 5/2/25 Licensed nurs3es in-serviced on using the Fire Alarm and Secured Unit Exit Release Activation and will also be included in the orientation process with any newly hired staff. To be completed by 5/2/25. Ad hoc QA meeting held with the Medical Director on 5/2/25 to inform him of the Immediate Jeopardy. Policy on Elopement was reviewed with no changes recommended. Fire alarm and Secured Unit Exit Release Activation Form as well as residents assessed at risk for elopement will be reviewed each month in the facility's QA meeting. Residents who leave the secured unit or facility will be accompanied by a staff member or responsible party until they return to the secured unit. The nurse assigned to the resident will monitor that the resident returned to the secured unit. No changes in assessment of current residents noted from Risk assessment completed on 5/2/25. DON/Administrator will monitor staff knowledge of elopement policy. Verification of 6 residents files showed that elopement assessments were completed on 5/2/25. Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews from 5/2/24 at 12:44 through 5/2/25 through 8:35 p.m. Observation on 4:55 p.m. revealed the DON was changing the code to the secured unit and showing it to the staff one on one. Director of Clinical Operations was in- servicing all nursing and aides one on one. The DON was in- serviced one on by the [NAME] President of Clinical Operations on 5/2/25. 5/2/25 Inservice by DON to nurses: Every nurse is responsible for head count at the start of their shift. If a resident is not in the facility, you should first check the sign out sheet. If the resident has signed out. You should account for that next to their name on the printed census for head count. Head count must be done at shift change/or nurse in charge change and with and emergency button pull or incident that leads to secure unit doors or gates coming open. Thes head counts must be turned into the DON under the DON's door. Do not put them in the DON's box. If any resident is not in the facility and not signed out DON and Administrator must be called at once. DON wants the nurses completing the count to sign/initial the halls they verified. DON will take these counts to morning meeting daily also. Inservice by DON on 5/2/25 on Fire Alarm/Secure Unit Emergency Exit Release Activation. Any time the fire alarm is activated or the emergency buttons are pulled on any other incident that releases secure unit doors or gates, the charge nurses are responsible for completing the attached form includes the date and time of the activation, how long or when the facility secure door and gates are resecured and that all residents in secure units are accounted for. This form should be turned into DON's office as well as a phone call to DON to let DON know this occurred. Please call after count has been completed so you can verify that all residents are present. DON will take these counts to morning meeting daily also. Interviews on 5/2/25 between 5:13 p.m. and 7:06 p.m. Nurses: LVN D, LVN J, LVN M (Day shift) and LVN RN T, LVN W (night shift) said the responsibilities and expectations of nurses to prevent an elopement. They were responsible for monitoring the gate at shift change that was documented in the narcotic book, doing a head count that was to be slipped under the DON's door, what to do if the fire alarm was pulled and what documentation needed to be done, incident-accident reports, and that a resident off the unit was to be signed in/out and be accompanied at all times by staff. The nurses were able to verbalize what to do in case of a possible elopement, who/when to notify and how to search a room. Interviews on 5/2/25 between 5:32 p.m. and 6:40 p.m. day shift: MA K, MA S (8 a.m. - 8 p.m.) were able to state the code on the unit had changed, what to do if a resident was discovered missing including how to do a room-to-room search, and that they were to sign a resident in/out of the unit and stay with them at all times. Interviews on 5/2/25 between 5:36 p.m. and 6:58 p.m. day shift aides CNA I, CNA L, HA N, CNA O, CNA P, HA Q, CNA R, CNA U, HA V (8a - 8 p), were able to say the code on the unit had changed, what to do if a resident was discovered missing including how to do a room-to-room search, and that they were to sign a resident in/out of the unit and stay with them at all times. Interviews on 5/2/25 between 6:48 p.m. and 7:42 p.m. Night shift aides CNA X, CNA Y, CNA Z, were able to state the code on the unit had changed, what to do if a resident was discovered missing including how to do a room-to-room search, and that they were to sign a resident in/out of the unit and stay with them at all times. The MDS Coordinator was provided one on one in-service on care planning. The DON, [NAME] President of Regional Operations, and Regional Director of Clinical Operations were informed that the IJ was lifted as of 5/2/25 at 8:45p.m. but the facility remained out of compliance at isolated at a level of no actual harm with potential for more than minimal harm due to their lack of time to monitor their corrective actions. Observation on 5/5/25 at 8:45 a.m. revealed the Administrator standing in front of the keypad of the door to one of the male secured units as she talked to a resident from pushing on the doors. Observation on 5/6/25 at 8:45 a.m. revealed a CNA leaning against the keypad of the door of the male secured unit as she tried to talk to the same resident from pushing on the door. Review of head counts from 5/1/25 through 5/5/25 found some that were not in the right time. Interview with the DON at 5/6/25 at 9:01 a.m. revealed she called the night shift and told them to do a drill count to make sure they had it right. DON was able to show where the count was completed at shift change. The DON was able to show where there were Emergency Exit Activation Forms also completed by nurses from drills and from residents pulling the alarm. The DON produced where all staff were in-serviced prior to beginning shift on their responsibilities on preventing an elopement.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being, consistent with the resident's comprehensive assessment and plan of care for 1 (Resident #1) of three residents reviewed for pain management. The facility failed to assess Resident #1's pain prior to wound care. Resident #1 experienced significant pain at a 7 This failure placed residents who receive pain medication at risk for unmanaged pain during treatment. Findings include: Review of Resident #1's undated face sheet revealed she was a [AGE] year-old-female admitted on [DATE] with the diagnoses of: Pressure ulcers of left buttock stage IV (pressure injury are very deep, reaching into muscle and bone and causing extensive damage), quadriplegia functional( functional quadriplegia is paralysis of the legs and arms but has some use of the upper extremities)(upper extremities arms hands), need for assistance with personal care, and pain unspecific. Resident #1 quarterly MDS assessment on 03/22/23 revealed she was a [AGE] year-old female with a BIMS of 15 indicating she was cognitively intact and able to make her needs known. Resident #1's Care Plan dated 03/11/2023 revealed: Focus: Resident complains of increased pain/discomfort and is at risk for injury Goal: The Resident (#1) will verbalize adequate relief of pain and ability to cope with incompletely relieved pain through the review date: (revision 03/11/2023) Intervention: Administer analgesia ibuprofen, Tylenol #3 as per order. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Record review of physician orders summary dated on 04/14/2023 revealed Resident #1 was ordered - Tylenol with Codeine #3 (Tylenol-codeine 300-30 mg) one tablet scheduled four times a day. - Tylenol 325 mg two tablets every 4 hours as needed for pain related to unspecified pain. Record review of physician orders summary dated on 04/18/2023 revealed Resident #1 was ordered Tylenol with Codeine #4 (Tylenol-codeine 60 mg) every four hours as needed (prn). Tylenol 325 mg two tablets every 4 hours as needed for pain related to unspecified pain. During initial tour on 04/12/23 at 4:30 p.m. Resident #1 was observed in a wheelchair in the smoking area. She said that during wound care the wound care nurses never ask her about her pain. She said that she is a quadriplegic but sometimes she can feel pain due to having an infection. She said since the beginning of her infection (unsure when it began) she said the pain medication during wound care was not effective. Regarding her ADLs (activity of daily living) she said she is totally dependent but able to brush her hair and propel herself in her wheelchair. She said her pain does not restrict her ADLs. On 5/01/2023 at 3:30 PM Resident #1 was observed self-propelling herself to the physical therapy department from about 200 feet without problems with maneuverings herself. During an observation and interview on 4/13/23 at 10:45 a.m., Wound Care Nurse was completing Resident #1's wound care. She was asked by surveyor if the resident was in pain during the wound care or if Resident #1 was assessed for pain, before or after the would care procedure she said, no the resident receives scheduled pain medication, and she did not need to assess her pain. The Wound Care Nurse and surveyor were standing outside of Resident #1's room (Resident #1 refused to allow surveyor to observe her wound care) and she was asked if she was in pain she said yes and rated it at a 7 (significant)(meaning 0 no pain to 10 the worst pain). Resident #1 was asked if the Wound Care Nurse asked her if she was in pain before the wound care was performed, she said no she did not ask if Resident #1 was in pain. During an interview on 04/13/2023 at 10:50 AM Wound Care Nurse said Resident #1 was a functional quadriplegic (meaning she has function in her upper extremity), and she cannot feel pain and so she does not ask if she is in pain. She said she was not aware Resident #1 was in pain. She knows Resident #1 get scheduled pain medication and did not ask her due to the fact she gets scheduled pain medication. She said she was unaware if the scheduled pain medication was effective During an interview on 04/13/2023 at 2:30 p.m. Resident #1 was asked if she is in pain during wound care she said yes, and the Wound Care Nurse never assesses her pain. She said she does not bother telling the Wound Care Nurse about her pain because she gets the same answer she gets scheduled pain medication even when it was done today (04/13/23 at 10:45 a.m.). She said Wound Care Nurse tells her she is getting scheduled pain medication and she should be ok, but it is never addressed during wound care. Record review of Resident #1's Nurses Notes dated April 2023 revealed there was no documentation that the resident was receiving medication or non-pharmacological intervention for pain prior to wound care daily or that the physician was contacted to address pain management for the resident. Record review of Resident #1's MAR dated April 2023revealed the resident was assessed for pain on the following dates: On 4/13/23 pain level -7, On 4/14/23 pain level -2, On 4/15/23 pain level -3, On 4/19/23 pain level -7, On 4/21/23 pain level- 5, On 4/23/23 pain level -6, From April 1, 2023, till April 12, 2023, Facility Pain Assessment form revealed Resident #1 pain was assessed at 0 (day and night shift) until Wound Care Nurse assessed her pain at 7 during wound care interview on 04/13/2023 at 10:45 AM and pain was assessed afterwards. During an interview with DON on 04/18/23 at 9:00 a.m. she said she nurses are supposed to assess for pain and that would be her expectation. She said that they go by the facility policy that address pain. (facility policy address the pain scale, location, intensity and the community recognizes that the resident's response to pain and is subjective and individual). During an interview on 04/18/2023 at 10:40 AM Wound Care Nurse Practitioner said Resident #1 was paralyzed from the waist down, but this does not mean she cannot feel pain. She said when she has an infection, she can feel pain and she has had an infection in her wounds, the Wound Care Nurse Practitioner said Resident #1 told her about the pain and she told the DON and the Wound Care Nurse because they made rounds with her. She said at this time (03/07/23). She said Resident #1 does feel pain and can tell the nurses when she has pain. She said the pain radiates on her left ischial (a bony prominence near the coccyx) Wound Care practitioner said she ordered antibiotics for the wounds. Record review of Physician orders dated on 04/18/23 revealed Resident #1 had order for Tylenol #4 (325 mg of acetaminophen 60 mg of codeine) scheduled every four hours as needed for pain. During an interview on 04/30/2023 at 2:00 PM Resident #1 said the change to Tylenol #4 (04/18/2023) is helpful and helps now with wound care. Facility's Policy, Pain Assessment and Management, dated August,10 2021 revealed the following: Policy It is the policy of this community that residents experiencing pain will be assessed and pain management provided in the degree possible to provide comfort and enhance the resident's quality of life. Procedure: 1. Each resident's pain will be assessed using the Pain tool UDA (assessment and evaluation) in Point click care (facility charting program) upon admission, the onset, or increased pain . 2. The community promotes residents self-reporting as the most effective reliable indicator of pain. 3. The community recognizes that the resident's response to pain and is subjective and individual. 4. Staff will assess pain using a consistent approach and a standardized pain management instrument appropriate to the resident's cognitive level. How To Assess Pain .Ask the resident to rank the pain using one of the Pain Intensity Scales appropriate for the resident's cognitive level. Behavior Response These include altered body position, moaning, grimacing, withdrawal, crying, restlessness, muscle twitching and immobility. Review of the facility's pain assessment competency revealed the following: Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on this or her clinical condition and established goals. .8.) Ask the resident if he/she is experiencing pain. Be aware that the resident may avoid the term Pain and uses other descriptors such as throbbing, aching and hurting, cramping, numbness, or tingling. 9) Review the medication administration record to determine how often the individual request and receives pain medication, and to what extent it is administered medications relieve the resident's pain. Review of the website: wwww.ncbi.nlm.nih.gov/books/NBK2658/ Revealed the following: Importance of Controlling Pain Inadequately managed pain can lead to adverse physical and psychological patient outcomes for individual patients and their families. Continuous, unrelieved pain activates the pituitary-adrenal axis, which can suppress the immune system and result in postsurgical infection and poor wound healing . Of particular importance to nursing care, unrelieved pain reduces patient mobility, resulting in complications such as deep vein thrombosis, pulmonary embolus, and pneumonia . complications related to inadequate pain management negatively affect the patient's welfare and the hospital performance because of extended lengths of stay and readmissions, both of which increase the cost of care.

Based on interviews, observations and record reviews the facility failed to ensure residents were free from abuse and neglect for 2 (Resident #1 and #2) of 5 residents reviewed for abuse and neglect. The facility failed to protect Resident #1 from abuse by Resident #2. Following an altercation between Resident #2 and Resident #1, and incidents in which Resident # 1 was found to have suspicious bruising and a laceration to his head, the residents who resided on the secure unit were left unsupervised by staff on 01/29/2020. During this time Resident #2 struck Resident #1 multiple times on the face and head with a metal coffee mug. Resident #1 had to be sent to the hospital due to sustaining several lacerations that required staples. These failures resulted in an Immediate Jeopardy (IJ) situation on 0[DATE]20. While the IJ was removed on 02/15/2020, the facility remained out of compliance at a severity level of actual harm at a scope of isolated due to the facility needing more time to monitor the plan of removal for effectiveness. These failures could lead to physical harm of other Residents and impact their psychosocial well-being in areas such as mental anguish and fear. Findings included: Record review of the facility's policy undated titled Abuse policy indicated in part: The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement and or Misappropriation of property. The facility staff will adhere to the policies and procedures and will follow the guidelines in the written policy and procedure. The facility administrator is appointed abuse coordinator and in his/her absence a designee will be appointed. Abuse is a willful infliction of injury or negligent, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident; or sexual abuse. The administrator and/or designee are responsible for maintaining ALL facility policies that prohibit abuse, neglect and misappropriation of funds/personal belongings, involuntary seclusion or corporal punishment. Screen potential employees - Train all employees - Identification of possible problems that need investigation - Investigating allegations - Reporting incidents, investigations and facility response to results of investigation with mandated time frames. Training: All employees are required to be trained in issues related to abuse prohibition practices. Training includes orientation and ongoing sessions. Staff will be knowledgeable in recognizing suspicious bruising, swelling, pain or other injuries. Documentation of this training will be available upon request. Prevention: The facility has in place policies and procedures to aid in the prevention of abuse, neglect, mistreatment, exploitation, involuntary seclusion and misappropriation of resident property. The following will be done. Each employee receives the standard of conduct which includes the standard for prohibiting abuse or neglect of a resident and the reporting of any suspected abuse or neglect of a resident. Reporting/Investigation: The law requires the abuse coordinator/designee, or employee of the facility who believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect or exploitation caused by another person to report the abuse, neglect or exploitation. Upon notification of an allegation of physical or mental abuse, neglect or involuntary seclusion, the facility will conduct interviews that include documented statements summaries from the alleged perpetrator, the alleged victim, family members, visitors who may have made observations, roommate and any staff who worked prior to and during the time of the incident. RESIDENT #1 Record review of Resident #1's admission record dated [DATE]20 indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #1's MDS dated [DATE] indicated in part: BI[CONDITION] = 07 indicating the resident had severe impairment. Record review of Resident #1's care plan revised 09/03/2019 indicated in part: Focus = Resident has impaired cognitive function or impaired thought process r/t Alzheimer's and dementia. Interventions = Cue, reorient and supervise as needed. Focus= Resident resides on the facility memory care unit d/t wandering/elopement risks r/t Alzheimer's and dementia. Resident wanders on the hallway and is a normal behavior for this resident. Goal = The resident's safety will be maintained through the review date. Interventions = distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Focus = Resident is an elopement risk/wanderer and is at risk for possible injury r/t impaired safety awareness and [DIAGNOSES REDACTED]. Goal = Resident's safety will be maintained throughout the review date. Interventions = distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Record review of the facility' self-report dated 12/01/2019 indicated in part: Resident #1 was found laying in his bed with blood on the pillow case and a laceration about 1-1.5 inches long to the top of his head. Resident is unable to verbalize how the injury occurred. Resident has had no recent falls or incidents that could explain this injury. Record review of nurses note dated 12/07/2019 indicated in part: Nurse informed this nurse that Resident #2 threw a bottle of Tabasco sauce at Resident #1 causing sauce to get on Resident #1's face and clothing. Resident #2 was told not to throw anything at other residents or staff due to possibly causing injury. Tabasco sauce was taken from resident and given to aide on hall. And was told that could have bottle back during meal times. Record review of the facility' self-report dated 0[DATE]20 indicated in part: Resident#1 was found with bruising around his left eye at approx. 9am on 1-10-2020. He is unable to explain how this occurred or when, due to being non-verbal. RESIDENT #2 Record review of Resident #2's admission record dated 02/07/2020 indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #2's MDS dated [DATE] indicated in part: BI[CONDITION] = 07 indicating the resident had severe impairment. Record review of Resident #2's care plan dated 11/26/2019 indicated in part: Focus = Resident resides on the facility secure unit d/t wander/elopement risks r/t [DIAGNOSES REDACTED]. Goal = the resident's safety will be maintained through the review date. Interventions = distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Record review of Resident #2's nurses note dated 01/29/2020 4:40pm indicated in part: CNA came to report resident had hit another resident. This nurse came onto unit and found the other resident (Resident #1) which Resident #2 had hit was being guided to his room by CNA, his face was covered in blood and he had multiple lacerations to the side of his face and his head, and a missing piece of skin to his ear, also an indention on top of his head. At this time I went in to check on Resident #2 who was trying to wipe off some blood from a metal coffee mug and I noticed some blood splatters on the wall near the top head board part of the bed. I asked Resident #2 what happened and he told me he had just hit this guy with his fists because he is a thief and comes in his room and steals his stuff. Signed by LVN C. Record review of Resident #1's hospital records dated 01/29/2020 indicated in part: Chief complaint assault with a coffee mug laceration. Pt presents from nursing home after being assaulted, Per E[CONDITION] pt. was hit multiple times in head with Yeti coffee mug. Pt awake and responsive, Pt has 2 lacerations to scalp and abrasion to left hand. Laceration repair staple closure procedure note - location: below left periorbital area the lateral aspect, number of staples 1. location: above left periorbital area, number of staples 2. location: left scalp, number of staples 3. Record review of the facility incident and accident report dated 01/29/2020 and revised on 02/08/2020 at indicated in part: Other info - The other resident (Resident #1) does wander into Resident #2's room and takes things and does lay down in his bed at times. Description: Another resident was lying in Resident #2's bed, according to witnesses he hit the other resident in the head repeatedly with his closed fist or object (which resident was seen wiping blood off a metal coffee mug in his room by this nurse shortly after incident ended). Resident #2 states he hit another resident because the other resident is a thief. Record review of the facility's PIR dated 01/29/2020 indicated in part: Incident date - 01/29/2020. Individuals involved: Resident #1 and #2. Description of the allegation: Resident #1 was in Resident #2's bed when Resident #2 came into his room. He then pulled Resident #1 off his bed and began to beat him with a metal coffee cup on top of his head. Resident #2 and Resident #1 were separated by the staff and Resident #1 was sent to the ER by ambulance. The police came out with the 911 call and assessed the situation. They said that since Resident #2 has a [DIAGNOSES REDACTED]. Mental health authority then was called, and they came out and said that they could not take him due to his Alzheimer's and Dementia and so we put Resident #2 on One on ones and called the RP to try to find someone to sit with him or take him out for the weekend. Investigation Summary During the course of the investigation it was found that Resident #1 was walking around the unit and went into Resident #2's room and laid down in his bed. Resident #2 came into his room and found Resident #1 in his bed and got upset that someone was in his bed. He then pulled Resident #1 off the bed and-began to hit him on his head with a metal coffee cup. Staff saw Resident #2 wiping the blood off the cup after the incident and he was trying to tell staff that Resident#1 had fallen out of Resident #2's bed. Resident #1 was sent to the hospital and received 12 staples to his head. His CT was clear and showed no injuries to his head besides the laceration to his scalp. Resident #2 was seen by the police and they did not take him due to his [DIAGNOSES REDACTED]. Mental Health Authorities showed up after the police left and said they could not take him due to his [DIAGNOSES REDACTED]. He was sent to stay with a family friend whom had to call the police on him and the police brought him back to the facility. After being on one to one again he had an episode with two staff members and mental health was called again and this time they took him to mental health facility. During an interview on 0[DATE]20 at 9:42 a.m. CNA A said she had worked hall E the men's secure unit on 01/29/20. CNA A said she did not see the fight start between Resident's #1 and #2 because she was busy with another Resident's family member. CNA A said she assisted the other family's resident out of the secure unit and escorted that resident to his family. CNA A said it seemed to her that she was not gone that long from the unit. CNA A said when she re-entered the unit one of the residents told her that another resident was bleeding. CNA A said she entered Resident #1's room and he had blood on his face and head. CNA A said Resident #2 was also in the room holding a coffee cup that had blood stains on it. CNA A said when she had gone back to the unit there were no staff present at that time. CNA A said she was the only CNA working the hall that day and did not feel she could monitor it all by herself. RESIDENT #19 Record review of Resident #19's admission record dated 02/12/2020 indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #19's MDS dated [DATE] indicated in part: BI[CONDITION] = 12 indicating the resident was moderately impaired. During an interview on 02/12/2020 at 2:48 p.m. Resident #19 said he had seen some of the altercation between Resident's #1 and #2. Resident #19 said he saw Resident #2 hitting Resident #1 on the face with some kind of object. Resident #19 said he did not know where the staff were at the time as he usually just kept to himself. The average census for these secure units (Halls C, E and F) for January 2020 and February 2020 was 13 residents on the women's secure unit Hall C, 11 residents on the men's secure unit Hall E and 18 residents on the men's secure unit Hall F. According to daily staffing schedule there was one CNA assigned to each of the three halls (Halls C, E and F). LIST OF INCIDENTS: Record review of incident indicated in part: Verbal aggression-initiated incidents = 3 separate incidents on 02/11/20 10:10pm, 02/11/20 5:30pm and 02/12/20 8:11pm. (all 3 incidents in the men's secure unit). Physical aggression-initiated incidents = 8 total in the secure units. Dating from 09/02/19 through 02/10/20. During an observation on [DATE]20 at 2:18 p.m. the men's secure unit hall F revealed there was one CNA in the unit. During an observation on [DATE]20 between 2:30 p.m. and 2:35 p.m. the men's secure unit hall E was left unsupervised by staff. Some of the residents were wandering in and out of other residents rooms. During an observation on [DATE]20 between 2:56 p.m. and 3:06 p.m. the men's secure unit hall E was left unsupervised by staff. CNA D was seen coming out of the unit with the cigarette box and did not return until 10 minutes later. The residents were seen going outside to the patio unsupervised and coming back in to the unit and wandering. During an observation on 02/07/2020 at 9:42 a.m. the men's secure unit hall E revealed there was one CNA on the unit. During an observation on 02/07/2020 at 9:50 a.m. CNA E was seen sitting down in the dining room of the women's secure unit also known as hall C. CNA E was seen looking down at her cellphone. CNA E was the only staff on the unit. The residents were wandering in the hall and going outside to the patio unsupervised. During an observation and interview on 02/07/2020 at 2:22 p.m. CNA E was seen sitting down in the dining room of the women's secure unit. CNA E was seen again looking down at her cellphone. CNA E was the only staff in the unit. Residents were standing by the front door wanting to talk to someone about getting out and going home. During an interview on 02/07/2020 at 2:23 p.m. CNA E said she was just looking at some texts on her cellphone. CNA E said she was not supposed to be on her cellphone and that she was the only aide on the floor. During an observation on 02/10/2020 at 8:45 a.m. the women's unit hall C and the men's units halls E and F were each staffed with 1 CNA. During an observation on 02/10/2020 between 9:05 a.m. and 9:10 a.m. the men's unit hall F was left unsupervised by staff for 5 minutes. CNA F was then seen entering the unit pushing an ice chest. The residents were seen wandering throughout the hallway or walking outside to the patio. During an interview on 02/10/2020 at 9:11 a.m. CNA F said she had been out of the unit getting ice water. CNA F said she usually told someone to watch the hall, but she had forgotten that time. CNA F said the residents in hall F did not really fight and that she was not that familiar with hall F because she usually worked on the other halls. During an observation and an interview on 02/10/2020 between 9:12 a.m. and 9:19 a.m. there were no staff seen in the women's unit hall C. The residents were seen wandering throughout the hall. Later CNA E entered the unit and said the unit was being monitored by the shower aide CNA A. CNA A had been in the shower room of the unit giving a shower and was not supervising the unit. During an observation and interview on 02/10/2020 between 10:34 a.m. and 10:39 a.m. there were no staff seen in the men's unit hall F. CNA F was later seen coming out of a resident's room. CNA F said she was in the resident room assisting a resident with personal care. CNA F said she had to close the door to provide privacy, so the hall was left alone through that time. CNA F said there were other residents in the hall that required assistance with personal care. Residents were seen wandering in and out of their rooms. During an interview on 02/10/2020 at 10:44 a.m. CNA B said if the residents in the secure unit were fighting she would try to separate them or call for help by going to the secure unit door and calling the nurse. CNA B said there were a couple of residents that required personal care and it would usually take her 5 minutes to provide the care in the resident's room. CNA B said the hall was left unsupervised while she was in the resident's room. During an observation and interview on 02/10/2020 3:40 p.m. between 3:56 p.m. CNA G was outside of the men's unit hall E patio CNA G was monitoring the residents while they smoked. Several of the residents in hall E were left unsupervised for 16 minutes since CNA G was outside monitoring the residents. CNA G entered hall E from outside and said she was the only aide on hall E and had to be outside monitoring the residents while they smoked. CNA G said usually someone watched the hall while she was outside but today there had not been someone to supervise hall E. CNA G said she usually monitored hall E from outside through the glass door while also monitoring the residents smoking. CNA G said if a resident fell in the hall she would have to go inside to help them and would have to leave the smokers unattended. CNA G said there were several residents that required assistance with personal care. CNA G said that when she went in to provide care for these residents she had to leave the hall unsupervised for about 5 to 10 minutes since she was the only aide on the floor. CNA G said she did not recall being told to ask the nurse to watch the hall while she was in a room assisting a resident. CNA G said some of the residents would get easily agitated so they required closer supervision. CNA G said when Resident #2 was there he was a handful because he would wander into other resident's rooms and get into their things which would cause an altercation with the other resident's. CNA G said Resident #1 also required close supervision because he would put anything in his mouth like plastic wrappings such as empty chip bags. Record review of Resident #1's nurses notes dated 01/03/2020 indicated in part: Resident was found choking by treatment nurse in secure unit. This nurse was alerted by the DON to go to secure unit due to choking episode. Resident eyes were bright red and watery. Could tell that resident was not able to breathe. Staff was able to dislodge plastic bag from resident throat. During an observation and an interview on 02/07/2020 at 2:58 p.m. the ADON was observed in the women's secure unit hall C. The residents were wandering in the hallway. The ADON was in the dining room looking at her cellphone. The ADON said she was monitoring the hall because the aide was out on her break. During an interview on 02/10/2020 at 4:18 p.m. the ADON said the secure units were staffed with one aide each. The ADON said if a staff member was the only person monitoring the units they could not be on their cellphones. The ADON was made aware that she was observed looking at her cellphone while she was monitoring the women's unit on 02/07/2020. The ADON said she had been texting about things with staffing and was just asking about it through texting. During an interview on 02/12/2020 9:52 AM. CNA J said the secure units probably needed 2 aides in there because when she had to help someone in the shower the unit was left unattended. CNA J said she would be in the shower for like 20 minutes at times. CNA J said some of the residents in the units required incontinent care or patient care so again the hall would be left unsupervised until she was done. CNA J said she had not been made aware of calling someone to watch the hall while she was showering the residents or providing personal care. During an interview on 02/12/2020 at 12:42 p.m. CNA I said she was assigned to the men's secure unit hall F today. CNA I said she was the only aide on the floor but that was the way it was staffed. CNA I said there were several residents on that unit that required assistance with personal care. CNA I said when she entered the resident's room to provide personal care she would leave the hall unsupervised since she was the only staff on the floor. CNA I said some of the resident's required more supervision than others due to behaviors. During an interview on 02/12/2020 at 1:34 p.m. CNA B said Resident #2 could be very combative and would fight with other residents and staff. CNA B said Resident #2 would fight with Resident #1 frequently as well as other residents. CNA B said Resident #1 mostly walked around and would put things in his mouth like wrappers. CNA B said both of those residents required quite a lot of supervision. Record review of the facility's daily staffing schedule from 01/01/2020 through 0[DATE]20 indicated in part: 6AM-2PM = Hall C women's secure unit (1 CNA), Hall E men's secure unit (1 CNA), Hall F men's secure unit (1 CNA). 2PM-10PM = Hall C women's secure unit (1 CNA), Hall E men's secure unit (1 CNA), Hall F men's secure unit (1 CNA). 10PM-6AM = Hall C women's secure unit (1 CNA), Hall E men's secure unit (1 CNA), Hall F men's secure unit (1 CNA). During an observation and interview on 02/12/2020 between 4:58 p.m. and 5:00 p.m. CNA D was observed leaving the secure unit hall E to get more coffee for the residents. The residents were left unsupervised for 2 minutes. The residents were wandering in and out to the outside patio or wandering in the hall. When CNA D returned to the unit she said she was the only aide on the hall and had to go and get coffee. CNA D said if there was a nurse at the nurse's station she would ask them to watch the hall but since there were none available she had to leave the hall unsupervised. CNA D said when she took the resident outside to smoke she would sit by the glass door and monitor the hallway from there. CNA D said if someone fell in the hall then she would have to go into the hall to assist and leave the smoking residents unsupervised since she was the only one in the hall. During an interview on 02/12/2020 at 5:16 p.m. CNA K said when she took the residents out to smoke she would sit by the glass door and monitor the hall and the smokers as she was the only one in the secure unit. CNA K said if a resident fell in the hall she would have to leave the smokers unassisted to come and assist the resident that needed help since she was the only one in the unit. CNA K said whenever she provided personal care for the residents she would have to leave the hall unsupervised since she was the only aide on the floor. CNA K said she had about 7 residents that required personal care. During an interview on 02/12/2020 at 5:22 p.m. CNA L said she did not think only 1 aide in the secure unit was sufficient to monitor the residents. CNA L said when she took the residents out to smoke she had to be watching the hall and the smokers at the same time. CNA L said if a resident needed assistance in the hall she would have to leave the smokers unsupervised since she was the only staff there. CNA L said at times some residents needed assistance with feeding in their rooms, so the hall would be unsupervised during that time. CNA L said it was the same when she had to provide personal care to the residents she would have to leave the hall unsupervised during that time. CNA L said that she would get one of the residents to watch the other residents while she was performing personal care as she would feel uncomfortable leaving the residents unsupervised. During an interview on 02/12/2020 at 5:40 p.m. RN M said there was 1 aide in each of the secure units. RN M said if that aide went in to perform incontinent care for a resident the aide would have to keep an eye on the hall and hopefully nothing would happen with the residents. RN M said it was her understanding that when the aide from E hall would take the residents out to smoke, the other aide form hall F would monitor hall E and hall F but then that would leave either hall unsupervised, so she was not sure how that worked. During an interview on 02/12/2020 at 5:44 p.m. LVN C said if an aide would go into a room to provide personal care then the hall would be unsupervised since there were only 1 aide on the hall. LVN C said CNAs would usually get someone to watch the hall when they took the residents out to smoke but that was not the case all the time. During an interview on 0[DATE]20 at 8:40 a.m. CNA B said that when she used to take the residents out to smoke she would have to be watching the smokers and also the secure unit. CNA B said she did not believe she could safely monitor the smokers and the unit. During an observation and interview on 0[DATE]20 at 8:50 a.m. CNA I was seen looking through her cellphone while monitoring the men's secure unit. CNA I said she was the aide assigned to the hall and that she knew she was not supposed to be on her cellphone. During an interview on 0[DATE]20 at 9:28 a.m. RN H said when it was 1 aide in the secure unit and if they entered a room to perform care for a resident then the hall was left unsupervised due to it just being 1 aide. RN H the aide would not come and ask her to watch the hall if they were going to be assisting residents and the hall was left unsupervised. During an interview on 0[DATE]20 at 10:24 a.m. the DON said she checks daily to see if the units had sufficient staff. The DON said some days the men's unit were a little more active than other days. The DON said the residents in the men's unit had their bad days. The DON said for example if the weather was bad and the residents could not be outside in the patio then they tended to be more restless. The DON said there was one CNA assigned to the hall and also a CMA that would come pass meds and the nurse which was at the nurse's station which is located outside of the secure units. The DON was asked if the units were supposed to be supervised at all times and not left unattended by staff. The DON said an aide can step out like to go to the vending machine to get something for a resident. The DON said it was ok for the unit to be left unattended for a short amount of time. The DON said the aides also had to leave the units at times to come and get second servings and such. The DON said 5 minutes was ok for the staff to leave the unit unattended. The DON said when the aide in the secure unit took the residents out to smoke, the aide would normally stand by the back door and monitor the smokers and the unit. The DON said in case of an altercation or a fall occurred in the unit, the aide would come in to the unit open the front entrance door to the unit and ask help from the nurse. The DON said the aide would have to leave the smokers unattended for a short while. The DON was asked who was watching the residents in the units while the only aide in the unit was in a resident's room performing personal care. The DON said she had not though about that, but they had a small number of residents that required assistance with personal care. During an interview on 0[DATE] at 11:08 a.m. the Administrator said she had been the Administrator at the facility since 12/09/2019. The Administrator said she would monitor the facility staff and residents by doing walking rounds. The Administrator said her expectation of the staff in the secure units was for the staff to ask for help when they were going to provide personal care, so the hall would not be left unsupervised. The Administrator said she did not like that the aide was having to watch the residents smoke and the hall at the same because if there was an issue in the hall then they would have to leave the smokers unsupervised to go and intervene. The Administrator said the secure units were supposed to be supervised at all times and not left unsupervised. The Administrator said staff were not allowed to be on their cellphones while working the floor. The Administrator was made aware of several observations of staff leaving the hall unsupervised and on their cellphones. The Administrator said that was unacceptable. Record review of the facility's CNA job description dated 09/2018 indicated in part: Essential functions - to assure resident safety, provide supportive protective and safe environments for residents. Record review of the facility's LVN/RN job description dated 09/2018 indicated in part: Essential functions - to assure resident safety, uses care plan as a basis for providing safe and therapeutic care to patients. The Administrator and the DON were informed of the identification of an immediate jeopardy situation on 0[DATE]20 at 4:25 p.m. and the need for a plan of removal. The Administrator was provided the IJ template. Review of the facility's Plan of Removal received on 0[DATE]20 documented: 1. Resident #1 and Resident #2 are no longer in the facility. 2. All residents in the secure units have the potential to be affected by this alleged deficient practice. 3. Staffing patterns have been adjusted to ensure 2 staff members are assigned on the secured units at all times. As of 5:11pm we initiated this new staffing pattern and it will continue indefinitely. The in services have been initiated as of 2pm on [DATE]20 and will be done at the beginning of each shift until all staff have been trained. This education will be provided to all new hires during the orientation process. We have a smoking aide for smoke breaks from 7am to 3pm and having the two staff members will allow one to be on the hall during smoke break to ensure the other residents are still being monitored. The training that we are doing is as follows: Never leave the hall without another staff member present to monitor the residents in your absence. Never ask a resident to watch the hall and other residents. When going behind a closed door to provide care, shower or any other kind of personal care, or to assist the residents to smoke another staff member must be present to monitor the hall. Any staff member is able to monitor the hall, housekeeping, laundry, nurse, cnas, cma dietary staff or management. Staff member assigned to work each secure unit must stay in an area where you can visualize the hall as well as the dining areas. Also started an in-service of abuse and neglect and how to handle resident to resident altercations. 4. Administrator and DON will monitor staffing to ensure that there are two staff members present for each shift on the secure units. DON will check staffing to ensure there are two staff members assigned and present to each secure hall each day before leaving and on Fridays will check for the weekend to ensure all halls are staffed with two staff members. Charge nurses will call to inform the On Call nurse if any secured staff does not show up. 5. Corrective action has been completed as of 5:11pm on [DATE]20. POR Verification Record review of a facility in-service dated 0[DATE] titled Behavioral assessment, intervention and monitoring indicated; 32 staff had participated in the in-service. The staff consisted of CNAs and charge nurses. Review of a facility in-service dated 0[DATE] titled Staff working on the secure units Any staff member assigned to work on a secure unit must follow the following guidelines - Never leave the hall without an

Based on interviews, observations and record reviews the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for 2 (Resident #1 and #2) of 5 residents reviewed for accidents and supervision. The facility failed to ensure residents on the secure units were provided adequate supervision. Following an altercation between Resident #2 and Resident #1, and incidents in which Resident # 1 was found to have suspicious bruising and a laceration to his head, the residents who resided on the secure unit were left unsupervised by staff on 01/29/2020. During this time Resident #2 struck Resident #1 multiple times on the face and head with a metal coffee mug. Resident #1 had to be sent to the hospital due to sustaining several lacerations that required staples. These failures resulted in an Immediate Jeopardy (IJ) situation on 0[DATE]20. While the IJ was removed on 02/15/2020, the facility remained out of compliance at a severity level of actual harm at a scope of isolated due to the facility needing more time to monitor the plan of removal for effectiveness. These failures could lead to physical harm of other Residents and impact their psychosocial well-being in areas such as mental anguish and fear. Findings included: RESIDENT #1 Record review of Resident #1's admission record dated [DATE]20 indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #1's MDS dated [DATE] indicated in part: BI[CONDITION] = 07 indicating the resident had severe impairment. Record review of Resident #1's care plan revised 09/03/2019 indicated in part: Focus = Resident has impaired cognitive function or impaired thought process r/t Alzheimer's and dementia. Interventions = Cue, reorient and supervise as needed. Focus= Resident resides on the facility memory care unit d/t wandering/elopement risks r/t Alzheimer's and dementia. Resident wanders on the hallway and is a normal behavior for this resident. Goal = The resident's safety will be maintained through the review date. Interventions = distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Focus = Resident is an elopement risk/wanderer and is at risk for possible injury r/t impaired safety awareness and [DIAGNOSES REDACTED]. Goal = Resident's safety will be maintained throughout the review date. Interventions = distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Record review of the facility' self-report dated 12/01/2019 indicated in part: Resident #1 was found laying in his bed with blood on the pillow case and a laceration about 1-1.5 inches long to the top of his head. Resident is unable to verbalize how the injury occurred. Resident has had no recent falls or incidents that could explain this injury. Record review of nurses note dated 12/07/2019 indicated in part: Nurse informed this nurse that Resident #2 threw a bottle of Tabasco sauce at Resident #1 causing sauce to get on Resident #1's face and clothing. Resident #2 was told not to throw anything at other residents or staff due to possibly causing injury. Tabasco sauce was taken from resident and given to aide on hall. And was told that could have bottle back during meal times. Record review of the facility' self-report dated 0[DATE]20 indicated in part: Resident#1 was found with bruising around his left eye at approx. 9am on 1-10-2020. He is unable to explain how this occurred or when, due to being non-verbal. RESIDENT #2 Record review of Resident #2's admission record dated 02/07/2020 indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #2's MDS dated [DATE] indicated in part: BI[CONDITION] = 07 indicating the resident had severe impairment. Record review of Resident #2's care plan dated 11/26/2019 indicated in part: Focus = Resident resides on the facility secure unit d/t wander/elopement risks r/t [DIAGNOSES REDACTED]. Goal = the resident's safety will be maintained through the review date. Interventions = distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Record review of Resident #2's nurses note dated 01/29/2020 4:40pm indicated in part: CNA came to report resident had hit another resident. This nurse came onto unit and found the other resident (Resident #1) which Resident #2 had hit was being guided to his room by CNA, his face was covered in blood and he had multiple lacerations to the side of his face and his head, and a missing piece of skin to his ear, also an indention on top of his head. At this time I went in to check on Resident #2 who was trying to wipe off some blood from a metal coffee mug and I noticed some blood splatters on the wall near the top head board part of the bed. I asked Resident #2 what happened and he told me he had just hit this guy with his fists because he is a thief and comes in his room and steals his stuff. Signed by LVN C. Record review of Resident #1's hospital records dated 01/29/2020 indicated in part: Chief complaint assault with a coffee mug laceration. Pt presents from nursing home after being assaulted, Per E[CONDITION] pt. was hit multiple times in head with Yeti coffee mug. Pt awake and responsive, Pt has 2 lacerations to scalp and abrasion to left hand. Laceration repair staple closure procedure note - location: below left periorbital area the lateral aspect, number of staples 1. location: above left periorbital area, number of staples 2. location: left scalp, number of staples 3. Record review of the facility incident and accident report dated 01/29/2020 and revised on 02/08/2020 at indicated in part: Other info - The other resident (Resident #1) does wander into Resident #2's room and takes things and does lay down in his bed at times. Description: Another resident was lying in Resident #2's bed, according to witnesses he hit the other resident in the head repeatedly with his closed fist or object (which resident was seen wiping blood off a metal coffee mug in his room by this nurse shortly after incident ended). Resident #2 states he hit another resident because the other resident is a thief. Record review of the facility's PIR dated 01/29/2020 indicated in part: Incident date - 01/29/2020. Individuals involved: Resident #1 and #2. Description of the allegation: Resident #1 was in Resident #2's bed when Resident #2 came into his room. He then pulled Resident #1 off his bed and began to beat him with a metal coffee cup on top of his head. Resident #2 and Resident #1 were separated by the staff and Resident #1 was sent to the ER by ambulance. The police came out with the 911 call and assessed the situation. They said that since Resident #2 has a [DIAGNOSES REDACTED]. Mental health authority then was called, and they came out and said that they could not take him due to his Alzheimer's and Dementia and so we put Resident #2 on One on ones and called the RP to try to find someone to sit with him or take him out for the weekend. Investigation Summary During the course of the investigation it was found that Resident #1 was walking around the unit and went into Resident #2's room and laid down in his bed. Resident #2 came into his room and found Resident #1 in his bed and got upset that someone was in his bed. He then pulled Resident #1 off the bed and-began to hit him on his head with a metal coffee cup. Staff saw Resident #2 wiping the blood off the cup after the incident and he was trying to tell staff that Resident#1 had fallen out of Resident #2's bed. Resident #1 was sent to the hospital and received 12 staples to his head. His CT was clear and showed no injuries to his head besides the laceration to his scalp. Resident #2 was seen by the police and they did not take him due to his [DIAGNOSES REDACTED]. Mental Health Authorities showed up after the police left and said they could not take him due to his [DIAGNOSES REDACTED]. He was sent to stay with a family friend whom had to call the police on him and the police brought him back to the facility. After being on one to one again he had an episode with two staff members and mental health was called again and this time they took him to mental health facility. During an interview on 0[DATE]20 at 9:42 a.m. CNA A said she had worked hall E the men's secure unit on 01/29/20. CNA A said she did not see the fight start between Resident's #1 and #2 because she was busy with another Resident's family member. CNA A said she assisted the other family's resident out of the secure unit and escorted that resident to his family. CNA A said it seemed to her that she was not gone that long from the unit. CNA A said when she re-entered the unit one of the residents told her that another resident was bleeding. CNA A said she entered Resident #1's room and he had blood on his face and head. CNA A said Resident #2 was also in the room holding a coffee cup that had blood stains on it. CNA A said when she had gone back to the unit there were no staff present at that time. CNA A said she was the only CNA working the hall that day and did not feel she could monitor it all by herself. RESIDENT #19 Record review of Resident #19's admission record dated 02/12/2020 indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #19's MDS dated [DATE] indicated in part: BI[CONDITION] = 12 indicating the resident was moderately impaired. During an interview on 02/12/2020 at 2:48 p.m. Resident #19 said he had seen some of the altercation between Resident's #1 and #2. Resident #19 said he saw Resident #2 hitting Resident #1 on the face with some kind of object. Resident #19 said he did not know where the staff were at the time as he usually just kept to himself. The average census for these secure units (Halls C, E and F) for January 2020 and February 2020 was 13 residents on the women's secure unit Hall C, 11 residents on the men's secure unit Hall E and 18 residents on the men's secure unit Hall F. According to daily staffing schedule there was one CNA assigned to each of the three halls (Halls C, E and F). LIST OF INCIDENTS: Record review of incident indicated in part: Verbal aggression-initiated incidents = 3 separate incidents on 02/11/20 10:10pm, 02/11/20 5:30pm and 02/12/20 8:11pm. (all 3 incidents in the men's secure unit). Physical aggression-initiated incidents = 8 total in the secure units. Dating from 09/02/19 through 02/10/20. During an observation on [DATE]20 at 2:18 p.m. the men's secure unit hall F revealed there was one CNA in the unit. During an observation on [DATE]20 between 2:30 p.m. and 2:35 p.m. the men's secure unit hall E was left unsupervised by staff. Some of the residents were wandering in and out of other residents rooms. During an observation on [DATE]20 between 2:56 p.m. and 3:06 p.m. the men's secure unit hall E was left unsupervised by staff. CNA D was seen coming out of the unit with the cigarette box and did not return until 10 minutes later. The residents were seen going outside to the patio unsupervised and coming back in to the unit and wandering. During an observation on 02/07/2020 at 9:42 a.m. the men's secure unit hall E revealed there was one CNA on the unit. During an observation on 02/07/2020 at 9:50 a.m. CNA E was seen sitting down in the dining room of the women's secure unit also known as hall C. CNA E was seen looking down at her cellphone. CNA E was the only staff on the unit. The residents were wandering in the hall and going outside to the patio unsupervised. During an observation and interview on 02/07/2020 at 2:22 p.m. CNA E was seen sitting down in the dining room of the women's secure unit. CNA E was seen again looking down at her cellphone. CNA E was the only staff in the unit. Residents were standing by the front door wanting to talk to someone about getting out and going home. During an interview on 02/07/2020 at 2:23 p.m. CNA E said she was just looking at some texts on her cellphone. CNA E said she was not supposed to be on her cellphone and that she was the only aide on the floor. During an observation on 02/10/2020 at 8:45 a.m. the women's unit hall C and the men's units halls E and F were each staffed with 1 CNA. During an observation on 02/10/2020 between 9:05 a.m. and 9:10 a.m. the men's unit hall F was left unsupervised by staff for 5 minutes. CNA F was then seen entering the unit pushing an ice chest. The residents were seen wandering throughout the hallway or walking outside to the patio. During an interview on 02/10/2020 at 9:11 a.m. CNA F said she had been out of the unit getting ice water. CNA F said she usually told someone to watch the hall, but she had forgotten that time. CNA F said the residents in hall F did not really fight and that she was not that familiar with hall F because she usually worked on the other halls. During an observation and an interview on 02/10/2020 between 9:12 a.m. and 9:19 a.m. there were no staff seen in the women's unit hall C. The residents were seen wandering throughout the hall. Later CNA E entered the unit and said the unit was being monitored by the shower aide CNA A. CNA A had been in the shower room of the unit giving a shower and was not supervising the unit. During an observation and interview on 02/10/2020 between 10:34 a.m. and 10:39 a.m. there were no staff seen in the men's unit hall F. CNA F was later seen coming out of a resident's room. CNA F said she was in the resident room assisting a resident with personal care. CNA F said she had to close the door to provide privacy, so the hall was left alone through that time. CNA F said there were other residents in the hall that required assistance with personal care. Residents were seen wandering in and out of their rooms. During an interview on 02/10/2020 at 10:44 a.m. CNA B said if the residents in the secure unit were fighting she would try to separate them or call for help by going to the secure unit door and calling the nurse. CNA B said there were a couple of residents that required personal care and it would usually take her 5 minutes to provide the care in the resident's room. CNA B said the hall was left unsupervised while she was in the resident's room. During an observation and interview on 02/10/2020 3:40 p.m. between 3:56 p.m. CNA G was outside of the men's unit hall E patio CNA G was monitoring the residents while they smoked. Several of the residents in hall E were left unsupervised for 16 minutes since CNA G was outside monitoring the residents. CNA G entered hall E from outside and said she was the only aide on hall E and had to be outside monitoring the residents while they smoked. CNA G said usually someone watched the hall while she was outside but today there had not been someone to supervise hall E. CNA G said she usually monitored hall E from outside through the glass door while also monitoring the residents smoking. CNA G said if a resident fell in the hall she would have to go inside to help them and would have to leave the smokers unattended. CNA G said there were several residents that required assistance with personal care. CNA G said that when she went in to provide care for these residents she had to leave the hall unsupervised for about 5 to 10 minutes since she was the only aide on the floor. CNA G said she did not recall being told to ask the nurse to watch the hall while she was in a room assisting a resident. CNA G said some of the residents would get easily agitated so they required closer supervision. CNA G said when Resident #2 was there he was a handful because he would wander into other resident's rooms and get into their things which would cause an altercation with the other resident's. CNA G said Resident #1 also required close supervision because he would put anything in his mouth like plastic wrappings such as empty chip bags. Record review of Resident #1's nurses notes dated 01/03/2020 indicated in part: Resident was found choking by treatment nurse in secure unit. This nurse was alerted by the DON to go to secure unit due to choking episode. Resident eyes were bright red and watery. Could tell that resident was not able to breathe. Staff was able to dislodge plastic bag from resident throat. During an observation and an interview on 02/07/2020 at 2:58 p.m. the ADON was observed in the women's secure unit hall C. The residents were wandering in the hallway. The ADON was in the dining room looking at her cellphone. The ADON said she was monitoring the hall because the aide was out on her break. During an interview on 02/10/2020 at 4:18 p.m. the ADON said the secure units were staffed with one aide each. The ADON said if a staff member was the only person monitoring the units they could not be on their cellphones. The ADON was made aware that she was observed looking at her cellphone while she was monitoring the women's unit on 02/07/2020. The ADON said she had been texting about things with staffing and was just asking about it through texting. During an interview on 02/12/2020 9:52 AM. CNA J said the secure units probably needed 2 aides in there because when she had to help someone in the shower the unit was left unattended. CNA J said she would be in the shower for like 20 minutes at times. CNA J said some of the residents in the units required incontinent care or patient care so again the hall would be left unsupervised until she was done. CNA J said she had not been made aware of calling someone to watch the hall while she was showering the residents or providing personal care. During an interview on 02/12/2020 at 12:42 p.m. CNA I said she was assigned to the men's secure unit hall F today. CNA I said she was the only aide on the floor but that was the way it was staffed. CNA I said there were several residents on that unit that required assistance with personal care. CNA I said when she entered the resident's room to provide personal care she would leave the hall unsupervised since she was the only staff on the floor. CNA I said some of the resident's required more supervision than others due to behaviors. During an interview on 02/12/2020 at 1:34 p.m. CNA B said Resident #2 could be very combative and would fight with other residents and staff. CNA B said Resident #2 would fight with Resident #1 frequently as well as other residents. CNA B said Resident #1 mostly walked around and would put things in his mouth like wrappers. CNA B said both of those residents required quite a lot of supervision. Record review of the facility's daily staffing schedule from 01/01/2020 through 0[DATE]20 indicated in part: 6AM-2PM = Hall C women's secure unit (1 CNA), Hall E men's secure unit (1 CNA), Hall F men's secure unit (1 CNA). 2PM-10PM = Hall C women's secure unit (1 CNA), Hall E men's secure unit (1 CNA), Hall F men's secure unit (1 CNA). 10PM-6AM = Hall C women's secure unit (1 CNA), Hall E men's secure unit (1 CNA), Hall F men's secure unit (1 CNA). During an observation and interview on 02/12/2020 between 4:58 p.m. and 5:00 p.m. CNA D was observed leaving the secure unit hall E to get more coffee for the residents. The residents were left unsupervised for 2 minutes. The residents were wandering in and out to the outside patio or wandering in the hall. When CNA D returned to the unit she said she was the only aide on the hall and had to go and get coffee. CNA D said if there was a nurse at the nurse's station she would ask them to watch the hall but since there were none available she had to leave the hall unsupervised. CNA D said when she took the resident outside to smoke she would sit by the glass door and monitor the hallway from there. CNA D said if someone fell in the hall then she would have to go into the hall to assist and leave the smoking residents unsupervised since she was the only one in the hall. During an interview on 02/12/2020 at 5:16 p.m. CNA K said when she took the residents out to smoke she would sit by the glass door and monitor the hall and the smokers as she was the only one in the secure unit. CNA K said if a resident fell in the hall she would have to leave the smokers unassisted to come and assist the resident that needed help since she was the only one in the unit. CNA K said whenever she provided personal care for the residents she would have to leave the hall unsupervised since she was the only aide on the floor. CNA K said she had about 7 residents that required personal care. During an interview on 02/12/2020 at 5:22 p.m. CNA L said she did not think only 1 aide in the secure unit was sufficient to monitor the residents. CNA L said when she took the residents out to smoke she had to be watching the hall and the smokers at the same time. CNA L said if a resident needed assistance in the hall she would have to leave the smokers unsupervised since she was the only staff there. CNA L said at times some residents needed assistance with feeding in their rooms, so the hall would be unsupervised during that time. CNA L said it was the same when she had to provide personal care to the residents she would have to leave the hall unsupervised during that time. CNA L said that she would get one of the residents to watch the other residents while she was performing personal care as she would feel uncomfortable leaving the residents unsupervised. During an interview on 02/12/2020 at 5:40 p.m. RN M said there was 1 aide in each of the secure units. RN M said if that aide went in to perform incontinent care for a resident the aide would have to keep an eye on the hall and hopefully nothing would happen with the residents. RN M said it was her understanding that when the aide from E hall would take the residents out to smoke, the other aide form hall F would monitor hall E and hall F but then that would leave either hall unsupervised, so she was not sure how that worked. During an interview on 02/12/2020 at 5:44 p.m. LVN C said if an aide would go into a room to provide personal care then the hall would be unsupervised since there were only 1 aide on the hall. LVN C said CNAs would usually get someone to watch the hall when they took the residents out to smoke but that was not the case all the time. During an interview on 0[DATE]20 at 8:40 a.m. CNA B said that when she used to take the residents out to smoke she would have to be watching the smokers and also the secure unit. CNA B said she did not believe she could safely monitor the smokers and the unit. During an observation and interview on 0[DATE]20 at 8:50 a.m. CNA I was seen looking through her cellphone while monitoring the men's secure unit. CNA I said she was the aide assigned to the hall and that she knew she was not supposed to be on her cellphone. During an interview on 0[DATE]20 at 9:28 a.m. RN H said when it was 1 aide in the secure unit and if they entered a room to perform care for a resident then the hall was left unsupervised due to it just being 1 aide. RN H the aide would not come and ask her to watch the hall if they were going to be assisting residents and the hall was left unsupervised. During an interview on 0[DATE]20 at 10:24 a.m. the DON said she checks daily to see if the units had sufficient staff. The DON said some days the men's unit were a little more active than other days. The DON said the residents in the men's unit had their bad days. The DON said for example if the weather was bad and the residents could not be outside in the patio then they tended to be more restless. The DON said there was one CNA assigned to the hall and also a CMA that would come pass meds and the nurse which was at the nurse's station which is located outside of the secure units. The DON was asked if the units were supposed to be supervised at all times and not left unattended by staff. The DON said an aide can step out like to go to the vending machine to get something for a resident. The DON said it was ok for the unit to be left unattended for a short amount of time. The DON said the aides also had to leave the units at times to come and get second servings and such. The DON said 5 minutes was ok for the staff to leave the unit unattended. The DON said when the aide in the secure unit took the residents out to smoke, the aide would normally stand by the back door and monitor the smokers and the unit. The DON said in case of an altercation or a fall occurred in the unit, the aide would come in to the unit open the front entrance door to the unit and ask help from the nurse. The DON said the aide would have to leave the smokers unattended for a short while. The DON was asked who was watching the residents in the units while the only aide in the unit was in a resident's room performing personal care. The DON said she had not though about that, but they had a small number of residents that required assistance with personal care. During an interview on 0[DATE] at 11:08 a.m. the Administrator said she had been the Administrator at the facility since 12/09/2019. The Administrator said she would monitor the facility staff and residents by doing walking rounds. The Administrator said her expectation of the staff in the secure units was for the staff to ask for help when they were going to provide personal care, so the hall would not be left unsupervised. The Administrator said she did not like that the aide was having to watch the residents smoke and the hall at the same because if there was an issue in the hall then they would have to leave the smokers unsupervised to go and intervene. The Administrator said the secure units were supposed to be supervised at all times and not left unsupervised. The Administrator said staff were not allowed to be on their cellphones while working the floor. The Administrator was made aware of several observations of staff leaving the hall unsupervised and on their cellphones. The Administrator said that was unacceptable. Record review of the facility's CNA job description dated 09/2018 indicated in part: Essential functions - to assure resident safety, provide supportive protective and safe environments for residents. Record review of the facility's LVN/RN job description dated 09/2018 indicated in part: Essential functions - to assure resident safety, uses care plan as a basis for providing safe and therapeutic care to patients. The Administrator and the DON were informed of the identification of an immediate jeopardy situation on 0[DATE]20 at 4:25 p.m. and the need for a plan of removal. The Administrator was provided the IJ template. Review of the facility's Plan of Removal received on 0[DATE]20 documented: 1. Resident #1 and Resident #2 are no longer in the facility. 2. All residents in the secure units have the potential to be affected by this alleged deficient practice. 3. Staffing patterns have been adjusted to ensure 2 staff members are assigned on the secured units at all times. As of 5:11pm we initiated this new staffing pattern and it will continue indefinitely. The in services have been initiated as of 2pm on [DATE]20 and will be done at the beginning of each shift until all staff have been trained. This education will be provided to all new hires during the orientation process. We have a smoking aide for smoke breaks from 7am to 3pm and having the two staff members will allow one to be on the hall during smoke break to ensure the other residents are still being monitored. The training that we are doing is as follows: Never leave the hall without another staff member present to monitor the residents in your absence. Never ask a resident to watch the hall and other residents. When going behind a closed door to provide care, shower or any other kind of personal care, or to assist the residents to smoke another staff member must be present to monitor the hall. Any staff member is able to monitor the hall, housekeeping, laundry, nurse, cnas, cma dietary staff or management. Staff member assigned to work each secure unit must stay in an area where you can visualize the hall as well as the dining areas. Also started an in-service of abuse and neglect and how to handle resident to resident altercations. 4. Administrator and DON will monitor staffing to ensure that there are two staff members present for each shift on the secure units. DON will check staffing to ensure there are two staff members assigned and present to each secure hall each day before leaving and on Fridays will check for the weekend to ensure all halls are staffed with two staff members. Charge nurses will call to inform the On Call nurse if any secured staff does not show up. 5. Corrective action has been completed as of 5:11pm on [DATE]20. POR Verification Record review of a facility in-service dated 0[DATE] titled Behavioral assessment, intervention and monitoring indicated; 32 staff had participated in the in-service. The staff consisted of CNAs and charge nurses. Review of a facility in-service dated 0[DATE] titled Staff working on the secure units Any staff member assigned to work on a secure unit must follow the following guidelines - Never leave the hall without another staff member present to monitor the residents in your absence. Never ask a resident to watch the hall and other residents. When going behind a closed door to provide care, shower or any other kind of personal care, or to assist the residents to smoke another staff member must be present to monitor the hall. Any staff member is able to monitor the hall, housekeeping, laundry, nurse, cnas, cma dietary staff or management. Staff member assigned to work each secure unit must stay in an area where you can visualize the hall as well as the dining areas. indicated; 40 staff had participated in the in-service. The staff consisted of CNAs and charge nurses. During interviews and observation on [DATE] between 10:18 a.m. and 5:54 p.m. 12 staff members consisting of nurses, CMAs and CNAs from 6a-2p and 2p-10p shifts were interviewed, and they answered accordingly to training. Observations revealed 2 staff in each unit. During an interview and observation on [DATE]20 at 5:16 p.m. upon entrance of the women's secure unit hall C there were no staff seen monitoring the unit. At the end of the hall in the dining room CNA N was out of view and looking at her cellphone CNA N said she was looking at some texts on her cellphone. CNA N said she knew was not supposed to be on her cell phone. CNA N said the other staff was out in another hall passing meds. During an interview and observation on [DATE]20 at 5:28 p.m. upon entrance of the men's secure unit hall F, LVN O was seen sitting down and looking through his cellphone. LVN O said he was doing some training on the computer, looking through his personal cellphone at some personal things and monitoring the hall. The LVN said he did not see how that was a problem since all he was told to do was watch the hall. Plan of removal verification completed [DATE]: regarding the facility's POR failed due to observation of the unit found unsupervised and staff on their cell phone. During an interviews and observations on 02/15/2020 between 12:30 p.m. and 2:28 p.m. 2 staff members were seen in the units and staff answered questions on how appropriately supervise the units. Plan of removal verification completed 02/15/20: regarding the training they had received regarding the secure unit staffing. The staff was able to explain on how to be sure the units were kept monitored when one of the staff was busy assisting the residents. During an interview on 02/15/2020 at 3:45 p.m. the Administrator was informed that th

Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 5 residents (Resident #1) whose records were reviewed for quality of care, in that: 1. Nursing staff failed to assess Resident #1 after he had [MEDICAL CONDITION] activity. 2. Nursing staff failed to identify, communicate, and assess a significant change in condition for assessment of underlying issues. These deficient practices could place residents at-risk of a delay of necessary medical treatment. The findings were: Review of Resident #1's Admission Record dated 9/20/19 documented he was a [AGE] year-old male originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's annual Minimum Data Set (MDS) assessment dated [DATE] documented: He scored a 13 of 15 on his mental status exam indicating he was mostly cognitively intact. He showed no signs of [MEDICAL CONDITION]. He reported experiencing no indicators of depression. He showed no signs of [MEDICAL CONDITION]. There were no behaviors indicated. His Activities of Daily Living (ADL) status included needing supervision of one staff for bed mobility, transfers, walking, locomotion, dressing, eating, toilet use, personal hygiene. There were no range of motion impairment. And he used no mobility devices. He was occasionally incontinent of bladder and frequently incontinent of bowel. Active [DIAGNOSES REDACTED]., anxiety disorder, and TIAs. There were no problem conditions identified. And there were no falls in the previous assessment timeframe. Triggering medications included an anti-anxiety medication for 7 of 7 days. Specialized treatment included [MEDICAL CONDITION]. Resident #1 had a significant change MDS that was in progress due 9/27/19. Review of Resident #1's Care Plan reviewed and updated 8/7/19 documented: Problem: resident has ADL self-care performance deficit related to disease process. The goal was resident will remain at current level of function through the review date. Identified interventions identified: 1. he required supervision or set up assistance for bed mobility; 2. he required supervision and set up assistance for dressing; 3. personal hygiene needed supervision set up or assistance; 4. toilet use required supervision and set up assistance; 5. transfers required supervision and set up assistance. Review of Resident #1's Nurses Notes documented: 9/13/19 at 5:16 AM resident with [MEDICAL CONDITION] activity. Doctor notified. No new orders. 9/13/19 at 11:15 AM resident awake and alert. No complaints of pain or discomfort noted at this time. Respirations even and unlabored. No [MEDICAL CONDITION] activity noted at this time. 9/14/19 at 6:09 AM resting in bed with no [MEDICAL CONDITION] activity; no complaints voiced at this time. Bed in low position. Resident received orders for [MEDICATION NAME] level on previous shift. To be drawn Monday, 9/16/19. 9/14/19 at 12:19 PM ongoing follow up on [MEDICAL CONDITION] reported on previous days; no [MEDICAL CONDITION] activity noted this shift. Resident reported no complaints of headache dizziness or blurred vision on the shift. Resident rested throughout the shift with no new concerns voiced. 9/14/19 at 4:22 PM resident noted with no [MEDICAL CONDITION] this shift. Resting in bed, no signs or symptoms of discomfort or distress noted, respiration even and unlabored. (There are no notes for 9/15/19 or 9/16/19.) 9/17/19 at 7:07 PM alert and oriented to self and situation. Generalized weakness persist, but able to sit in wheelchair, respirations even and unlabored, no syncopal or [MEDICAL CONDITION] activities noted to this time. Assistance with oral intake due to bilateral upper extremity weakness and in coordination. 9/18/19 at 3:40 PM up from bed this shift. Consulted with hospice care for possible admission. For hospice, resident will be admitted for tomorrow. Resident states that he understands rationale for hospice consult and willing to have services. Redirected to times to use wheelchair for locomotion due to generalized weakness and impaired gait. Review of Resident #1's vital signs documented he had blood pressure and pulse taken on 9/13/19 at 8:23 AM (approximately three hours after the [MEDICAL CONDITION] activity). No Change in Condition Evaluation for the 9/13/19 [MEDICAL CONDITION] activity had been completed. Review of the ADL Flowsheets completed by the CNAs (Certified Nurse Aides) between 8/26/19 through 9/23/19 documented: Care ranged from Independent (no help) - supervision (cueing but resident does the task) - Limited assistance - extensive assistance - total assistance. 1. Bed Mobility: 8/26/19 through 9/12/19 Resident #1 was independent to limited assistance 44 of 48 entries. 9/13/19 through 9/23/19 Resident #1 was extensive - totally dependent 15 of 29 entries. 2. Transfer: 8/26/19 through 9/12/12: Resident #1 was independent - limited assistance 27 of 28 entries. 9/13/19 through 9/23/19 Resident #1 was extensive - totally dependent 11 of 28 entries. 3 Walking in Corridor: 8/26/19 through 9/12/19 Resident #1 was independent to limited assistance 28 of 28 entries (The staff selected not applicable once) 9/13/19 through 9/23/19 Resident #1 needed extensive - total dependence 3 of 9 entries. (The staff selected not applicable 12 times) 4 Locomotion 8/26/19 through 9/12/19 Resident #1 was independent to limited assistance 25 of 27 times. The staff selected not applicable twice) 9/13/19 through 9/23/19 Resident #1 was needed extensive assist - total dependence 11 of 17 entries. (The staff selected not applicable three times) 5. Dressing 8/26/19 through 9/12/19 Resident #1 was independent to limited assistance 28 of 30 entries. 9/13/19 through 9/23/19 Resident #1 needed extensive - total assistance 17 of 20 entries. 6. Toilet Use: 8/26/19 through 9/13/19 Resident #1 was independent to limited assistance 42 of 45 entries. 9/13/19 through 9/23/19 Resident #1 needed extensive - total assistance 19 of 29 entries. 7. Personal Hygiene 8/26/19 through 9/12/19 Resident #1 was independent - limited assistance for 27 of 30 entries. 9/13/19 through 9/23/19 Resident #1 needed extensive - total assistance 18 of 20 entries. 8. Bladder Continence 8/26/19 through 9/12/19 Resident #1 was continent 36 of 49 entries 9/13/19 through 9/23/29 Resident #1 was incontinent 19 of 28 entries. 9. Bowel Continence Status. 8/26/19 through 9/12/19 Resident #1 was continent 29 of 34 entries 9/13/19 through 9/26/19 Resident #1 was incontinent 9 of 16 entries During an interview on 9/20/19 at 11:47 AM the Director of Nurses (DON) said she was not aware of any [MEDICAL CONDITION] activity in Resident #1. She said the night nurse did not notify her. She said they know they were supposed to call her. The DON said she would have assessed him that day had she known. She said no one told her that he had a decline in ADL status. She said Resident #1 had days where he refused to get out of bed. She acknowledged it should be charted especially after a [MEDICAL CONDITION]. The DON read the nurses notes and said she would not have identified a decline in the nurse's notes. She said, looking at the ADL sheets there is a clear decline. I'll have to see what's going on there. The DON acknowledged that the nurses notes and the ADL Flowsheets did not match. The DON said she was working with her nurses to be more specific on their documentation and she had no idea what [MEDICAL CONDITION] activity looked like. The DON said that nurse was new to Resident #1's side of the building but could still document what she saw. The DON said, this is a nursing home, we document by exception. She acknowledged she would consider a [MEDICAL CONDITION] an exception. During an interview on 9/20/19 at 2:43 PM with the Administrator and the DON said she would expect to see more description about what [MEDICAL CONDITION] activity was. She said there were 100 things that [MEDICAL CONDITION] activity could look like. The DON said the documentation in the facility had been a concern she has had discussions with the nurses about it. She said she did them at the change of shift pow-wow. The DON said she did not do an in-service and document it but it was discussed. The DON acknowledged the nurse's notes did not match the CNA documentation and said that's communication between the nurses and CNA's. She acknowledged she missed the [MEDICAL CONDITION] activity in the morning meeting review of the notes. The Administrator wanted to know who did not communicate the change of condition on what shift. He was informed of the poor documentation and documentation that did not match between the Nurses Notes and the ADL Flowsheets. He acknowledged it was an issue. During an interview on 9/23/19 at 3:01 PM the DON said that Resident #1 had an incontinent episode. She said she had to ask the other charge nurse and who went to check on him; he was not talking normally and being incontinent. The DON said to her knowledge no one saw him convulsing, twitching, thrashing or anything like that. The DON said the nurse needed to be more descriptive - did he bite his tongue or what? She said for the immediate decline she would at least have it discussed with the doctor. The DON said from her understanding the resident had a revolving history of being up and down. She said Resident #1 would be up and then go to bed for two or three days. The DON said Resident #1 looked like he needed help but would not let the staff help him. She said she would have at least called the doctor. She said she did not know the resident well enough to say if the decline was normal or not. She said she did not see previous [MEDICAL CONDITION] in the clinical record. During an interview on 9/24/19 at 9:37 AM Licensed Vocational Nurse (LVN) A said, she worked at the facility for two months. She said she normally worked the 10 p.m. - 6 a.m. shift on the other side of the building and 9/12/19 - 9/13/19 was the first night she had worked on Resident #1 side. She acknowledged she charted [MEDICAL CONDITION] activity. LVN A said that she was called in there by an aide and when she entered the room he was diaphoretic, he was incontinent, and his mouth was moving but he was slurring his words. She said, he appeared to be coming out of a [MEDICAL CONDITION] he was really tired and slow to respond because he was worn out. LVN A acknowledged she did not actually see him seizing. LVN A said the aide said he wasn't right and he was different. LVN A said Resident #1 had not been independent for two months. She said Resident #1 had good days and bad days but he was declining. LVN A said for the last month he had been completely dependent. LVN A said she had no idea what the aides were charting. LVN A said the other charge nurse said he probably had a [MEDICAL CONDITION] off and on and it was not a new condition. LVN A said the other charge nurse believed other nurses were documenting the possible [MEDICAL CONDITION] as a TI[NAME] LVN A said, I'm not familiar, I'm still learning these people. LVN A said she should have documented better she was not sure why she did not. LVN A said she was usually pretty good at documenting, when I look back on it I thought what was I thinking . obviously not. She acknowledged she was probably thinking it was not her hall so it was not her problem. LVN A said she did not remember which aide said Resident #1 was not acting like himself. LVN A said she did not remember if she asked what the aide meant. LVN A said before she left (45 minutes after the [MEDICAL CONDITION] activity) Resident #1 was acting like himself and didn't look worse for wear. During an interview on 9/24/19 at 10:05 AM Resident #6 asked if LVN A was the one on the night shift and gave a physical description. Resident #6 said LVN A did not want to be here and you could tell. Resident #6 said LVN A was nice but she lets the aides do all the work and doesn't really assess the residents. Resident #6 said if she checks on us I've never seen it. During an interview on 9/24/19 11:15 a.m. Resident #1's Doctor said Resident #1 had not been doing well he was very fragile because of the [MEDICAL CONDITION] and the [MEDICAL CONDITION]. The doctor said this episode was possibly a [MEDICAL CONDITION] and they ordered a [MEDICATION NAME] level. The doctor said this was the first [MEDICAL CONDITION] for Resident #1 he was aware of. The doctor said he was not made aware of the change in ADL status. He said because Resident #1 had [MEDICAL CONDITION] and it was huge Resident #1 was very diminished. The doctor said he was assuming the decline was disease process. He said it would not be unusual for a resident to take a week to bounce back from a [MEDICAL CONDITION]. The doctor acknowledged he saw Resident #1 last Wednesday and there was a change in the resident. The doctor said Resident #1 had significant muscle wasting so he assumed it was [MEDICAL CONDITION]. During an interview on (MONTH) 24, 2019 at 11:29 AM CNA B said she had worked at the facility since 2/2019. She said she was aware of Resident #1's care. CNA B said Resident #1 tried to be very independent. CNA B said this weekend she noticed he was using his wheelchair more and not able to use his feet very well. She said she was not sure if Resident #1 had a [MEDICAL CONDITION]. CNA B said she was not asked to fill out an incident report which is how these things usually go and was not asked to fill out a witness statement. CNA B said she was working with an agency aide but she did not remember which one. CNA B said Resident #1 usually slept through the night. She described Resident #1 was very shaky due to [MEDICAL CONDITION]. She said she did not remember seeing him on the night of the 9/12 - 9/13 since she was assigned the other side of the building. CNA B said Resident #1 was shaky to begin with if he was in bed and had been able to do stuff for himself until recently. She said now he did a sideways shuffle when walking. CNA be said LVN A was a newer nurse that had only been at the facility a couple of months. CNA B said LVN A needed the other charge nurse to tell her what to do all the time. CNA B said LVN A was pretty much the desk nurse who sits at the nurse's station and lets the aides do all the work. CNA B said she believed if another aide said Resident #1 had a [MEDICAL CONDITION] that LVN A would just go with it. CNA B said she remembered telling the other charge nurse was acting different and was shaking worse and leaning to the side. She said I know there was a change, I don't know exactly what. During an interview on 9/24/19 at 1:36 PM the DON said unless a nurse sent a resident out via 911, she would expect vital signs after a [MEDICAL CONDITION]. During an interview on 9/24/19 at 2 PM the DON said LVN A did not get vital signs when Resident #1 had his [MEDICAL CONDITION]. She acknowledged his blood pressure and pulse were not taken until 8:23 a.m. and no other vital signs were taken. Review of the facility's policy and procedure on Charting and Documentation, revised (MONTH) 2008, documented: Policy: all services provided to the resident, or any changes in the resident medical or mental condition, shall be documented in the resident medical record. Policy interpretation: All observations, medications administered, services performed, etc., must be documented in the residence clinical record. All incidents, accidents, or changes in the residence condition must be recorded. Documentation of procedures and treatments shall include care specific details and shall include at a minimum: a. the date and time the procedure or treatment was provided; b. the name and title of the individuals who provided care; c. the assessment data and or any unusual findings obtained during the procedure or treatment; d. how the resident tolerated the procedure or treatment; e. whether the resident refused the procedure or treatment; f. notification of family, physician or other staff, if indicated; and g. the signature and title of the individual documenting. Review of the facility's undated policy and procedure on Change of Condition documented: (Corporation) will use the (Computer Program Form) definition for a Change in Condition. It will be the policy that once the nurses have notified the physician for a change in condition the resident/patient will be monitored every hour until the physician has responded. The monitoring will include vital signs, pulse ox, and fingerstick blood sugar if a diabetic (one time only). A physical assessment should be completed relative to the symptoms present and a pain assessment. SBAR started (situation, baseline, assessment, response.). Review of the facility's policy and procedure on Change in a Resident's Condition or Status, revised (MONTH) (YEAR), documented in part: Policy statement: our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and or status. The nurse will record in the resident's medical record information relative to changes in the resident medical/mental condition or status.

Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services were provided to prevent complications of enteral feedings in accordance with each resident's comprehensive assessment for 1 (Resident #18) of 2 residents reviewed for a gastrostomy tube ([DEVICE], a tube surgically inserted into the stomach used for hydration, feeding, and medication administration). a) Resident #18's [DEVICE] became clogged, Licensed Vocation Nurse (LVN) A disconnected the feeding tube from Resident #18, increased the flow rate on the feeding pump machine to 295 milliliters (ml) an hour, in an attempt to unclog the tubing. LVN A failed to lower the flow rate on the feeding pump before she turned it off. b) LVN B failed to verify Resident #18's physician ordered flow rate of 70 ml an hour when she turned on his feeding pump. LVN B placed new tubing/bag of enteral formula feeding, connected the tubing to Resident #18's [DEVICE] and turned on the pump. The formula infused at 295 ml an hour. Resident #18 was sent to the local emergency roiagnom on [DATE]. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the inspection. This failure placed 1 additional resident who received nutrition/hydration via [DEVICE] at risk of not receiving care as ordered by the physician, which could lead to aspiration pneumonia, dehydration, inadequate nutrition, weight loss, significant illness, and even death. The findings included: During initial tour on 3/13/17 at 9:30 a.m. with Director of Nurses (DON) Q he said Resident #18 needed total care with all activities of daily living and had a peg tube (percutaneous endoscopic gastrostomy, also called [DEVICE]). DON Q said Resident #18 was currently in the hospital for aspiration pneumonia. Review of Resident #18's closed record Resident Face Sheet printed 3/16/17 documented he was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's quarterly Minimum Data Set assessment dated [DATE] documented: - He had unknown recall but severely impaired decision making decisions. He showed no signs of [MEDICAL CONDITION]. - He was completely dependent on one or two staff for all activities of daily living. - He took 51% or more of nutrition and fluids through a feeding tube. - He had no infections, including pneumonia. Review of Resident #18's Physician order [REDACTED]. - 1/10/16 Nothing by mouth - 8/24/16 Check [DEVICE] placement by auscultation and aspiration before administering formula, medications, or water. Every shift. - 8/24/16 Check residual; if > (greater than) 150 ML (milliliters); hold feeding and notify MD (medical doctor). Every shift. - 8/24/16 Flush peg tube with 60 ml H2O (water) before & after meds, also at stop and start of feedings; give 10 ml H2O per tube in between medications. Every shift. - 8/24/16 Flush peg tube with 100 ml of water every 6 hours - 8/24/16 Head of bed to be elevated at least 30 degrees at all times during any GT (gastrostomy tube) administration. - 8/24/16 [MEDICATION NAME] 1.2 Cal (calorie) (lactose-reduced food with fiber) OTC (over the counter) liquid. 70 ml / hour; gastric tube. Special instructions: continuously; off for one hour before and one hour after administration of [MEDICATION NAME] at 8:00 a.m., 2:00 p.m., and 8:00 p.m. Review of Resident #18's care plan last revised on 3/10/17 documented: Dependent on tube feeding for nutrition and hydration, with potential for complications, side effects. [MEDICATION NAME]. Weight- 119. Identified approaches included: - Administer tube feeding and water flushes as ordered. See MD orders for current feeding orders. - Observe document, and report to MD as needed: aspiration, tube dysfunction or malfunction. Review of Resident #18's Nurse's Notes documented: - 3/10/17 written at 12:09 a.m.: At 11:35 p.m. heard resident's feeding pump alarm sounding. Immediately entered resident's room and and resident appeared diaphoretic with labored breathing. Vital signs equal, blood pressure 137/80, pulse 147, respirations 42, Temperature 100.8, O2 Saturation = 77% on room air. Called 911 at 11:40 p.m. EMT (Emergency Medical Technician) x 4 arrived at 11:45 p.m. and transported resident to local emergency room at 11:55 p.m., notified Doctor / Nurse Practitioner. Attempted to notify Administrator and DON and resident's family members x 3. Left messages for family members to return my call as soon as possible. Written by LVN B - 3/10/17 at 3:39 a.m. Family member #1 called; I explained that we had sent in her family member due to respiratory distress and a increased temperature. I explained that he was sent to ER for evaluation and treatment. She thanked me for the information. WCTM (Will Continue to Monitor). - 3/10/17 4:59 a.m. Family Member #2 returned my call. I informed her that resident had been sent to ER for Eval and TX (treatment) of respiratory distress and elevated temperature. Also informed her that he had been admitted to ICU (intensive care unit) for respiratory distress. - 3/10/17 12:00 p.m. (noon) - Hospital called and gave update on resident's condition. Verified that he is a resident as well as verifying we would be readmitting him after discharge from hospital. Review of Resident #18's 3/10/17 Emergency Department Report documented he arrived at the ER at 12:07 a.m. with his chief complaint being fever. The patient complaints of chills and sweating and diaphoresis (sweating). Disposition: Admit to inpatient, ICCU (intensive critical care unit). Review of the Preliminary Reports of the 3/10/17 2:02 a.m. Computed Tomography (CT) Scan of the chest documented, in part: Large loculated right pleural effusion without definite pleural enhancement. Diffuse atelectasis or consolidation of much of the right and lower lobe. Lower lobe shows low density area within it likely representing necrotizing type pneumonia. Necrotizing Pneumonia - Causes of Necrotizing Pneumonia, Symptoms, Diagnosis, Treatment, Prevention Necrotizing pneumonia is an inflammation of the lungs and airways to lungs, that is [MEDICATION NAME] tubes from breathing in the foreign substances. This is also known as aspiration pneumonia, aspiration of vomitus, anaerobic pneumonia and aspiration pneumonitis. This is caused by breathing in foreign materials , generally liquids, food, fluids from mouth or vomit) into lungs. http://breath.ygoy.com/2010/06/29/necrotizing-pneumonia-causes-of-necrotizing-pneumonia-symptoms-diagnosis-treatment-prevention/ Accessed 03/24/17. Review of Resident #18's Nutrition assessment dated [DATE] documented Resident #18 had a nothing by mouth diet. His suggested tube feeding was [MEDICATION NAME] 1.2 at 70 cc (cubic centimeters)/hr via (by) [DEVICE] per pump for at least 18 hours per day. 100 cc water flush every 6 hours. Hold tube feeding 1 hour before or after [MEDICATION NAME] (a [MEDICAL CONDITION] medication) three times per day per pharmacist recommendation. During an interview on 3/14/17 at 3:15 p.m. DON Q said the night nurse called him and informed him they were sending Resident #18 to the ER for shortness of breath. He said LVN B took over early for LVN A. He said LVN A told LVN B that she was having problems with getting Resident #18's PEG connected again. DON Q said both nurses said LVN B agreed to take care of it. DON Q said LVN A got everything set up and Resident # 4 (the roommate) began having behaviors. DON Q said LVN A admitted to setting the pump at 295 and LVN B did not realize it. DON Q said that was the highest the pump would go. DON Q elaborated that LVN A disconnected Resident #18 and turned the rate all the way up to get the formula to flow but she could not get it to work; so LVN A took everything off the machine but did not reset the rate. When asked if that was the usual practice for unclogging tubing DON Q said I've never done it that way. He said he printed the trouble shooting instructions and turning the rate all the way up was not one of the recommended solutions. DON Q explained LVN A felt the tube was clogged and if she made the flow faster, the pressure would clear it. DON Q said at that point LVN B came in and did not realize LVN A changed the rate. He said you don't change the rate; the rate stays the same. He said the average nurse expectation was the nurse would turn on the pump and look at it. He said all the buttons blinked and you hit the run button so you have to look at the pump twice. DON Q said LVN B looked at the machine twice and did not realize the rate had been changed. He said when LVN B heard the pump go off she realized something was weird because it should not have sounded. DON Q said when LVN B went to disconnect the pump she realized the rate was set too high. DON Q said aspiration was pretty normal in residents with peg tubes. He said if caught in time, the resident would have a round of antibiotics and a couple of days in the hospital and it had a good recovery rate. During an interview on 3/16/17 at 9:00 a.m. LVN A said she went into Resident #18's room to flush his Peg and do Resident #4 when Resident #18's pump started beeping. She said the machine read 'free flow' which meant that the formula was going straight down but the machine was not doing that. She said she disconnected the machine and checked the placement to Resident #18's peg tube. LVN A said she flushed the tube and the tube was fine so she put the feeding tube back. She said she pushed the on/ start button and the machine was beeping 'free flow' again, so she took it off (disconnected Resident #18 from the machine) and pushed the hold button. LVN A said she held the feeding line over the trash can and nothing came out. She said she tried cleaning the chamber because there was typically dried milk on the side or bottom of it. She said she rinsed out the chamber until the water ran clear. LVN A said when that did not work she pushed the rate up to 295 and rethreaded the tubing. She said she hit start hoping the increase in the rate would flush it out because she knew the blockage was in the bottom of the tubing. LVN A said she pushed start and still nothing came out. LVN A said at that point she turned the machine off and threw the whole set up away. She said at that point it was 7:00 p.m. and LVN B came in to relieve her. She said she told LVN B that she (LVN A) just took the bag and tubing off and threw it away because she could not get it to work. LVN A said she asked LVN B to set up the rest and LVN B agreed to do that. LVN A acknowledged she did not tell LVN B she bumped up the flow rate. LVN A said she had been a nurse for [AGE] years and she had cleared peg tubing by increasing the rate before because some of them could not flow to gravity. She said she bumped up the rate to get the tubing primed and intended to turn it down but she just turned it off and threw away the set up. LVN B said she didn't think to bump it back down. She said that was not how she was trained and she did not remember if she had been checked off on peg tube care at the time of the incident or not. She acknowledged Resident #18 was still in the hospital. LVN A said she felt like she was the one to blame and that she set up LVN B. LVN A's statement written 3/10/17 documented: Resident #18's pump was beeping (free flow). I disconnected feeding, verified placement and flushed his [DEVICE] without difficulty. I then flushed chamber around with milk, disconnected attachment below chamber and let milk run out. I reconnected tubing and held over trash can to see if milk would free flow out. It would not. I applied tubing back to machine turned up volume to 290 to see if milk would come out there. It did not. I turned off machine and threw bag and tubing away. I gave report to on-coming nurse after walking out of room. I advised nurse I discarded entire bag and tubing because I couldn't get it to work. During an interview on 3/16/17 at 2:05 p.m. LVN B said she came in early to relieve another nurse. LVN B said in report the nurse told her that Resident #18's bag and tubing was clogged and could not get it unclogged. LVN B said it was around 8:00 p.m. when she went into the room and Resident #18's Peg tube was clogged and she had to milk it to get it to flush properly. She said the whole time Resident #18's roommate was yelling out and agitated. LVN B said she got a whole new set up for the peg and a few hours later the alarm went off. LVN B said it must have taken 3 hours for the alarm to go off. LVN B said she used three cans of formula. LVN B said the CNA who took care of Resident #18 said he was fine and did not have any labored breathing. LVN B said as soon as she entered the room she noticed Resident #18's breathing was distressed. She said she put the head of the bed up and did not wait for vital signs before calling 911 because when she went in she noticed the whole bag was gone and the rate was set at 295. She said I don't have an excuse, I should have checked the flow rate. I can remember talking to Resident #4 who was very agitated so I just turned it on and I did not check the flow rate. She said she called 911 and they arrived pretty quickly and then he called the Administrator and the DON. She said she left messages for all three family members. LVN B said Resident #18's flow rate was usually 70 ml/hr not, 295. She confirmed that 295 was four times faster than what he was supposed to receive. LVN B's statement written 3/10/17 documented: During shift to shift report I was informed by LVN A that she was having difficulty with Resident #18's feeding bag/tubing being 'clogged'. She so she disconnected it and threw bag/ tubing away and Resident #18 was currently off feeding. LVN B entered Resident #18's room and after checking and verifying peg tube placement I attempted to flush peg tube. Peg tube would not immediately flush. After some time of working with it, I was able to flush peg tube. I then hung a new set - bag and tubing - and connected and started infusing. HOB (Head of Bed) was up. During the time I was working on Resident #18, his roommate, Resident #4 was cussing at me telling me to 'turn the light out and get the hell out of here'. He also stated 'you [***] , I'll kill you'. I kept talking to him explaining that I needed to change his feeding bag/tubing next and then I would turn out the light and let him get some rest. After starting both pumps I left the room. At about 11:35 p.m. I heard the pump alarm sounding. I immediately entered residents room and observed Resident #18 was diaphoretic and breathing was labored. I stepped into the hallway and called LVN S for assistance and instructed him to bring the vital sign kit with him. I re-entered the room and raised the HOB. LVN S started vitals and I returned to nurse's station and called 911 at 11:40 p.m. I then returned to Resident #18's room and noticed the bag of [MEDICATION NAME] 1.2 was empty and pump was infusing at 295 ml/hr (milliliters per hour). Emergency Medical Technicians x 4 arrived at 11:45 p.m. and transported resident to local hospital ER (emergency room ) at 11:55 p.m. LVN S's statement written 3/10/17 documented: On 3/10/17 at 12:10 a.m. I was headed down hall D going to a resident's room to set up a breathing treatment when I heard LVN B yell out, LVN S grab your Vital Sign kit and come to Resident #18's room, I need you NOW! Upon entering the room, I noted that LVN B was extremely upset, she was pale and visibly shaken. I looked at Resident #18 and noted his HOB was up 30 degree, but he was in extreme distress. He was diaphoretic and ruddy in complexion. I looked at the feeding pump and noted the empty bag hanging on the IV pole, I then noted the flow rate was et at 295 ml/hr. (His feeding rate is normally 70 ml/hr.) I stated, He has aspirated. LVN B immediately went and called 911 for transport while I acquired his vital signs. Transport arrived within minutes, resident assisted to the stretcher x 2 attendants and myself. They left immediately. During an interview on 3/16/17 at 4:45 p.m. Certified Nurse Aide (CNA) C said she worked with Resident #18 the night he went to the hospital. She said he was a total care resident and he squirmed a lot and would slide up and down in the bed. She said he never stayed in one spot. CNA C said Resident #18 was a person who sweated a lot so there was nothing unusual about that. She said he was moving around the way he normally did. She said the head of the bed was ok but he was moving around making noises. CNA C confirmed Resident #18 was still connected to his feeding pump. She said she provided incontinent care to Resident #18. She said she did not put the head of the bed down and she never messed with the head of the bed, she just changed him because he was a small man. During an interview on 3/17/17 at 8:10 a.m. DON Q said the Medical Director was informed of the facility's plan of action on 3/14/17 and had no other recommendations. During an interview on 3/17/17 at 8:23 a.m. the Administrator said the facility QA'd (Quality Assurance) the situation because as soon as it occurred they began to take steps to prevent it from happening again. She said they put everything they could think of in place to prevent it from happening again. She said she talked to the wife who was very understanding about the situation. Review of the 3/10/17 Provider Self-Reporting of Incidents documented: Report Details: LVN A was in Resident #18's room attempting to get flow through the pe[DEVICE]. She realized it was the tubing not the peg tube which was clogged. She unhooked Resident #18 from the feeding. While trying to fix the flow, she increased the rate on the kangaroo pump She was unsuccessful in getting it to flow, so she turned off the pump and took off the rig to replace it. When she was on her way to get the rig, her relief came in (LVN B). She told her she was changing the rig. LVN B said she would do it. She was able to successfully reconnect resident to his feedings. She did not realize the rate had been adjusted when she started the feedings. The resident's roommate was upset because the light was on. She directed her attention to him and failed to verify the rate on the kangaroo pump. The pump went off. She went to to the room the check the pump and found the resident having Shortness of Breath. She immediately sent him out to hospital, where he was diagnosed with [REDACTED].#8's wife reports Resident #18 is doing well. Awake and moving around. He is on a preventative antibiotic regimen. Immediate actions Taken& Entities Notified: Resident #18 was sent to the local hospital ER for evaluation and treatment. Medical Director/ Resident Physician was notified. Administrator and DON were notified. LVN B was suspended pending investigation. LVN A was written up for failing to complete the changing of the rig. In-service to Nurses about 1. Two nurses will now sign off on the peg tube rate and two will sign off on flushings. 2. In-service on trouble shooting a clogged tube. 3. In-serviced on using the Kangaroo pump. 4. In-service staff on abuse and neglect. 5. In-serviced staff to have a nurse stop the feeding prior to providing care. Review of the 3/17/17 Provider Investigation Report documented: Description of injury: Resident #18 aspirated. Investigation Summary: No evidence was found to support this action as being intentional. The nurse became distracted and failed to ensure all steps were taken in the process of changing the rig and restarting the feeding. Provider Action Taken Post-Investigation: I. Measures put into place to address the deficient practice include: 3/10/17 1. Facility In-serviced for nursing staff members on the definition of abuse and neglect. 2. Facility in-serviced and conducted profiencies for licensed nurses on proper Gastric Tube set-up, administration and trouble shooting of the pump. Instructions were laminated and hung on pump pole for reference. 3/11/17 3. Facility in-serviced nursing staff to ensure only a licensed nurse can turn off a feeding pump and that a licensed nurse must be called to do so when necessary. Only the licensed nurse can resume feeding when care is completed. 4. Facility in-serviced nursing staff to ensure that the Head of Bed is elevated 30 degrees or more. Signs have been placed in the room to show 30 degree placement. 5. Facility in-serviced nursing staff on the standards and expectations of all staff members with regard to conducting themselves in a professional and ethical manner in all interactions with residents. II Measures put into place to ensure deficient practice does not reoccur. 1. Two nurses must sign off on treatment sheet verifying the rate is correct and flushes are provided appropriately. 2. Nurse managers verify both signatures on treatment sheet daily during start up to ensure compliance with Plan of Correction. 3. Random check-off sheets has been initiated by Director of Nursing or designee whereby the rate, TAR (treatment administration record) signatures and HOB elevation are verified. 4. Results of findings will be brought to the QA&A (quality assessment and assurance) committee to review effectiveness of the initiated plan. Review of the facility's December 2011 Policy and Procedure on Enteral Tube Feeding via Gravity Bag documented, in part: Purpose: The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally. General Guidelines: Check the enteral nutrition label against the order before administration. Check the following information a. Resident name, ID and room number; b. Type of formula; c. Date and time formula was prepared; d. Route of delivery; e. Access site; f. Method (pump, gravity, syringe; and g. Rate of administration (ml/hour). Verify Placement of tube: Observe for signs of respiratory distress (if applicable). Auscultate: Do not rely on this as the singular method to differentiate between respiratory, gastric, [MEDICAL CONDITION], and bowel placement. Review of the facility's December 2011 policy and procedure on Enteral Feedings - Safety Precautions documented, in part: Purpose: To ensure the safe administration of enteral nutrition. Preparation: All personnel responsible for preparing, storing, and administering enteral nutrition formulas will be trained, qualified, and competent in his or her responsibilities. Preventing Errors in administration 1. Check the enteral nutrition label against the order before administration. f. Method (pump, gravity, syringe) g. Rate of administration. (ml/ hr) 2. On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order. Preventing aspiration Monitor the tube-fed resident for signs and symptoms of respiratory distress during feedings and medication administration. Recognize the risk factors for aspiration including: -improper position of the feeding tube Review of the undated Operating Instruction Manual Occl/Empty/ Free Flow was defined as when the pump is on, this alarm is activated under one of the following conditions: 1. Feeding container is empty; 2. An occlusion has caused delivery to stop; 3. The pump is left on hold for more than 2 1/2 (2.5) minutes; 4. Drip chamber is overfilled or dislodged; 5. Drip chamber walls are coated with solution; 6. Sensors in drip chamber bracket need cleaning; 7. Drip chamber is improperly placed. Trouble shooting guide: Situation: Free Flow Alarm Activated Potential Cause 1: Silicone tubing detached from pump rotor, formula is gravity flowing. Solution 1: Assemble silicone tubing properly around pump rotor and secure in pump adaptor bracket and tubing guide per diagrams Potential Cause 2: Drip chamber walls coated with formula or condensation in sensor path. Solution 2: Manipulate chamber to clear drops or condensation in sensor path. Potential Cause 3: Drip sensor in direct path of intense light Solution 3: Turn pump so sensor is not in direct sunlight Potential Cause 4: Flow sensors need cleaning Solution 4: Clean with cotton swab dampened with [MEDICATION NAME] alcohol. During an interview on 3/16/17 at 3:15 p.m. DON Q said to prevent a reoccurrence the facility in-serviced staff to know that the nurses had to turn off the pump prior to care so the tubing does not become plugged. He said now two nurses have to verify rates and flushing amounts and this was documented on the Treatment Administration Records. He said random checks would be completed. During an interview on 3/16/17 at 4:40 p.m. the Administrator said they facility in-serviced the staff. She said in the investigation they determined that Resident #18's roommate distracted the staff so they added a second staff member to verify the care. It was determined these failures placed Resident #18 in an Actual Harm situation on 3/09/17 The facility took the following actions to correct the non-compliance on 3/10/17. 3/10/17 Incident Plan of Correction The measures put into place to address the deficient practice included: 1. Facility in-serviced for nursing staff members on the definition of abuse and neglect. (in-service provided) 2. Facility in-serviced and conducted proficiencies for licensed nurses on proper [DEVICE] set -up, administration and trouble shooting of the pump. Instructions were laminated and hung on pole for reference (proficiency checklists provided) 3. Facility in-serviced nursing staff to ensure that only a licensed nurse can turn off a feeding pump and that a licensed nurse must be called to do so when necessary. Only the licensed nurse can resume feeding when care is complete 4. Facility in-serviced nursing staff to ensure that the HOB is elevated 30 degrees or more. Signs have been placed in the room to show 30 degree placement. (surveyor observed 3/13/17 - entrance) 5. Facility in-serviced nursing staff on the standards and expectations of all staff members with regard to conducting themselves in a professional and ethical manner in all interactions with residents. The measures put into place to ensure deficient practice does not recur: 1. Two nurses must sign off treatment sheet verifying the rate is correct and flushes are provided appropriately. 2. Nurse managers verify both signatures on treatment sheet daily during start-up to ensure compliance with Plan of Correction 3. Random check-off sheet has been initiated by DON or designee whereby the rate, TAR signature and HOB elevation are verified. 4. Results of findings will be brought to QA&A committee to review effectiveness of the initiated plan. Observation on 3/13/17 at 9:40 a.m. showed LVN T getting DON Q for assistance with [DEVICE] care. The facility provided documentation of completed changes: - 3/10/17 Make sure Peg Tube resident Head of Bed are elevated above 30 degrees at all times and make sure pump setting are per MD orders. Two Nurses must sign off any time pump is turned off to make sure correct settings. Two nurses must sign off the flushing was performed. Abuse and Neglect. - 3/10/17 Kangaroo Pump: In-services on Kangaroo manual where it's located, instructions on how to use Kangaroo Pump, instruction what alarms mean, and troubleshooting tips if concerns develop. - 3/10/17 CNA must notify nurse prior to providing care to a Peg Tube resident so nursing staff can stop the Peg Tube feeding and disconnect resident so staff can appropriately provide care for the resident and when they complete the care they must notify nurse again to reconnect resident. Peg Tube resident must be maintained at a 30 degree angle bed position at all times. - Treatment Flowsheets were updated 3/10/17 to include a space for a nurse witness. -Nurse Profiencies check-offs were completed - New Check Off for List for Residents to included month/ year, day, time, pump rate, second nurse's witness initials on TARS (Y/N), Head of Bed elevated above 30 degrees (Y/N), Nurse Signature - 3/10/17 LVN A was counseled for not completing the Rig Change. Review of the form CMS 672 Resident Census and Conditions of Residents completed by the MDS Coordinator on 3/13/17 documented there was 1 resident in the facility currently receiving tube feedings.

Based on interview and record review, the facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source were reported immediately to the administrator of the facility and to other officials in accordance with State Law and failed to have evidence that all alleged violations were thoroughly investigated for 1 of 8 residents (Resident #1), a resident on one of three of the facility's secure units, reviewed for abuse and neglect as evidenced by failure to thoroughly investigate and report to the State Authority when Resident #1 had an unwitnessed fall on 11/7/16 that resulted in a nose fracture. An Immediate Jeopardy (IJ) was identified on 11/20/16 at 1:40 p.m. While the IJ was removed on 11/23/16 at 11:00 a.m., the facility remained out of compliance at a level of actual harm that is not Immediate Jeopardy at a scope of a pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. These failures could affect the 93 residents that reside in the facility due to unidentified incidences of neglect that could result in avoidable accidents and injuries. Findings included: 1. An undated computer face sheet documented Resident #1 was a [AGE] year old female admitted to the facility 2/18/16 with Mild Intellectual disability, major [MEDICAL CONDITION], persistant mood disorder, diabetes mellitus, [MEDICAL CONDITION] disorder, anxiety disorder, hypertension, [MEDICAL CONDITION], reflux disorder and pruritis. A Minimum Data Set (MDS) Assessment date 8/29/16 documented that Resident #1 had a brief interview for mental status score of 03 indicating severe cognitive impairment. Resident #1 used a wheelchair for mobility. She required limited assistance of two staff to transfer, and extensive assistance of one staff for personal hygeine, dressing and toilet use. She had range of motion limitation for both lower extremities. She was always incontinent of bowel and bladder. physician's orders [REDACTED].#1 was prescribed checks of her blood sugar twice daily at 7:00 a.m. and 5:00 p.m. with [MEDICATION NAME] R insulin to be administered on a sliding scale based on the blood sugar reading. She was also prescribed [MEDICATION NAME] 40 units subcutaneous once daily at 7:00 a.m. Resident #1's care plan with a review date of 9/13/16 included the following: Problem: Resident is at risk for frequent infections, pressure/venous-statis ulcers, vision impairment, hyper/[DIAGNOSES REDACTED], [MEDICAL CONDITION], cognitive/physical impairment, slow healing process skin desensitized to pain or pressure related to diabetes mellitus. .Approach start date 9/13/16: Assess/record/report to MD (medical doctor) prn (as needed): [DIAGNOSES REDACTED] s/sx (signs/symptoms) : tremors, shaking, confusion, headache, irritability, hunger, n/v, cool, clammy, pale skin, and diaphoresis. [MEDICAL CONDITION] s/sx: extreme thirst, frequent urination, abnormal pain, blurred vision, dry flushed skin, rapid breathing. A review of nurse's notes for Resident #1 revealed they included the following entries on 11/7/16: (Late entry) 1:15 p.m.: At 0700 (7:00 a.m.) CBG (capillary blood glucose) read 45 mg/dL. Res lethargic, unable to open eyes, follow commands, or answer questions. Res given [MEDICATION NAME] injection IM (intramuscular) in Rt. delt (deltoid). Re-checked at 0800 (8:00 a.m.) CBG (capillary blood glucose) read 154 mg/dL. 8:00: While on the phone with 911 operator to send res (resident) out for first fall, second nurse reported to this nurse res had fallen out of bed a second time. CNA found res on floor beside bed in prone position. Upon assessment, res left on floor and pillow placed under head. No new injuries noted from second fall. CBG (capillary blood glucose) read 154 mg/dL. VS (vital signs) T (temperature) 97.5, R (respirations) 22, BP (blood pressure) 110/76, P (pulse) 116. x2 EMTs (emergency medical technicians) on unit at 0805 and left unit with res via stretcher at 0815. 10:58 a.m.: Res (Resident) found on floor of room by CNA (certified nurse's aide). ROM (range of motion) x 4. VS (vital signs) BP (blood pressure) 128/76, P (pulse) 117, R (respiration) 22 regular. Blood noted to face, under nose, and lt (left) hand. S/T (skin tear) noted to lt post proximal 3rd digit. Nose displaced to rt. (right) side. Large hematoma noted under lt eye. Res weak and speech slurred. Neuros initiated. Res placed back onto bed at this time. All appropriate notifications made. Awaited call back from guardian and Dr. (name). Spoke with ADON (Assistant Director of Nursing) and made the decision to send res out to (hospital) ER for eval and tx (treatment) if necessary. While on the phone with 911 operator, CNA reported res fell again. See second fall notes. 3:12 p.m.: Returned to facility from (hospital) at 1500 (3:00 p.m.) x2 assist via gurney . A hospital emergency department report dated 11/7/16 at 8:35 a.m. documented Resident #1 arrived at the emergency department with a chief complaint of a fracture to nasal bridge and hematoma to left cheek following a fall at the facility. Findings following a CT scan included: Angulated nasal bone fracture. During an interview on 11/19/16 at 6:30 p.m., CNA (certified nurse's aide) B said that she worked the night shift on 11/6/16 - 11/7/16 (Sunday night to Monday morning) with Resident #1. CNA B said she had concerns about Resident #1's condition most of the night as Resident #1 was thrashing about in bed and was not responding normally. She said she had reported to the night nurse but never saw him assess Resident #1 so she immediately reported her concerns to CNA A and LVN D when they arrived at 6:00 a.m. on 11/7/16 for the day shift. During interviews on 11/17/16 at 10:30 a.m. and 11/18/16 at 12:15 p.m., CNA A said that when she came to work at 6:00 a.m. on 11/7/16, she heard RN C (the night nurse) telling LVN (licensed vocational nurse) D (the day nurse) during shift change that Resident #1 was acting out, wanted attention, and there was nothing wrong with her. She said CNA B (who had worked the night shift) asked her to check on Resident #1 because she told her there was something not right about Resident #1. CNA A said she knew Resident #1's symptoms of [DIAGNOSES REDACTED] and she was immediately concerned with what CNA B was saying, so she went to look at Resident #1. She said Resident #1 could barely move, and the way she was talking I knew she was not herself. She said she immediately notified LVN D. CNA A said that LVN D checked Resident #1's blood sugar and it was 32 or 34 and this was a few minutes before the breakfast carts arrived at 7:00 a.m. CNA A said after LVN D checked on Resident #1, Resident #1 was left in her bed as LVN D left the secure unit, and she (CNA A) went to pass out breakfast trays as she was the only staff left on the secure unit. She said a few minutes after she left Resident #1's room, the therapy staff came and told her Resident #1 was on the floor. She found Resident #1 face down on the floor with blood on the floor around her face. She had the staff member get LVN D again. LVN D and LVN E came to Resident #1's room and assessed Resident #1 for injuries and they put her in bed again. CNA A said she left the room again and both LVN D and LVN E left the secure unit and Resident #1 was left alone a second time. She said Resident #1 then fell out of her bed again only a few minutes later, face forward as before. CNA A said she did stay with Resident #1 after the second fall until the ambulance came. During an interview on 11/18/16 at 10:45 a.m. LVN D said that she was charge nurse for Resident #1 on the day she had a low blood sugar and fell . She said that CNA A reported Resident #1 had a change of condition and that she checked the resident's blood sugar at approximately 7:00 a.m. with a result of 45, which was low. She said Resident #1 was slurring, not opening her eyes and was having involuntary movements. She said she left the unit to go get a [MEDICATION NAME] shot. LVN D acknowledged that she left Resident #1 and told CNA A that the [MEDICATION NAME] shot would bring the resident's blood sugar up slowly. She said that between 7:00 a.m. and 8:00 a.m., Resident #1 fell twice in her room. She said she could not remember the exact timeline of events, only that everything happened in a very short time. She said after Resident #1's first fall, she assessed Resident #1 and told CNA A to put the resident back in bed. LVN D said she left the secure unit stating she did not know what went on after she left, except that within minutes Resident #1 had fallen again. LVN D acknowledged she did not instruct anyone to stay with Resident #1 and monitor her before the first fall, or before the second fall. After the second fall, CNA A did stay with Resident #1 until the ambulance arrived. She said Resident #1's blood sugar was checked before the ambulance arrived at approximately 8:00 a.m. and it was 154, which was okay. During an interview on 11/18/16 at 9:45 a.m., LVN E said that she was assisting LVN D the day that Resident #1 fell from her bed. She said she was went to the resident's room when Resident #1 had a low blood sugar and then fell . She said she did know Resident #1 had a low blood sugar but she did not know and was not there when LVN D administered the [MEDICATION NAME] shot. She did respond when Resident #1 fell the first time and did see Resident #1 on the floor. She stated that she had helped CNA A put Resident #1 back in her bed. LVN E said after putting Resident #1 back to bed, she left the unit with LVN D to assist her. She said that within only about ten minutes they were told Resident #1 fell again. Once again she went down the hall to see that Resident #1 had fallen face down from her bed again. She said Resident #1 had a hematoma to her eye and her nose was bloody. When discussing why Resident #1 was left alone in her room after having been assessed to have low blood sugar, LVN D said she did not know. LVN D acknowledged that someone should have stayed with Resident #1 until she was stable or sent to the hospital. During an interview on 11/18/16 at 5:10 p.m. the DON (Director of Nurses) stated that he knew Resident #1 fell forward on to the floor 11/7/16, and he thought it had something to do with her blood sugar. The DON said he was aware Resident #1 was left alone twice after she was found to have low blood sugar, and that each time she had fallen. He also stated he knew the resident had never been re-assessed to determine if her blood sugar had stabilized before she was left alone. When discussing whether the facility conducted an investigation and reported this incident to the State Authority, the DON said he had talked to the staff involved but stated, We knew she fell forward but we didn't suspect anything. If we feel it's not suspicious, we don't report it. When discussing that he had identified several failures by facility staff that he was aware of, he stated that the incident should have been investigated and reported to the State. During an interview on 11/20/16 at 1:30 p.m. the Administrator said she was the Abuse and Neglect Coordinator. She said that although she was made aware of the incident, she focused her attention on ensuring the resident got to the hospital, neuro checks were done, and that proper monitoring took place when she returned from the hospital. She said she was not fully aware of all the details of the incident, and did not know Resident #1's nose was broken during one of her falls. The Administrator stated she also was not aware that Resident #1 had been left alone when the falls took place and she thought they were witnessed falls. She said she did not find out until yesterday (11/19/16) that Resident #1 was left alone. She said, That shouldn't have happened. She said that the DON forgot to mention that Resident #1 was given a [MEDICATION NAME] shot then left alone. She acknowledged that the incident probably should have been investigated and reported based on this information. During an interview on 11/28/16 at 3:05 p.m., Resident #1's physician said she was notified of Resident #1's condition the day she was sent to the hospital. Her physician stated that if Resident #1 exhibited a change of condition during the night before, she should have been assessed every 15 minutes and if her condition did not improve, the physician should have been notified. 2. A facility policy titled, Abuse Investigation Protocol, provided by the facility on 11/28/16 revealed it included the following: Should an incident or suspected incient of resident abuse, neglect, injury of an unknown source, resident-to-resident abuse and/or resident to staff abuse be reported, the administrator, or his/her designee, will appoint an individual to investigate the incident. .3. The individual conducting the investigation will, as a minimum: .d. Review the resident's medical record to determime events that may have triggered the incident. e. Interview the person(s) reporting the incident f. Interview any witnesses to the incident. g. Interview the resident (as medically appropriate). .i. Interview staff members on all shifts who have had contact with the resident during the 48-hour period prior to the time of the incident. .o. Review all events preceding the alleged incident. .16. The administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency within 4 days of the reported incident. Under the section titled, Investigating allegations of Neglect: 1. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness, or the deterioration of a resident's physical or mental condition . 2. When conducting an investigation of neglect, implement the following protocol: a. Determine what goods or services were not provided to the resident; b. Determine if physical harm, mental anguish, mental illness or deterioration in the resident's physical or mental condition resulted from the failure of the facility to provide goods or services . Under the section titled, Reporting Abuse to Facility Management, the policy included the following: .4. When an alleged or suspected case of mistreatment, neglect, injuries of an unknown source, or abuse is reported, the facility administrator, or his/her designee, will notify the following persons or agencies of such incident: a. The State licensing/certification agency responsible for surveying/licensing the facility . 5. Notices to the above agencies/individuals shall be made within 24 hours after the occurrence of the incident or when the facility learns of the abuse . IMMEDIATE JEOPARDY 3. On 11/20/16 at 1:40 p.m. the Administrator was notified of an Immediate Jeopardy. The facility's Plan of Removal of Immedate Jeopardy was accepted on 11/23/16 at 11:00 a.m. and included the following: From 11/20/16 through 11/23/16, the facility provided an Administrative Nursing staff in the facility at the end of every shift to personally review all incidents, the 24-hour report, changes in resident condition, and any concerns voiced by staff, family, residents or visitors during the previous shift. All concerns were addressed as they occurred. Completed 11/23/16. On 11/16/16 Resident #1 was sent to the hospital emergency room for treatment. All nurses have been in-serviced on follow-up and assessing any resident with a reports of a change of condition. Completed 11/22/16. All nurses were educated and in-serviced 11/22/16 on how to properly assess a resident. A head to toe assessment was implemented on 11/22/16 for all incidents and changes in condition. In-service included that a staff member will stay with all residents until a resident is stable or emergency medical technicians arrive on site. Staff were in-serviced 11/22/16 on reporting changes of condition or any voiced concerns by family members or visitors to the charge nurse immediately. Staff were given a list of numbers to call if they felt like action was not being taken with a resident on 11/22/16. Licensed nurses were in-serviced on 11/22/16 to contact the DON or designee regarding any incidents or changes of resident condition as they occur. The DON or designee will have a clinical meeting, with the clinical team every morning, Monday through Friday. Any resident on the 24-hour report will be reviewed for proper documentation, assessment and notifications. Findings will be reviewed monthly by Quality Assurance team quarterly until the satisfaction of the committee is achieved to ensure compliance. Implemented 11/22/16. The Administrator or Designee will review all incidents during morning meetings so that any issue that is reportable is immediately reported to the State authority. Initiated 11/22/16. An Administrative team member will be assigned to weekends and holidays to review incidents/accidents and the 24 hour report and make notification to the Administrator/Designee when there is a reportable incident identified. All trends will be reviewed in the weekly Quality Assurance meetings. Any resident specific interventions will be implemented and added to the resident's care plan such as one on one staff, every 15 minute checks, and/or adding another staff member if needed. All staff have been in-serviced on the guidelines for reporting abuse/neglect or change in resident's condition. The Administrator posted and distributed copies of a complete list of all numbers to contact if an employee, resident, or responsible party suspects abuse or neglect, including but not limited to the Administrator, Director of Nurses, Regional Director of Operations, and Regional Nurse. Completed 11/21/16. 4. Action Plan verification activities were conducted from 11/22/16 through 11/23/16 and included the following activities: Review of in-service documentation, interview with nurses aides and nurses from various shifts to verify in-service understanding, review of nursing 24-hour reports and resident change of conditions through 11/23/16, and interview with the Director of Nurses regarding follow up of all resident issues identified on nursing reports. 5. The Administrator was notified that the IJ was removed on 11/23/16 at 11:00 a.m., but the facility remained out of compliance at a scope and severity level of Actual Harm at scope of a pattern as the facility continued to monitor their plan for effectiveness. 6. On 12/2/16 the facility provided a Census Worksheet that identified 93 residents in the facility.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents by failure to thoroughly and investigate a fall resulting in a fracture for 1 of 8 residents (Resident #1) reviewed for abuse and neglect. An Immediate Jeopardy (IJ) was identified on 11/20/16 at 1:40 p.m. While the IJ was removed on 11/23/16 at 11:00 a.m., the facility remained out of compliance at a level of actual harm that is not Immediate Jeopardy at a scope of a pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. These failures could affect the 93 residents that reside in the facility due to unidentified incidences of neglect that could result in avoidable accidents and injuries. Findings included: 1. A facility policy titled, Abuse Investigation Protocol, provided by the facility on 11/28/16 revealed it included the following: Should an incident or suspected incient of resident abuse, neglect, injury of an unknown source, resident-to-resident abuse and/or resident to staff abuse be reported, the administrator, or his/her designee, will appoint an individual to investigate the incident. .3. The individual conducting the investigation will, as a minimum: .d. Review the resident's medical record to determime events that may have triggered the incident. e. Interview the person(s) reporting the incident f. Interview any witnesses to the incident. g. Interview the resident (as medically appropriate). .i. Interview staff members on all shifts who have had contact with the resident during the 48-hour period prior to the time of the incident. .o. Review all events preceding the alleged incident. .16. The administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency within 4 days of the reported incident. Under the section titled, Investigating allegations of Neglect: 1. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness, or the deterioration of a resident's physical or mental condition . 2. When conducting an investigation of neglect, implement the following protocol: a. Determine what goods or services were not provided to the resident; b. Determine if physical harm, mental anguish, mental illness or deterioration in the resident's physical or mental condition resulted from the failure of the facility to provide goods or services . Under the section titled, Reporting Abuse to Facility Management, the policy included the following: .4. When an alleged or suspected case of mistreatment, neglect, injuries of an unknown source, or abuse is reported, the facility administrator, or his/her designee, will notify the following persons or agencies of such incident: a. The State licensing/certification agency responsible for surveying/licensing the facility . 5. Notices to the above agencies/individuals shall be made within 24 hours after the occurrence of the incident or when the facility learns of the abuse . 2. An undated computer face sheet documented Resident #1 was a [AGE] year old female admitted to the facility 2/18/16 with Mild Intellectual disability, major [MEDICAL CONDITION], persistant mood disorder, diabetes mellitus, [MEDICAL CONDITION] disorder, anxiety disorder, hypertension, [MEDICAL CONDITION], reflux disorder and pruritis. A Minimum Data Set (MDS) Assessment date 8/29/16 documented that Resident #1 had a brief interview for mental status score of 03 indicating severe cognitive impairment. Resident #1 used a wheelchair for mobility. She required limited assistance of two staff to transfer, and extensive assistance of one staff for personal hygeine, dressing and toilet use. She had range of motion limitation for both lower extremities. She was always incontinent of bowel and bladder. physician's orders [REDACTED].#1 was prescribed checks of her blood sugar twice daily at 7:00 a.m. and 5:00 p.m. with [MEDICATION NAME] R insulin to be administered on a sliding scale based on the blood sugar reading. She was also prescribed [MEDICATION NAME] 40 units subcutaneous once daily at 7:00 a.m. Resident #1's care plan with a review date of 9/13/16 included the following: Problem: Resident is at risk for frequent infections, pressure/venous-statis ulcers, vision impairment, hyper/[DIAGNOSES REDACTED], [MEDICAL CONDITION], cognitive/physical impairment, slow healing process skin desensitized to pain or pressure related to diabetes mellitus. .Approach start date 9/13/16: Assess/record/report to MD prn: [DIAGNOSES REDACTED] s/sx (signs/symptoms) : tremors, shaking, confusion, headache, irritability, hunger, n/v, cool, clammy, pale skin, and diaphoresis. [MEDICAL CONDITION] s/sx: extreme thirst, frequent urination, abnormal pain, blurred vision, dry flushed skin, rapid breathing. A review of nurse's notes for Resident #1 revealed they included the following entries on 11/7/16: (Late entry) 1:15p.m.: At 0700 (7:00 a.m.) CBG (capillary blood glucose) read 45 mg/dL. Res lethargic, unable to open eyes, follow commands, or answer questions. Res given [MEDICATION NAME] injection IM (intramuscular) in Rt. delt (deltoid). Re-checked at 0800 (8:00 a.m.) CBG (capillary blood glucose) read 154 mg/dL. 8:00 a.m.: While on the phone with 911 operator to send res (resident) out for first fall, second nurse reported to this nurse res had fallen out of bed a second time. CNA found res on floor beside bed in prone position. Upon assessment, res left on floor and pillow placed under head. No new injuries noted from second fall. CBG (capillary blood glucose) read 154 mg/dL. VS (vital signs) T (temperature) 97.5, R (respirations) 22, BP (blood pressure) 110/76, P (pulse) 116. x2 EMTs (emergency medical technicians) on unit at 0805 and left unit with res via stretcher at 0815. 10:58 a.m.: Res (Resident) found on floor of room by CNA (certified nurse's aide). ROM (range of motion) x 4. VS (vital signs) BP (blood pressure) 128/76, P (pulse) 117, R (respiration) 22 regular. Blood noted to face, under nose, and lt (left) hand. S/T (skin tear) noted to lt post proximal 3rd digit. Nose displaced to rt. (right) side. Large hematoma noted under lt eye. Res weak and speech slurred. Neuros initiated. Res placed back onto bed at this time. All appropriate notifications made. Awaited call back from guardian and Dr. (name). Spoke with ADON (Assistant Director of Nursing) and made the decision to send res out to (hospital) ER for eval and tx if necessary. While on the phone with 911 operator, CNA reported res fell again. See second fall notes. 3:12 p.m.: Returned to facility from (hospital) at 1500 (3:00 p.m.) x2 assist via gurney . A hospital emergency department report dated 11/7/16 at 8:35 a.m. documented Resident #1 arrived at the emergency department with a chief complaint of a fracture to nasal bridge and hematoma to left cheek following a fall at the facility. Findings following a CT scan included: Angulated nasal bone fracture. During an interview on 11/19/16 at 6:30 p.m., CNA (certified nurse's aide) B said that she worked the night shift on 11/6/16 - 11/7/16 (Sunday night to Monday morning) with Resident #1. CNA B said she had concerns about Resident #1's condition most of the night as Resident #1 was thrashing about in bed and was not responding normally. She said she had reported to the night nurse but never saw him assess Resident #1 so she immediately reported her concerns to CNA A and LVN D when they arrived at 6:00 a.m. on 11/7/16 for the day shift. During interviews on 11/17/16 at 10:30 a.m. and 11/18/16 at 12:15 p.m., CNA A said that when she came to work at 6:00 a.m. on 11/7/16, she heard RN C (the night nurse) telling LVN (licensed vocational nurse) D (the day nurse) during shift change that Resident #1 was acting out, wanted attention, and there was nothing wrong with her. She said CNA B (who had worked the night shift) asked her to check on Resident #1 because she told her there was something not right about Resident #1. CNA A said she knew Resident #1's symptoms of [DIAGNOSES REDACTED] and she was immediately concerned with what CNA B was saying, so she went to look at Resident #1. She said Resident #1 could barely move, and the way she was talking I knew she was not herself. She said she immediately notified LVN D. CNA A said that LVN D checked Resident #1's blood sugar and it was 32 or 34 and this was a few minutes before the breakfast carts arrived at 7:00 a.m. CNA A said after LVN D checked on Resident #1, Resident #1 was left in her bed as LVN D left the secure unit, and she (CNA A) went to pass out breakfast trays as she was the only staff left on the secure unit. She said a few minutes after she left Resident #1's room, the therapy staff came and told her Resident #1 was on the floor. She found Resident #1 face down on the floor with blood on the floor around her face. She had the staff member get LVN D again. LVN D and LVN E came to Resident #1's room and assessed Resident #1 for injuries and they put her in bed again. CNA A said she left the room again and both LVN D and LVN E left the secure unit and Resident #1 was left alone a second time. She said Resident #1 then fell out of her bed again only a few minutes later, face forward as before. CNA A said she did stay with Resident #1 after the second fall until the ambulance came. During an interview on 11/18/16 at 10:45 a.m. LVN D said that she was charge nurse for Resident #1 on 11/7/16 when she had a low blood sugar and fell . She said that CNA A reported Resident #1 had a change of condition and that she checked the resident's blood sugar at approximately 7:00 a.m. with a result of 45, which was low. She said Resident #1 was slurring, not opening her eyes and was having involuntary movements. She said she left the unit to go get a [MEDICATION NAME] shot. LVN D acknowledged that she left Resident #1 and told CNA A that the [MEDICATION NAME] shot would bring the resident's blood sugar up slowly. She said that between 7:00 a.m. and 8:00 a.m., Resident #1 fell twice in her room. She said she could not remember the exact timeline of events, only that everything happened in a very short time. She said after Resident #1's first fall, she assessed Resident #1 and told CNA A to put the resident back in bed. LVN D said she left the secure unit stating she did not know what went on after she left, except that within minutes Resident #1 had fallen again. LVN D acknowledged she did not instruct anyone to stay with Resident #1 and monitor her before the first fall, or before the second fall. After the second fall, CNA A did stay with Resident #1 until the ambulance arrived. She said Resident #1's blood sugar was checked before the ambulance arrived at approximately 8:00 a.m. and it was 154, which was okay. During an interview on 11/18/16 at 9:45 a.m., LVN E said that she was assisting LVN D on 11/7/16 when Resident #1 fell from her bed. She said she was went to the resident's room when Resident #1 had a low blood sugar and then fell . She said she did knew Resident #1 had a low blood sugar but she did not know and was not there when LVN D administered the [MEDICATION NAME] shot. She did respond when Resident #1 fell the first time and did see Resident #1 on the floor. She stated that she had helped CNA A put Resident #1 back in her bed. LVN E said after putting Resident #1 back to bed, she left the unit with LVN D to assist her. She said that within only about ten minutes they were told Resident #1 fell again. Once again she went down the hall to see that Resident #1 had fallen face down from her bed again. She said Resident #1 had a hematoma to her eye and her nose was bloody. When discussing why Resident #1 was left alone in her room after having been assessed to have low blood sugar, LVN D said she did not know. LVN D acknowledged that someone should have stayed with Resident #1 until she was stable or sent to the hospital. During an interview on 11/18/16 at 5:10 p.m. the DON (Director of Nurses) stated that he knew Resident #1 fell forward on to the floor 11/7/16, and he thought it had something to do with her blood sugar. The DON said he was aware Resident #1 was left alone twice after she was found to have low blood sugar, and that each time she had fallen. He also stated he knew the resident had never been re-assessed to determine if her blood sugar had stabilized before she was left alone. When discussing whether the facility conducted an investigation and reported this incident to the State Authority, the DON said he had talked to the staff involved but stated, We knew she fell forward but we didn't suspect anything. If we feel it's not suspicious, we don't report it. When discussing that he had identified several failures by facility staff that he was aware of, he stated that the incident should have been investigated and reported to the State. During an interview on 11/20/16 at 1:30 p.m. the Administrator said she was the Abuse and Neglect Coordinator. She said that although she was made aware of the incident, she focused her attention on ensuring the resident got to the hospital, neuro checks were done, and that proper monitoring took place when she returned from the hospital. She said she was not fully aware of all the details of the incident, and did not know Resident #1's nose was broken during one of her falls. The Administrator stated she also was not aware that Resident #1 had been left alone when the falls took place and she thought they were witnessed falls. She said she did not find out until yesterday that Resident #1 was left alone. She said, That shouldn't have happened. She said that the DON forgot to mention that Resident #1 was given a [MEDICATION NAME] shot then left alone. She acknowledged that the incident probably should have been investigated and reported based on this information. During an interview on 11/28/16 at 3:05 p.m., Resident #1's physician said she was notified of Resident #1's condition the day she was sent to the hospital. Her physician stated that if Resident #1 exhibited a change of condition during the night before, she should have been assessed every 15 minutes and if her condition did not improve, the physician should have been notified. IMMEDIATE JEOPARDY 3. On 11/20/16 at 1:40 p.m. the Administrator was notified of an Immediate Jeopardy. The facility's Plan of Removal of Immedate Jeopardy was accepted on 11/23/16 at 11:00 a.m. and included the following: From 11/20/16 through 11/23/16, the facility provided an Administrative Nursing staff in the facility at the end of every shift to personally review all incidents, the 24-hour report, changes in resident condition, and any concerns voiced by staff, family, residents or visitors during the previous shift. All concerns were addressed as they occurred. Completed 11/23/16. On 11/16/16 Resident #1 was sent to the hospital emergency room for treatment. All nurses have been in-serviced on follow-up and assessing any resident with a reports of a change of condition. Completed 11/22/16. All nurses were educated and in-serviced 11/22/16 on how to properly assess a resident. A head to toe assessment was implemented on 11/22/16 for all incidents and changes in condition. In-service included that a staff member will stay with all residents until a resident is stable or emergency medical technicians arrive on site. Staff were in-serviced 11/22/16 on reporting changes of condition or any voiced concerns by family members or visitors to the charge nurse immediately. Staff were given a list of numbers to call if they felt like action was not being taken with a resident on 11/22/16. Licensed nurses were in-serviced on 11/22/16 to contact the DON or designee regarding any incidents or changes of resident condition as they occur. The DON or designee will have a clinical meeting, with the clinical team every morning, Monday through Friday. Any resident on the 24-hour report will be reviewed for proper documentation, assessment and notifications. Findings will be reviewed monthly by Quality Assurance team quarterly until the satisfaction of the committee is achieved to ensure compliance. Implemented 11/22/16. The Administrator or Designee will review all incidents during morning meetings so that any issue that is reportable is immediately reported to the State authority. Initiated 11/22/16. An Administrative team member will be assigned to weekends and holidays to review incidents/accidents and the 24 hour report and make notification to the Administrator/Designee when there is a reportable incident identified. All trends will be reviewed in the weekly Quality Assurance meetings. Any resident specific interventions will be implemented and added to the resident's care plan such as one on one staff, every 15 minute checks, and/or adding another staff member if needed. All staff have been in-serviced on the guidelines for reporting abuse/neglect or change in resident's condition. The Administrator posted and distributed copies of a complete list of all numbers to contact if an employee, resident, or responsible party suspects abuse or neglect, including but not limited to the Administrator, Director of Nurses, Regional Director of Operations, and Regional Nurse. Completed 11/21/16. 4. Action Plan verification activities were conducted from 11/22/16 through 11/23/16and included the following activities: Review of in-service documentation, interview with nurses aides and nurses from various shifts to verify in-service understanding, review of nursing 24-hour reports and resident change of conditions through 11/23/16, and interview with the Director of Nurses regarding follow up of all resident issues identified on nursing reports. 5. The Administrator was notified that the IJ was removed on 11/23/16 at 11:00 a.m., but the facility remained out of compliance at a scope and severity level of Actual Harm at a scope of a pattern as the facility continued to monitor their plan for effectiveness. 6. On 12/2/16 the facility provided a Census Worksheet that identified 93 residents resided in the facility.

Based on observations, record review and interviews the administration failed to manage the facility in a manner that enabled it to use the facility's resources effectively as evidenced by: a) Failure of the DON (Director of Nurses) to supervise and monitor that nurses assessed, monitored and notified the physician of a significant change of condition for 3 of 8 residents (Residents #1, 2, and 3) reviewed for change of conditon resulting in delayed medical care and hospital treatment for [REDACTED].#1, a partial bowel obstruction for Resident #2, and a GI bleed for Resident #3. b) Failure of the DON to supervise and monitor that nursing staff provided supervision for 1 of 6 residents reviewed for accidents (Resident #1) to prevent her from falling from her bed twice after it was determined that her physical condition was not stable (low blood sugar). Resident #1 sustained a fractured nose from two falls from her bed. c) Failure of the Administrator, who was the abuse and neglect coordinator of the facility, to conduct a thorough investigation and report to the state authority when 1 of 6 residents (Resident #1) reviewed for accidents had two un-witnessed falls from her bed after it was determined that her physical condition was not stable (low blood sugar) and sustained a fractured nose. An Immediate Jeopardy (IJ) was identified on 11/20/16 at 1:40 p.m. While the IJ was removed on 11/23/16, the facility remained out of compliance at a level of actual harm that is not Immediate Jeopardy at a pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. These failures resulted in a delay of medical treatment, pain, and discomfort for Residents #1, 2, and 3, who resided on the secured units of the facility and could affect the 40 residents that reside on the secure units (Halls C, E, and F) and result in pain, decline in health, or death. The failure to thoroughly investigate and report an allegation of neglect could affect the 93 residents that reside in the facility due to unidentified incidences of neglect that could result in avoidable accidents and injuries. The failure to provide adequate supervision resulted in Resident #1's falls and injury (broken nose) and could affect the 40 residents that reside on the secure units (Halls C, E, and F) and could result in accidents and injury. Findings included: 1. An undated computer face sheet documented Resident #1 was a [AGE] year old female admitted to the facility 2/18/16 with Mild Intellectual disability, major [MEDICAL CONDITION], persistant mood disorder, diabetes mellitus, [MEDICAL CONDITION] disorder, anxiety disorder, hypertension, [MEDICAL CONDITION], reflux disorder and pruritis. A Minimum Data Set (MDS) Assessment date 8/29/16 documented that Resident #1 had a brief interview for mental status score of 03 indicating severe cognitive impairment. Resident #1 used a wheelchair for mobility. She required limited assistance of two staff to transfer, and extensive assistance of one staff for personal hygeine, dressing and toilet use. She had range of motion limitation for both lower extremities. She was always incontinent of bowel and bladder. Physician's orders 10/1/16-11/30/16 documented Resident #1 was prescribed checks of her blood sugar twice daily at 7:00 a.m. and 5:00 p.m. with [MEDICATION NAME] R insulin to be administered on a sliding scale based on the blood sugar reading. She was also prescribed [MEDICATION NAME] 40 units subcutaneous once daily at 7:00 a.m. Physician's orders documented to notify the physician for a blood sugar less than 40 or greater than 450. Resident #1's care plan with a review date of 9/13/16 included the following: Problem: Resident is at risk for frequent infections, pressure/venous-statis ulcers, vision impairment, hyper/[DIAGNOSES REDACTED], [MEDICAL CONDITION], cognitive/physical impairment, slow healing process skin desensitized to pain or pressure related to diabetes mellitus. .Approach start date 9/13/16: Assess/record/report to MD prn (as needed): [DIAGNOSES REDACTED] s/sx (signs/symptoms) : tremors, shaking, confusion, headache, irritability, hunger, n/v (nausea/vomiting), cool, clammy, pale skin, and diaphoresis. [MEDICAL CONDITION] s/sx: extreme thirst, frequent urination, abnormal pain, blurred vision, dry flushed skin, rapid breathing. A review of nurse's notes for Resident #1 revealed they included the following entries on 11/7/16: Late entry at 1:15 p.m.: At 0700 (7:00 a.m.) CBG read 45 mg/dL. Res lethargic, unable to open eyes, follow commands, or answer questions. Res given [MEDICATION NAME] injection IM (intramuscular) in Rt. delt (deltoid). Re-checked at 0800 (8:00 a.m.) CBG (capillary blood glucose) read 154 mg/dL. (Noted by LVN D). 8:00: While on the phone with 911 operator to send res (resident) out for first fall, second nurse reported to this nurse res had fallen out of bed a second time. CNA found res on floor beside bed in prone position. Upon assessment, res left on floor and pillow placed under head. No new injuries noted from second fall. CBG (capillary blood glucose) read 154 mg/dL. VS (vital signs) T (temperature) 97.5, R (respirations) 22, BP (blood pressure) 110/76, P (pulse) 116. x2 EMTs (emergency medical technicians) on unit at 0805 and left unit with res via stretcher at 0815. (Noted by LVN D). 10:58 a.m.: Res (Resident) found on floor of room by CNA (certified nurse's aide). ROM (range of motion) x 4. VS (vital signs) BP (blood pressure) 128/76, P (pulse) 117, R (respiration) 22 regular. Blood noted to face, under nose, and lt (left) hand. S/T (skin tear) noted to lt post proximal 3rd digit. Nose displaced to rt. (right) side. Large hematoma noted under lt eye. Res weak and speech slurred. Neuros initiated. Res placed back onto bed at this time. All appropriate notifications made. Awaited call back from guardian and Dr. (name). Spoke with ADON and made the decision to send res out to (hospital) ER for eval and tx if necessary. While on the phone with 911 operator, CNA reported res fell again. See second fall notes. 3:12 p.m.: Returned to facility from (hospital) at 1500 (3:00 p.m.) x2 assist via gurney . There were no nursing notes from RN C, who was charge nurse, or any other nursing notes entered for the night shift that began at 10:00 p.m. 11/6/16 and ended at 6:00 a.m. on 11/7/16. A hospital emergency department report dated 11/7/16 at 8:35 a.m. documented Resident #1 arrived at the emergency department with a chief complaint of a fracture to nasal bridge and hematoma to left cheek following a fall at the facility. Findings following a CT scan included: Angulated nasal bone fracture. During an interview on 11/19/16 at 6:30 p.m., CNA (certified nurse's aide) B said that she worked the night shift on 11/6/16 - 11/7/16 (Sunday night to Monday morning) with Resident #1. CNA B said that she began noticing Resident #1 acting very unusually and thrashing about in her bed not long after the resident went to bed. She said it was much more than tossing and turning, but almost violently thrashing. She said Resident #1 would do this and then seem to go to sleep, only to start doing it again. CNA B said she told RN (Registered Nurse) C she was very concerned that something was wrong with Resident #1. CNA B said RN C would say okay but did not go down and check on Resident #1. She said she went to him three separate times throughout the night, and the last time he had just smiled at her, and said, Oh, I've seen her like that before. CNA B said RN C was sitting in a chair writing something at the nurse's station and he never left the nurse's station. CNA B said she gave up on asking him after the third time, but when the morning shift came on, she personally told the oncoming nurse and the oncoming CNA her concerns. During an interview on 11/20/16 at 3:00 p.m., CNA F said she was working the night shift on 11/6 - 11/7/16 on a different hall than CNA B. She said she was at the nurse's station and did hear CNA B tell RN C multiple times that Resident #1 was not responding and was all over the bed. CNA F said CNA B was very worried, and even asked CNA F to come down and look at Resident #1. She said she did, and CNA B was right, Resident #1 would not talk or respond. She said she never saw RN C get up to go to the unit to see the resident. CNA F said, You report stuff and nothing gets done. She said that RN C played on his cell phone all night, stating, That's all he does. During interviews on 11/17/16 at 10:30 a.m. and 11/18/16 at 12:15 p.m., CNA A said that when she came to work at 6:00 a.m. on 11/7/16, she heard RN C (the night nurse) telling LVN D (the day nurse) during shift change that Resident #1 was acting out, wanted attention, and there was nothing wrong with her. She said CNA B (who had worked the night shift) asked her to check on Resident #1 because she told her there was something not right about Resident #1. She said CNA B told her that she could not get RN C to check the resident because he thought Resident #1 was just wanting attention. CNA A said she knew Resident #1's symptoms of [DIAGNOSES REDACTED] and she was immediately concerned with what CNA B was saying, so she went to look at Resident #1. She said Resident #1 could barely move, and the way she was talking I knew she was not herself. She said she immediately notified the nurse. CNA A said that LVN D checked Resident #1's blood sugar and it was 32 or 34 and this was a few minutes before the breakfast carts arrived at 7:00 a.m. CNA A said after LVN D checked on Resident #1, Resident #1 was left in her bed. CNA A went to pass out breakfast trays as she was the only staff left on the secure unit. She said a few minutes after she left Resident #1's room, the therapy staff came and told her Resident #1 was on the floor. She found Resident #1 face down on the floor with blood on the floor around her face. She had the staff member get LVN D again. LVN D and LVN E came to Resident #1's room and assessed Resident #1 for injuries and they put her in bed again. CNA A said she left the room again and both LVN D and LVN E left the secure unit. She said Resident #1 then fell out of her bed again, face forward as before. CNA A said she did stay with Resident #1 after the second fall until the ambulance came. During an interview on 11/20/16 at 8:00 a.m. RN C first stated that he did not remember receiving any reports from CNAs regarding Resident #1's condition on the night of 11/6/16. When discussing whether he remembered CNA B reporting concern regarding Resident #1 thrashing in bed, he said, More or less. When discussing whether he remembered the report being made to him multiple times, he said she might have. RN C then stated he went on to the secure unit and saw Resident #1 that night some time around or right after midnight. He said he thought she was asleep, and he turned her over and she looked at him so he did not see a problem. When specifically asked if he assessed the resident's blood sugar or vital signs, he said he only checked her oxygen and it was normal. RN C said, I didn't see anything out of order. She's always been a problem child and it's not unusual for her to have bizarre behavior. He said he saw no reason to further assess or call the doctor. RN C said it never occurred to him to check Resident #1's blood sugar, but now states he should have checked it. During an interview on 11/28/16 at 3:05 p.m., Resident #1's physician said she was notified of Resident #1's condition the day she was sent to the hospital. Her physician stated that if Resident #1 exhibited a change of condition during the night she should have been assessed every 15 minutes and if her condition did not improve, the physician should have been notified. During an interview on 11/18/16 at 5:10 p.m. the DON (Director of Nurses) stated that he was aware that RN C had been told about Resident #1's condition during the night on 11/6/16 and was aware RN C had not assessed Resident #1. The DON said he counselled RN C about it. The DON stated he knew Resident #1 fell forward on to the floor, and he thought it had something to do with her blood sugar. The DON said he was aware Resident #1 was left alone twice after she was found to have low blood sugar, and that each time she had fallen. He also stated he knew the resident had never been re-assessed to determine if her blood sugar had stabilized before she was left alone. When discussing whether the facility conducted an investigation and reported this incident to the State Authority, the DON said he had talked to the staff involved but stated, We knew she fell forward but we didn't suspect anything. If we feel it's not suspicious, we don't report it. When discussing that he had identified several failures by facility staff that he was aware of, he stated that the incident should have been investigated and reported to the State. During an interview on 11/20/16 at 1:30 p.m. the Administrator said she was the Abuse and Neglect Coordinator. She said that although she was made aware of the incident, she focused her attention on ensuring the resident got to the hospital, neuro checks were done, and that proper monitoring took place when she returned from the hospital. She said she was not fully aware of all the details of the incident, and did not know Resident #1's nose was broken during one of her falls. The Administrator stated she also was not aware that Resident #1 had been left alone when the falls took place and she thought they were witnessed falls. She said she did not find out until yesterday that Resident #1 was left alone. She said, That shouldn't have happened. She said that the DON forgot to mention that Resident #1 was given a [MEDICATION NAME] shot then left alone. She acknowledged that the incident probably should have been investigated and reported based on this information. 2. An undated computer face sheet for Resident #2 documented she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set assessment dated [DATE] documented Resident #2 had a Brief Interview for Mental Status score of 12 indicating she had moderate cognitive impairment. She required only supervision for dressing, eating, toilet use, and transfer. She was ambulatory without an assistive device. She was occasionally incontinent of bladder and frequently incontinent of bowel. A care plan for Resident #2, last reviewed on 10/17/16 documented that Resident #2 exhibited manipulative behaviors related to [MEDICAL CONDITION], including chronic health complaints. A hospital emergency department (ED) report for Resident #2 dated 11/14/16 documented Resident #2 entered the emergency department on 11/14/16 at 3:19 p.m. Her chief complaint was documented as abdominal pain and swelling with diffuse abdominal pain for the past several days. Under Clinical History the hospital report documented Abdominal pain. Abdominal distention for 1 week. History of ulcer surgery and hysterectomy. Triage notes documented that Resident #2 complained of a 10/10 pain level in the left upper quadrant and left lower quadrant of her abdomen radiating to the back. Resident #2 complained of nausea, vomiting diarrhea, weakness, and dizziness. Prior treatment included antacid. Hospital ED nursing notes dated 11/14/16 at 3:59 p.m. documented that Resident #2's abdomen was distended and tender, and bowel sounds were hypactive in all four quadrants. At 5:45 p.m. a bladder scan revealed more than 999 mL in the bladder and the physician confirmed the appropriateness of an indwelling foley catheter. On 11/14/16 at 22:10 (10:10 p.m.) the hospital ED report documented [DIAGNOSES REDACTED]. She was admitted to the Intensive care unit/Critical Care unit on the surgical floor of the hospital. During an interview on 11/17/16 at 10:15 a.m. CNA A said Resident #2 was in the hospital. CNA A said Resident #2 was sick and throwing up last weekend (11/12/16 and 11/13/16), but stated, They didn't do anything. Nursing notes for 11/14/16 at 14:33 (2:33 p.m.) documented Resident #2 was vomiting [MEDICATION NAME] (sticky/thick), red specks and her blood pressure was 99/65, pulse was 113, respiration was 22 and labored, and temperature was 98.5. A telephone order dated 11/14/16 at 14:41 (2:41 p.m.) documented an order to send Resident #2 to the hospital for evaluation. During an interview on 11/17/16 at 4:00 p.m., LVN D said she was the nurse that sent Resident #2 out to the hospital on [DATE]. She said that CNA A reported to her that Resident #2's stomach was distended and she did not feel good. LVN D said she assessed Resident #2 and found her stomach was grossly distended. She said, She looked nine months pregnant. LVN D said Resident #2 told her she had been throwing up and she had told the staff but no one had checked on her. LVN D said she noticed Resident #2 gagging every time she would move. She contacted the physician and sent Resident #2 to the hospital. LVN D pointed to Resident #2's medical record and told the investigator that there would be a lack of progress notes from nurses in the the record. LVN D said that there was nothing reported to her about Resident #2 having problems on prior shifts or during the weekend. LVN D said that had been a problem in the facility for awhile. She said she had expressed her frustration to the DON when she worked on the night shift and communication about residents was lacking. She said she told him, What am I supposed to do, when I don't know what's going on! She said the issue was not resolved, but she was offered a position on the day shift. During an interview on 11/19/16 at 6:30 p.m. CNA B said that Resident #2 was throwing up on Saturday night (11/12/16) and she informed RN C. She said she thought he might have given Resident #2 some [MEDICATION NAME]. She said Resident #2 was complaining of her stomach hurting and going to the bathroom a lot. CNA B said that when she came to work Sunday night (11/13/16), Resident #2 was worse. CNA B said, She didn't look good. She said that Resident #2 was nauseated and throwing up so she had put a trash can next to Resident #2's bed. CNA B said she reported to RN C that Resident #2 was sick and throwing up. She said the emesis was red, but she thought the resident had drank a red drink. CNA B said she never saw RN C get up from the nurse's station or go check Resident #2. She said he did not ask her any questions about how many times the resident had thrown up or any other questions about her observations. CNA B said that she believed that because Resident #2 had mental issues, that the nurses never took her very serious. CNA B said, My opinion is he should have at least examined her. During an interview on 11/20/16 at 3:00 p.m., CNA F said she worked the night shift on Sunday, 11/13/16 on a different hall than CNA B. She said she had gone on the secure unit and had seen that Resident #2 was in distress. CNA F said she told RN C that Resident #2 was crying in pain and vomiting. CNA F said that she and CNA B had explained to RN C that Resident #2's pain was different than her usual complaints of pain. CNA F said RN C never went to check on Resident #2 on Sunday night. During an interview on 11/19/16 at 12:30 p.m., CNA G said she worked the day shift with Resident #2 on the weekend of 11/12/16 and 11/13/16. She said that Resident #2 was incontinent and wearing a brief because of small episodes of diarrhea. She said this was upsetting to Resident #2 since this was not normal for her. She said that Resident #2 kept complaining of nausea, and this was occurring both on Saturday and Sunday. She said she told the medication aide, but she did not tell the nurse. During an interview on 11/19/16 at 4:00 p.m., LVN K said she worked the day shift on the weekend of 11/12/16 and 11/13/16 and she was never made aware that Resident #2 was spitting up, throwing up, or having diarrhea. She said Resident #2 never complained and if they had told her these things, she definitely would have addressed it. During an interview with RN C on 11/20/16 at 8:00 a.m., when discussing whether he had received reports of Resident #2's nausea, vomiting, and diarrhea during the weekend of 11/12-11/13/16, he stated, She's very drug seeking. She was seeking her 2:00 a.m. [MEDICATION NAME] and she complained of constipation. He said he checked her bowel sounds and the lower left was slow but the others were active. When discussing whether CNA B had reported her concerns and observations to him on Saturday and Sunday night, RN C said, I'm sure she said she was asking for her pain pill. RN C said he checked on her Sunday night, but he did not even remember what had happened on Saturday night. He said that the reason he listened to her bowel sounds was because Resident #2 said she felt bloated. He said he did not document anything in the nursing notes or notify the physician because he did not find anything wrong. When discussing that Resident #2 was hospitalized and placed in the critical care unit on Monday, RN C said, But you have to know (Resident #2) like I do. Most of her complaints turn out to be nothing. During an interview on 12/1/16 at 9:00 a.m. LVN H said he was working with RN C on the weekend nights of 11/12/16 and 11/13/16. He said he heard the nurse aides reporting Resident #2's change of condition to RN C. He said they asked RN C several times to look at Resident #2, but LVN H said he never saw whether RN C checked on Resident #2 or not. LVN H said the CNAs asked him to check on her also, and he told them, He's an RN and I'm not stepping on his toes. A review of facility nursing notes for Resident #2 revealed there were no nursing entries documenting a change of condition or notification of the physician for Saturday 11/12/16 or Sunday 11/13/16. A review of physician's telephone orders for Resident #2 revealed no physician's orders for 11/12/16 or 11/13/16. During a return telephone call from Resident #2's physician on 12/6/16 at 3:00 p.m., Resident #2's physician said that the first notification of Resident #2's condition that she received was on 11/14/16 when Resident #2 was sent to the hospital. Resident #2's physician said that the symptoms described on 11/12/16 and 11/13/16 indicated an acute abdomen and anytime that situation existed, it warranted a call to her. She said that she was available to the facility 24 hours a day, 7 days a week and there was no excuses not to notify her of changes of condition at any time. During interview on 11/20/16 at 1:40 p.m. the DON stated he was unaware that Resident #2 had symptoms of a change of condition reported to nurses during the weekend before she was sent out to the hospital. A review of Nursing Notes and Physician's orders for November 2016 revealed Resident #2 remained in the hospital for the duration of this investigation and was not available for interview. 3. An undated face sheet for Resident #3 documented he was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set Assessment for Resident #3 dated 10/17/16 documented a brief interview for mental status score of 12 indicating Resident #3 had moderately impaired cognitive functioning. He had no indicators of [MEDICAL CONDITION] and no behavioral symptoms identified. Resident #3 required limited assistance from staff for mobility, transfer, dressing, eating, toilet use, and personal hygeine. He was ambulatory and did not use a mobility device . Facility nursing notes included the following: 10/22/16: Resident complaining of abdominal pain and nausea. Gave resident [MEDICATION NAME]. Resident has had no vomiting at this time. Will continue to monitor. (Noted by RN C). 10/23/16 at 0420 (4:20 a.m.): At 0255, CNA I reported resident with c/o (complaints of) abdominal pain and cramping. Upon entering resident's room I noted he was laying with left side down. He was holding/guarding right abdominal area to the right of his umbilicus. Respirations were labored and uneven. At times resident would gasp loudly while breathing. Resident was grimacing, moaning, and rocking. When asked why he stated, I hurt. Resident has a small amount of brown emesis on the bed and floor. It has a moderate smell of feces. I auscultated his 4 quadrants and heard no bowel sounds. I digitally evaluated the resident for impaction, none felt. Stated last BM was yesterday. It was very firm and small in size, stated passing it was extremely difficult. I immediately had fell ow nurse (LVN D) auscultate the resident''s abdomen and she also noted the absence of bowel sounds. I asked CNA to please get the resident prepared for transport to (hospital) ER for eval and possible treatment. Physician was notified. (Noted by LVN H). A hospital Emergency Department report dated 10/23/16 documented Resident #3 entered with complaints of abdominal pain. The pain began suddenly two days prior was constant, and worsened in the last hours. The pain was described as 10/10. Resident #3 complained of vomiting a brown substance. Resident #3 was admitted to the hospital from the Emergency Department with [DIAGNOSES REDACTED]. During an interview on 12/1/16 at 10:45 a.m., CNA I said that on 10/22/16, he observed Resident #3 moaning and grimacing but Resident #3 kept saying he was okay. At approximately 3:00 a.m., Resident #3 was holding his abdomen and said he was in pain. CNA I said he went and told RN C about Resident #3's complaint. CNA I said that when RN C came to see Resident #3, Resident #3 collapsed to the floor. CNA I said, His stomach was hurting so bad, he couldn't stand. CNA I said that RN C did not check Resident #3's vital signs or listen to bowel sounds. He said he gave Resident #3 some [MEDICATION NAME]. During an interview on 11/20/16 at 8:00 a.m., RN C said that on 10/22/16 CNA I told him that Resident #3 had a problem. He said that when he went on the secure unit, Resident #3 was holding on the the hand rail on the wall, standing in the hallway. He said Resident #3 then sat on the floor and told RN C, My stomach's all messed up. When asked why he thought Resident #3 sat on the floor in the hallway, RN C said Resident #3 did it for effect. When asked if he meant that Resident #3 was being overly dramatic, RN C said, Oh absolutely. RN C said he did not assess bowel sounds or take vital signs. He said that he gave Resident #3 [MEDICATION NAME] and Resident #3 reported feeling better so he saw no reason to call the physician. An attempt to interview Resident #3 on 12/2/16 at 11: 35 a.m. was not successful. Resident #3 said he did not feel like talking. He complained that his back hurt. He said the nurse had already attended to him and given him medication, but it had not begun to work. During a return telephone call from Resident #3's physician on 12/6/16 at 3:00 p.m., she said that the best of her recollection was that she sent Resident #3 to the hospital when she was notified he had abdominal symptoms so she must have been notified 10/23/16 because that was the day he was sent. She said if she would have been notified on 10/22/16 that Resident #3 was having such pain in his abdomen she certainly would have sent him to the hospital immediately. 4. During an interview on 12/1/16 at 9:00 a.m., LVN H said he worked nights with RN C. When discussing the reports regarding RN C with regard to Residents #1, #2, and #3, he said he was concerned about working alongside RN C due to RN C spending his time at night playing solitaire on his phone instead of taking care of his residents. LVN H said he called the Assistant Director of Nurses about his concern. He did not know the date he reported the concerns but it was in the last 3 or 4 months. He said that she told him his concern was noted and would be passed on to the Director of Nurses. LVN H said he was never contacted by the DON about his concern. 5. During an interview on 11/20/16 at 1:40 p.m., the DON said he had not received any complaints about RN C's work performance or lack of resident care on the night shift. When discussing whether the DON was ever at the facility on the night shift, he said his communication with the night shift was by telephone. 6. During an interview on 11/28/16 at 4:00 p.m., the Administrator stated that the facility had not previously had a process in place for a nursing clinical review of resident hospitalization s or resident deaths, outside of just discussing them in the larger stand-up meetings in the morning. She said that the information that had come to light during this investigation indicated that this type of review would be beneficial. IMMEDIATE JEOPARDY 7. On 11/20/16 at 1:40 p.m. the Administrator was notified of an Immediate Jeopardy. The facility's Plan of Removal of Immedate Jeopardy was accepted on 11/23/16 at 11:00 a.m. and included the following: From 11/20/16 through 11/23/16, the facility provided an Administrative Nursing staff in the facility at the end of every shift to personally review all incidents, the 24-hour report, changes in resident condition, and any concerns voiced by staff, family, residents or visitors during the previous shift. All concerns were addressed as they occurred. Completed 11/23/16. The RN who failed to assess Residents #1, #2, and #3 was terminated. On 11/16/16 Resident #1 was sent to the hospital emergency room for treatment. On 11/14/16, Resident #2 was sent to the hospital emergency room for treatment. On 10/23/16, Resident #3 was sent to the hospital emergency room for treatment. All nurses have been in-serviced on follow-up and assessing any resident with a reports of a change of condition. Completed 11/22/16. All nurses were educated and in-serviced 11/22/16 on how to properly assess a resident. A head to toe assessment was implemented on 11/22/16 for all incidents and changes in condition. In-service included that a staff member will stay with all residents until a resident is stable or emergency medical technicians arrive on site. Staff were in-serviced 11/22/16 on reporting changes of condition or any voiced concerns by family members or visitors to the charge nurse immediately. Staff were given a list of numbers to call if they felt like action was not being taken with a resident on 11/22/16. Licensed nurses were in-serviced on 11/22/16 to contact the DON or designee regarding any incidents or changes of resident condition as they occur. The DON or designee will have a clinical meeting, with the clinical team every morning, Monday through Friday. Any resident on the 24-hour report will be reviewed for proper documentation, assessment and notifications. Findings will be reviewed monthly by Quality Assurance team quarterly until the satisfaction of the committee is achieved to ensure compliance. Implemented 11/22/16. The Administrator or Designee will review all incidents during morning meetings so that any issue that is reportable is immediately reported to the State authority. Initiated 11/22/16. An Administrative team member will be assigned to weekends and holidays to review incidents/accidents and the 24 hour report and make notification to the Administrator/Designee when there is a reportable incident identified. All trends will be reviewed in the wee

Based on interview and record review, the facility failed to ensure that each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 3 of 8 residents (Residents #1, 2, and 3) reviewed for change of condition as evidenced by: a) failure to recognize and assess Resident #1 during the night beginning 11/6/16 and early morning hours of 11/7/16 when CNAs (certified nurse's aides) B and F reported that Resident #1, who was a diabetic, was non-responsive and exhibiting unusual thrashing in her bed throughout the night. Resident #1 was assessed the following morning at approximately 7:00 a.m. with a blood sugar of 45; b) failure to conduct a thorough nursing assessment of Resident #2 when CNAs B and F reported abdominal pain, vomiting, and diarrhea on 11/12/16 and 11/13/16. The physician was notified 11/14/16 and Resident #2 was admitted to the critical care unit with a partial bowel obstruction. c) failure to conduct a thorough nursing assessment of Resident #3 on 10/22/16 at approximately 3:00 a.m. when CNA I reported Resident #3 was in pain and when RN C observed Resident #3 hold his abdomen and fall to the floor due to abdominal pain. Resident #3 was sent to the hospital with abdominal pain and vomiting a brown substance on 10/23/16 and diagnosed with [REDACTED]. An Immediate Jeopardy (IJ) was identified on 11/20/16. While the IJ was removed on 11/23/16, the facility remained out of compliance at a level of actual harm that is not Immediate Jeopardy at a pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. These failures resulted in a delay of medical treatment, pain, and discomfort for Residents #1, 2, and 3, who resided on the secured units of the facility and could affect the 40 residents that reside on the secure units (Halls C, E, and F) and result in pain, decline in health, or death. Findings included: 1. An undated computer face sheet documented Resident #1 was a [AGE] year old female admitted to the facility 2/18/16 with Mild Intellectual disability, major [MEDICAL CONDITION], persistant mood disorder, diabetes mellitus, [MEDICAL CONDITION] disorder, anxiety disorder, hypertension, [MEDICAL CONDITION], reflux disorder and pruritis. A Minimum Data Set (MDS) Assessment date 8/29/16 documented that Resident #1 had a brief interview for mental status score of 03 indicating severe cognitive impairment. Resident #1 used a wheelchair for mobility. She required limited assistance of two staff to transfer, and extensive assistance of one staff for personal hygeine, dressing and toilet use. She had range of motion limitation for both lower extremities. She was always incontinent of bowel and bladder. Physician's orders 10/1/16-11/30/16 documented Resident #1 was prescribed checks of her blood sugar twice daily at 7:00 a.m. and 5:00 p.m. with [MEDICATION NAME] R insulin to be administered on a sliding scale based on the blood sugar reading. She was also prescribed [MEDICATION NAME] 40 units subcutaneous once daily at 7:00 a.m. Physician's orders documented to notify the physician for a blood sugar less than 40 or greater than 450. Resident #1's care plan with a review date of 9/13/16 included the following: Problem: Resident is at risk for frequent infections, pressure/venous-statis ulcers, vision impairment, hyper/[DIAGNOSES REDACTED], [MEDICAL CONDITION], cognitive/physical impairment, slow healing process skin desensitized to pain or pressure related to diabetes mellitus. .Approach start date 9/13/16: Assess/record/report to MD prn (as needed): [DIAGNOSES REDACTED] s/sx (signs/symptoms) : tremors, shaking, confusion, headache, irritability, hunger, n/v (nausea/vomiting), cool, clammy, pale skin, and diaphoresis. [MEDICAL CONDITION] s/sx: extreme thirst, frequent urination, abnormal pain, blurred vision, dry flushed skin, rapid breathing. A review of nurse's notes for Resident #1 revealed they included the following entries on 11/7/16: Late entry at 1:15 p.m.: At 0700 (7:00 a.m.) CBG read 45 mg/dL. Res lethargic, unable to open eyes, follow commands, or answer questions. Res given [MEDICATION NAME] injection IM (intramuscular) in Rt. delt (deltoid). Re-checked at 0800 (8:00 a.m.) CBG (capillary blood glucose) read 154 mg/dL. (Noted by LVN D). 8:00 a.m.: While on the phone with 911 operator to send res (resident) out for first fall, second nurse reported to this nurse res had fallen out of bed a second time. CNA found res on floor beside bed in prone position. Upon assessment, res left on floor and pillow placed under head. No new injuries noted from second fall. CBG (capillary blood glucose) read 154 mg/dL. VS (vital signs) T (temperature) 97.5, R (respirations) 22, BP (blood pressure) 110/76, P (pulse) 116. x2 EMTs (emergency medical technicians) on unit at 0805 and left unit with res via stretcher at 0815. (Noted by LVN D). 10:58 a.m.: Res (Resident) found on floor of room by CNA (certified nurse's aide). ROM (range of motion) x 4. VS (vital signs) BP (blood pressure) 128/76, P (pulse) 117, R (respiration) 22 regular. Blood noted to face, under nose, and lt (left) hand. S/T (skin tear) noted to lt post proximal 3rd digit. Nose displaced to rt. (right) side. Large hematoma noted under lt eye. Res weak and speech slurred. Neuros initiated. Res placed back onto bed at this time. All appropriate notifications made. Awaited call back from guardian and Dr. (name). Spoke with ADON and made the decision to send res out to (hospital) ER for eval and tx if necessary. While on the phone with 911 operator, CNA reported res fell again. See second fall notes. 3:12 p.m.: Returned to facility from (hospital) at 1500 (3:00 p.m.) x2 assist via gurney . There were no nursing notes from RN C, who was charge nurse, or any other nursing notes entered for the night shift that began at 10:00 p.m. 11/6/16 and ended at 6:00 a.m. on 11/7/16. A hospital emergency department report dated 11/7/16 at 8:35 a.m. documented Resident #1 arrived at the emergency department with a chief complaint of a fracture to nasal bridge and hematoma to left cheek following a fall at the facility. Findings following a CT scan included: Angulated nasal bone fracture. During an interview on 11/19/16 at 6:30 p.m., CNA (certified nurse's aide) B said that she worked the night shift on 11/6/16 - 11/7/16 (Sunday night to Monday morning) with Resident #1. CNA B said that she began noticing Resident #1 acting very unusually and thrashing about in her bed not long after the resident went to bed. She said it was much more than tossing and turning, but almost violently thrashing. She said Resident #1 would do this and then seem to go to sleep, only to start doing it again. CNA B said she told RN (Registered Nurse) C she was very concerned that something was wrong with Resident #1. CNA B said RN C would say okay but did not go down and check on Resident #1. She said she went to him three separate times throughout the night, and the last time he had just smiled at her, and said, Oh, I've seen her like that before. CNA B said RN C was sitting in a chair writing something at the nurse's station and he never left the nurse's station. CNA B said she gave up on asking him after the third time, but when the morning shift came on, she personally told the oncoming nurse and the oncoming CNA (CNA A) her concerns. During an interview on 11/20/16 at 3:00 p.m., CNA F said she was working the night shift on 11/6 - 11/7/16 on a different hall than CNA B. She said she was at the nurse's station and did hear CNA B tell RN C multiple times that Resident #1 was not responding and was all over the bed. CNA F said CNA B was very worried, and even asked CNA F to come down and look at Resident #1. She said she did, and CNA B was right, Resident #1 would not talk or respond. She said she never saw RN C get up to go to the unit to see the resident. CNA F said, You report stuff and nothing gets done. She said that RN C played on his cell phone all night, stating, That's all he does. During interviews on 11/17/16 at 10:30 a.m. and 11/18/16 at 12:15 p.m., CNA A said that when she came to work at 6:00 a.m. on 11/7/16, she heard RN C (the night nurse) telling LVN D (the day nurse) during shift change that Resident #1 was acting out, wanted attention, and there was nothing wrong with her. She said CNA B (who had worked the night shift) asked her to check on Resident #1 because she told her there was something not right about Resident #1. She said CNA B told her that she could not get RN C to check the resident because he thought Resident #1 was just wanting attention. CNA A said she knew Resident #1's symptoms of [DIAGNOSES REDACTED] and she was immediately concerned with what CNA B was saying, so she went to look at Resident #1. She said Resident #1 could barely move, and the way she was talking I knew she was not herself. She said she immediately notified the nurse. CNA A said that LVN D checked Resident #1's blood sugar and it was 32 or 34 and this was a few minutes before the breakfast carts arrived at 7:00 a.m. CNA A said after LVN D checked on Resident #1, Resident #1 was left in her bed. CNA A went to pass out breakfast trays as she was the only staff left on the secure unit. She said a few minutes after she left Resident #1's room, the therapy staff came and told her Resident #1 was on the floor. She found Resident #1 face down on the floor with blood on the floor around her face. She had the staff member get LVN D again. LVN D and LVN E came to Resident #1's room and assessed Resident #1 for injuries and they put her in bed again. CNA A said she left the room again and both LVN D and LVN E left the secure unit. She said Resident #1 then fell out of her bed again, face forward as before. CNA A said she did stay with Resident #1 after the second fall until the ambulance came. During an interview on 11/20/16 at 8:00 a.m. RN C first stated that he did not remember receiving any reports from CNAs regarding Resident #1's condition on the night of 11/6/16. When discussing whether he remembered CNA B reporting concern regarding Resident #1 thrashing in bed, he said, More or less. When discussing whether he remembered the report being made to him multiple times, he said she might have. RN C then stated he went on to the secure unit and saw Resident #1 that night some time around or right after midnight. He said he thought she was asleep, and he turned her over and she looked at him so he did not see a problem. When specifically asked if he assessed the resident's blood sugar or vital signs, he said he only checked her oxygen and it was normal. RN C said, I didn't see anything out of order. She's always been a problem child and it's not unusual for her to have bizarre behavior. He said he saw no reason to further assess or call the doctor. RN C said it never occurred to him to check Resident #1's blood sugar, but now states he should have checked it. During an interview on 11/18/16 at 5:10 p.m. the DON (Director of Nurses) said he was aware that RN C had been told about Resident #1's condition during the night on 11/6/16 - 11/7/16 and was aware RN C had not assessed to identify a change of condition and had not acted to inform the physician. The DON said, I counselled him. He stated that he knew Resident #1 fell forward on to the floor 11/7/16, and he thought it had something to do with her blood sugar. The DON said he was aware Resident #1 was left alone twice after she was found to have low blood sugar, and that each time she had fallen. He also stated he knew the resident had never been re-assessed to determine if her blood sugar had stabilized before she was left alone. During an interview on 11/28/16 at 3:05 p.m., Resident #1's physician said she was notified of Resident #1's condition the day she was sent to the hospital. Her physician stated that if Resident #1 exhibited a change of condition during the night she should have been assessed every 15 minutes and if her condition did not improve, the physician should have been notified. 2. An undated computer face sheet for Resident #2 documented she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set assessment dated [DATE] documented Resident #2 had a Brief Interview for Mental Status score of 12 indicating she had moderate cognitive impairment. She required only supervision for dressing, eating, toilet use, and transfer. She was ambulatory without an assistive device. She was occasionally incontinent of bladder and frequently incontinent of bowel. A care plan for Resident #2, last reviewed on 10/17/16 documented that Resident #2 exhibited manipulative behaviors related to [MEDICAL CONDITION], including chronic health complaints. A hospital emergency department (ED) report for Resident #2 dated 11/14/16 documented Resident #2 entered the emergency department on 11/14/16 at 3:19 p.m. Her chief complaint was documented as abdominal pain and swelling with diffuse abdominal pain for the past several days. Under Clinical History the hospital report documented Abdominal pain. Abdominal distention for 1 week. History of ulcer surgery and hysterectomy. Triage notes documented that Resident #2 complained of a 10/10 pain level in the left upper quadrant and left lower quadrant of her abdomen radiating to the back. Resident #2 complained of nausea, vomiting diarrhea, weakness, and dizziness. Prior treatment included antacid. Hospital ED nursing notes dated 11/14/16 at 3:59 p.m. documented that Resident #2's abdomen was distended and tender, and bowel sounds were hypactive in all four quadrants. At 5:45 p.m. a bladder scan revealed more than 999 mL in the bladder and the physician confirmed the appropriateness of an indwelling foley catheter. On 11/14/16 at 22:10 (10:10 p.m.) the hospital ED report documented [DIAGNOSES REDACTED]. She was admitted to the Intensive care unit/Critical Care unit on the surgical floor of the hospital. During an interview on 11/17/16 at 10:15 a.m. CNA A said Resident #2 was in the hospital. CNA A said Resident #2 was sick and throwing up last weekend (11/12/16 and 11/13/16), but stated, They didn't do anything. Nursing notes for 11/14/16 at 14:33 (2:33 p.m.) documented Resident #2 was vomiting [MEDICATION NAME] (sticky/thick), red specks and her blood pressure was 99/65, pulse was 113, respiration was 22 and labored, and temperature was 98.5. A telephone order dated 11/14/16 at 14:41 (2:41 p.m.) documented an order to send Resident #2 to the hospital for evaluation. During an interview on 11/17/16 at 4:00 p.m., LVN D said she was the nurse that sent Resident #2 out to the hospital on [DATE]. She said that CNA A reported to her that Resident #2's stomach was distended and she did not feel good. LVN D said she assessed Resident #2 and found her stomach was grossly distended. She said, She looked nine months pregnant. LVN D said Resident #2 told her she had been throwing up and she had told the staff but no one had checked on her. LVN D said she noticed Resident #2 gagging every time she would move. She contacted the physician and sent Resident #2 to the hospital. During an interview on 11/19/16 at 6:30 p.m. CNA B said that Resident #2 was throwing up on Saturday night (11/12/16) and she informed RN C. She said she thought he might have given Resident #2 some [MEDICATION NAME]. She said Resident #2 was complaining of her stomach hurting and going to the bathroom a lot. CNA B said that when she came to work Sunday night (11/13/16), Resident #2 was worse. CNA B said, She didn't look good. She said that Resident #2 was nauseated and throwing up so she had put a trash can next to Resident #2's bed. CNA B said she reported to RN C that Resident #2 was sick and throwing up. She said the emesis was red, but she thought the resident had drank a red drink. CNA B said she never saw RN C get up from the nurse's station or go check Resident #2. She said he did not ask her any questions about how many times the resident had thrown up or any other questions about her observations. CNA B said that she believed that because Resident #2 had mental issues, that the nurses never took her very serious. CNA B said, My opinion is he should have at least examined her. During an interview on 11/20/16 at 3:00 p.m., CNA F said she worked the night shift on Sunday, 11/13/16 on a different hall than CNA B. She said she had gone on the secure unit and had seen that Resident #2 was in distress. CNA F said she told RN C that Resident #2 was crying in pain and vomiting. CNA F said that she and CNA B had explained to RN C that Resident #2's pain was different than her usual complaints of pain. CNA F said RN C never went to check on Resident #2 on Sunday night. During an interview on 11/19/16 at 12:30 p.m., CNA G said she worked the day shift with Resident #2 on the weekend of 11/12/16 and 11/13/16. She said that Resident #2 was incontinent and wearing a brief because of small episodes of diarrhea. She said this was upsetting to Resident #2 since this was not normal for her. She said that Resident #2 kept complaining of nausea, and this was occurring both on Saturday and Sunday. She said she told the medication aide, but she did not tell the nurse. During an interview on 11/19/16 at 4:00 p.m., LVN K said she worked the day shift on the weekend of 11/12/16 and 11/13/16 and she was never made aware that Resident #2 was spitting up, throwing up, or having diarrhea. She said Resident #2 never complained and if they had told her these things, she definitely would have addressed it. During an interview with RN C on 11/20/16 at 8:00 a.m., when discussing whether he had received reports of Resident #2's nausea, vomiting, and diarrhea during the weekend of 11/12-11/13/16, he stated, She's very drug seeking. She was seeking her 2:00 a.m. [MEDICATION NAME] and she complained of constipation. He said he checked her bowel sounds and the lower left was slow but the others were active. When discussing whether CNA B had reported her concerns and observations to him on Saturday and Sunday night, RN C said, I'm sure she said she was asking for her pain pill. RN C said he checked on her Sunday night, but he did not even remember what had happened on Saturday night. He said that the reason he listened to her bowel sounds was because Resident #2 said she felt bloated. He said he did not document anything in the nursing notes or notify the physician because he did not find anything wrong. When discussing that Resident #2 was hospitalized and placed in the critical care unit on Monday, RN C said, But you have to know (Resident #2) like I do. Most of her complaints turn out to be nothing. During an interview on 12/1/16 at 9:00 a.m. LVN H said he was working with RN C on the weekend nights of 11/12/16 and 11/13/16. He said he heard the nurse aides reporting Resident #2's change of condition to RN C. He said they asked RN C several times to look at Resident #2, but LVN H said he never saw whether RN C checked on Resident #2 or not. LVN H said the CNAs asked him to check on her also, and he told them, He's an RN and I'm not stepping on his toes. A review of facility nursing notes for Resident #2 revealed there were no nursing entries documenting a change of condition or notification of the physician for Saturday 11/12/16 or Sunday 11/13/16. A review of physician's telephone orders for Resident #2 revealed no physician's orders for 11/12/16 or 11/13/16. During a return telephone call from Resident #2's physician on 12/6/16 at 3:00 p.m., Resident #2's physician said that the first notification of Resident #2's condition that she received was on 11/14/16 when Resident #2 was sent to the hospital. Resident #2's physician said that the symptoms described on 11/12/16 and 11/13/16 indicated an acute abdomen and anytime that situation existed, it warranted a call to her. She said that she was available to the facility 24 hours a day, 7 days a week and there was no excuses not to notify her of changes of condition at any time. According to Resident #2's medical record (nursing notes and physician's orders for November 2016) Resident #2 remained in the hospital for the duration of this investigation and was not available for interview. 3. An undated face sheet for Resident #3 documented he was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set Assessment for Resident #3 dated 10/17/16 documented a brief interview for mental status score of 12 indicating Resident #3 had moderately impaired cognitive functioning. He had no indicators of [MEDICAL CONDITION] and no behavioral symptoms identified. Resident #3 required limited assistance from staff for mobility, transfer, dressing, eating, toilet use, and personal hygeine. He was ambulatory and did not use a mobility device. Facility nursing notes included the following: 10/22/16: Resident complaining of abdominal pain and nausea. Gave resident [MEDICATION NAME]. Resident has had no vomiting at this time. Will continue to monitor. (Noted by RN C). 10/23/16 at 0420 (4:20 a.m.): At 0255, CNA I reported resident with c/o (complaints of) abdominal pain and cramping. Upon entering resident's room I noted he was laying with left side down. He was holding/guarding right abdominal area to the right of his umbilicus. Respirations were labored and uneven. At times resident would gasp loudly while breathing. Resident was grimacing, moaning, and rocking. When asked why he stated, I hurt. Resident has a small amount of brown emesis on the bed and floor. It has a moderate smell of feces. I auscultated his 4 quadrants and heard no bowel sounds. I digitally evaluated the resident for impaction, none felt. Stated last BM was yesterday. It was very firm and small in size, stated passing it was extremely difficult. I immediately had fell ow nurse (LVN D) auscultate the resident''s abdomen and she also noted the absence of bowel sounds. I asked CNA to please get the resident prepared for transport to (hospital) ER for eval and possible treatment. Physician was notified. (Noted by LVN H). A hospital Emergency Department report dated 10/23/16 documented Resident #3 entered with complaints of abdominal pain. The pain began suddenly two days prior was constant, and worsened in the last hours. The pain was described as 10/10. Resident #3 complained of vomiting a brown substance. Resident #3 was admitted to the hospital from the Emergency Department with [DIAGNOSES REDACTED]. During an interview on 12/1/16 at 10:45 a.m., CNA I said that on 10/22/16, he observed Resident #3 moaning and grimacing but Resident #3 kept saying he was okay. At approximately 3:00 a.m., Resident #3 was holding his abdomen and said he was in pain. CNA I said he went and told RN C about Resident #3's complaint. CNA I said that when RN C came to see Resident #3, Resident #3 collapsed to the floor. CNA I said, His stomach was hurting so bad, he couldn't stand. CNA I said that RN C did not check Resident #3's vital signs or listen to bowel sounds. He said he gave Resident #3 some [MEDICATION NAME]. During an interview on 11/20/16 at 8:00 a.m., RN C said that on 10/22/16 CNA I told him that Resident #3 had a problem. He said that when he went on the secure unit, Resident #3 was holding on the the hand rail on the wall, standing in the hallway. He said Resident #3 then sat on the floor and told RN C, My stomach's all messed up. When asked why he thought Resident #3 sat on the floor in the hallway, RN C said Resident #3 did it for effect. When asked if he meant that Resident #3 was being overly dramatic, RN C said, Oh absolutely. RN C said he did not assess bowel sounds or take vital signs. He said that he gave Resident #3 [MEDICATION NAME] and Resident #3 reported feeling better so he saw no reason to call the physician. An attempt to interview Resident #3 on 12/2/16 at 11: 35 a.m. was not successful. Resident #3 said he did not feel like talking. He complained that his back hurt. He said the nurse had already attended to him and given him medication, but it had not begun to work. During a return telephone call from Resident #3's physician on 12/6/16 at 3:00 p.m., she said that the best of her recollection was that she sent Resident #3 to the hospital when she was notified he had abdominal symptoms so she must have been notified 10/23/16 because that was the day he was sent. She said if she would have been notified on 10/22/16 that Resident #3 was having such pain in his abdomen she certainly would have sent him to the hospital immediately. 4. A facility policy titled, Acute Condition Changes - Clinical Protocol, Revised December 2012 , provided by the facility on 11/28/16 at 3:30 p.m. in response to a request for the facility's policy regarding nursing assessment of a resident with a change of condition, revealed it included the following: 5a. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident's current symptoms and status. 6. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one half hour or less). Under Monitoring and Follow up: 1. The staff will monitor and document the resident's progress and responses to treatment and the physician will adjust treatment accordingly. IMMEDIATE JEOPARDY 5. On 11/20/16 at 1:40 p.m. the Administrator was notified of an Immediate Jeopardy. The facility's Plan of Removal of Immedate Jeopardy was accepted on 11/23/16 at 11:00 a.m. and included the following: From 11/20/16 through 11/23/16, the facility provided an Administrative Nursing staff in the facility at the end of every shift to personally review all incidents, the 24-hour report, changes in resident condition, and any concerns voiced by staff, family, residents or visitors during the previous shift. All concerns were addressed as they occurred. Completed 11/23/16. The RN who failed to assess Residents #1, #2, and #3 was terminated. On 11/16/16 Resident #1 was sent to the hospital emergency room for treatment. On 11/14/16, Resident #2 was sent to the hospital emergency room for treatment. On 10/23/16, Resident #3 was sent to the hospital emergency room for treatment. All nurses have been in-serviced on follow-up and assessing any resident with a reports of a change of condition. Completed 11/22/16. All nurses were educated and in-serviced 11/22/16 on how to properly assess a resident. A head to toe assessment was implemented on 11/22/16 for all incidents and changes in condition. In-service included that a staff member will stay with all residents until a resident is stable or emergency medical technicians arrive on site. Staff were in-serviced 11/22/16 on reporting changes of condition or any voiced concerns by family members or visitors to the charge nurse immediately. Staff were given a list of numbers to call if they felt like action was not being taken with a resident on 11/22/16. Licensed nurses were in-serviced on 11/22/16 to contact the DON or designee regarding any incidents or changes of resident condition as they occur. The DON or designee will have a clinical meeting, with the clinical team every morning, Monday through Friday. Any resident on the 24-hour report will be reviewed for proper documentation, assessment and notifications. Findings will be reviewed monthly by Quality Assurance team quarterly until the satisfaction of the committee is achieved to ensure compliance. Implemented 11/22/16. The Administrator or Designee will review all incidents during morning meetings so that any issue that is reportable is immediately reported to the State authority. Initiated 11/22/16. An Administrative team member will be assigned to weekends and holidays to review incidents/accidents and the 24 hour report and make notification to the Administrator/Designee when there is a reportable incident identified. All trends will be reviewed in the weekly Quality Assurance meetings. Any resident specific interventions will be implemented and added to the resident's care plan such as one on one staff, every 15 minute checks, and/or adding another staff member if needed. All staff have been in-serviced on the guidelines for reporting abuse/neglect or change in resident's condition. The Administrator posted and distributed copies of a complete list of all numbers to contact if an employee, resident, or responsible party suspects abuse or neglect, including but not limited to the Administrator, Director of Nurses, Regional Director of Operations, and Regional Nurse. Completed 11/21/16. 6. Action Plan verification activities were conducted from 11/22/16 through 11/23/16and included the following activities: Review of in-service documentation, interview with nurses aides and nurses from various shifts to verify in-service understanding, review of nursing 24-hour reports and resident change of conditions through 11/23/16, and interview with the Director of Nurses regarding follow up of all resident issues identified on nursing reports. 7. The Administrator was notified that the IJ was removed on 11/23/16 at 11:00 a.m., but the facility remained out of compliance at a scope and severity level of Actual Harm at a pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 8. On 12/2/16 the facility provided a Census Worksheet that identified 40 residents residing on the secure units of the facility.

Based on interview and record review, the facility failed to immediately inform the resident's physician when a change in the resident's physical, mental, or psychosocial status occurred for 3 of 8 residents (Residents #1, 2, and 3) reviewed for change of condition and 2 of 7 residents (Residents #10 and 12) reviewed for change of condition specific to diabetes monitoring as evidenced by: a) failure to immediately notify Resident #1's physician during the night shift (11/6/16 - 11/7/16 when Resident #1, who was a diabetic, was reported to be non-responsive and exhibiting unusual thrashing in her bed. Resident #1 was found to have a blood sugar of 45 at 7:00 a.m.; b) failure to immediately notify Resident #2's physician when staff reported to RN (Registered Nurse) C that Resident #2 had abdominal pain, vomiting, and diarrhea on 11/12/16 and 11/13/16. The physician was notified 11/14/16 and Resident #2 was admitted to the critical care unit with a partial bowel obstruction. c) failure to immediately notify Resident #3's physician on 10/22/16 at approximately 3:00 a.m. when staff reported and RN C observed Resident #3 hold his abdomen and fall to the floor due to intense abdominal pain. Resident #3 was sent to the hospital with similar symptoms on 10/23/16 and diagnosed with [REDACTED]. d) failure to immediately notify Resident #10's physician 11/06/16 at 4:30 p.m.,for a blood sugar of 428 at 8:00 p.m. when physician's order required notification when over 399. e) failure to immediately notify Resident #12's physician on 11/16/16 for a blood sugar of 445 when physician's order required notification when over 399. An Immediate Jeopardy (IJ) was identified on 11/20/16. While the IJ was removed on 11/23/16, the facility remained out of compliance at a level of actual harm that is not Immediate Jeopardy at a pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. These failures resulted in a delay of medical treatment, pain, and discomfort for Residents #1, 2, and 3, who resided on the secured units of the facility and could affect the 40 residents that reside on the secure units (Halls C, E, and F) and result in pain, decline in health, or death. Failure to notify physician of a change of condition for diabetics could affect the 23 residents that reguired blood sugar monitoring and result in [DIAGNOSES REDACTED] (low blood sugar), [MEDICAL CONDITION] (high blood sugar), decline in condition, and death. Findings included: 1. An undated computer face sheet documented Resident #1 was a [AGE] year old female admitted to the facility 2/18/16 with Mild Intellectual disability, major [MEDICAL CONDITION], persistant mood disorder, diabetes mellitus, [MEDICAL CONDITION] disorder, anxiety disorder, hypertension, [MEDICAL CONDITION], reflux disorder and pruritis. A Minimum Data Set (MDS) Assessment date 8/29/16 documented that Resident #1 had a brief interview for mental status score of 03 indicating severe cognitive impairment. Resident #1 used a wheelchair for mobility. She required limited assistance of two staff to transfer, and extensive assistance of one staff for personal hygeine, dressing and toilet use. She had range of motion limitation for both lower extremities. She was always incontinent of bowel and bladder. Physician's orders 10/1/16-11/30/16 documented Resident #1 was prescribed checks of her blood sugar twice daily at 7:00 a.m. and 5:00 p.m. with [MEDICATION NAME] R insulin to be administered on a sliding scale based on the blood sugar reading. She was also prescribed [MEDICATION NAME] 40 units subcutaneous once daily at 7:00 a.m. Physician's orders documented to notify the physician for a blood sugar less than 40 or greater than 450. Resident #1's care plan with a review date of 9/13/16 included the following: Problem: Resident is at risk for frequent infections, pressure/venous-statis ulcers, vision impairment, hyper/[DIAGNOSES REDACTED], [MEDICAL CONDITION], cognitive/physical impairment, slow healing process skin desensitized to pain or pressure related to diabetes mellitus. .Approach start date 9/13/16: Assess/record/report to MD prn: [DIAGNOSES REDACTED] s/sx (signs/symptoms) : tremors, shaking, confusion, headache, irritability, hunger, n/v, cool, clammy, pale skin, and diaphoresis. [MEDICAL CONDITION] s/sx: extreme thirst, frequent urination, abnormal pain, blurred vision, dry flushed skin, rapid breathing. A review of nurse's notes for Resident #1 revealed they included the following entries on 11/7/16: (Late Entry) at 1:15 p.m.: At 0700 (7:00 a.m.) the day shift nurse (LVN D) documented- CBG (capillary blood glucose) read 45 mg/dL. Res lethargic, unable to open eyes, follow commands, or answer questions. Res given [MEDICATION NAME] injection IM (intramuscular) in Rt. delt (deltoid). Re-checked at 0800 (8:00 a.m.) CBG (capillary blood glucose) read 154 mg/dL. 8:00 a.m.: While on the phone with 911 operator to send res (resident) out for first fall, second nurse reported to this nurse res had fallen out of bed a second time. CNA found res on floor beside bed in prone position. Upon assessment, res left on floor and pillow placed under head. No new injuries noted from second fall. CBG (capillary blood glucose) read 154 mg/dL. VS (vital signs) T (temperature) 97.5, R (respirations) 22, BP (blood pressure) 110/76, P (pulse) 116. x2 EMTs (emergency medical technicians) on unit at 0805 and left unit with res via stretcher at 0815. 10:58 a.m.: Res (Resident) found on floor of room by CNA (certified nurse's aide). ROM (range of motion) x 4. VS (vital signs) BP (blood pressure) 128/76, P (pulse) 117, R (respiration) 22 regular. Blood noted to face, under nose, and lt (left) hand. S/T (skin tear) noted to lt post proximal 3rd digit. Nose displaced to rt. (right) side. Large hematoma noted under lt eye. Res weak and speech slurred. Neuros initiated. Res placed back onto bed at this time. All appropriate notifications made. Awaited call back from guardian and Dr. (name). Spoke with ADON (Assistant Director of Nursing) and made the decision to send res out to (hospital) ER for eval and tx if necessary. While on the phone with 911 operator, CNA reported res fell again. See second fall notes. 3:12 p.m.: Returned to facility from (hospital) at 1500 (3:00 p.m.) x2 assist via gurney . There were no nursing notes entered for the night shift that began at 10:00 p.m. 11/6/16 and ended at 6:00 a.m. on 11/7/16. A hospital emergency department report dated 11/7/16 at 8:35 a.m. documented Resident #1 arrived at the emergency department with a chief complaint of a fracture to nasal bridge and hematoma to left cheek following a fall at the facility. Findings following a CT scan included: Angulated nasal bone fracture. During an interview on 11/19/16 at 6:30 p.m., CNA (certified nurse's aide) B said that she worked the night shift on 11/6/16 - 11/7/16 (Sunday night to Monday morning) with Resident #1. CNA B said Resident #1 was still up when she got to work at 10:00 p.m. that evening, and she assisted Resident #1 to bed. CNA B said that she began noticing Resident #1 acting very unusually and thrashing about in her bed not long after she put her to bed. CNA B said she did not remember times that the night's events occurred from her memory. She said the resident's thrashing about was much more than tossing and turning, but almost violently thrashing. She said Resident #1 would do this and then seem to go to sleep, only to start doing it again. CNA B said she told RN (Registered Nurse) C she was very concerned that something was wrong with Resident #1 (unknown time). CNA B said RN C would say okay but did not go down and check on Resident #1. She said she went to him three separate times throughout the night, and the last time he had just smiled at her, and said, Oh, I've seen her like that before. CNA B said RN C was sitting in a chair writing something at the nurse's station and he never left the nurse's station. CNA B said she gave up on asking him after the third time, but when the morning shift came on, she personally told the oncoming nurse and the oncoming CNA her concerns. During an interview on 11/20/16 at 3:00 p.m., CNA F said she was working the night shift on 11/6 - 11/7/16 on a different hall than CNA B. She said she was at the nurse's station and did hear CNA B tell RN C multiple times that Resident #1 was not responding and was all over the bed. CNA F said CNA B was very worried, and even asked CNA F to come down and look at Resident #1. She said she did, and CNA B was right, Resident #1 would not talk or respond. She said she never saw RN C get up to go to the unit to see the resident. CNA F said, You report stuff and nothing gets done. She said that RN C played on his cell phone all night, stating, That's all he does. During interviews on 11/17/16 at 10:30 a.m. and 11/18/16 at 12:15 p.m., CNA A said that when she came to work at 6:00 a.m. on 11/7/16, she heard RN C (the night nurse) telling LVN (licensed vocational nurse) D (the day nurse) during shift change that Resident #1 was acting out, wanted attention, and there was nothing wrong with her. She said CNA B (who had worked the night shift) asked her to check on Resident #1 because she told her there was something not right about Resident #1. CNA said that CNA B told her that she could not get RN C to check the resident because he thought Resident #1 was just wanting attention. CNA A said she knew Resident #1's symptoms of [DIAGNOSES REDACTED] and she was immediately concerned with what CNA B was saying, so she went to look at Resident #1. She said Resident #1 could barely move, and the way she was talking I knew she was not herself. She said she immediately notified the nurse. CNA A said that LVN D checked Resident #1's blood sugar and it was 32 or 34 and this was a few minutes before the breakfast carts arrived at 7:00 a.m. CNA A said after LVN D checked on Resident #1, Resident #1 was left in her bed. CNA A went to pass out breakfast trays as she was the only staff left on the secure unit. She said a few minutes after she left Resident #1's room, the therapy staff came and told her Resident #1 was on the floor. She found Resident #1 face down on the floor with blood on the floor around her face. She had the staff member get LVN D again. LVN D and LVN E came to Resident #1's room and assessed Resident #1 for injuries and they put her in bed again. CNA A said she left the room again and both LVN D and LVN E left the secure unit. She said Resident #1 then fell out of her bed again, face forward as before. CNA A said she did stay with Resident #1 after the second fall until the ambulance came. During an interview on 11/20/16 at 8:00 a.m. RN C first stated that he did not remember receiving any reports from CNAs regarding Resident #1's condition on the night of 11/6/16. When discussing whether he remembered CNA B reporting concern regarding Resident #1 thrashing in bed, he said, More or less. When discussing whether he remembered the report being made to him multiple times, he said she might have. RN C then stated he went on to the secure unit and saw Resident #1 that night some time around or right after midnight. He said he thought she was asleep, and he turned her over and she looked at him so he did not see a problem. When specifically asked if he assessed the resident's blood sugar or vital signs, he said he only checked her oxygen and it was normal. RN C said, I didn't see anything out of order. She's always been a problem child and it's not unusual for her to have bizarre behavior. He said he saw no reason to further assess or call the doctor. RN C said it never occurred to him to check Resident #1's blood sugar, but now states he should have checked it. During an interview on 11/18/16 at 5:10 p.m. the DON (Director of Nurses) said he was aware that RN C had been told about Resident #1's condition during the night on 11/6/16 - 11/7/16 and was aware RN C had not assessed to identify a change of condition and had not acted to inform the physician. The DON said, I counselled him. During an interview on 11/28/16 at 3:05 p.m., Resident #1's physician said she was notified of Resident #1's condition the day she was sent to the hospital. Her physician stated that if Resident #1 exhibited a change of condition during the night she should have been assessed every 15 minutes and if her condition did not improve, the physician should have been notified. Resident #2 remained in the hospital during this investigation and was not available for interview. 2. An undated computer face sheet for Resident #2 documented she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set assessment dated [DATE] documented Resident #2 had a Brief Interview for Mental Status score of 12 indicating she had moderate cognitive impairment. She required only supervision for dressing, eating, toilet use, and transfer. She was ambulatory without an assistive device. She was occasionally incontinent of bladder and frequently incontinent of bowel. A care plan for Resident #2, last reviewed on 10/17/16 documented that Resident #2 exhibited manipulative behaviors related to [MEDICAL CONDITION], including chronic health complaints. A hospital emergency department (ED) report for Resident #2 dated 11/14/16 documented Resident #2 entered the emergency department on 11/14/16 at 3:19 p.m. Her chief complaint was documented as abdominal pain and swelling with diffuse abdominal pain for the past several days. Under Clinical History the hospital report documented Abdominal pain. Abdominal distention for 1 week. History of ulcer surgery and hysterectomy. Triage notes documented that Resident #2 complained of a 10/10 pain level in the left upper quadrant and left lower quadrant of her abdomen radiating to the back. Resident #2 complained of nausea, vomiting diarrhea, weakness, and dizziness. Prior treatment included antacid. Hospital ED nursing notes 11/14/16 at 3:59 p.m. documented that Resident #2's abdomen was distended and tender, and bowel sounds were hypactive in all four quadrants. At 5:45 p.m. a bladder scan revealed more than 999 mL in the bladder and the physician confirmed the appropriateness of an indwelling foley catheter. On 11/14/16 at 22:10 (10:10 p.m.) the hospital ED report documented [DIAGNOSES REDACTED]. She was admitted to the Intensive care unit/Critical Care unit on the surgical floor of the hospital. During an interview on 11/17/16 at 10:15 a.m. CNA A said Resident #2 was in the hospital. CNA A said Resident #2 was sick and throwing up last weekend (ll/12/16 and 11/13/16), but stated, They didn't do anything. Nursing notes for 11/14/16 at 14:33 (2:33 p.m.) documented Resident #2 was vomiting [MEDICATION NAME] (sticky/thick), red specks and her blood pressure was 99/65, pulse was 113, respiration was 22 and labored, and temperature was 98.5. A telephone order dated 11/14/16 at 14:41 (2:41 p.m.) documented an order to send Resident #2 to the hospital for evaluation. During an interview on 11/17/16 at 4:00 p.m., LVN D said she was the nurse that sent Resident #2 out to the hospital on [DATE]. She said that CNA A reported to her that Resident #2's stomach was distended and she did not feel good. LVN D said she assessed Resident #2 and found her stomach was grossly distended. She said, She looked nine months pregnant. LVN D said Resident #2 told her she had been throwing up and she had told the staff but no one had checked on her. LVN D said she noticed Resident #2 gagging every time she would move. She contacted the physician and sent Resident #2 to the hospital. During an interview on 11/19/16 at 6:30 p.m. CNA B said that Resident #2 was throwing up on Saturday night (11/12/16) and she informed RN C. She said she thought he might have given Resident #2 some [MEDICATION NAME]. She said Resident #2 was complaining of her stomach hurting and going to the bathroom a lot. CNA B said that when she came to work Sunday night (11/13/16), Resident #2 was worse. CNA B said, She didn't look good. She said that Resident #2 was nauseated and throwing up so she had put a trash can next to Resident #2's bed. CNA B said she reported to RN C that Resident #2 was sick and throwing up. She said the emesis was red, but she thought the resident had drank a red drink. CNA B said she never saw RN C get up from the nurse's station or go check Resident #2. She said he did not ask her any questions about how many times the resident had thrown up or any other questions about her observations. CNA B said that she believed that because Resident #2 had mental issues, that the nurses never took her very serious. CNA B said, My opinion is he should have at least examined her. During an interview on 11/20/16 at 3:00 p.m., CNA F said she worked the night shift on Sunday, 11/13/16 on a different hall than CNA B. She said she had gone on the secure unit and had seen that Resident #2 was in distress. CNA F said she told RN C that Resident #2 was crying in pain and vomiting. CNA F said that she and CNA B had explained to RN C that Resident #2's pain was different than her usual complaints of pain. CNA F said RN C never went to check on Resident #2 on Sunday night. During an interview on 11/19/16 at 12:30 p.m., CNA G said she worked the day shift with Resident #2 on the weekend of 11/12/16 and 11/13/16. She said that Resident #2 was incontinent and wearing a brief because of small episodes of diarrhea. She said this was upsetting to Resident #2 since this was not normal for her. She said that Resident #2 kept complaining of nausea, and this was occurring both on Saturday and Sunday. She said she told the medication aide, but she did not tell the nurse. During an interview with RN C on 11/20/16 at 8:00 a.m., when discussing whether he had received reports of Resident #2's nausea, vomiting, and diarrhea during the weekend of 11/12-11/13/16, he stated, She's very drug seeking. She was seeking her 2:00 a.m. [MEDICATION NAME] and she complained of constipation. He said he checked her bowel sounds and the lower left was slow but the others were active. When discussing whether CNA B had reported her concerns and observations to him on Saturday and Sunday night, RN C said, I'm sure she said she was asking for her pain pill. RN C said he checked on her Sunday night, but he did not even remember what had happened on Saturday night. He said that the reason he listened to her bowel sounds was because Resident #2 said she felt bloated. He said he did not document anything in the nursing notes or notify the physician because he did not find anything wrong. When discussing that Resident #2 was hospitalized and placed in the critical care unit on Monday, RN C said, But you have to know (Resident #2) like I do. Most of her complaints turn out to be nothing. During an interview on 12/1/16 at 9:00 a.m. LVN H said he was working with RN C on the weekend nights of 11/12/16 and 11/13/16. He said he heard the nurse aides reporting Resident #2's change of condition to RN C. He said they asked RN C several times to look at Resident #2, but LVN H said he never saw whether RN C checked on Resident #2 or not. LVN H said the CNAs asked him to check on her also, and he told them, He's an RN and I'm not stepping on his toes. A review of facility nursing notes for Resident #2 revealed there were no nursing entries documenting a change of condition or notification of the physician for Saturday 11/12/16 or Sunday 11/13/16. A review of physician's telephone orders for Resident #2 revealed no physician's orders for 11/12/16 or 11/13/16. During a return telephone call from Resident #2's physician on 12/6/16 at 3:00 p.m., Resident #2's physician said that the first notification of Resident #2's condition that she received was on 11/14/16 when Resident #2 was sent to the hospital. Resident #2's physician said that the symptoms described on 11/12/16 and 11/13/16 indicated an acute abdomen and anytime that situation existed, it warranted a call to her. She said that she was available to the facility 24 hours a day, 7 days a week and there was no excuses not to notify her of changes of condition at any time. According to Resident #2's medical record (nursing notes and physician's orders for November 2016) Resident #2 remained in the hospital for the duration of this investigation and was not available for interview. 3. An undated face sheet for Resident #3 documented he was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set Assessment for Resident #3 dated 10/17/16 documented a brief interview for mental status score of 12 indicating Resident #3 had moderately impaired cognitive functioning. He had no indicators of [MEDICAL CONDITION] and no behavioral symptoms identified. Resident #3 required limited assistance from staff for mobility, transfer, dressing, eating, toilet use, and personal hygeine. He was ambulatory and did not use a mobility device. Facility nursing notes included the following: 10/22/16 at 0451 (4:51 a.m.): Resident complaining of abdominal pain and nausea. Gave resident [MEDICATION NAME]. Resident has had no vomiting at this time. Will continue to monitor. (Noted by RN C) 10/23/16 at 0420 (4:20 a.m.): At 0255, CNA I reported resident with c/o (complaints of) abdominal pain and cramping. Upon entering resident's room I noted he was laying with left side down. He was holding/guarding right abdominal area to the right of his umbilicus. Respirations were labored and uneven. At times resident would gasp loudly while breathing. Resident was grimacing, moaning, and rocking. When asked why he stated, I hurt. Resident has a small amount of brown emesis on the bed and floor. It has a moderate smell of feces. I auscultated his 4 quadrants and heard no bowel sounds. I digitally evaluated the resident for impaction, none felt. Stated last BM was yesterday. It was very firm and small in size, stated passing it was extremely difficult. I immediately had fell ow nurse (LVN D) auscultate the resident''s abdomen and she also noted the absence of bowel sounds. I asked CNA to please get the resident prepared for transport to (hospital) ER for eval and possible treatment. Physician was notified. (Noted by LVN H). A hospital Emergency Department report dated 10/23/16 documented Resident #3 entered with complaints of abdominal pain. The pain began suddenly two days prior was constant, and worsened in the last hours. The pain was described as 10/10. Resident #3 complained of vomiting a brown substance. Resident #3 was admitted to the hospital from the Emergency Department with [DIAGNOSES REDACTED]. During an interview on 12/1/16 at 10:45 a.m., CNA I said that on 10/22/16, he observed Resident #3 moaning and grimacing but Resident #3 kept saying he was okay. At approximately 3:00 a.m., Resident #3 was holding his abdomen and said he was in pain. CNA I said he went and told RN C about Resident #3's complaint. CNA I said that when RN C came to see Resident #3, Resident #3 collapsed to the floor. CNA I said, His stomach was hurting so bad, he couldn't stand. CNA I said that RN C did not check Resident #3's vital signs or listen to bowel sounds. He said he gave Resident #3 some [MEDICATION NAME]. During an interview on 11/20/16 at 8:00 a.m., RN C said that on 10/22/16 CNA I told him that Resident #3 had a problem. He said that when he went on the secure unit, Resident #3 was holding on the the hand rail on the wall, standing in the hallway. He said Resident #3 then sat on the floor and told RN C, My stomach's all messed up. When asked why he thought Resident #3 sat on the floor, RN C said Resident #3 did it for effect. When asked if he meant that Resident #3 was being overly dramatic, RN C said, Oh absolutely. RN C said he did not assess bowel sounds or take vital signs. He said that he gave Resident #3 [MEDICATION NAME] and Resident #3 reported feeling better so he saw no reason to call the physician. An attempt to interview Resident #3 on 12/2/16 at 11: 35 a.m. was not successful. Resident #3 said he did not feel like talking. He complained that his back hurt. He said the nurse had already attended to him and given him medication, but it had not begun to work. During a return telephone call from Resident #3's physician on 12/6/16 at 3:00 p.m., she said that the best of her recollection was that she sent Resident #3 to the hospital when she was notified he had abdominal symptoms so she must have been notified 10/23/16 because that was the day he was sent. She said if she would have been notified on 10/22/16 that Resident #3 was having such pain in his abdomen she certainly would have sent him to the hospital immediately. 4. Review of Resident #10's undated face sheet documented she was a [AGE] year-old female admitted [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Physician monthly orders for Resident #10 dated 11/01/16- 12/31/16 documented an order dated 7/22/16 for accu checks (finger stick blood sugar tests) ac and hs (before meals and at night). There was also an order dated 7/22/16 for blood sugar parameters; less than 60 if conscious give orange juice with sugar and snack. If unable to tolerate, give [MEDICATION NAME] 1 milligram (mg) sub-cutaneous (sq) and notify physician of accu checks over 399. Review of Resident # 10's MDS assessment dated [DATE] showed the resident had a Brief Interview for Mental Status (BIMS) score of 10 which means the resident had moderate cognitive impairment. The MDS showed the resident to have diabetes. Review of the Diabetic Flow sheet for November 2016 revealed that on 11/06/16 at 4:30 p.m., the resident had a CBG of 57 then at 8:00 p.m. the CBG was 428 but there was no documentation on the nurse's notes or medication administration records that the physician had been notified. Review of Resident # 10's care plan dated 11/15/16 showed the problem as: resident at risk for hyper/[DIAGNOSES REDACTED] related to diabetes. The goal was: diabetic state will remain stable as evidenced by resident blood sugar staying within the resident ' s normal limits. The approaches were: administer medication as ordered and assess/record/report to doctor hypo or [MEDICAL CONDITION] signs/symptoms. 5. Review of Resident # 12's undated face sheet showed she was an [AGE] year-old female admitted [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident 12's Minimum Data Set (MDS) assessment dated [DATE] showed the resident had a BIMS score of 11 which meant the resident had moderately impaired cognitive functioning. The MDS showed the resident to have diabetes. Physician monthly orders dated 11/01/16- 12/31/16 documented that Resident #12 was to have accuchecks every morning every other day at 7:30 a.m. For glucose levels less than 60 and the resident was conscious give orange juice with sugar and snack. If unable to tolerate give [MEDICATION NAME] 1 mg sc from emergency kit and notify physician of accuchecks over 399. Review of the Diabetic Flow sheet for November 2016 showed the resident was to have a CBG test at 7:30 a.m. every other day. The flow sheet showed to notify the physician of CBG less than 60 or greater than 399. The CBG reading for 11/16/16 was 445. Review of progress notes revealed no documention that notification to the resident's physician was made. Review of Resident #12's care plan dated 2/02/15 showed the problem as: resident HAS DIABETES. The goal was: resident will have no complications related to diabetes for the next 90 days. The approaches were: diabetic medication as ordered, monitor for side effects, CBG as ordered and monitor/document/report signs/symptoms of hypo/[MEDICAL CONDITION]. 6. In an interview on 11/21/16 at 11:30 a.m., the Director of Nurses acknowledged there was no documentation found to show staff notified Resident #10 and #12's physician of CBG readings outside the set parameters. 7. A facility policy titled, Change in a Resident's Condition or Status revised February 2014, provided on 11/28/16 at 3:30 p.m. revealed it included the following: 1. The Nurse Supervisor/Charge nurse will notify the resident's attending physician or on-call physician when there has been: .d. A significant change in the resident's physical/emotional/mental condition; e. A need to alter the resident's medical treatment significantly. .g. A need to transfer the resident to a hospital/treatment center. 2. A significant change of condition is a decline or improvement in the resident's status that a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self limiting). b. Impacts more than one area of the resident's health status. c. requires interdisciplinary review and/or revision to the care plan; ; and d. Ultimately is based on the judgment of the clinical staff and guidlelines outlined in the Resident Assessment Instrument. IMMEDIATE JEOPARDY 8. On 11/20/16 at 1:40 p.m. the Administrator was notified of an Immediate Jeopardy. The facility's Plan of Removal of Immedate Jeopardy was accepted on 11/23/16 at 11:00 a.m. and included the following: From 11/20/16 through 11/23/16, the facility provided an Administrative Nursing staff in the facility at the end of every shift to personally review all incidents, the 24-hour report, changes in resident condition, and any concerns voiced by staff, family, residents or visitors during the previous shift. All concerns were addressed as they occurred. Completed 11/23/16. The RN who failed to assess Residents #1, #2, and #3 was terminated. On 11/16/16 Resident #1 was sent to the hospital emergency room for treatment. On 11/14/16, Resident #2 was sent to the hospital emergency room for treatment. On 10/23/16, Resident #3 was sent to the hospital emergency room for treatment. All nurses have been in-serviced on follow-up and assessing any resident with a reports of a change of condition. Completed 11/22/16. All nurses were educated and in-serviced 11/22/16 on how to properly assess a resident. A head to toe assessment was implemented on 11/22/16 for all incidents and changes in condition. In-service included that a staff member will stay with all residents until a resident is stable or emergency medical technicians arrive on site. Staff were in-serviced 11/22/16 on reporting changes of condition or any voiced concerns by family members or visitors to the charge nurse immediately. Staff were given a list of numbers to call if they felt like action was not being taken with a resident on 11/22/16. Licensed nurses were in-serviced on 11/22/16 to contact the DON or designee regarding any incidents or changes of resident condition as they occur. The DON or designee will have a clinical meeting, with the clinical team every morning, Monday through Friday. Any resident on the 24-hour report will be reviewed for proper documentation, assessment and notifications. Findings will be reviewed monthly by Quality Assurance team quarterly until the satisfaction of the committee is achi

Based on interview and record review, the facility failed to provide the services necessry to avoid physical harm, mental anguish or mental illness for 3 of 8 residents (Residents #1, 2, and 3) reviewed for change of condition as evidenced by: a) failure to recognize and assess Resident #1 during the night beginning 11/6/16 and early morning hours of 11/7/16 when CNAs (certified nurse's aides) B and F reported that Resident #1, who was a diabetic, was non-responsive and exhibiting unusual thrashing in her bed throughout the night. Resident #1 was assessed the following morning at approximately 7:00 a.m. with a blood sugar of 45; b) failure to conduct a thorough nursing assessment of Resident #2 when CNAs B and F reported abdominal pain, vomiting, and diarrhea on 11/12/16 and 11/13/16. The physician was notified 11/14/16 and Resident #2 was admitted to the critical care unit with a partial bowel obstruction. c) failure to conduct a thorough nursing assessment of Resident #3 on 10/22/16 at approximately 3:00 a.m. when CNA I reported Resident #3 was in pain and when RN C observed Resident #3 hold his abdomen and fall to the floor due to abdominal pain. Resident #3 was sent to the hospital with abdominal pain and vomiting a brown substance on 10/23/16 and diagnosed with [REDACTED]. An Immediate Jeopardy (IJ) was identified on 11/20/16. While the IJ was removed on 11/23/16, the facility remained out of compliance at a level of actual harm that is not Immediate Jeopardy at a pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. These failures resulted in a delay of medical treatment, pain, and discomfort for Residents #1, 2, and 3, who resided on the secured units of the facility and could affect the 40 residents that reside on the secure units (Halls C, E, and F) and result in pain, decline in health, or death. Findings included: 1. An undated computer face sheet documented Resident #1 was a [AGE] year old female admitted to the facility 2/18/16 with Mild Intellectual disability, major [MEDICAL CONDITION], persistant mood disorder, diabetes mellitus, [MEDICAL CONDITION] disorder, anxiety disorder, hypertension, [MEDICAL CONDITION], reflux disorder and pruritis. A Minimum Data Set (MDS) Assessment date 8/29/16 documented that Resident #1 had a brief interview for mental status score of 03 indicating severe cognitive impairment. Resident #1 used a wheelchair for mobility. She required limited assistance of two staff to transfer, and extensive assistance of one staff for personal hygeine, dressing and toilet use. She had range of motion limitation for both lower extremities. She was always incontinent of bowel and bladder. Physician's orders 10/1/16-11/30/16 documented Resident #1 was prescribed checks of her blood sugar twice daily at 7:00 a.m. and 5:00 p.m. with [MEDICATION NAME] R insulin to be administered on a sliding scale based on the blood sugar reading. She was also prescribed [MEDICATION NAME] 40 units subcutaneous once daily at 7:00 a.m. Physician's orders documented to notify the physician for a blood sugar less than 40 or greater than 450. Resident #1's care plan with a review date of 9/13/16 included the following: Problem: Resident is at risk for frequent infections, pressure/venous-statis ulcers, vision impairment, hyper/[DIAGNOSES REDACTED], [MEDICAL CONDITION], cognitive/physical impairment, slow healing process skin desensitized to pain or pressure related to diabetes mellitus. .Approach start date 9/13/16: Assess/record/report to MD prn (as needed): [DIAGNOSES REDACTED] s/sx (signs/symptoms) : tremors, shaking, confusion, headache, irritability, hunger, n/v (nausea/vomiting), cool, clammy, pale skin, and diaphoresis. [MEDICAL CONDITION] s/sx: extreme thirst, frequent urination, abnormal pain, blurred vision, dry flushed skin, rapid breathing. A review of nurse's notes for Resident #1 revealed they included the following entries on 11/7/16: Late entry at 1:15 p.m.: At 0700 (7:00 a.m.) CBG read 45 mg/dL. Res lethargic, unable to open eyes, follow commands, or answer questions. Res given [MEDICATION NAME] injection IM (intramuscular) in Rt. delt (deltoid). Re-checked at 0800 (8:00 a.m.) CBG (capillary blood glucose) read 154 mg/dL. (Noted by LVN D). 8:00 a.m.: While on the phone with 911 operator to send res (resident) out for first fall, second nurse reported to this nurse res had fallen out of bed a second time. CNA found res on floor beside bed in prone position. Upon assessment, res left on floor and pillow placed under head. No new injuries noted from second fall. CBG (capillary blood glucose) read 154 mg/dL. VS (vital signs) T (temperature) 97.5, R (respirations) 22, BP (blood pressure) 110/76, P (pulse) 116. x2 EMTs (emergency medical technicians) on unit at 0805 and left unit with res via stretcher at 0815. (Noted by LVN D). 10:58 a.m.: Res (Resident) found on floor of room by CNA (certified nurse's aide). ROM (range of motion) x 4. VS (vital signs) BP (blood pressure) 128/76, P (pulse) 117, R (respiration) 22 regular. Blood noted to face, under nose, and lt (left) hand. S/T (skin tear) noted to lt post proximal 3rd digit. Nose displaced to rt. (right) side. Large hematoma noted under lt eye. Res weak and speech slurred. Neuros initiated. Res placed back onto bed at this time. All appropriate notifications made. Awaited call back from guardian and Dr. (name). Spoke with ADON and made the decision to send res out to (hospital) ER for eval and tx if necessary. While on the phone with 911 operator, CNA reported res fell again. See second fall notes. 3:12 p.m.: Returned to facility from (hospital) at 1500 (3:00 p.m.) x2 assist via gurney . There were no nursing notes from RN C, who was charge nurse, or any other nursing notes entered for the night shift that began at 10:00 p.m. 11/6/16 and ended at 6:00 a.m. on 11/7/16. A hospital emergency department report dated 11/7/16 at 8:35 a.m. documented Resident #1 arrived at the emergency department with a chief complaint of a fracture to nasal bridge and hematoma to left cheek following a fall at the facility. Findings following a CT scan included: Angulated nasal bone fracture. During an interview on 11/19/16 at 6:30 p.m., CNA (certified nurse's aide) B said that she worked the night shift on 11/6/16 - 11/7/16 (Sunday night to Monday morning) with Resident #1. CNA B said that she began noticing Resident #1 acting very unusually and thrashing about in her bed not long after the resident went to bed. She said it was much more than tossing and turning, but almost violently thrashing. She said Resident #1 would do this and then seem to go to sleep, only to start doing it again. CNA B said she told RN (Registered Nurse) C she was very concerned that something was wrong with Resident #1. CNA B said RN C would say okay but did not go down and check on Resident #1. She said she went to him three separate times throughout the night, and the last time he had just smiled at her, and said, Oh, I've seen her like that before. CNA B said RN C was sitting in a chair writing something at the nurse's station and he never left the nurse's station. CNA B said she gave up on asking him after the third time, but when the morning shift came on, she personally told the oncoming nurse and the oncoming CNA (CNA A) her concerns. During an interview on 11/20/16 at 3:00 p.m., CNA F said she was working the night shift on 11/6 - 11/7/16 on a different hall than CNA B. She said she was at the nurse's station and did hear CNA B tell RN C multiple times that Resident #1 was not responding and was all over the bed. CNA F said CNA B was very worried, and even asked CNA F to come down and look at Resident #1. She said she did, and CNA B was right, Resident #1 would not talk or respond. She said she never saw RN C get up to go to the unit to see the resident. CNA F said, You report stuff and nothing gets done. She said that RN C played on his cell phone all night, stating, That's all he does. During interviews on 11/17/16 at 10:30 a.m. and 11/18/16 at 12:15 p.m., CNA A said that when she came to work at 6:00 a.m. on 11/7/16, she heard RN C (the night nurse) telling LVN D (the day nurse) during shift change that Resident #1 was acting out, wanted attention, and there was nothing wrong with her. She said CNA B (who had worked the night shift) asked her to check on Resident #1 because she told her there was something not right about Resident #1. She said CNA B told her that she could not get RN C to check the resident because he thought Resident #1 was just wanting attention. CNA A said she knew Resident #1's symptoms of [DIAGNOSES REDACTED] and she was immediately concerned with what CNA B was saying, so she went to look at Resident #1. She said Resident #1 could barely move, and the way she was talking I knew she was not herself. She said she immediately notified the nurse. CNA A said that LVN D checked Resident #1's blood sugar and it was 32 or 34 and this was a few minutes before the breakfast carts arrived at 7:00 a.m. CNA A said after LVN D checked on Resident #1, Resident #1 was left in her bed. CNA A went to pass out breakfast trays as she was the only staff left on the secure unit. She said a few minutes after she left Resident #1's room, the therapy staff came and told her Resident #1 was on the floor. She found Resident #1 face down on the floor with blood on the floor around her face. She had the staff member get LVN D again. LVN D and LVN E came to Resident #1's room and assessed Resident #1 for injuries and they put her in bed again. CNA A said she left the room again and both LVN D and LVN E left the secure unit. She said Resident #1 then fell out of her bed again, face forward as before. CNA A said she did stay with Resident #1 after the second fall until the ambulance came. During an interview on 11/20/16 at 8:00 a.m. RN C first stated that he did not remember receiving any reports from CNAs regarding Resident #1's condition on the night of 11/6/16. When discussing whether he remembered CNA B reporting concern regarding Resident #1 thrashing in bed, he said, More or less. When discussing whether he remembered the report being made to him multiple times, he said she might have. RN C then stated he went on to the secure unit and saw Resident #1 that night some time around or right after midnight. He said he thought she was asleep, and he turned her over and she looked at him so he did not see a problem. When specifically asked if he assessed the resident's blood sugar or vital signs, he said he only checked her oxygen and it was normal. RN C said, I didn't see anything out of order. She's always been a problem child and it's not unusual for her to have bizarre behavior. He said he saw no reason to further assess or call the doctor. RN C said it never occurred to him to check Resident #1's blood sugar, but now states he should have checked it. During an interview on 11/18/16 at 5:10 p.m. the DON (Director of Nurses) said he was aware that RN C had been told about Resident #1's condition during the night on 11/6/16 - 11/7/16 and was aware RN C had not assessed to identify a change of condition and had not acted to inform the physician. The DON said, I counselled him. He stated that he knew Resident #1 fell forward on to the floor 11/7/16, and he thought it had something to do with her blood sugar. The DON said he was aware Resident #1 was left alone twice after she was found to have low blood sugar, and that each time she had fallen. He also stated he knew the resident had never been re-assessed to determine if her blood sugar had stabilized before she was left alone. During an interview on 11/28/16 at 3:05 p.m., Resident #1's physician said she was notified of Resident #1's condition the day she was sent to the hospital. Her physician stated that if Resident #1 exhibited a change of condition during the night she should have been assessed every 15 minutes and if her condition did not improve, the physician should have been notified. 2. An undated computer face sheet for Resident #2 documented she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set assessment dated [DATE] documented Resident #2 had a Brief Interview for Mental Status score of 12 indicating she had moderate cognitive impairment. She required only supervision for dressing, eating, toilet use, and transfer. She was ambulatory without an assistive device. She was occasionally incontinent of bladder and frequently incontinent of bowel. A care plan for Resident #2, last reviewed on 10/17/16 documented that Resident #2 exhibited manipulative behaviors related to [MEDICAL CONDITION], including chronic health complaints. A hospital emergency department (ED) report for Resident #2 dated 11/14/16 documented Resident #2 entered the emergency department on 11/14/16 at 3:19 p.m. Her chief complaint was documented as abdominal pain and swelling with diffuse abdominal pain for the past several days. Under Clinical History the hospital report documented Abdominal pain. Abdominal distention for 1 week. History of ulcer surgery and hysterectomy. Triage notes documented that Resident #2 complained of a 10/10 pain level in the left upper quadrant and left lower quadrant of her abdomen radiating to the back. Resident #2 complained of nausea, vomiting diarrhea, weakness, and dizziness. Prior treatment included antacid. Hospital ED nursing notes dated 11/14/16 at 3:59 p.m. documented that Resident #2's abdomen was distended and tender, and bowel sounds were hypactive in all four quadrants. At 5:45 p.m. a bladder scan revealed more than 999 mL in the bladder and the physician confirmed the appropriateness of an indwelling foley catheter. On 11/14/16 at 22:10 (10:10 p.m.) the hospital ED report documented [DIAGNOSES REDACTED]. She was admitted to the Intensive care unit/Critical Care unit on the surgical floor of the hospital. During an interview on 11/17/16 at 10:15 a.m. CNA A said Resident #2 was in the hospital. CNA A said Resident #2 was sick and throwing up last weekend (11/12/16 and 11/13/16), but stated, They didn't do anything. Nursing notes for 11/14/16 at 14:33 (2:33 p.m.) documented Resident #2 was vomiting [MEDICATION NAME] (sticky/thick), red specks and her blood pressure was 99/65, pulse was 113, respiration was 22 and labored, and temperature was 98.5. A telephone order dated 11/14/16 at 14:41 (2:41 p.m.) documented an order to send Resident #2 to the hospital for evaluation. During an interview on 11/17/16 at 4:00 p.m., LVN D said she was the nurse that sent Resident #2 out to the hospital on [DATE]. She said that CNA A reported to her that Resident #2's stomach was distended and she did not feel good. LVN D said she assessed Resident #2 and found her stomach was grossly distended. She said, She looked nine months pregnant. LVN D said Resident #2 told her she had been throwing up and she had told the staff but no one had checked on her. LVN D said she noticed Resident #2 gagging every time she would move. She contacted the physician and sent Resident #2 to the hospital. During an interview on 11/19/16 at 6:30 p.m. CNA B said that Resident #2 was throwing up on Saturday night (11/12/16) and she informed RN C. She said she thought he might have given Resident #2 some [MEDICATION NAME]. She said Resident #2 was complaining of her stomach hurting and going to the bathroom a lot. CNA B said that when she came to work Sunday night (11/13/16), Resident #2 was worse. CNA B said, She didn't look good. She said that Resident #2 was nauseated and throwing up so she had put a trash can next to Resident #2's bed. CNA B said she reported to RN C that Resident #2 was sick and throwing up. She said the emesis was red, but she thought the resident had drank a red drink. CNA B said she never saw RN C get up from the nurse's station or go check Resident #2. She said he did not ask her any questions about how many times the resident had thrown up or any other questions about her observations. CNA B said that she believed that because Resident #2 had mental issues, that the nurses never took her very serious. CNA B said, My opinion is he should have at least examined her. During an interview on 11/20/16 at 3:00 p.m., CNA F said she worked the night shift on Sunday, 11/13/16 on a different hall than CNA B. She said she had gone on the secure unit and had seen that Resident #2 was in distress. CNA F said she told RN C that Resident #2 was crying in pain and vomiting. CNA F said that she and CNA B had explained to RN C that Resident #2's pain was different than her usual complaints of pain. CNA F said RN C never went to check on Resident #2 on Sunday night. During an interview on 11/19/16 at 12:30 p.m., CNA G said she worked the day shift with Resident #2 on the weekend of 11/12/16 and 11/13/16. She said that Resident #2 was incontinent and wearing a brief because of small episodes of diarrhea. She said this was upsetting to Resident #2 since this was not normal for her. She said that Resident #2 kept complaining of nausea, and this was occurring both on Saturday and Sunday. She said she told the medication aide, but she did not tell the nurse. During an interview on 11/19/16 at 4:00 p.m., LVN K said she worked the day shift on the weekend of 11/12/16 and 11/13/16 and she was never made aware that Resident #2 was spitting up, throwing up, or having diarrhea. She said Resident #2 never complained and if they had told her these things, she definitely would have addressed it. During an interview with RN C on 11/20/16 at 8:00 a.m., when discussing whether he had received reports of Resident #2's nausea, vomiting, and diarrhea during the weekend of 11/12-11/13/16, he stated, She's very drug seeking. She was seeking her 2:00 a.m. [MEDICATION NAME] and she complained of constipation. He said he checked her bowel sounds and the lower left was slow but the others were active. When discussing whether CNA B had reported her concerns and observations to him on Saturday and Sunday night, RN C said, I'm sure she said she was asking for her pain pill. RN C said he checked on her Sunday night, but he did not even remember what had happened on Saturday night. He said that the reason he listened to her bowel sounds was because Resident #2 said she felt bloated. He said he did not document anything in the nursing notes or notify the physician because he did not find anything wrong. When discussing that Resident #2 was hospitalized and placed in the critical care unit on Monday, RN C said, But you have to know (Resident #2) like I do. Most of her complaints turn out to be nothing. During an interview on 12/1/16 at 9:00 a.m. LVN H said he was working with RN C on the weekend nights of 11/12/16 and 11/13/16. He said he heard the nurse aides reporting Resident #2's change of condition to RN C. He said they asked RN C several times to look at Resident #2, but LVN H said he never saw whether RN C checked on Resident #2 or not. LVN H said the CNAs asked him to check on her also, and he told them, He's an RN and I'm not stepping on his toes. A review of facility nursing notes for Resident #2 revealed there were no nursing entries documenting a change of condition or notification of the physician for Saturday 11/12/16 or Sunday 11/13/16. A review of physician's telephone orders for Resident #2 revealed no physician's orders for 11/12/16 or 11/13/16. During a return telephone call from Resident #2's physician on 12/6/16 at 3:00 p.m., Resident #2's physician said that the first notification of Resident #2's condition that she received was on 11/14/16 when Resident #2 was sent to the hospital. Resident #2's physician said that the symptoms described on 11/12/16 and 11/13/16 indicated an acute abdomen and anytime that situation existed, it warranted a call to her. She said that she was available to the facility 24 hours a day, 7 days a week and there was no excuses not to notify her of changes of condition at any time. According to Resident #2's medical record (nursing notes and physician's orders for November 2016) Resident #2 remained in the hospital for the duration of this investigation and was not available for interview. 3. An undated face sheet for Resident #3 documented he was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set Assessment for Resident #3 dated 10/17/16 documented a brief interview for mental status score of 12 indicating Resident #3 had moderately impaired cognitive functioning. He had no indicators of [MEDICAL CONDITION] and no behavioral symptoms identified. Resident #3 required limited assistance from staff for mobility, transfer, dressing, eating, toilet use, and personal hygeine. He was ambulatory and did not use a mobility device. Facility nursing notes included the following: 10/22/16: Resident complaining of abdominal pain and nausea. Gave resident [MEDICATION NAME]. Resident has had no vomiting at this time. Will continue to monitor. (Noted by RN C). 10/23/16 at 0420 (4:20 a.m.): At 0255, CNA I reported resident with c/o (complaints of) abdominal pain and cramping. Upon entering resident's room I noted he was laying with left side down. He was holding/guarding right abdominal area to the right of his umbilicus. Respirations were labored and uneven. At times resident would gasp loudly while breathing. Resident was grimacing, moaning, and rocking. When asked why he stated, I hurt. Resident has a small amount of brown emesis on the bed and floor. It has a moderate smell of feces. I auscultated his 4 quadrants and heard no bowel sounds. I digitally evaluated the resident for impaction, none felt. Stated last BM was yesterday. It was very firm and small in size, stated passing it was extremely difficult. I immediately had fell ow nurse (LVN D) auscultate the resident''s abdomen and she also noted the absence of bowel sounds. I asked CNA to please get the resident prepared for transport to (hospital) ER for eval and possible treatment. Physician was notified. (Noted by LVN H). A hospital Emergency Department report dated 10/23/16 documented Resident #3 entered with complaints of abdominal pain. The pain began suddenly two days prior was constant, and worsened in the last hours. The pain was described as 10/10. Resident #3 complained of vomiting a brown substance. Resident #3 was admitted to the hospital from the Emergency Department with [DIAGNOSES REDACTED]. During an interview on 12/1/16 at 10:45 a.m., CNA I said that on 10/22/16, he observed Resident #3 moaning and grimacing but Resident #3 kept saying he was okay. At approximately 3:00 a.m., Resident #3 was holding his abdomen and said he was in pain. CNA I said he went and told RN C about Resident #3's complaint. CNA I said that when RN C came to see Resident #3, Resident #3 collapsed to the floor. CNA I said, His stomach was hurting so bad, he couldn't stand. CNA I said that RN C did not check Resident #3's vital signs or listen to bowel sounds. He said he gave Resident #3 some [MEDICATION NAME]. During an interview on 11/20/16 at 8:00 a.m., RN C said that on 10/22/16 CNA I told him that Resident #3 had a problem. He said that when he went on the secure unit, Resident #3 was holding on the the hand rail on the wall, standing in the hallway. He said Resident #3 then sat on the floor and told RN C, My stomach's all messed up. When asked why he thought Resident #3 sat on the floor in the hallway, RN C said Resident #3 did it for effect. When asked if he meant that Resident #3 was being overly dramatic, RN C said, Oh absolutely. RN C said he did not assess bowel sounds or take vital signs. He said that he gave Resident #3 [MEDICATION NAME] and Resident #3 reported feeling better so he saw no reason to call the physician. An attempt to interview Resident #3 on 12/2/16 at 11: 35 a.m. was not successful. Resident #3 said he did not feel like talking. He complained that his back hurt. He said the nurse had already attended to him and given him medication, but it had not begun to work. During a return telephone call from Resident #3's physician on 12/6/16 at 3:00 p.m., she said that the best of her recollection was that she sent Resident #3 to the hospital when she was notified he had abdominal symptoms so she must have been notified 10/23/16 because that was the day he was sent. She said if she would have been notified on 10/22/16 that Resident #3 was having such pain in his abdomen she certainly would have sent him to the hospital immediately. 4. A facility policy titled, Acute Condition Changes - Clinical Protocol, Revised December 2012 , provided by the facility on 11/28/16 at 3:30 p.m. in response to a request for the facility's policy regarding nursing assessment of a resident with a change of condition, revealed it included the following: 5a. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident's current symptoms and status. 6. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one half hour or less). Under Monitoring and Follow up: 1. The staff will monitor and document the resident's progress and responses to treatment and the physician will adjust treatment accordingly. IMMEDIATE JEOPARDY 5. On 11/20/16 at 1:40 p.m. the Administrator was notified of an Immediate Jeopardy. The facility's Plan of Removal of Immedate Jeopardy was accepted on 11/23/16 at 11:00 a.m. and included the following: From 11/20/16 through 11/23/16, the facility provided an Administrative Nursing staff in the facility at the end of every shift to personally review all incidents, the 24-hour report, changes in resident condition, and any concerns voiced by staff, family, residents or visitors during the previous shift. All concerns were addressed as they occurred. Completed 11/23/16. The RN who failed to assess Residents #1, #2, and #3 was terminated. On 11/16/16 Resident #1 was sent to the hospital emergency room for treatment. On 11/14/16, Resident #2 was sent to the hospital emergency room for treatment. On 10/23/16, Resident #3 was sent to the hospital emergency room for treatment. All nurses have been in-serviced on follow-up and assessing any resident with a reports of a change of condition. Completed 11/22/16. All nurses were educated and in-serviced 11/22/16 on how to properly assess a resident. A head to toe assessment was implemented on 11/22/16 for all incidents and changes in condition. In-service included that a staff member will stay with all residents until a resident is stable or emergency medical technicians arrive on site. Staff were in-serviced 11/22/16 on reporting changes of condition or any voiced concerns by family members or visitors to the charge nurse immediately. Staff were given a list of numbers to call if they felt like action was not being taken with a resident on 11/22/16. Licensed nurses were in-serviced on 11/22/16 to contact the DON or designee regarding any incidents or changes of resident condition as they occur. The DON or designee will have a clinical meeting, with the clinical team every morning, Monday through Friday. Any resident on the 24-hour report will be reviewed for proper documentation, assessment and notifications. Findings will be reviewed monthly by Quality Assurance team quarterly until the satisfaction of the committee is achieved to ensure compliance. Implemented 11/22/16. The Administrator or Designee will review all incidents during morning meetings so that any issue that is reportable is immediately reported to the State authority. Initiated 11/22/16. An Administrative team member will be assigned to weekends and holidays to review incidents/accidents and the 24 hour report and make notification to the Administrator/Designee when there is a reportable incident identified. All trends will be reviewed in the weekly Quality Assurance meetings. Any resident specific interventions will be implemented and added to the resident's care plan such as one on one staff, every 15 minute checks, and/or adding another staff member if needed. All staff have been in-serviced on the guidelines for reporting abuse/neglect or change in resident's condition. The Administrator posted and distributed copies of a complete list of all numbers to contact if an employee, resident, or responsible party suspects abuse or neglect, including but not limited to the Administrator, Director of Nurses, Regional Director of Operations, and Regional Nurse. Completed 11/21/16. 6. Action Plan verification activities were conducted from 11/22/16 through 11/23/16and included the following activities: Review of in-service documentation, interview with nurses aides and nurses from various shifts to verify in-service understanding, review of nursing 24-hour reports and resident change of conditions through 11/23/16, and interview with the Director of Nurses regarding follow up of all resident issues identified on nursing reports. 7. The Administrator was notified that the IJ was removed on 11/23/16 at 11:00 a.m., but the facility remained out of compliance at a scope and severity level of Actual Harm at a pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 8. On 12/2/16 the facility provided a Census Worksheet that identified 40 residents residing on the secure units of the facility.

Based on interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #1), a resident on one of three of the facility's secure units, reviewed for incidents and accidents as evidenced by failure to supervise Resident #1 on 11/7/16 when she was assessed to have a low blood sugar and altered level of consciousness. Resident #1 was left alone twice and fell twice within a one hour period resulting in a broken nose. An Immediate Jeopardy (IJ) was identified on 11/20/16 at 1:40 p.m. While the IJ was removed on 11/23/16, the facility remained out of compliance at a level of actual harm that is not Immediate Jeopardy at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. These failures resulted in Resident #1's falls and injury (broken nose) and could affect the 40 residents that reside on the secure units (Halls C, E, and F) and could result in accidents and injury. Findings included: 1. An undated computer face sheet documented Resident #1 was a [AGE] year old female admitted to the facility 2/18/16 with Mild Intellectual disability, major depressive disorder, persistant mood disorder, diabetes mellitus, schizoaffective disorder, anxiety disorder, hypertension, [DIAGNOSES REDACTED], reflux disorder and pruritis. A Minimum Data Set (MDS) Assessment date 8/29/16 documented that Resident #1 had a brief interview for mental status score of 03 indicating severe cognitive impairment. Resident #1 used a wheelchair for mobility. She required limited assistance of two staff to transfer, and extensive assistance of one staff for personal hygeine, dressing and toilet use. She had range of motion limitation for both lower extremities. She was always incontinent of bowel and bladder. physician's orders [REDACTED].#1 was prescribed checks of her blood sugar twice daily at 7:00 a.m. and 5:00 p.m. with Novolin R insulin to be administered on a sliding scale based on the blood sugar reading. She was also prescribed Lantus insulin 40 units subcutaneous once daily at 7:00 a.m. Resident #1's care plan with a review date of 9/13/16 included the following: Problem: Resident is at risk for frequent infections, pressure/venous-statis ulcers, vision impairment, hyper/[DIAGNOSES REDACTED], renal failure, cognitive/physical impairment, slow healing process skin desensitized to pain or pressure related to diabetes mellitus. .Approach start date 9/13/16: Assess/record/report to MD (medical doctor) prn (as needed): [DIAGNOSES REDACTED] s/sx (signs/symptoms) : tremors, shaking, confusion, headache, irritability, hunger, n/v, cool, clammy, pale skin, and diaphoresis. Hyperglycemia s/sx: extreme thirst, frequent urination, abnormal pain, blurred vision, dry flushed skin, rapid breathing. A review of nurse's notes for Resident #1 revealed they included the following entries on 11/7/16: Late entry at 1:15 p.m.: At 0700 (7:00 a.m.) CBG (capillary blood glucose) read 45 mg/dL. Res lethargic, unable to open eyes, follow commands, or answer questions. Res given Glucagon injection IM (intramuscular) in Rt. delt (deltoid). Re-checked at 0800 (8:00 a.m.) CBG (capillary blood glucose) read 154 mg/dL. 8:00: While on the phone with 911 operator to send res (resident) out for first fall, second nurse reported to this nurse res had fallen out of bed a second time. CNA found res on floor beside bed in prone position. Upon assessment, res left on floor and pillow placed under head. No new injuries noted from second fall. CBG (capillary blood glucose) read 154 mg/dL. VS (vital signs) T (temperature) 97.5, R (respirations) 22, BP (blood pressure) 110/76, P (pulse) 116. x2 EMTs (emergency medical technicians) on unit at 0805 and left unit with res via stretcher at 0815. 10:58 a.m.: Res (Resident) found on floor of room by CNA (certified nurse's aide). ROM (range of motion) x 4. VS (vital signs) BP (blood pressure) 128/76, P (pulse) 117, R (respiration) 22 regular. Blood noted to face, under nose, and lt (left) hand. S/T (skin tear) noted to lt post proximal 3rd digit. Nose displaced to rt. (right) side. Large hematoma noted under lt eye. Res weak and speech slurred. Neuros initiated. Res placed back onto bed at this time. All appropriate notifications made. Awaited call back from guardian and Dr. (name). Spoke with ADON (Assistant Director of Nursing) and made the decision to send res out to (hospital) ER for eval and tx (treatment) if necessary. While on the phone with 911 operator, CNA reported res fell again. See second fall notes. 3:12 p.m.: Returned to facility from (hospital) at 1500 (3:00 p.m.) x2 assist via gurney . A hospital emergency department report dated 11/7/16 at 8:35 a.m. documented Resident #1 arrived at the emergency department with a chief complaint of a fracture to nasal bridge and hematoma to left cheek following a fall at the facility. Findings following a CT scan included: Angulated nasal bone fracture. During an interview on 11/19/16 at 6:30 p.m., CNA (certified nurse's aide) B said that she worked the night shift on 11/6/16 - 11/7/16 (Sunday night to Monday morning) with Resident #1. CNA B said she had concerns about Resident #1's condition most of the night as Resident #1 was thrashing about in bed and was not responding normally. She said she had reported to the night nurse but never saw him assess Resident #1 so she immediately reported her concerns to CNA A and LVN D when they arrived at 6:00 a.m. on 11/7/16 for the day shift. During interviews on 11/17/16 at 10:30 a.m. and 11/18/16 at 12:15 p.m., CNA A said that when she came to work at 6:00 a.m. on 11/7/16, she heard RN C (the night nurse) telling LVN (licensed vocational nurse) D (the day nurse) during shift change that Resident #1 was acting out, wanted attention, and there was nothing wrong with her. She said CNA B (who had worked the night shift) asked her to check on Resident #1 because she told her there was something not right about Resident #1. CNA A said she knew Resident #1's symptoms of [DIAGNOSES REDACTED] and she was immediately concerned with what CNA B was saying, so she went to look at Resident #1. She said Resident #1 could barely move, and the way she was talking I knew she was not herself. She said she immediately notified LVN D. CNA A said that LVN D checked Resident #1's blood sugar and it was 32 or 34 and this was a few minutes before the breakfast carts arrived at 7:00 a.m. CNA A said after LVN D checked on Resident #1, Resident #1 was left in her bed as LVN D left the secure unit, and she (CNA A) went to pass out breakfast trays as she was the only staff left on the secure unit. She said a few minutes after she left Resident #1's room, the therapy staff came and told her Resident #1 was on the floor. She found Resident #1 face down on the floor with blood on the floor around her face. She had the staff member get LVN D again. LVN D and LVN E came to Resident #1's room and assessed Resident #1 for injuries and they put her in bed again. CNA A said she left the room again and both LVN D and LVN E left the secure unit and Resident #1 was left alone a second time. She said Resident #1 then fell out of her bed again only a few minutes later, face forward as before. CNA A said she did stay with Resident #1 after the second fall until the ambulance came. During an interview on 11/18/16 at 10:45 a.m. LVN D said that she was charge nurse for Resident #1 on 11/7/16 when she had a low blood sugar and fell . She said that CNA A reported Resident #1 had a change of condition and that she checked the resident's blood sugar at approximately 7:00 a.m. with a result of 45, which was low. She said Resident #1 was slurring, not opening her eyes and was having involuntary movements. She said she left the unit to go get a Glucagon shot. LVN D acknowledged that she left Resident #1 and told CNA A that the Glucagon shot would bring the resident's blood sugar up slowly. She said that between 7:00 a.m. and 8:00 a.m., Resident #1 fell twice in her room. She said she could not remember the exact timeline of events, only that everything happened in a very short time. She said after Resident #1's first fall, she assessed Resident #1 and told CNA A to put the resident back in bed. LVN D said she left the secure unit stating she did not know what went on after she left, except that within minutes Resident #1 had fallen again. LVN D acknowledged she did not instruct anyone to stay with Resident #1 and monitor her before the first fall, or before the second fall. After the second fall, CNA A did stay with Resident #1 until the ambulance arrived. She said Resident #1's blood sugar was checked before the ambulance arrived at approximately 8:00 a.m. and it was 154, which was okay. During an interview on 11/18/16 at 9:45 a.m., LVN E said that she was assisting LVN D on 11/7/16 when Resident #1 fell from her bed. She said she was went to the resident's room when Resident #1 had a low blood sugar and then fell . She said she did knew Resident #1 had a low blood sugar but she did not know and was not there when LVN D administered the Glucagon shot. She said Resident 1's blood sugar was in the 30's. She did respond when Resident #1 fell the first time and did see Resident #1 on the floor. She stated that she had helped CNA A put Resident #1 back in her bed. LVN E said after putting Resident #1 back to bed, she left the unit with LVN D to assist her. She said that within only about ten minutes they were told Resident #1 fell again. Once again she went down the hall to see that Resident #1 had fallen face down from her bed again. She said Resident #1 had a hematoma to her eye and her nose was bloody. When discussing why Resident #1 was left alone in her room after having been assessed to have low blood sugar, LVN D said she did not know. LVN D acknowledged that someone should have stayed with Resident #1 until she was stable or sent to the hospital. During an interview on 11/18/16 at 5:10 p.m. the DON (Director of Nurses) stated that he knew Resident #1 fell forward on to the floor 11/7/16, and he thought it had something to do with her blood sugar. The DON said he was aware Resident #1 was left alone twice after she was found to have low blood sugar, and that each time she had fallen. He also stated he knew the resident had never been re-assessed to determine if her blood sugar had stabilized before she was left alone. He stated he told LVN D she should not have left the resident alone. During an interview on 11/20/16 at 1:30 p.m. the Administrator said that although she was made aware of the incident, she focused her attention on ensuring the resident got to the hospital, neuro checks were done, and that proper monitoring took place when she returned from the hospital. She said she was not fully aware of all the details of the incident, and did not know Resident #1's nose was broken during one of her falls. The Administrator stated she also was not aware that Resident #1 had been left alone when the falls took place and she thought they were witnessed falls. She said she did not find out until yesterday that Resident #1 was left alone. She said, That shouldn't have happened. She said that the DON forgot to mention that Resident #1 was given a Glucagon shot then left alone. 2. A facility policy titled Falls-Clinical Protocol Revised April 2013 included the following: 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. .c. After a first fall, the staff (and physician when possible) should watch the individual rise from a chair without using his or her arms, walk several paces, and return to sitting. If the individual has no difficulty or is unsteady in performing this test, additional evaluation should occur. 2. If the cause of a fall is unclear, if the fall may have a significant medical cause such as a stroke or an adverse drug reaction, or if the individual continues to fall despite attempted interventions, a physician will review the situation and help identify contributing causes. Under the heading, Assessing Falls and their Causes the following was included: The staff, with the physician's guidance will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. .When a resident ralls, the following information should be recorded in the resident's medical record: .6. Appropriate interventions taken to prevent future falls. IMMEDIATE JEOPARDY 3. On 11/20/16 at 1:40 p.m. the Administrator was notified of an Immediate Jeopardy. The facility's Plan of Removal of Immedate Jeopardy was accepted on 11/23/16 at 11:00 a.m. and included the following: From 11/20/16 through 11/23/16, the facility provided an Administrative Nursing staff in the facility at the end of every shift to personally review all incidents, the 24-hour report, changes in resident condition, and any concerns voiced by staff, family, residents or visitors during the previous shift. All concerns were addressed as they occurred. Completed 11/23/16. On 11/16/16 Resident #1 was sent to the hospital emergency room for treatment. All nurses have been in-serviced on follow-up and assessing any resident with a reports of a change of condition. Completed 11/22/16. All nurses were educated and in-serviced 11/22/16 on how to properly assess a resident. A head to toe assessment was implemented on 11/22/16 for all incidents and changes in condition. In-service included that a staff member will stay with all residents until a resident is stable or emergency medical technicians arrive on site. Staff were in-serviced 11/22/16 on reporting changes of condition or any voiced concerns by family members or visitors to the charge nurse immediately. Staff were given a list of numbers to call if they felt like action was not being taken with a resident on 11/22/16. Licensed nurses were in-serviced on 11/22/16 to contact the DON or designee regarding any incidents or changes of resident condition as they occur. The DON or designee will have a clinical meeting, with the clinical team every morning, Monday through Friday. Any resident on the 24-hour report will be reviewed for proper documentation, assessment and notifications. Findings will be reviewed monthly by Quality Assurance team quarterly until the satisfaction of the committee is achieved to ensure compliance. Implemented 11/22/16. The Administrator or Designee will review all incidents during morning meetings so that any issue that is reportable is immediately reported to the State authority. Initiated 11/22/16. An Administrative team member will be assigned to weekends and holidays to review incidents/accidents and the 24 hour report and make notification to the Administrator/Designee when there is a reportable incident identified. All trends will be reviewed in the weekly Quality Assurance meetings. Any resident specific interventions will be implemented and added to the resident's care plan such as one on one staff, every 15 minute checks, and/or adding another staff member if needed. All staff have been in-serviced on the guidelines for reporting abuse/neglect or change in resident's condition. The Administrator posted and distributed copies of a complete list of all numbers to contact if an employee, resident, or responsible party suspects abuse or neglect, including but not limited to the Administrator, Director of Nurses, Regional Director of Operations, and Regional Nurse. Completed 11/21/16. 4. Action Plan verification activities were conducted from 11/22/16 through 11/23/16 and included the following activities: Review of in-service documentation, interview with nurses aides and nurses from various shifts to verify in-service understanding, review of nursing 24-hour reports and resident change of conditions through 11/23/16, and interview with the Director of Nurses regarding follow up of all resident issues identified on nursing reports. 5. The Administrator was notified that the IJ was removed on 11/23/16 at 11:00 a.m., but the facility remained out of compliance at a scope and severity level of Actual Harm at a scope of a pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 6. On 12/2/16 the facility provided a Census Worksheet that identified 40 residents residing on the secure units of the facility.

Based on observations, interviews and record reviews the facility failed to provide adequate supervision and monitoring for 1 of 3 residents (#1) reviewed for accidents and supervision. · Resident #1, who was known to have wandering and exit seeking behaviors, was left alone at the dialysis clinic where he exited the clinic without the knowledge of the clinic or the facility on 01/05/16. Later that day Resident #1 was found by the police in the street sitting on his wheelchair around 10:00 p.m. Resident #1 was transferred by the Emergency Medical Services (EMS) to a local hospital where he was admitted for hypothermia (Condition of having an abnormally low body temperature, typically one that is dangerously low). Resident #1 had a history of [REDACTED]. The dialysis clinic is located next to a six lane street with 40 miles per hour limit that Resident #1 apparently crossed to get to the place where he was found by the police. An Immediate Jeopardy (IJ) was identified on 01/13/16. The IJ was removed on 01/14/16 but the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to monitor its corrective action for effectiveness. These failures could affect any of the 3 residents identified by the facility as possible flight risks by placing them at risk of leaving the doctor's or dialysis office without being seen by staff in situations that might lead to serious injury or death. Findings Include: Record review of resident #1's record of admitted d 07/15/14 indicated he was admitted to facility on 03/16/10 with [DIAGNOSES REDACTED]. He was [AGE] years of age Record review of Resident #1's Minimum Data Set ((MDS) dated [DATE] indicated in part; · Brief Interview Mental Status (BIMS) = 4 (indicating severe impairment). · Transfer: how resident moves between surfaces including to or from bed, chair, wheelchair, standing position = 2 (limited assistance) and 2 (indicating one person physical assist). · Balance during transitions and walking: Moving from seated to standing position, walking, surface to surface transfer = 0 (indicating steady at all times). · Mobility devices = Wheelchair. Record review of Resident #1's care plan dated 12/02/14 indicated in part; · Focus: Resides on secure unit due to wandering and exit seeking. Date initiated 12/02/14. · Goal: Maximum safety with no incidents over the next 90 days. Review at next care conference. Target date - 02/29/16. · Interventions: Resident will wander in the safety of the secure unit, staff to monitor. · Goal: The resident will have no signs or symptoms of complications from dialysis for the next 90 days. Review at next care conference. Target date - 02/29/16. · Interventions: monitor labs and report to doctor as needed, monitor vital signs, notify doctor of significant abnormalities. The facility's care plan for Resident #1 did not address who or how he would be monitored or supervised while he was out of the facility at dialysis appointments. Record review of Resident #1's dialysis clinic schedule dated 08/24/15 indicated in part; · The new patient schedule will become effective 09/08/15. · Patient: Resident #1's new schedule time for treatment is- Tuesday-Thursday-Saturday. · Treatment time: 10:15 a.m. · Please have the patient arrive at the facility at: 10:00 a.m. Record review of Resident #1's nurses notes at the facility dated 01/05/16 completed by Licensed Vocational Nurse (LVN) B indicated in part; · 1800 (6:00 p.m.) CNA reported to this nurse that she was unable to locate resident in his room or on the secure unit. This nurse called dialysis clinic and spoke to the nurse who stated that resident was no longer at the clinic, but when this nurse asked if resident was sent to emergency room (ER) from the clinic the nurse said no, this nurse then called the hospital who told this nurse that resident had been admitted to the hospital. Record review of Resident #1's EMS report dated 01/05/16 indicated in part; · EMS dispatched to hypothermia, upon arrival we found patient with police department. Patient had been found in the middle of the street in a wheelchair. Patient had been left unattended for at least half an hour he said. · Dispatch notified 21:52 (9:52 p.m.). · Depart scene 22:13 (10:13 p.m.). · At destination (hospital) 22:20 (10:20 p.m.). Record review of Resident #1's hospital ER records dated 01/05/16 indicated in part; · DOS (Date of Service): 01/05/16, 22:23 (10:23 p.m.) · Chief complaint: Cold exposure. · The patient presents after approximately 30 minutes generalized exposure to moderate wet cold. The temperature was 89 degrees Fahrenheit (Refering to Resident #1's body temperature of 89 degrees Fahrenheit. Normal body temperature averages 98.6 degrees. With hypothermia, core temperature drops below 95 degrees. In severe hypothermia, core body temperature can drop to 82 degrees or lower.) Affected areas include generalized over the head/face hands, feet and arms. Patient appears to have a mild altered mental status. Patient states he was outside waiting for his son. He is from out of town. Patient is not complaining of pain or tingling at this time. · Nurses notes 01/05/16, 22:40 (10:40 p.m.) Patient was brought in via EMS. They state he was sitting in a wheelchair in the middle of the sidewalk. He was incontinent of urine, cold, wet and mildly altered in mental status. · History of present illness (HPI): 01/05/16, 23:19 (11:19 p.m.). Patient was found by police in wheelchair in street with no one around. Patient states he was visiting son who is attending school in town. Patient states he lives in East Texas and just arrived here today to visit. Symptoms include: Altered mental status, incontinence, altered level of consciousness, no chest pain. Prior related problems include: Recent hospitalization , history of dialysis. During an interview on 01/06/16 at 2:45 p.m. Certified Nurse Aide (CNA) A said on 01/05/16 she was the aide for the 2:00 p.m. till 10:00 p.m. shift and assigned to hall F (male resident secure hall) where Resident #1 resided. CNA A said she noticed Resident #1 was not in his room or anywhere in the hall. CNA A said she asked LVN B between 4:30 p.m. and 5:00 p.m., if he knew where Resident #1 was at. LVN B said Resident #1 was probably still out at the dialysis clinic. CNA A said Resident #1 is usually back to the facility between 4:00 p.m. and 5:00 p.m. when he is out to dialysis. During a telephone interview on 01/06/16 at 3:09 p.m. van driver D said he had dropped off Resident #1 at the dialysis clinic yesterday around 10:00 a.m. The van driver said that was how they usually did it and the clinic would call the facility when the resident was ready to be picked up. The van driver said the facility nurse had called him and asked him if he had picked up Resident #1 from dialysis yesterday. The van driver said the facility later found out the resident was at the hospital. During an interview on 01/06/16 at 3:42 p.m. the MDS coordinator C said she received a call from a different dialysis clinic on 01/05/16 that the 2 other residents were ready to be picked up. The MDS coordinator C said she told transport about it and they picked them up. The MDS coordinator C said she never received a call from the other clinic where Resident #1 was indicating he was ready to be picked up. The MDS coordinator said they usually called when he was ready. The MDS coordinator C said there was not one staff assigned to answer the phone, so whenever the dialysis clinic called whoever answered the phone at the facility would take the message and notify transport that the resident was ready. The MDS coordinator C said that one time she went to pick up Resident #1 at the dialysis clinic and found him outside of the clinic sitting on his wheelchair. The MDS coordinator C said the resident did not want to get in the van because she had not dropped him off and he refused to board the van. The MDS coordinator C said she had to call the previous Director of Nurses (DON) and she came out and was able to get him in her car and back to the facility. The MDS coordinator C said she did not recall telling the DON she had found Resident #1 waiting outside of the clinic for them. The MDS coordinator C said when the DON arrived at the clinic they were waiting outside so the DON might have thought that she wheeled him out of the clinic. During an interview on 01/06/16 at 3:58 p.m. LVN B said he was the nurse for F hall where Resident #1 resided on 01/05/16 for the 2:00 p.m. to 10:00 p.m. shift. LVN B said CNA A came and asked him if he knew where Resident #1 was at. LVN B said he told her that Resident #1 was probably still at dialysis. LVN B said he called the dialysis clinic around 5:00 p.m. and asked if Resident #1 was ready to be picked up. LVN B said the nurse at the clinic told him Resident #1 was not there. LVN B said he then called the transport staff and asked them if they had picked him up to which they said no. LVN B said he called the clinic again and spoke with the same nurse again. LVN B said the clinic nurse told him that he had wheeled Resident #1 into the lobby and left him there. LVN B said he asked the nurse if he could please go check the lobby to see if he was there. LVN B said the clinic nurse went and checked and told him that Resident #1 was not in the lobby. LVN B then asked the clinic nurse if they had sent Resident #1 to the hospital which the clinic nurse answered no. LVN B said he then called the hospital around 5:15 p.m.--5:30 p.m. and asked if Resident #1 was there. LVN B said the hospital staff told him that Resident #1 was at the hospital and had been admitted . During an observation on 01/06/16 at 4:22 p.m. the dialysis clinic had 2 entrances and exits. One of the entrances/exits consisted of double doors that have to be manually pushed to enter and exit the clinic. The other entrance/exit door was located in the lobby area. The lobby entrance/exit door had an automatic door mat that swung the door open when stepped on. The lobby area is out of view from the actual clinic area. There were no cameras observed in the lobby area. During an interview on 01/06/16 at 4:31 p.m. the dialysis clinic Administrator said that on 01/05/16 he had seen that Resident #1 was still at the clinic around 5:00 p.m. The Administrator said he asked the nurse if he had called the facility to come pick up Resident #1. The Administrator said the nurse told him that he had already called and they were not here yet. The Administrator said they usually did not put Resident #1 out in the lobby and they usually kept him in the back until they came to pick him up. The Administrator said Resident #1 could be combative at times. The Administrator said they could not forcibly keep the resident from exiting the clinic. The Administrator said he told his staff if that happened to just call the police. The Administrator said they were not responsible for monitoring the resident once he was out in the lobby. During an interview on 01/06/16 at 4:54 p.m. clinic tech 1 said she remembered seeing Resident #1 in the clinic area on 01/05/16. Tech 1 said they did not wheel Resident #1 out to the lobby. Tech 1 then said the clinic nurse asked her to check the lobby for Resident #1 around 5:30 p.m. and when she checked the resident was not there. During an interview on 01/06/16 at 5:02 p.m. clinic tech 2 said he had wheeled Resident #1 out into the lobby on 01/05/16. Tech 2 said the nurse had called the facility to tell them that Resident #1 was ready to be picked up around 3:00 p.m. and then again at 4:00 p.m. During an observation on 01/07/16 at 10:30 a.m. Resident #1 was in the hospital being dialyzed at the hospital in their in house dialysis clinic. Resident #1 was in bed watching television. Resident #1 was awake, alert and pleasantly confused with hospital staff at bedside. During an interview on 01/07/16 at 10:31 a.m. Resident #1 said he did not remember how he got to the hospital. Resident #1 said he did not remember being cold the day before or out in the street. Resident #1 said he kind of remembered going to dialysis and a white van dropping him off but that was all (Note: Surveyor had to do some prompting to help resident recall). During an observation on 01/07/16 at 2:02 p.m. the area where Resident #1 was found according to EMS was visited. In order for the resident to reach that area he has to cross a street with 6 lanes, which consists of 3 coming, 2 going and one center turning lane. The speed limit posted is 40 miles an hour. It is not sure at what time the resident crossed this street on 01/05/16. This particular street is known to have a high traffic rate during the 5 o'clock rush hour but then calms down around 6:00 p.m. Across this street are restaurants and several bank business areas with one apartment complex. There is an S shaped private road made of brick with sidewalks on both sides. This area is usually low traffic. According to the National Weather Service the temperature on 01/05/16 at 6:00 p.m. was 55 degrees Fahrenheit and at 9:00 p.m. it was 48 degrees. During a telephone interview on 01/07/16 at 2:20 p.m. the clinic nurse said he had called the facility to notify them that Resident #1 was ready to be picked up. The nurse said he remembered the facility nurse LVN B calling on 01/05/16 around 6:00 p.m. to ask if Resident #1 was at the clinic and if they had sent Resident #1 to the hospital. The clinic nurse said he told LVN B that Resident #1 was not at the clinic and they had not sent him to the hospital. The clinic nurse said he went to check the lobby and Resident #1 was not in the lobby. The clinic nurse said he had not pushed Resident #1 out to the lobby. The clinic nurse said Tech 1 told him that resident #1 was out in the lobby earlier that day. The clinic nurse said the nurses' station was located in the back and you could not view the lobby from there. The clinic nurse said as far as he knew there was no sign in or sign out sheet for residents at the clinic. The clinic nurse said he had done a water check (task performed by dialysis staff to test the water to make sure it's within regulatory compliance) and remembered seeing Resident #1 out in the lobby at that time. (The Administrator provided the time of the water check time performed and it was 5:15 p.m.). During an interview on 01/07/16 at 4:30 p.m. the facility interim DON said they were not able to locate a policy for dialysis but they were in the process of constructing one. The interim DON said the previous facility Administration (Administrator, DON and ADON) had purposely removed a lot of the facility policies so they were having to redo them. The interim DON said the new company had just taken over the facility on January 1st 2016 and this was her second day there. During an interview on 01/07/16 at 4:32 p.m. the Regional Nurse said they had just completed the dialysis policy and they were having a meeting with the dialysis clinic to go over the agreement. The Regional Nurse said they were going to start sending someone from the facility to sit with Resident #1 when he went for treatment. During an interview on 01/07/16 at 5:46 p.m. LVN B said he did call the hospital around 5:00 p.m. and 6:00 p.m. on 01/05/16. LVN B said he was sure it was not after 10:00 p.m. because the sun was still out. LVN B said the hospital ER staff told him that Resident #1 was at the hospital at that time. LVN B said he then told the Regional Nurse and the interim DON that Resident #1 was at the hospital. LVN B said the time of 6:00 p.m. noted on his nurse's notes was from when he actually wrote the note, not when the CNA notified him that Resident #1 was not in the secure unit. LVN B said he had been working at the facility since 2007. LVN B said he did not recall if Resident #1 had been admitted directly to the secure unit. LVN B said Resident #1 was exit seeking and that was probably why he was currently in the secure unit. During an interview on 01/07/16 at 5:52 p.m. CNA A said she had told LVN B that Resident #1 was not in the secure unit around 4:30 p.m. and 5:00 p.m. on 01/05/16. CNA A said Resident #1 usually kept to himself. CNA A said Resident #1 usually got up to go eat and then back to his room and that he seldom spent time out of his room. During an interview on 01/07/16 at 6:00 p.m. the Regional Nurse said LVN B had called the hospital on [DATE] and they told him that Resident #1 was at the hospital. The Regional Nurse said LVN B called the hospital around 5:00 p.m. and 6:00 p.m. The Regional Nurse said that the dialysis clinic had sent Resident #1 before to the hospital from there and they had not notified the facility. During a telephone interview on 01/08/16 at 9:27 a.m. the hospital Social Worker (SW) said Resident #1 had been brought to the hospital around 10:00 p.m. on 01/05/16. The SW said there was no way the resident could have been at the hospital around 6:00 p.m. since he did not arrive till 10:00 p.m. During a telephone interview on 01/08/16 at 12:08 p.m. the facility's previous DON said she recalled going to the dialysis clinic to help the MDS coordinator C with Resident #1 sometime ago. The DON said when she arrived at the clinic Resident #1 and the MDS coordinator C were outside waiting for her. The DON said she was not aware the resident had been found outside of the clinic since the MDS coordinator C did not mention anything about it. Record review of the facility's undated policy and procedure Dialysis management and communication with the dialysis center provided by the Regional nurse on 01/07/16 indicated in part: · Communicate the dialysis center instructions to the resident, attending physician and the family/responsible party. · Ensure appropriate transportation is scheduled and posted at the designated place. · If necessary, ensure person available to accompany resident to and from dialysis center. · Upon return from the dialysis center-note concerns noted during treatment and any new instructions/orders. · Update the care plan appropriately according to any adjustments to the resident care. Record review of the facility's undated policy and procedure Dialysis communication form provided by the Regional nurse on 01/07/16 indicated in part: · This section: To be completed by the facility- Residents name-Facility-Any changes in condition or problems since last dialysis visit. · This section: To be completed by the dialysis unit-Concerns while at dialysis-Any special instructions. · Return completed form to facility with resident, include copy of latest laboratory results and telephone order form with orders listed. Record review of the facility's dialysis service agreement dated 09/09/2009 indicated in part: · This agreement for dialysis services is entered into between dialysis clinic and the facility. · The facility agrees to be responsible to notify provider of any medical changes pertinent to assist in resident care prior to dialysis treatment. · The dialysis clinic agrees to communicate to the facility results of labs monthly and any critical upon return from treatment. Clinic will communicate to the facility of any and all medical changes and/or information necessary to assist in resident plan of care. Clinic will communicate any teaching for monitoring resident following treatments to the facility. · This agreement is to ensure that clinic and the facility communication information pertaining to patient. · This contract will begin September 9, 2009 and automatically be renewed each year. This agreement may be cancelled by either party with 30 day written notice. · Signed by clinic Administrator and Facility Administrator. (Note: Facility Administrator no longer at this facility, New Corporation in process of obtaining new contract with the clinic, obtain signatures and will provide a copy when it is ready). Review of the facility's policy/ procedure and service agreement from above revealed that neither addressed who or how residents would be monitored or supervised while out of the facility at appointments. During an interview on 01/13/16 at 4:03 p.m. the Regional Nurse was informed of the IJ based on the lack of supervision to prevent accidents. The Regional Nurse said she understood the problem and would get on it right away to prevent that from happening again. Plan of removal was submitted on 01/14/16 at 3:15 p.m. a) One resident was identified as affected by this alleged deficient practice. b) Three residents have been identified as potential elopement risk with frequent physician appointments. c) The facility met with the Administrator of the dialysis clinic center on 01/11/16 and we came to an agreement that the following plan will be implemented as soon as the resident returns from the hospital. d) The resident will receive dialysis on Tuesday, Thursday and Saturday at 10am and will be finished by 2pm. The facility driver will accompany the resident to the dialysis center at 10am. The resident will be taken to the back by the driver and the driver will sign the Dialysis sign-in sheet at the time the resident is taken by the dialysis staff. The driver will return to the dialysis clinic at 2pm and pick up the resident from the back. At this time, the driver will sign the Dialysis sign-in sheet showing the time the resident was picked up. The dialysis clinic will not place the resident in the lobby unattended until the resident is picked up by the facility. If the driver is not at the dialysis clinic by 2:15pm, the dialysis clinic will notify the facility and the facility will have an employee go to the dialysis center to stay with the resident until the facility van or other mode of transportation picks up the resident to return to the facility. If the facility fails to follow this plan as agreed upon, the facility will send a person to accompany the resident before, during and after dialysis treatment to ensure his continued safety. e) The facility will meet with the other dialysis center to ensure the safety of one of the other identified residents who receives dialysis. The facility and the other dialysis clinic will develop a plan to ensure the resident is not left unaccompanied and the facility is providing timely transportation for this resident for his scheduled dialysis treatments. The third identified resident will be accompanied by a family member or facility staff to all scheduled appointments. a) Report of employee education: 01/14/16, 9:30 a.m. Presented by Regional Nurse. b) Signing residents in and out when they leave the facility. Resident #1 or any residents who go to dialysis will be accompanied by driver to the back, sign in at the appropriate time and sign out when picked up. If the transportation is late the dialysis center will call the charge nurse who must send an employee immediately to the clinic to sit with the resident until transportation arrives. a) Report of employee education: 01/14/16, 2:00 p.m. Presented by Regional Nurse. b) If the facility is late picking up a resident from dialysis, the dialysis center will call the charge nurse who will immediately send an employee to the center to sit with resident until the van arrives. All residents leaving the facility will be signed out and in. Licensed nurses will note on the 24 hour report all residents who went out on pass/returned from pass. Plan of removal verification completed 01/14/16: a) Interviews were conducted with staff (van drivers, nurses, MDS nurses and front office staff) regarding the training and knowledge of residents sent out of the facility on appointments. Staff answered appropriately and accordingly to the training received. During an interview on 01/14/16 at 5:22 p.m. the Regional Nurse was informed the Plan of Removal was accepted and the IJ was removed but the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to monitor its corrective action for effectiveness. A list provided by the Regional Nurse on 01/14/16 at 10:00 a.m. documented there were 3 residents at the facility that were exit seeking that attended scheduled appointments on a set schedule.