Every finding on record at Focused Care at Mount Pleasant

Based on observation, interview, and record review, the facility failed to provide a safe, clean, sanitary, comfortable, and homelike environment for 3 of 7 resident rooms and 1 of 2 hallways reviewed for environment. (Room # 2, Room # 4, Room # 5, room [ROOM NUMBER], Hallway #1)The facility failed to ensure Room # 2's air conditioning unit was free from gaps to outside on 5/18/2026 at 10:14 AM.The facility failed to ensure Room # 4 had base boards below the air conditioning unit on 5/18/2026 at 10:17 AM.The facility failed to ensure room [ROOM NUMBER]'s floor was not stained under air conditioning unit on 5/19/2026 at 11:50 AM.The facility failed to ensure room [ROOM NUMBER]'s white casing board was secured to wall and patch work along the border below the air conditioning unit was even and in good repair on 5/19/2026 at 11:00 AM.The facility failed to ensure Hallway #1's window seal on the secure men's unit was not broken, exposing wood fragments on 5/18/2026 at 10:14 AM.These failures could place residents at risk of an unsafe, unsanitary, uncomfortable environment, and embarrassment due to rooms not appearing homelike, and a decrease in quality of life and self-worth. Findings included: During an observation on 5/19/2026 at 11:00 A.M., room [ROOM NUMBER] revealed uneven patch work before the air conditioning unit. The patchwork had discoloration of tan/brown mixed with white drywall patching below the air conditioning unit. There was an observed white casing that held electrical wiring partially attached to the wall hanging down on the floor.During an interview on 5/20/2026 at 9:00 A.M., the Maintenance Director said the air conditioning unit started leaking and he said he went into room [ROOM NUMBER] and put mud plaster over it to fix it. The Maintenance Director said the mud was a coal base covering the wall. The Maintenance Director said there should not be space in the air conditioning unit to the outside. The Maintenance Director said the whiteboard was a racetrack (wire cover) to hide cables and phone lines. The Maintenance Director said it was an eye sore meaning it was not pleasing to the eye. The Maintenance Director said he was working on getting a new window on the men's secured unit in reference to the window seal that was broken and exposed the wood. The Maintenance Director said conversations had been back and forth regarding big money spending on how the facility would fix it. The Maintenance Director said he did not feel it was a homelike environment.During an interview on 5/20/2026 at 9:12 A.M., CNA D said no one complained to her about the environment. She said the nurses, CNAs and families were responsible for the resident's room being homelike. She did not say how the residents could be negatively affected. During an interview on 5/20/2026 at 12:40 P.M., the DCO said room [ROOM NUMBER] was not pleasing to the site. The DCO said the facility was pouring financially into the building and had hired an assistant to address the concerns with the building. The DCO said the last remodel did not last and explained the residents on the men's unit were busy. The DCO said the facility tried to give the residents an environment that the residents deserved. The DCO said the facility was actively being worked on. The DCO said he expected the facility to be homelike for the residents. The DCO said the administration was responsible for ensuring the facility and resident rooms were homelike. The DCO said he continued to ask the residents what the facility could do better to keep the residents happy. During an interview on 5/20/2026 at 1:19 P.M., the ADM said she expected resident rooms to be homelike. The ADM said she felt the aesthetics on the secure unit were unpleasant. The ADM said the facility hired a second maintenance assistant to help renovate. The ADM said she was responsible for ensuring the rooms were homelike. The ADM said it could negatively impact the residents' quality of life and demeanor. The ADM said the facility was resolving environmental issues and was starting on the men's unit. Record review of a facility policy, dated May 2017, titled, Quality of Life-Homelike Environment, indicated residents were provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Policy: Interpretation and Implementation.1. Staff shall provide person-centered care that emphasizes the residents comfort.2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #1) reviewed for infection control.The facility failed to ensure the ADON applied enhanced barrier precautions when she performed a skin assessment and provided incontinent care to Resident #1 on 5/18/2026 at 3:00 PM.The facility failed to ensure the CNA applied enhanced barrier precautions while assisting the ADON with positioning and holding Resident #1 on 5/18/2026 at 3:00 PM.These failures could place residents at risk of cross-contamination and infections leading to illness. Findings included: Record review of Resident #1's Face sheet, dated 5/20/2026, indicated a 38-year- old female admitted [DATE], diagnoses included chronic respiratory failure (a long-term condition where the lungs cannot maintain adequate oxygen levels to remove carbon dioxide effectively), obesity (a medical condition in which excess body fat has accumulated to such an extent that it can have negative effects on health), quadriplegia (a symptom of paralysis that affects all limbs and body from the neck down), bipolar disorder (a mental health condition characterized by significant mood swings), neuromuscular dysfunction of bladder (occurs when nerve damage disrupts communication between the brain, spinal cord and bladder, leading to urinary control problems) and tracheostomy status(a surgical procedure that creates an opening in the neck to facilitate breathing when the usual airway is obstructed or compromised). Record review of Resident #1's quarterly MDS assessment, dated 2/7/2026, indicated the resident was understood and understood others. Resident #1 had a BIMS score of 12 indicating she was moderately cognitively impairment. The MDS also indicated Resident #1 was dependent on bathing, dressing, and toileting. Resident #1's MDS indicated she had an indwelling catheter and tracheostomy. Record review of Resident #1's Care Plan, initiated on 12/27/2024, indicated the resident had enhanced barrier precautions related to foley catheter, tracheostomy, and open skin areas. The care plan, revised on 11/25/2025, indicated Resident #1 had a tracheostomy related to chronic respiratory failure and an indwelling catheter related to neurogenic bladder (a condition in which damage to brain, spinal cord, or nerves disrupts the normal electrical signals between the nervous system and bladder) and was at risk for infection and pain. Resident #1's Care plan also indicated she had potential for skin impairment or infection related to attempting to tattoo to arms. Resident #1 scrapes areas of skin then attempts to color it with pens and markers. During an observation on 5/18/2026 at 2:00 P.M., Resident #1 was lying in bed under the covers. Resident #1 was observed with a tracheostomy, indwelling catheter, and skin irritations on her left upper arm. During an observation on 5/18/2026 at 3:00 P.M., the ADON perform skin an assessment on Resident #1. The ADON did not wash her hands prior to placing gloves. The ADON did not put on PPE while assessing Resident #1's skin. The ADON cleansed Resident #1's skin with wipes to remove barrier ointment. The ADON did not use hand sanitizer between glove changes during the skin assessment. Resident #1 was observed to have red areas under the creases of her left breast and creases between her legs. The ADON reapplied barrier ointment to areas. The ADON changed Resident #1's brief during the encounter and covered her back up with blankets. Resident #1 had a container located inside her room with PPE and a yellow sign was above her bed indicating she was on EBP (enhanced barrier precautions). During an observation on 5/18/2026 at 3:00 P.M., CNA A entered Resident #1's room to assist the ADON with positioning Resident #1. CNA A washed her hands and applied gloves only. CNA A did not apply PPE prior to assisting with care for Resident #1. During an interview on 5/18/2026 at 3:25 P.M., CNA A said if Resident #1 was on EBP there would be a sign on the outside of her door. She said she did not have to wear PPE while providing Resident #1's care. CNA A said PPE was worn if the resident was coughing or if there was a feces smell, a bad wound or staph infection (a bacteria that can spread through cuts, scrapes and skin to skin contact). CNA A said if PPE were not worn with a resident who required PPE, it could cause germs to be transmitted to staff or another resident through cross-contamination. CNA A said the nurse was responsible for ensuring the PPE was worn and EBP were followed. CNA A said she was in-serviced on EBP and PPE but could not recall the date. During an interview on 5/18/2026 3:34 PM, the ADON said she washed her hands prior to entering Resident #1's room. The ADON said she should have worn PPE and realized it when CNA A washed her hands. The ADON said she should have stopped and put on PPE. The ADON said staff should wear PPE when a resident had a foley catheter, tracheostomy, or open wounds. The ADON said CNA A should also have worn PPE. The ADON said she was in-serviced and had in-serviced staff on PPE and EBP. The ADON could not recall the last in-service date. The ADON said not wearing proper PPE while providing care could result in transferring germs to the resident or could spread infection. She said she was responsible for ensuring PPE was worn and staff were educated. The ADON said she had not observed any bugs in Resident #1's room and stated Resident #1 picked at her skin. During an interview on 5/19/2026 at 3:00 PM, LVN B said the nurses never wore PPE to provide care and wore gloves. LVN B said she had never worn PPE while providing care to Resident #1 and said she only wears gloves. LVN B said Resident #1 was non-compliant. LVN B said she had been in-serviced on EBP and said it was only for residents who had MRSA (a type of bacteria that causes skin infections and is resistant to many antibiotics). LVN B said the staff also used PPE during Covid (a contagious disease cause by coronavirus SARS-CoV-2). LVN B said the charge nurse and DCO were responsible for ensuring precautions were used. LVN B said if proper PPE were not worn with a resident on EBP precautions, it could cause infection and spread germs. During an interview on 5/19/2026 at 3:11 PM, CNA C said she wore PPE when the staff told her to. CNA C said the nurses do not tell the CNAs when to wear PPE. CNA C said sometimes the residents had a sign on the door and the staff put out PPE. CNA C said she did not know any residents who required PPE while providing care. CNA C said Resident #1 was not on EBP precautions and she was not required to wear PPE while providing her care. CNA C said she only wore gloves while providing her care. CNA C said mask and respirator were PPE. CNA C said she did not know what EBP meant. CNA C said the charge nurse and DON were responsible for ensuring EBP and PPE were available to use. CNA C said staff could get sick and cause cross-contamination. CNA C said she was in-serviced before she was hired on EBP. During an interview on 5/20/2026 at 9:12 AM, CNA D said she was not sure about PPE. CNA D said EBP was when the staff put on gloves, gowns, and goggles. CNA D said the residents would have a sign on the door. CNA D said EBP were for residents who had Covid and other reasons, but she could not recall. CNA B said she took EBP training last week. CNA D said the nurse was responsible for ensuring PPE and EBP were followed. CNA D said a resident could get sick through cross-contamination. CNA D said there were not any residents on EBP precautions. During an interview on 5/20/2026 at 9:26 AM, LVN E said EBP was for residents who had wounds, catheters, tracheostomy, and feeding tubes. LVN E said there were a couple of residents on the male secure unit and one resident on the women's unit. LVN E said the male resident was currently in the hospital. LVN E said the staff placed signs on the door but sometimes the sign got torn up. LVN E said the storage containers with PPE should be outside the resident's room. LVN E said the ADON was the infection preventionist. LVN E said a resident could get an infection if staff were not wearing proper PPE. During an observation on 5/20/2026 at 9:26 AM, LVN E went to the medication closet and there were face shields and the blue gowns in supply closet on the male secure unit. During an interview on 5/20/2026 at 12:20 PM, the ADON said a resident with tracheostomy, wounds, feedings, IVs (Intravenous- a medical procedure that involves delivering fluids, medications, or nutrients directly into a vein). The ADON said an EBP sign was on the wall in the resident's room. She said the DCO was the one who made the decision to place the sign in the room. The ADON said the facility just ordered extra mask. The ADON said the staff were supposed to know what to wear by the type of residents they are providing care for. The ADON said the sign was to remind them. The ADON said the nurse administration was observing staff when she was working on the floor but said she was not watching to see if they were using PPE. During an interview on 5/20/2026 at 12:32 PM, the DCO said he expected the staff to wear PPE while providing care to residents with wounds, foley catheters, tracheostomy, feeding tube, ostomies, and dialysis ports. The DCO said he expected staff to wear PPE while direct care or if they were touching the resident. DCO said the staff were aware due to the sign at the top of the resident's headboard. The DCO said the facility was implementing EBP on the EMR. The DCO said he had done in-services on EBP. The DCO said he was responsible for ensuring PPE was worn. The DCO said a resident could get an infection and could have secondary complications. During an interview on 5/20/2026 at 1:11 PM, the ADM said she expected the nurses to use EBP and PPE while providing care as well as handwashing. The ADM said the administration and nurses were responsible and monitoring through checkoffs. The ADM said a staff member could get sick or cross-contamination could make a resident ill. The ADM said she expected the staff to know which residents were on EBP precautions and expected staff to know what types of residents who required EBP. Record review of an enhanced barrier precautions policy, dated 4/1/2024, and titled, Enhanced Barrier Precautions indicated, .Enhanced Barrier Precautions (EBP) are a CDC guidance to reduce the transmission of multi-drug resistant organisms (MDRO) in health care settings.EBP require team members to wear a gown and gloves while performing high-contact care activities with resident who are infected or colonized with a targets MDRO or have open wound or indwelling medical device. Procedure: 1. Determine residents MDRO status on admission to community.2. Determine if a resident has any wounds.Determine if any of the following indwelling medical devices are in use: urinary catheter, g-tube, tracheostomy, central lines.EBP will be implemented if any of the above wounds or invasive medical devices are present. 3. Place signage on resident's closet door, maintain PPE in residents' room and assure all team members are aware of resident status and need for EBP during high contact care. 4. High contact resident care activities: dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care, or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care. Record review of CDC guideline titled, Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities, dated June 2021, indicated .Healthcare Infection Control Practices Advisory Committee is a federal advisory committee charted to provide advice and guidance to the Centers for Disease Control and Prevention.Executive Summary.1. Multidrug-resistant organism transmission is common in skilled nurse facilities.2. Enhanced Barrier Precautions is an approach of targeted gown and glove use during high contact resident activities.3. EBP may be applied (when Contact Precautions do not otherwise apply) to residents with any of the following.Wounds or indwelling medical devices, regardless of MDRO colonization status, Infection, or colonization with an MDRO. 4. Effectiveness implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE with hand hygiene products at the point of care. Implementation Approaches.The application of EBP to routine care of residents with wounds or indwelling medical devices requires that staff participate in initial and ongoing training on the facility's expectations about hand hygiene and gown and glove use.Facilities should develop a method to identify resident with wounds or indwelling medical devices, and post clear signage outside of resident rooms indicating the type of PPE required and defining high risk activities. Gown and gloves should be available outside each resident room, and alcohol-based hand rub be available for every resident room.A trash can large enough to dispose of multiple gowns should be available for each room.

Based on interview and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 1 of 6 residents reviewed for misappropriation of resident property. (Resident #1) The facility to failed keep Resident #1 free of misappropriation of property when RN A took a discontinued medication, 60 tablets of Meloxicam 7.5 milligrams, from the facility. This failure could place residents at risk for decreased quality of life, misappropriation of property, and dignity.Findings Included: Record review of face sheet dated 01/13/26 indicated Resident #1 was [AGE] years old and was initially admitted to the facility on [DATE] with diagnoses of senile degeneration of the brain (significant age-related cognitive decline), difficulty in walking, and a cognitive communication deficit.Record review of an Order Summary Report dated 01/13/26 for Resident #1 indicated an order for Meloxicam (a prescription nonsteroidal anti-inflammatory drug (NSAID) used primarily to relieve pain, swelling, and stiffness caused by various forms of arthritis, including osteoarthritis, rheumatoid arthritis, and juvenile rheumatoid arthritis. It is not a narcotic or an opioid) Oral Tablet 7.5 milligrams with a start date of 01/28/25 and an end date of 10/25/25. There were no current orders for Meloxicam.Record review of a significant change MDS assessment dated [DATE] indicated Resident #1 was usually understood and usually understood others. The MDS indicated a BIMS of 03 which indicated severe cognitive impairment.Record review of a care plan last revised on 12/30/25 for Resident #1 had potential for pain related to inability to detect/notify staff of pain in a timely manner. There was an intervention to administer pain medications as order.Record review of the Medication Administration Records for Resident #1 for October 2025, November 2025, December 2025, and January 2026 indicated Resident #1 had not received a dose of Meloxicam since 10/27/25.Record review of a police report dated 01/09/26 indicated that on 01/01/26, RN A was in possession of 60 Meloxicam 7.5 milligram pills belonging to Resident #1. The police reported indicated the incident type was criminal.Record review of a Provider Investigation Report dated 01/09/26 indicated on 01/01/26 at 3:30 p.m. RN A was pulled over by the police for a routine traffic stop. The report indicated RN A was the perpetrator. The report indicated the DCO was contacted by a police officer to notify him that RN A was found in possession of a resident's medication while on a traffic stop. The report indicated Resident #1 was not affected by the incident. The report indicated a medication count at the facility confirmed that no other medications were missing from the facility. The report indicated RN A confirmed she had the medication in her presence. The report indicated, .She stated it was a misunderstanding and accident that she picked it up. The medication was not under current physician order. No resident went without prescribed medication. Nurse did not deny that it was in her possession. The police drew up a report and plan to pursue charges as appropriate. The facility investigation findings were confirmed. The report indicated staff were educated regarding medication administration and storage. The report indicated that RN A was removed from her assignment due to mismanagement of prescribed medication. The report was signed by the EDO.Record review of an email to the EDO from RN A dated 01/06/26 at 10:22 a.m. indicated, During a very busy shift, the medication aide and I.were administering residents medications at the nurses station. I got called down to a residents room, I placed blister-pack medications underneath some paper at the nurse station, which was a lapse in protocol. When I later gathered by belongings to leave, I inadvertently picked up the papers with the blister packs underneath and placed them into my bag without realizing the medications were included. I was unaware that the mediations were in my possession until I was stopped by law enforcement for an unrelated matter, at which time a search revealed the blister packs. There was no intent to remove, conceal, divert, or misuse medications. I acknowledge this breach of protocol and understand the importance of strict adherence to medication handling procedures.Record review of a Termination Recommendation form dated 01/02/26 indicated RN A was terminated for unsatisfactory performance, violation of company policy, and misappropriation. The form indicated RN A misappropriated medication in overflow for resident use, she did not deny fault.the police report confirms her fault. The form indicated RN A was suspended on 01/01/26.During an interview on 01/13/26 at 10:47 a.m., Resident #1 was non-verbal and did not answer any questions when asked.During an interview on 1/13/26 at 11:04 p.m., Medication Aide B said she got a call at home on [DATE] that RN A was stopped, and the police had found pills in her car. She said it was RN A's husband that called her. She said RN A was found with Meloxicam. She said she talked to RN A that evening and RN A told her it was a mistake. She said on a previous shift there had been two cards of Meloxicam for Resident #1 on the medication cart. She said both cards were full and contained 60 pills total. She said she took the two cards to RN A and told her that Resident #1 was no longer on the medication. She said RN A checked Resident #1's electronic medical record and confirmed the resident was no longer on the medications. She said RN A took the cards and laid them beside her, near her computer. She said she did not know what RN A did with them after that. She said RN A told her that when she got off work she was in a hurry, and the pills must have been scooped up with her personal items. Medication Aide B said she believed that was what happened. She said she had never seen RN A take anything she should not have taken. She said she did not know RN A well enough to say if she would take them or not. She said she would like to believe RN A did not take them purposely. She said, normally when she found discontinued medications on the medication cart, she took them to the nurse to verify there was no longer an order for the medication and then she put them in the discontinued box locked in the medication room. She said this time that was not what happened because RN A told her that she would handle it.During an interview on 01/13/26 at 12:43 p.m., the EDO said that RN A had been terminated. She said RN A had not been back in the building since 01/01/26. She said she did not handle the referral, but the information had been sent to corporate, and RN A would be referred to the state board.During an interview on 01/13/26 at 1:39 p.m., the DCO said on 01/01/26 he was notified by the police directly that they had searched RN A's car. He said the police told him they found medication belonging to Resident #1 in her car. He said the medication was a discontinued medication. He said he was told that RN A and Medication Aide B were cleaning out the cart. He said the process was there was a box in the locked medication room for discontinued medications. He said the nurse should have placed the medications in the discontinued box. He said he checked the box every week. He said he has now increased monitoring of medications. He said what was told to him was that RN A had sat the medications on down and when she was ready to pick up her personal items to leave, she accidentally picked up the medications too. He said the police told him there were two cards of the Meloxicam and none were missing from the cards. He said since the incident they had increased spot checking the medications. He said they had scheduled extra visits from the pharmacy company to audit all medication. He said after the incident he immediately audited medications, and everything checked out fine. He said they are also using a form to keep up with medication counts. He said he would have expected the nurse to have immediately put the discontinued medications in the medication room in the discontinued box. He said there was no reason for a medication to be left out anywhere. He said they have completed in-services on medication administration and had scheduled frequent meetings with staff on all high points on how the building needed to be run. He said a nurse taking a medication could place a resident at risk for pain, alteration in vitals, and wellbeing. He said staff taking a medication was just not tolerated. He said RN A had been terminated and would be referred by corporate staff to the state board.During an interview on 01/13/26 at 2:12 p.m., the EDO said RN A called her on 01/01/26 and said that her husband had just been arrested and said, we had stuff in the car and I am afraid it is going to come back on me. She said at that point she was thinking it was drugs but not medications from the facility. She said the police had called the DCO and told him about the medication and which resident it belonged to. She said she did not know anything further until she had the police report. She said RN A ended up having 2 full cards containing a total of 60 pills of Meloxicam. She said then RN A sent her the emailed statement where she admitted to taking the medication and it was accidental. She said it could not have been accidental because it was in a small laptop case. She said there was no way RN A did not know she took the medication. She said there was no way RN A accidentally scooped up the medications. She said it was a discontinued medication, and it did not affect the resident. She said once Medication Aide B handed RN A the discontinued medication it should have been immediately secured. She said it should never have been left out for just anyone to access. She said immediately they counted every other medication in the facility. She said they had the pharmacist come to check all locked storage areas. She said now she expected all discontinued medications to come off the cart immediately, so that there is not an accidental use of the medication. She said previously it was not done daily. She said after this incident this will be done daily. She said the police told her that because it was not a controlled substance and the resident had not been using the medication they would not press charges. She said the facility had requested to press charges against RN A. She said there was now a warrant for her arrest because they chose to press charges. She said a staff member taking a resident's medication could cause them to not have the medications they need, could delay care, and affect their condition negatively.During an interview on 01/14/26 at 7:50 a.m., RN A said she and Medication Aide B were busy at work. She said Medication Aide B asked her about Resident #1's Meloxicam and if the resident still needed it or not. She said she was at the computer at the time. She said the medication had been discontinued. She said Medication Aide B handed her the medication. She said she then got called away from the computer. She said she laid the two cards beside the computer and covered them with some papers. She said at the end of the day she picked up her personal items and placed them in her bag. She said she did not know the medication was in her bag until the police searched her car. She said she was not arrested. She said Resident #1 had not missed any medications because the medications had been discontinued. She said she could not remember when the medication had been discontinued. She said as soon as she determined that the medication had been discontinued, she should have immediately locked them in the medication room in the discontinued box.Record review of an Abuse facility policy last revised on 01/27/20, 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 guidelines in the written policy and procedure.Residents will not be subjected to abuse by anyone, including, but not limited to community staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, or legal guardians, care taker, friends, or other individuals.Record review of a Storage of Medications facility policy last revised April 2007 indicated, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.The facility shall no use discontinued, outdated, or deteriorated drugs or biological. All such drugs shell be returned to the dispensing pharmacy or destroyed.

Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 6 (Resident #1) residents reviewed for quality of care. The facility failed to ensure Resident #1 had a skin assessment performed weekly on the weeks of 10/6/25, 10/13/25, 10/20/25, and 10/27/25 per facility policy. These failures could result in skin issues on residents being missed, skin issues deteriorating without being monitored, and decreased quality of life. Findings Included: 1. Record review of the face sheet dated 11/12/25 indicated Resident #1 admitted to the facility on [DATE] with diagnoses including cerebral infarction (a type of stroke caused by the blood vessels supplying the brain being blocked), Atrial Fibrillation (an irregular heartbeat where the upper chambers of the heart beat chaotically and very fast), COPD, and hypertension (elevated blood pressure). Record review of the MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 10 and was moderately cognitively impaired. The MDS indicated Resident #1 was at risk for developing pressure ulcers. Record review of the care plan revised 8/21/25 indicated Resident #1 was at risk for skin breakdown related to thin, fragile skin, incontinence and ambulating with decreased sense of safety. Record review of the weekly skin assessments for October 2025 indicated Resident #1 had a skin assessment on 10/1/25. The skin assessment dated [DATE] indicated Resident #1 did not have any skin issues. Record review of the weekly skin assessment for October 2025 indicated Resident #1 did not have weekly skin assessments in the weeks of 10/6/25, 10/13/25, 10/20/25, and 10/27/25. Record review of the weekly skin assessment dated [DATE] indicated Resident #1 did not have any skin issues. During an interview on 11/12/25 at 1:38 p.m. the Treatment Nurse said skin assessments were to be performed weekly, and all skin issues should be on the weekly skin assessments. The Treatment Nurse said the importance of weekly skin assessments was to assess the skin for an issue. During an interview on 11/12/25 at 2:47 p.m. the DON said skin assessments should be performed weekly, and he would look at his soft file to see if he had skin assessments on Resident #1 for the missing dates in October 2025. During an interview on 11/12/25 at 3:00 p.m. the DON brought the surveyor shower sheets for Resident #1 for the missing dates that were filled out by the CNAs where they could mark on the image of a body if they saw any skin issues. The DON showed the surveyor where a nurse signed off on the shower sheets. The DON said that the nurses were not usually there when a shower was given to assess the skin themselves. The DON said he understood it was out of the CNAs' scope of practice to assess. The DON said the weekly skin assessment should be performed by a nurse. Record review of the facility's Skin Management Policy last revised 10/6/22 indicated, The purpose of this procedure is for prevention and treatment of skin breakdown such as pressure injuries, diabetic ulcers, arterial ulcers, and skin wounds.Skin assessments will be documented at a minimum of every 7 days on a Weekly Skin Assessment.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights for 3 of 16 (Resident #4, Resident #5, and Resident #6) residents reviewed for care plans, The facility failed to ensure Resident #4's pressure ulcer to her buttock was care planned from her re-admission on [DATE] until 11/11/25. The facility failed to ensure Resident #5's wander guard status was properly care planned with the care plan indicating Resident #5 had a wander guard in place and observations and interviews indicating Resident #5 did not have a wander guard. The facility failed to ensure Resident #6's secured unit status was properly care planned with the care plan indicating Resident #6 resided on the secured unit and a social services note dated 5/6/25 indicating she had been moved off the secured unit. This failure could place the residents at increased risk of not having their individual needs met and a decreased quality of life. Findings Included:1. Record review of the face sheet dated 11/12/25 indicated Resident #4 was re-admitted to the facility on [DATE] with diagnoses including diabetes, schizoaffective disorder (a chronic mental health condition that combines symptoms of schizophrenia with symptoms of mood disorder like bipolar disorder or depression), hypertension (elevated blood pressure), and lack of coordination. Record review of the MDS dated [DATE] indicated Resident #4 usually understood others and was usually understood by others. The MDS indicated Resident #4 was unable to complete the BIMS assessment. The MDS indicated Resident #4 did not have a pressure ulcer. Record review of the nursing progress note dated 10/16/25 indicated, [Resident #4] returned from hospital via wheelchair accompanied by staff.Perineum (the region of the body between the pubic arch (a bony structure in the pelvis) and the tail bone) and scalp assessed, no redness, open areas, or skin breakdown observed on scalp. [Resident #4] does have an existing wound to buttocks dressing changed per wound care orders. Record review of the care plan last revised 11/11/25 indicated Resident #4 was at risk for skin Breakdown related to thin, fragile skin with poor turgor (the elasticity or firmness of the skin) and decreased mobility. The care plan indicated Resident #4 had a surgical incision to abdominal midline with staples intact. The care plan indicated on 11/11/25 it was initiated that Resident #4 had a pressure ulcer to her coccyx (small bone at the base of the spine) and bilateral buttocks with interventions including encourage good nutrition and hydration in order to promote healthier skin, identify/document potential causative factors and eliminate/resolve where possible, monitor/document location, size and treatment of skin injury, and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. During an interview on 11/12/25 at 11:14 am the Treatment Nurse said she had been the treatment nurse at the facility for approximately 1 year. The Treatment Nurse said Resident #4 had a wound on her bottom when she admitted to the facility. The Treatment Nurse said the MDS Nurse was responsible for completing the MDS and the Care Plans. The Treatment Nurse said when Resident #4 admitted to the facility on [DATE] she just had redness to her bottom that they were treating with barrier cream. The Treatment Nurse said when Resident #4 re-admitted to the facility on [DATE] she had a pressure ulcer to her bottom that was opened. The Treatment Nurse said she reported the pressure ulcer to the MDS Nurse in the morning meeting after Resident #4 had re-admitted to the facility on [DATE]. The Treatment Nurse said a care plan regarding a wound should be initiated as soon as the wound was found. The Treatment Nurse said she did not know why Resident #4's care plan regarding her wounds was not initiated until 11/11/25. The Treatment Nurse said the importance in a resident's care plan being updated when a wound was discovered was continuance of care. 2. Record review of the face sheet dated 11/13/25 indicated Resident #5 re-admitted to the facility on [DATE] with diagnoses including difficulty walking, muscle weakness, lack of coordination, right BKA, and hypertension. Record review of the MDS dated [DATE] indicated Resident #5 usually understood others and was usually understood by others. The MDS indicated Resident #5 had a BIMS of 09 and was moderately cognitively impaired. The MDS indicated Resident #5 used a wheelchair for mobility and required partial/moderate assistance with transfers. Record review of the care plan last revised 2/28/25 indicated Resident #5 had a history of elopement risk and was at risk for possible injury related to impaired safety awareness and intermittent confusion with interventions including wander guard (a safety system used in facilities to prevent residents at risk of wandering from leaving designated areas) placed for resident's safety, bracelet will alert staff if and when resident attempts to exit doors of facility. During an observation on 11/13/25 at 2:11 p.m. Resident #5 was sitting in his wheelchair in the dining room playing BINGO. Resident #5 was not observed with a wander guard in place. During an interview on 11/13/25 at 3:20 p.m. the Administrator said they did have a wander guard system at the facility, but they did not have any residents with a wander guard on at this time. 3. Record review of the face sheet dated 11/13/25 indicated Resident #6 was re-admitted to the facility on [DATE] with diagnoses including dementia difficulty walking, convulsions (sudden uncontrolled muscle contractions or spasms), muscle weakness, and lack of coordination. Record review of the MDS dated [DATE] indicated Resident #6 usually understood others and was usually understood by others. The MDS indicated Resident #6 had a BIMS of 02 and was severely cognitively impaired. The MDS indicated Resident #6 required substantial/maximum assistance with transfers. Record review of the care plan last revised 8/4/25 indicated Resident #6 resided on the facility's memory care unit related to exit seeking which could place her in an unsafe environment. Record review of the social services progress note dated 5/6/25 indicated Resident #6 had been moved from the women's secured unit into a regular room. During an observation and interview attempt on 11/13/25 at 2:08 p.m. Resident #6 was observed in her room not on the women's secured unit sitting on edge of bed with bed in low position. Resident #6 did not respond to surveyor, when asked questions she smiled and moved her hands. During an interview on 11/12/25 at 3:00 p.m. the DON said the MDS Nurse was responsible for completing the MDS. The DON said the care plans were updated by the respective members of the IDT. The DON said he expected a pressure ulcer to be care planned as soon as it was identified or in a reasonable timeframe. The DON said when a resident was moved on or off the secured unit or had a wander guard placed or removed it should be care planned in a reasonable timeframe. The DON said a reasonable timeframe would be within a week of a pressure ulcer being identified, a move to or from the secured unit, or when a wander guard is put on or removed. The DON said the importance of care plans being updated was continuance of care. During an interview on 11/14/25 at 12:42 p.m. the MDS Nurse said she was not responsible for all care plans. The MDS Nurse said each member of the IDT was responsible for their portion of the care plans. The MDS Nurse said she was responsible for the initial care plan, and she tried to ensure all updates were entered on the care plan. The MDS Nurse said the Treatment Nurse was responsible for updating the care plans regarding wounds. The MDS Nurse said Resident #4's wound should have been care planned by the Treatment Nurse. The MDS Nurse said she was responsible for updating the care plans when a resident moved on or off the secure unit and when a resident had a wander guard put on or removed. The MDS Nurse said she was unaware Resident #5's care plan had not been updated when he had his wander guard removed. The MDS Nurse said she was unaware Resident #6's care plan had not been updated when she was moved out of the secured unit. The MDS Nurse said the importance of ensuring that care plans were accurate and updated was to let other caregivers know the residents' needs and how to care for them. Record review of the facility's Comprehensive Care Plan policy last revised 4/25/21 indicated, Every resident will have an individualized interdisciplinary plan of care in place. A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of Admission. The Interdisciplinary Team will continue to develop the plan in conjunction with the RAI (MDS 3.0) ., completing and conducting Comprehensive Care Plan Meeting and Reviews by day 21 after Admission. The Care Plan is revised every quarter, significant change of condition, Annual, or as the resident condition changes on an individualized basis. The Care Plan process is an ongoing review process.

Based on interviews and record review, the facility failed to ensure in accordance with accepted standards of practices, the medical records on each resident were accurately documented for 2 of 16 residents (Resident #4 and Resident #7) reviewed for accurate medical records. The facility failed to ensure Resident #4's wound assessment completed on 11/7/25 by the Treatment Nurse accurately reflected her pressure ulcer was worsening as the Wound Care NP had documented on 11/7/25. The facility failed to ensure Resident #7's wound assessment completed on 11/7/25 by the Treatment Nurse accurately reflected her pressure ulcer was worsening as the Wound Care NP had documented on 11/7/25. These failures could place residents receiving wound care at risk for confusion on whether a wound is improving or worsening. Findings included:1. Record review of the face sheet dated 11/12/25 indicated Resident #4 was re-admitted to the facility on [DATE] with diagnoses including diabetes, schizoaffective disorder (a chronic mental health condition that combines symptoms of schizophrenia with symptoms of mood disorder like bipolar disorder or depression), hypertension (elevated blood pressure), and lack of coordination. Record review of the MDS dated [DATE] indicated Resident #4 usually understood others and was usually understood by others. The MDS indicated Resident #4 was unable to complete the BIMS assessment. The MDS indicated Resident #4 did not have a pressure ulcer. Record review of the nursing progress note dated 10/16/25 indicated, [Resident #4] returned from hospital via wheelchair accompanied by staff.Perineum (the region of the body between the pubic arch (a bony structure in the pelvis) and the tail bone) and scalp assessed, no redness, open areas, or skin breakdown observed on scalp. [Resident #4] does have an existing wound to buttocks dressing changed per wound care orders. Record review of the care plan last revised 11/11/25 indicated Resident #4 was at risk for skin Breakdown related to thin, fragile skin with poor turgor (the elasticity or firmness of the skin) and decreased mobility. The care plan indicated Resident #4 had a surgical incision to abdominal midline with staples intact. The care plan indicated on 11/11/25 it was initiated that Resident #4 had a pressure ulcer to her coccyx (small bone at the base of the spine) and bilateral buttock. Record review of the wound assessment completed by the Treatment Nurse dated 11/7/25 indicated Resident #4 had a pressure ulcer to her coccyx/bilateral buttocks that was improving. Record review of the Wound Care NP's progress note dated 11/7/25 indicated Resident #4's wound to her coccyx/bilateral buttocks that was worsening. During an interview on 11/12/25 at 11:14 a.m. the Treatment Nurse said she had been the treatment nurse at the facility for approximately 1 year. The Treatment Nurse said Resident #4 had a wound on her bottom when she admitted to the facility. The Treatment Nurse said the wound had been improving but when Resident #4 had stopped eating the wound began to decline. The Treatment Nurse said Resident #4 received wound care daily and was seen by the Wound Care NP weekly. The Treatment Nurse said she made a mistake in the wound assessment dated [DATE] when she documented Resident #4's wound to her coccyx was improving after the Wound Care NP documented the wound was worsening. The Treatment Nurse said the importance of ensuring proper documentation was performed was continuance of care. 2. Record review of the face sheet dated 11/14/25 indicated Resident #7 was re-admitted to the facility on [DATE] with diagnoses including lack of coordination, diabetes, obesity, and pressure ulcers to the sacral region (triangular area of the lower back at the base of the spine) and right buttock. Record review of the MDS dated [DATE] indicated Resident #7 understood others and was understood by others. The MDS indicated Resident #7 had a BIMS of 10 and was moderately cognitively impaired. The MDS indicated Resident #7 had one or more unhealed pressure ulcers. Record review of the wound assessment completed by the Treatment Nurse dated 11/7/25 and signed 11/12/25 indicated the pressure ulcer to Resident #7's left ischium (a thick, irregularly shaped bone in the pelvis) was worsening. Record review of the audit report dated 11/14/25 indicated the wound assessment dated [DATE] had been audited on 11/12/25 by the Treatment Nurse from originally indicating on 11/7/25 the pressure ulcer to Resident #7's left ischium was worsening to improving. Record review of the Wound Care NP's progress note dated 11/7/25 indicated the pressure ulcer to Resident #7's left ischium was worsening. During an interview on 11/12/25 at 11:29 a.m. the Wound Care NP said he expected the nursing wound assessments that were completed on the same day as his assessments to accurately reflect what his assessment reflected regarding wound status of improving, stable, or worsening. During an interview on 11/12/25 at 3:00 p.m. the DON said he expected clinical documentation of wounds to reflect what the wound care physician documented on their notes. The DON said the importance in accurate documentation was to provide appropriate care. Record review of an email from the Administrator dated 11/12/25 at 5:50 p.m. indicated the Administrator was unable to locate a policy regarding accuracy of documentation.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 3 residents (Resident #1) reviewed for treatment and services related to indwelling catheters. The facility failed to ensure Resident #1's Foley catheter drainage bag was kept off the floor on 10/21/25. These failures could place residents at risk for urinary tract infections, injuries, and a decreased quality of life.The findings included: Record review the face sheet, dated 10/22/25, reflected Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of senile degeneration of the brain (progressive deterioration of brain tissue and function that occurs with aging), neuromuscular dysfunction of the bladder (nerve damage that affects bladder control), benign prostatic hyperplasia (enlargement of the prostate gland), and retention of urine (inability to completely empty the bladder). Record review of the admission MDS assessment, dated 09/29/25, reflected Resident #1 had clear speech, was understood by others, and was usually able to understand others. Resident #1 had a BIMS score of 11, which indicated moderately impaired cognition. Resident #1 had no behaviors or refusal of care during the look-back period. The MDS reflected Resident #1 had an indwelling catheter with an active urinary tract infection during the last 30 days (look-back period). Record review of the comprehensive care plan, initiated 10/02/25, reflected Resident #1 used a Foley catheter related to a neurogenic bladder and retention. The interventions included: position drainage bag below the level of the bladder and away from entrance door, check tubing for kinds, monitor intake and output, monitor pain/discomfort, and monitor for signs and symptoms of UTI. Record review of the progress notes, dated 10/14/25 reflected Resident #1 had a functional decline and altered mental status. Orders were given for urinalysis. Record review of the lab results, reported on 10/16/25, reflected Resident #1 had a positive urinalysis, which grew Escherichia coli (Gram-Negative bacteria) and Candida glabrata (yeast). Record review of the McGeer Criteria for Infection, dated 10/18/25, reflected Resident #1 had leukocytosis (high white blood cell count) and a functional decline. The assessment reflected that he was prescribed antibiotics for a urinary tract infection with an indwelling catheter. The assessment revealed Resident #1 did meet the criteria for antibiotic use. Record review of the 72 Hour Antibiotic Review, dated 10/18/25, reflected a one-time dose of antibiotic was given on 10/18/25 for a urinary tract infection. Record review of the order recap report, dated between 10/01/25 and 10/31/25, reflected Resident #1 had the following orders:1. Monitor for signs and symptoms of sepsis development throughout the antibiotic course and 72 hours after., which started on 10/18/25 and ended on 10/23/25.2. Fosfomycin (antibiotic) 3 GM - Give 1 packet by mouth one time only for UTI which started and ended on 10/18/25. Record review of the MAR, dated October 2025, reflected Resident #1 was given an antibiotic for a UTI on 10/18/25. During an observation on 10/21/25 at 9:42 AM, Resident #1's foley catheter drainage bag was laying on the ground under his bed. Resident #1 stated he did not know the bag was on the ground. During an interview on 10/22/25 at 12:48 PM, RN A stated everyone was responsible for monitoring to ensure the Foley catheter drainage bags were kept off the floor. RN A stated she did not notice that Resident #1's Foley catheter drainage bag was on the ground. RN A stated she checked the Foley catheter drainage bag at least two times a day during rounds. RN A stated she also checked as needed for any issues. RN A stated if the catheter drainage bag was kept on the ground it would have placed Resident #1 at risk of injury if it was stepped on or accidentally pulled out. During an interview on 10/22/25 at 1:59 PM, the DCO stated Resident #1's Foley catheter drainage bag should not have been kept on the floor. The DCO stated everyone was responsible for monitoring to ensure that Foley catheter drainage bags were kept off the ground. The DCO stated he was new to the position, but he would have provided in-service education for the staff. The DCO stated it was important to keep Foley catheter drainage bags off the floor to prevent urinary tract infections, maintain infection control practices, and prevent injuries. During an interview on 10/22/25 at 2:13 PM, the Administrator stated Foley catheter drainage bags should have been secured to the bed and kept off the ground. The Administrator stated all staff was responsible for monitoring to ensure Foley catheter drainage bags were kept off the ground. The Administrator stated the nursing direct care staff should be monitoring the Foley catheter routinely. The Administrator stated it was important to ensure the Foley catheter drainage bag was kept off the ground to prevent the spread of infection to others or prevent Resident #1 from obtaining a urinary tract infection. Record review of the Catheters-Insertion and Care: Indwelling, Straight, Supra-Pubic, and External policy, dated 04/2021, reflected It is the policy of this community that the resident with a urinary catheter will be provided services in a safe and appropriate manner to minimize the risks of urinary tract complication.secure urinary drainage bag below the level of the bladder and keep off the floor.

Based on interview and record review the facility failed to complete an accurate MDS assessment to reflect residents' status for 1 of 16 residents reviewed for assessments. (Resident #4) The facility failed to ensure Resident #4's MDS dated [DATE] documented the presence of a pressure ulcer that she re-admitted to the facility with on 10/16/25. This failure could place residents at risk for inaccurate assessments and not receiving needed services.Findings included:1. Record review of the face sheet dated 11/12/25 indicated Resident #4 was re-admitted to the facility on [DATE] with diagnoses including diabetes, schizoaffective disorder (a chronic mental health condition that combines symptoms of schizophrenia with symptoms of mood disorder like bipolar disorder or depression), hypertension (elevated blood pressure), and lack of coordination. Record review of the MDS dated [DATE] indicated Resident #4 usually understood others and was usually understood by others. The MDS indicated Resident #4 was unable to complete the BIMS assessment. The MDS indicated Resident #4 did not have a pressure ulcer. Record review of the nursing progress note dated 10/16/25 indicated, [Resident #4] returned from hospital via wheelchair accompanied by staff.Perineum (the region of the body between the pubic arch (a bony structure in the pelvis) and the tail bone) and scalp assessed, no redness, open areas, or skin breakdown observed on scalp. [Resident #4] does have an existing wound to buttocks dressing changed per wound care orders. During an interview on 11/12/25 at 11:14 a.m. the Treatment Nurse said the MDS Nurse was responsible for completing the MDS and the Care Plans. The Treatment Nurse said she did not know why the MDS dated [DATE] did not indicate Resident #4 had a pressure ulcer. The Treatment Nurse said when Resident #4 admitted to the facility on [DATE] she just had redness to her bottom that they were treating with barrier cream. The Treatment Nurse said when Resident #4 re-admitted to the facility on [DATE] she had a pressure ulcer to her bottom that was opened. The Treatment Nurse said she reported the pressure ulcer to the MDS Nurse in the morning meeting after Resident #4 had re-admitted to the facility on [DATE]. During an interview on 11/14/25 at 12:42 p.m. the MDS Nurse was she was responsible for completing all MDSs. The MDS Nurse said when she was completing an MDS regarding wounds she obtained the information to enter into the MDS from the weekly wound report, skin assessments, and weekly IDT meeting. The MDS Nurse said she had just missed the wound on Resident #4 when she re-admitted to the facility on [DATE]. The MDS Nurse said the importance of ensuring the MDS was completed accurately was to accurately depict the residents and to trigger all care needed on the care plan. During an interview on 11/12/25 at 3:00 p.m. the DON said the MDS Nurse was responsible for completing the MDS. Record review of the facility MDS Completion Accuracy and Timeliness policy last revised 11/15/23 indicated, The purpose of this policy is to ensure accuracy and timeliness of MDS completion.

Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 16 (Resident #2) residents review for dignity and respect. The facility failed ensure Resident #2 was treated with dignity and respect by LVN A on 11/12/25 when LVN A told Resident #2 to sit his ass down. These failures could place residents at risk of a diminished quality of life, loss of dignity and self-worth.Findings included: 1. Record review of the face sheet dated 11/13/25 indicated Resident #2 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, disorganized schizophrenia (a subtype of schizophrenia characterized by disorganized thinking, speech, and behavior), and anxiety disorder. Record review of the MDS dated [DATE] indicated Resident #2 sometimes understood others and was sometimes understood by others. The MDS indicated Resident #2 was not able to complete the BIMS assessment. The MDS indicated Resident #2 had not had any physical behaviors or verbal behaviors directed toward others during the 7-day look back period. Record review of the care plan last revised on 11/11/25 indicated Resident #2 had anxiety related to cognitive deficit and Schizophrenia as evidenced by constant wandering and exit seeking. During an observation and interview attempt on 11/13/25 at 12:50 p.m. Resident #2 was observed wandering around the men's secured unit. The surveyor attempted to interview Resident #2, but he just smiled and agreed to everything the surveyor said. During an interview on 11/13/25 at 1:01 p.m. COTA B said she was exiting the shower with CNA C and another resident. COTA B said she observed LVN A walking with Resident #3. COTA B said when LVN A and Resident #3 walked past Resident #2 that Resident #3 accidentally bumped into Resident #2. COTA B said Resident #2 became agitated and started yelling and acting like he was going to hit Resident #3. COTA B said LVN A got in between Resident #2 and Resident #3. COTA B said LVN A began yelling at Resident #2 telling him he was not going to hit her people, and he needed to go sit his ass down. During an interview on 11/13/25 at 1:11 p.m. the Administrator said she did not have an official disciplinary action for LVN A regarding the incident on 11/12/25 with Resident #2. The Administrator said LVN A had been suspended and would be terminated if for nothing more than in her statement confirming she told Resident #2 to sit his ass down. During an interview on 11/15/25 at 1:47 p.m. LVN A said on 11/12/25 during an altercation between Resident #3 and Resident #2 she got in between the residents to intervene. LVN A said she got Resident #2's attention and got him to sit down. LVN A said she told Resident #2 to sit his ass down in his chair before she got into trouble. Record review of the facility's Resident Rights policy last revised December 2016 indicated, Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to.b. be treated with respect, kindness, and dignity.

Based on observation, record review, and interview the facility failed to have an ongoing and effective pest control program for 3 of 7 resident rooms reviewed for pest control (Resident #1, Resident #2 and Resident #3.) The facility did not have an effective pest control program to eradicate the cockroaches in the facility. The facility failure placed residents at risk for diarrhea, dysentery (infectious diarrhea), salmonella (an infection that can lead to diarrhea, fever, and stomach cramps), and other serious health concerns. Findings included: 1.Record review of the face sheet for Resident #1 indicated he was re-admitted to the facility on [DATE] with diagnoses including chronic heart failure, COPD (Chronic obstructive pulmonary disease is a group of lung diseases that cause ongoing breathing problems), history of cellulitis to lower extremities (common bacterial skin infection that affects the deeper layers of the skin and underlying tissue). Record review of Resident #1's MDS dated [DATE] indicated Resident #1 had clear speech, made himself understood and usually understood others. The MDS indicated Resident #1 had no cognitive impairment (BIMS of 15). The MDS indicated Resident #1 had a behavior of rejecting care that had occurred 1-3 days during the 7-day look back period. The MDS indicated Resident was dependent on staff toileting hygiene, showers/bathing, dressing the lower body, and putting on footwear. The MDS indicated Resident #1 required substantial assistance dressing the upper body. The MDS indicated Resident #1 required moderate assistance with personal hygiene. The MDS indicated Resident #1 required setup or clean-up assistance only with eating and oral hygiene. Record review of the care plan revised on 6/3/25 indicated Resident #1 was on enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms which could lead to infection). The care plan indicated Resident #1 was risk for skin impairment and infection. During an interview and observation on 8/22/25 at 11:00 a.m., at the hospital, Resident #1 said he saw roaches in his room all the time because his roommate would keep uncovered food items in his room. Resident #1 said he had not seen any roaches in his bed. Resident #1 said he saw small roaches and the big water bugs in his room. Resident #1 said he never saw anyone spray his room. During an interview on 9/8/25 at 8:00 a.m., Resident #1 laid in his bed at the facility. Resident #1 said he was happy to be back at the facility but had seen roaches crawling on his floor since he had been back. During a telephone interview on 9/9/25 at 2:09 p.m., EMS personnel A said she assisted in the transport of Resident #1 from the facility to the on 8/18/25 hospital. EMS personnel A said Resident #1 is a very large man and could not transfer himself. She said when they (EMS personnel) moved Resident #1 from his bed to the stretcher she saw small roaches were crawling on his bed. She said the roaches were small and not like large water bugs. During a telephone interview on 9/9/25 at 2:14 p.m., EMS personnel B said he assisted in the transport of Resident #2 from the facility to the hospital on 8/18/25. EMS personnel B said he saw bugs crawling on the bed but could not say for sure if they were roaches. 2.Record review of Resident#2's face sheet indicated he was readmitted to the facility on [DATE] with diagnoses including COPD and type II diabetes. Record review of the MDS dated [DATE] indicated Resident #2 had short term memory problems and some difficulty with cognitive skills for daily decision making. The MDS indicated Resident #2 required supervision or touch assistance for most ADLs (oral hygiene; toileting; shower/bathing; dressing of the upper/lower body; putting on/off footwear). The MDS Resident #2 needed set up or clean-up assistance only for eating. Record review of the care plan dated 8/28/25 indicated Resident #2 had COPD. The care plan interventions included; monitor for signs and symptoms of respiratory infection. During an interview and observation on 8/21/25 at 1:40 p.m., Resident#2 was sitting in his wheelchair in his room. Resident #2 indicated Resident #1 was his roommate. Resident #2 said he saw roaches in his room all the time. There were multiple covered containers containing food on Resident #1's side of the bed. Resident #2 pointed to the space between the two nightstands and said look there is one right now. A small cockroach was noted crawling on the floor in between the space between the two night stands. Resident #2 declined to talk further with the surveyor and left the room in his wheelchair. 3.Record review of the face sheet for Resident #3 indicated she was readmitted to the facility on 11/30 24 with diagnoses including heart failure, and type II diabetes. Record review of the MDS dated [DATE] indicated Resident #3. The MDS indicated she had clear speech. The MDS indicated she usually understood and usually made herself understood. The MDS indicated she was cognitively intact (BIMS of 14). Record review of the care plan revised on 8/11/25 indicated Resident #3 was at risk for frequent infections related to her diabetes. During an interview and observation on 8/21/25 at 2:00 p.m., Resident #3 was sitting in her bed. Resident #3 said she saw large water bugs and small cockroaches just about every day in her room. Resident #3 said she did see facility staff spray the bugs. During an interview on 8/21/25 at 12:45 p.m. the maintenance director said staff were to report any bug sightings (including roaches) in the maintenance repair book located at the nurses station . The maintenance director said usually staff just came to him and told them if they saw bugs and he would he spray for them. The maintenance director said he was not always at the facility and usually worked 8am -5 pm Monday through Friday. He explained that is why they have the maintenance book for staff to write in. Record review of the facility maintenance log from April 2025 to August 2025 had revealed no loggings of bug sightings. During an observation and interview with CNA D on 8/22/25 at 3:00 p.m., CNA D picked up a large dead bug (commonly described as a water bug) from the hallway to the left of the nurses station with a paper towel and threw it in the trash. CNA D wiped the area with a Cavi wipe. CNA D said she saw large water bugs 2-3 times a week. CNA D said she would usually just squish them and clean the area. CNA D said she was not aware of a book she was suppose to record bug sightings in. During an interview on 8/22/25 at 3:30 p.m., CNA E said she saw water bugs and roaches maybe twice weekly. CNA E said she would report the sightings to the maintenance man if he was still in the building. CNA E said if the maintenance man was not in the building she would squish the bug and throw it away. CNA E said ashe was not aware of any book staff were to write bug sightings in. During a phone interview interview on 9/8/25 at 9:49 a.m., the contracted exterminator reported he sprayed the facility monthly. He said he had sprayed for both American cockroaches and stated theses bugs are what people often refer to as water bugs as well as German roaches, which people generally identify as roaches. He said he always talked to the maintenance director, if he is available, in attempt to identify any problem areas. The contracted exterminator said he also had a book for facility staff to log bug sightings in. He said he checks the book before he sprays monthly but has never saw it utilized for bug sightings. The contracted exterminator said he could spray more frequently and target the areas/bugs the facility continues to have issues with in-between the monthly treatments if it was communicated. During an interview with the ADON on 9/8/25 at 9:50 am the ADON said he had seen large water bugs but could not say he had seen small roaches. The ADON said staff are to write in the maintenance book any bug sightings so they can be targeted if needed. The ADON said it was important to maintain an effective pest control program to prevent infection. During an interview on 9/8/25 at 10:20 a.m., the Administrator said the facility conducts administrative rounds in which Monday through Friday an administrative personnel rounds on no more than 6 residents. Any issues reported by the resident and anything they see in the environment (such as bugs) are placed on a sheet to discuss solutions in morning meetings but any bug sightings are also to be written in the maintenance book. The Administrator during the weekends, the weekend administrator performs the rounds for all residents. The Administrator said all staff identifying bugs, such as roaches, should be writing that in the maintenance book so it can be addressed. Record review of the facility policy and procedure dated 2/1/17, titled Pest Control, stated Policy Our facility shall maintain and effective pest control program. Procedure The facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on observation and interview the facility failed to maintain all mechanical and electrical equipment in safe operating condition for 1 of 1 kitchen reviewed for safe operating condition.The facility failed to ensure Freezer #2 maintained a safe storage temperature and not allow food items to thaw.This failure poses a risk of essential kitchen equipment malfunctions causing foods to be held at an unsafe temperature and cause food borne illness. Findings included: Record review of a Kitchen Freezer Log for June 2025 revealed on 06/27/25 the morning temperature for Freezer #1 was 5 degrees. The temperature was initialed by [NAME] G. The evening temperature for 06/27/25 was 2 degrees Fahrenheit. On 06/28/25, the morning temperature was 0 degrees Fahrenheit, and the evening temperature was 3 degrees Fahrenheit. The morning temperature was initialed by the Dietary Manager. On 06/29/25, the morning temperature was 2 degrees Fahrenheit, and the evening temperature was 0 degrees Fahrenheit. The morning temperature was initialed by the Dietary Manager. On 06/30/25, the morning temperature was 0 degrees Fahrenheit. There were no initials. During an observation and interview on 06/30/25 at 8:44 a.m., revealed the outside digital thermometer on the upper right-hand corner of Freezer #1 read Hi. In the freezer was 1 package of egg rolls thawed and soft to the touch. There was one package of breaded shrimp thawed and soft to the touch. There was 1 box of containing three briskets. One brisket was soft to the touch and another brisket was thawed but cold. [NAME] G said they had been having problems with Freezer #1. She said the Maintenance Supervisor had worked on Freezer #1 on Friday, 06/27/25. During an observation and interview on 06/30/25 at 8:56 a.m., the Dietary Manager said sometimes the door stayed open and it caused ice buildup and food items would thaw. There was a small amount of ice noted at top of Freezer #1. He said the freezer would need to be thawed out. He said the thermometer on the outside of the freezer always read Hi. The Dietary Manager said they used a thermometer inside the freezer. The Dietary Manager had difficulty finding a thermometer in the freezer. A digital thermometer was placed in the freezer by the surveyor. During an observation on 06/30/25 at 8:57 a.m., revealed the digital thermometer in Freezer #1 read 58 degrees Fahrenheit. Within seconds of the door being opened an alarm sounded. The outside digital thermometer on the upper right-hand corner of Freezer #1 read Hi. During an observation on 06/30/25 at 9:01 a.m., revealed the digital thermometer in Freezer #1 read 50 degrees Fahrenheit. Within seconds of the door being opened an alarm sounded. The outside digital thermometer on the upper right-hand corner of Freezer #1 read Hi. During an observation on 06/30/25 at 9:15 a.m., revealed the digital thermometer in Freezer #1 read 50 degrees Fahrenheit. Within seconds of the door being opened an alarm sounded. The outside digital thermometer on the upper right-hand corner of Freezer #1 read Hi. During an observation and interview on 06/30/25 at 2:59 p.m., revealed there was a thermometer attached to a shelf inside Freezer #1. The temperature was 28 degrees Fahrenheit. The Dietary Manager said he had thrown out the food items that had thawed and removed things to increase air circulation and the temperature was returning to normal. During an observation and interview on 07/01/25 at 8:05 a.m., revealed the temperature in Freezer #1 to be 28 degrees Fahrenheit. The briskets were soft to touch. The Dietary Manager said he stayed until 8:00 p.m. on 06/30/25 and the temperature had come down to 20 degrees Fahrenheit. Within seconds of the door being opened an alarm sounded. He said he was in the process of finding an alternative freezer at this time. The outside digital thermometer on the upper right-hand corner of Freezer #1 read Hi. During an observation on 07/01/25 at 11:00 a.m., the temperature in Freezer #1 was 24 degrees Fahrenheit. Outside digital thermometer reads Hi. Within seconds of the door being opened an alarm sounded. The outside digital thermometer on the upper right-hand corner of Freezer #1 read Hi. During an interview on 07/02/25 at 10:13 a.m., the Maintenance Supervisor said he had worked on Freezer #1 on Friday, 06/27/25. He said the fans were frozen up in the freezer. He said he pulled them all out and got them to where they could run. He said he thought the fans were burned up on that freezer. He said on Friday, 06/27/25 the fans were running but running slow. He said the temperature was right at freezing on 06/27/25. He said he had no documentation. During an interview on 07/02/25 at 10:40 a.m., the Dietary Manager said the Maintenance Supervisor did work on Freezer #1 on Friday, 06/27/25. He said he was not at work that day, so he was not sure what the Maintenance Supervisor had done. He said he did work over the weekend, and the freezer was working fine. He said he felt the documented temperatures on the Kitchen Freezer Log were not accurate because it would have taken awhile for the food items to have thawed out. He said they used a thermometer inside the freezer to monitor the temperatures because the outside built-in digital thermometer had been reading hi. He said the outside digital thermometer had not been working for a while. He said food items not being kept frozen could cause foodborne illness if the temperatures got to the temperature danger zone. During an interview on 07/02/25 at 3:02 p.m., the EDO said she expected frozen foods to be kept frozen solid. She said the freezer should freeze the food solid and keep the food frozen. She said all of the food in the freezer had been thrown away. She said the Dietary Manager told her there were issues on Friday, 06.27/25. She said if they used food that was not stored properly at the right temperature it could make a resident ill with foodborne illness. Record review a Food Storage facility policy dated 01/2018 indicated, .Freezer will be maintained at 0 degrees F (Fahrenheit) or below; or at a temperature where frozen foods remain frozen . Record review of a Supplies and Equipment, Environmental Services facility policy dated 2001 indicated, .Equipment must be ready for use at all times of the day and night to serve the residents' needs .

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety.1. The facility failed to ensure all food items were labeled and dated in Refrigerator #1.2. The facility ensure that wall in the pantry was in good repair. 3. The facility failed to ensure that the pantry was free of rotting food.4. The facility failed to ensure that a scoop for the sugar bin was properly stored. 5. The facility failed to ensure the ceiling under the air conditioner duct was in good repair.6. The facility failed to ensure that all air conditioner vents were clean and free of condensation. These failures could place residents at risk of foodborne illness and food contamination.Findings include: During an observation on 06/30/25 at 8:41 a.m., revealed one plastic bag containing one light brown round food item with no date or label in Refrigerator #1. During an observation 06/30/25 at 8:44 a.m., revealed a wall in the pantry with an air conditioner in the wall. Below the air conditioner there was a large gray stain with peeling paint on the wall. Below the stain and peeling paint there was approximately 3 to 4 feet of the baseboard that was pulled away from the wall. There was a towel on the floor pushed against the baseboard. In the corner at the end of the baseboard, there was a hole in the wall with pieces of sheetrock protruding from the hole. A bin in the pantry contained potatoes with rotten areas and growing sprouts. During an observation on 06/30/25 at 8:53 a.m., revealed there was a cup in the sugar bin. During an observation on 07/01/25 at 11:56 a.m., in the kitchen area the ceiling under the air conditioning duct had several brown stains and was buckled. There were several brackets in place securing the ceiling in place. Between the air conditioning duct and the vent hood over the stove there were five towels stuck in between the vent hood and duct. There were five vents coming from the air conditioning duct and each had gray dust particles built up. One vent had condensation built up and was occasionally dripping onto the kitchen floor. One vent had a black substance on it. During an interview on 07/02/25 at 10:13 a.m., the Maintenance Supervisor said he was not aware of the damage, the baseboard being pulled out or the hole in wall in the pantry. He said he did not go in the kitchen unless he was told about something in the kitchen. He said the Dietary Manager reported any maintenance issues to him. He said the ceiling under the air conditioner duct was old and needed to be replaced. He said he did not know how long it had been buckled and the stains. He said it had been like that at least year. He said the vents dripped because of the heat from the stove caused condensation. He said he did not know who was responsible for cleaning the vents. He said he had cleaned them before. He said he would not go in and clean them unless the DM asked him to clean them. He said the towels were behind the air condition duct to keep the ceiling pushed up and not droop. He said the towels were not to collect condensation. He said he noticed the towels there when he was in the kitchen on 07/01/25. During an interview on 07/02/25 at 10:40 a.m., the Dietary Manager said all dietary staff were responsible for dating and labeling food. He said a food items not being dated could cause old or out of date food to be served. He said even though a food item was not labeled staff would still know what the food item was, but dating and labeling food was important. He said, They go hand in hand. He said usually scoops were not left in bulk food items. He said he did not know why the scoop was left in the sugar. He said a scoop being left in the sugar could cause cross contamination. He said all dietary staff were responsible for removing rotting food. He said any rotting food should be thrown away. He said he would have expected for the potatoes to have been thrown out. He said rotten food could lead to foodborne illness. He said he did not know how long the wall had been damaged in the pantry. He said at some point the air conditioner in that wall had frozen up. He said the towel was placed there to absorb the moisture from the air conditioner. He said moisture from the air conditioner caused the baseboard to pull away and caused the hole in the wall. He said he had forgotten to report it to maintenance. He said the moisture could cause mold and the hole being in the wall could increase the chances of pest in the pantry. He said the ceiling being buckled and stained under the air conditioner duct had been that way for at least a year. He said the Maintenance Supervisor was aware because he had done a walk through. He said he did not know why the towels were between the air duct and the vent-o-hood. He said he thought it was the Maintenance Supervisor's responsibility to clean the air conditioner vents. He said the one vent had a lot of condensation since the weather had gotten hot. He said the condensation or dusty particles from the vents could fall into the food and cause cross contamination. During an interview on 07/02/25 at 3:02 p.m., the EDO said anyone that opened foods was responsible for dating and labeling foods. She said, ultimately the DM was responsible for making sure that was done. She said food not being dated could cause food to be kept past the time of consumption and make the resident ill. She said food not being labeled could cause you not to know what the item was, and it not be safe for consumption. She said scoops should not be stored in food items because it could pass germs to the food item. This could cause a risk for infection and spread of germs. She said any food item with obvious signs of aging or decay should not be consumed because you do not want to keep a spoiled item that could make a resident sick. She said they should not have retained the potatoes. She said the wall in the pantry should have been reported to her and to the Maintenance Supervisor and it should have been repaired upon knowledge. She said the ceiling under the air conditioner duct should have been repaired and towels should be utilized in that space. She said condensation dripping could cause a fall. She said the air conditioning vents should be kept clean by dietary staff. She said there were times and places that would require assistance from the Maintenance Supervisor. She said she would have expected the vents to have been kept clean or at least let her know they were not able to clean them. She said the particle or germs from the dirty air conditioning vents could contaminate the food. Record review of a Food Storage facility policy dated 01/2018 indicated, .All food purchased will be wholesome, manufactured, process, and prepared in compliance with all State, Federal, and local laws and regulations. Food will be handled in a safe and sanitary method to prevent contamination and food-borne illness .Stock will be rotated first-in, first-out. Foods will be used or discarded prior to the expiration date .Food removed from its original packaging will be labeled with the following .Receive Date .Open Date .Contents in the Package .Opened package or leftover food is to be tightly wrapped or covered in airtight, clean containers. It should be labeled, dated with the opened or use by date .Do not store scoops in ready to eat food .

Based on observation, interview, and record review the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 5 of 17 residents (Resident #3, Resident #24, Resident #39, Resident #48, and Resident #119) and 4 anonymous residents reviewed for palatable food. 1. The facility failed to ensure residents received food that tasted good. 2. The facility failed to ensure residents did not receive cold food. 3. The facility failed to ensure residents received preferred portion sizes. These failures could place residents at risk of weight loss, altered nutritional status and diminished quality of life. Findings included: 1. Record review of a face sheet dated 07/01/25 revealed Resident #3 was a [AGE] year-old female and was admitted to the facility on [DATE] with diagnoses including congestive heart failure, muscle weakness, and anxiety. Record review of a quarterly MDS assessment dated [DATE] revealed Resident #3 was usually understood and usually understood others. The MDS revealed Resident #3 had a BIMS score of 15, which indicated intact cognition. During an interview on 06/30/25 at 2:08 p.m., Resident #3 said, the food ain't good. She said the vegetables had too much salt and were watery. She said when she ate in her room the food was always cold. 2. Record review of a face sheet dated 07/01/25 revealed Resident #24 was a [AGE] year-old female and was admitted to the facility on [DATE] with diagnoses including congestive heart failure, depressive episodes, and anxiety. Record review of an annual MDS assessment dated [DATE] revealed Resident #24 was usually understood and usually understood others. The MDS revealed Resident #24 had a BIMS score of 14 which indicated the resident had intact cognition. During an interview on 06/30/25 at 10:28 a.m., Resident #24 said the food had no taste. She said they were served the same things over and over. She said the food was cold. During an interview on 07/01/25 at 2:35 p.m., Resident #24 said her lunch was not good. She said nothing tasted good. She said the broccoli salad was terrible. 3. Record review of a face sheet dated 07/01/25 revealed Resident #39 was a [AGE] year-old male and was admitted to the facility on [DATE] with diagnoses including congestive heart failure, recurrent depressive disorders, and anxiety. Record review of a quarterly MDS assessment dated [DATE] revealed Resident #39 was usually understood and usually understood others. The MDS revealed Resident #39 had a BIMS score of 15 which indicated the resident had intact cognition. During an interview on 06/30/25 at 10:15 a.m., Resident #39 said the food was terrible. He said it was cold and bland. 4. Record review of a face sheet dated 07/01/25 revealed Resident #48 was a [AGE] year-old male and was admitted to the facility on [DATE] with diagnoses including muscle weakness, depressive episodes, and anxiety disorder. Record review of a quarterly MDS assessment dated [DATE] revealed Resident #48 was understood and understood others. The MDS revealed Resident #48 had a BIMS score of 12 which indicated the resident had moderate impaired cognition. During an interview on 06/30/25 at 10:16 a.m., Resident #48 said, the food sucks. He said they needed a better variety of vegetables. He said the food was served like they were little kids. He said the portions were small. He said the food did not taste good and was sometimes cold. During an interview and observation on 07/01/25 at 8:43 a.m., Resident #39 said the food was terrible. He said he would like to be served some corn or black-eyed peas. He said all they ever had were mixed vegetables and zucchini. He said one night he was served one boiled egg and 4 pieces of toast. He said every Sunday night they were served tomato soup and a grilled cheese sandwich. He said, Even a dog eats more than that. On his cellphone was a picture dated June 23 at 5:41 p.m. of a plate with a tortilla containing four small pieces of meat, cheese, and a few vegetables. He said there was not enough meat. He said, All it tasted like was salsa. A second picture dated June 24 at 5:26 p.m. was of a plate with two pieces of bread and a small scoop of a cucumber tomato onion salad. He said the bread was a sandwich with only one small slice of meat. The meat was not visible in the picture. He said when he was served a sandwich the bread was hard like it had been left out. During an interview on 07/01/25 at 12:50 p.m., Resident #39 said the broccoli salad he was served at lunch was awful. 5. Record review of a face sheet dated 07/01/25 revealed Resident #119 was a [AGE] year-old male and was admitted to the facility on [DATE] with diagnoses including heart disease, diabetes, and chronic kidney disease. Record review of a MDS assessment dated [DATE] for revealed Resident #119 was usually understood and usually understood others. The MDS revealed Resident #119 had a BIMS score of 15 which indicated the resident had intact cognition. During an interview on 06/30/25 at 2:11 p.m., Resident #119 said the food tasted like he was eating someone else's spit. He said the food had no taste. He said it was horrible. During an observation and interview on 07/01/25 at 12:45 p.m., revealed a lunch tray was sampled with 4 surveyors and the Dietary Manager. The sample tray consisted of Beef Macaroni Casserole, broccoli salad, a roll, and a summer fruit cup. The Beef Mac Casserole was seasoned well, but the macaroni was overcooked and falling apart. The Dietary Manager agreed the macaroni was overcooked. The broccoli salad consisted of cooked broccoli with a dressing. All four surveyors agreed the salad did not taste good . The dressing did not taste like it belonged on cooked broccoli. The dressing was too tangy. The Dietary Manager said he did not like broccoli, and it did not taste good. The broccoli salad was the only vegetable on the tray. During a confidential resident group interview on 12/03/24 at 2:00 p.m., Anonymous Resident #1, Anonymous Resident #2, Anonymous Resident #3, Anonymous Resident #4, Resident #3, Resident #24, and Resident #119 stated they had asked for fried chicken and had not gotten any. They stated they were not served enough meat with meals. They stated the food did not taste good at all and it was cold. During an interview on 07/02/25 at 8:26 a.m., RCP A said Resident #119 had told her he did not like his food. She said he told her it had no flavor, and he could not eat it. She said she reported it to the family. She said she had not gotten food complaints very often. She said residents had told her the portions were not big enough. She said when she heard food complaints she had reported them to the dietary department. During an interview on 07/02/25 at 8:40 a.m., RN B said she heard a lot of food complaints. She said she had heard things like What is this? and I wouldn't give this to my dog. She said residents had told her the food was plain and tasted like water. She said she had heard from the residents who ate on the hall that their food was cold. She said when she first started working at the facility, she reported it to the dietary department. She said she quit reporting it because nothing got better. She said when there were certain people in the kitchen it was horrible. She said, The meals are not up to par here. During an interview on 07/02/25 at 10:40 a.m., the Dietary Manager said he had heard food complaints from staff and residents. He said they had to follow corporate made menus. He said they tried to go above and beyond for each specific resident. He said he had made rounds in the past. He said during those rounds no one really complained to him. He said he was not aware of any concerns mentioned during Resident Council. He said residents not liking the food could lead to weight loss and the resident not getting proper nutrition. During an interview on 07/02/25 at 2:38 p.m., the DCO said she had heard complaints about portion sizes and taste. She said the dietician was very active in the kitchen. She said there was a big employee turnover with cooks in the kitchen. She said they had started asking residents specifically what meals the residents would like and then they serve it the next month. She said residents not liking their food could cause weight loss and illness. During an interview on 07/02/25 at 3:02 p.m., the EDO said she had heard food complaints. She said they had been adjusting the menu to try to please the residents. She said they served a lot of sandwiches. She said residents not liking their food could cause weight loss and unhappiness. She said Resident #48 had requested boiled eggs. She said he was served boiled eggs and toast for breakfast after the request. Record review of a Resident Grievance/Complaint Investigation Report dated 06/26/25 indicated Resident #48 said on 06/23/25 the tortilla hardly had any filling, and the beans were burnt and runny. The corrective action taken was for staff to continue to monitor meals. Record review of the resident council minutes, dated between January 2024 and June 2025, revealed the following: 1. On 01/22/25, .Food & Nutrition Services Department .still coming out cold .Meal of the Month .Entrée: Fried Chicken .Side .green beans & corn - cream style - no broc (broccoli). 2. On 02/19/25, .Food & Nutrition Services Department .food is coming out burnt or to hard .still coming out cold .would like to have more fried chicken than baked or rosemary . 3. On 03/20/25, .Food & Nutrition Services Department .food hasn't changed, still cold or burnt. Have not got their fried chicken. Still getting rosemary . 4. On 04/23/25, .Food & Nutrition Services Department .still cold coming down the hall .Meal of the Month .Vegetable: no broc (broccoli) . 5. On 05/21/25, .Food & Nutrition Services Department .still cold coming down the hall .Meal of the Month .Entrée: Fried chicken .Vegetable: Carrots, not broc (broccoli) . 6. On 06/18/25, .Food & Nutrition Service Department .some days it is cold & some days it is warm . Record review of a Preparation of Foods facility policy dated 04/2022 indicated, .Food is to be prepared by methods that conserve nutritive value, flavor, and appearance .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 form to meet the individual needs of the resident .

Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 9 residents reviewed for respiratory care. (Resident #7 and Resident #26)1. The facility failed to ensure Resident #7's oxygen concentrator (takes air from the surroundings, extracts oxygen and filters it into purified oxygen for resident to breathe) air intake area (mouth of the oxygen concentrator bringing in the air that will be processed) was not covered in gray fuzzy dust-like and hair-like particles.2. The facility failed to ensure Resident #7 had an order and care plan for oxygen therapy.3. The facility failed to ensure Resident #26's oxygen concentrator air intake area was not covered in gray fuzzy dust-like and hair-like particles.These failures could place residents at risk of respiratory complications or respiratory infection. Findings included:1. Record review of Resident #7's face sheet dated 6/30/25 indicated she was [AGE] years old and admitted to the facility on [DATE]. Resident #7 had diagnoses which included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), diabetes (high blood sugar), and hypertension (high blood pressure).Record review of Resident #7's quarterly MDS assessment dated [DATE], indicated she had a BIMS score of 13, which indicated she was cognitively intact. The MDS did not indicate Resident #7 was receiving oxygen therapy.Record review of Resident #7's undated Care Plan Report indicated she had potential for ineffective airway clearance, anxiety, and disturbed sleeping pattern related to chronic obstructive pulmonary disease. The care plan report did not indicate Resident #7 was receiving oxygen therapy.Record review of Resident #7's Order Summary Report dated 6/30/25 did not reflect an order for oxygen therapy.Record review of Resident #7's Medication Administration and Treatment Administration Records dated 6/01/25-6/30/25 did not indicate administration of oxygen therapy.During an observation and interview on 6/30/25 at 11:36 AM, Resident #7 was sitting in her chair in her room, and she reached over and put the oxygen tubing in her nose and over her ears. Resident #7 said she used her oxygen as needed for shortness of breath. Resident #7's oxygen was set on 2 LPM and the tubing was dated 6/30/25. Resident #7's oxygen concentrator's air intake area was covered in gray fuzzy dust and hair-like particles. Resident #7 said she did not know how often the facility cleaned the oxygen concentrator.During an observation on 7/01/25 at 1:45 PM, Resident #7's oxygen concentrator continued to have gray fuzzy dust and hair-like particles covering the air intake area.2. Record review of Resident #26's face sheet dated 6/30/25 indicated he was [AGE] years old and admitted to the facility on initially on 6/19/19 and re-admitted on [DATE]. Resident #26 had diagnoses which included chronic obstructive pulmonary disease, and hypertensive (high blood pressure) heart disease with heart failure.Record review of Resident #26's quarterly MDS assessment dated [DATE], indicated he had a BIMS score of 12, which indicated he had moderate cognitive impairment. The MDS indicated Resident #26 was receiving oxygen therapy.Record review of Resident #26's undated Care Plan Report indicated he had ineffective breathing pattern related to COPD and emphysema. Interventions included administer medications as ordered and may utilize oxygen as needed per physician orders. Resident #26 also had potential for problems related to COPD: problem with ineffective airway clearance related to excessive and tenacious secretions, problem with anxiety related to breathlessness and fear of suffocation, problem with disturbed sleep pattern related to cough or inability to assume recumbent position (lay flat) and used routine oxygen related to shortness of breath with exertion, upon rest and when lying flat. Interventions included administer oxygen per physician orders and change tubing/cannula per facility protocol. Resident also had continuous oxygen therapy related to COPD. Record review of Resident #26's Order Summary Report dated 6/30/25 reflected an order to clean/change oxygen concentrator filters every night shift on Sundays and an order for oxygen at 2-3 LPM by nasal cannula PRN shortness of breath with a start date of 4/14/22. Record review of Resident #26's Licensed Nurse Medication Administration Record dated 6/01/25-6/30/25 indicated there was an order to clean/change oxygen concentrator filters every night shift on Sundays and indicated RN D had completed the task on 6/29/25. Record review of Resident #26's Medication Administration Record dated 6/01/25-6/30/25 indicated he could have oxygen 2-3 LPM PRN shortness of breath and to document if oxygen was in use. The Medication Administration Record indicated he used oxygen daily 6/01/25-6/30/25.During an observation on 6/30/25 at 10:33 AM, Resident #26 self-propelled himself into room. Resident #26 was wearing oxygen by a nasal cannula in his nose attached to an oxygen tank hung on the back of his wheelchair. Resident #26 had an oxygen concentrator in his room with oxygen running at 3 LPM with oxygen tubing dated 6/30/25. Resident #26's oxygen concentrator's air intake area was covered in thick gray, fuzzy dust and hair-like particles. Resident #26 said the staff changed the oxygen tubing weekly, but he did not know if they cleaned the oxygen concentrator air intake area. Resident #26 said the oxygen concentrator air intake area looked really dirty.During an observation on 7/01/25 at 1:55 PM, Resident #26's oxygen concentrator continued to have gray fuzzy dust and hair-like particles covering the air intake area.During an interview on 7/02/25 at 10:16 AM, RN B said she was the nurse on the back hallway and did not have Resident #7 or Resident #26 on her hall. RN B said the nursing staff were responsible for cleaning and changing filters and the oxygen machines. RN B said she checked all her concentrators during her shift to make sure the filters were clean, and she would pop off the back of the oxygen concentrator to clean vents (air intake area). RN B said if the oxygen concentrator filters and vents were not cleaned, they could hold bacteria, and it could get in the resident's lungs. RN B said dirty filters or vents (air intake area) could cause the resident to develop an upper respiratory infection and could even possibly kill the resident if it got bad enough. RN B said if a resident had oxygen in their room and using it, there should be an order for it, it should be care planned, and included on the MDS if it's in the look back timeframe. RN B said the care plan let everyone know what the resident needed to care for them and how to take care of them, what to monitor for, and what medications they were on. RN B said sometimes they have standing orders in their book to use when needed, but she looked in the standing orders and did not see any for oxygen, so anytime a resident needed oxygen they would need to get an order from the physician.During an interview on 7/02/25 at 10:55 AM, the Director of Plant Operations said he had worked at the facility for approximately one and a half years. He said he was told the nurses were responsible for cleaning/changing the oxygen filters. He said if he was supposed to clean the internal air intake areas of the oxygen concentrator, he had not been told and did not know who would be responsible for cleaning them. He said the oxygen concentrator air intake areas should be clean, because it would be an infection control issue and could cause the resident an infection.During an interview on 7/02/25 at 11:34 AM, RN C said she had worked at the facility for less than a week. RN C said she was the nurse assigned to Resident #7 and Resident #26. RN C said the nurses were responsible for cleaning the oxygen concentrator machines and filters. RN C said it was important to keep them clean because the resident could breathe in bacteria from a dirty filter and the resident could get an infection. RN C said she had not checked the oxygen concentrators that day, but she would during her shift. RN C said she had not had to clean the air intake area of the oxygen concentrator yet. RN C said if the resident was using oxygen, they should have an order for oxygen, and it should be care planned. RN C said oxygen was a medication and must have an order and it should be care planned so staff know what to do to care for the resident. RN C said today (7/02/25) was her first day on that hall. RN C reviewed Resident #7's chart and said she did not have an order for oxygen, and it was not care planned.During an interview on 7/02/25 at 11:52 AM, the ADCO said the 10 PM -6 AM nurses on Sundays were responsible for changing out the oxygen filters, tubing, and cleaning the air intake areas of the oxygen concentrators. The ADCO said it was important to keep the oxygen concentrator filters and air intake areas clean because they did not want any microorganisms to be inhaled that could produce infections. The ADCO said the resident was at risk for infection if the oxygen concentrator filters and air intake areas were not kept clean. The ADCO said there should be an order for oxygen and should be care planned if the resident was utilizing oxygen. The ADCO said they have standing orders for like 2 LPM by nasal cannula PRN for all the residents, but if the resident was using oxygen routinely, then it should be added to the resident's orders. The ADCO said the care plan was to allow for the continuity of care and the care to be individualized for the resident. The ADCO said Resident #7 used the oxygen PRN. The ADCO observed the picture of Resident #26's air intake and said, that's not good. The ADCO said he believed Resident #7 had been using the oxygen PRN since her admission [DATE]) and should have had an order and been care planned.During an interview on 7/02/25 at 12:33 PM, RN D said she worked the night shift on 6/29/25. RN D said the night shift nurses on Sundays were responsible for cleaning the oxygen filters, oxygen concentrators, changing out the oxygen tubing and nebulizers. RN D said on the machines without the filters, she just cleaned the outside of the machine. RN D said she did not know who was responsible for cleaning the air intake areas of the concentrator. RN D said if the filter or air intake area was dirty, the resident could breathe dirty air and the resident could possibly have a low oxygen level, upper respiratory infection, and bacteria could go into their lungs.During an interview on 7/02/25 at 2:14 PM, the DCO said the oxygen concentrators were to be done weekly on the night shift nurse on Sundays. The DCO said the same person would be responsible for cleaning the air intake area of the oxygen concentrators. The DCO said dirty filters and air intakes, could cause respiratory issues such as pneumonia and respiratory infections. The DCO said a resident who utilized oxygen should have an order for it and it should be care planned. The DCO said there should be an order for oxygen to ensure the MD was aware if the resident required oxygen, was having shortness of breath, and to identify if the resident was having other issues, and the care plan was so everyone could follow the same plan of care for the resident. The DCO observed the picture of Resident #26's oxygen air intake area and said the air intake area was absolutely not acceptable. The DCO said Resident #7 had been utilizing oxygen since her admission and there should have been an order for it, and it should have been care planned.During an interview on 7/02/25 at 2:39 PM, the EDO said the nursing staff should be checking the oxygen concentrators and cleaning out the air intake weekly. The EDO said the maintenance man should also be checking the oxygen concentrator machines when they were changing out a machine. The EDO said a dirty filter or dirty air intake area could cause the resident a respiratory illness or infection, and it could affect the functioning of the machine. The EDO said she would expect the machines to be kept clean. The EDO said the resident should have an order for oxygen and it should be care planned. The EDO said if the resident was needing oxygen, they needed to document the use of oxygen and whether it was affective. Review of the facility's policy titled Oxygen Therapy dated 04/2021 indicated . policy of this community to ensure all oxygen administration was conducted in a safe manner . verify there was an order for oxygen administration to include . method of delivery, flow rate, oxygen saturation parameters if indicated . start oxygen flow of rate as ordered . document resident's response to PRN oxygen therapy . date and time of oxygen administration . type of delivery . oxygen rate . assessment of resident's respiration status to include oxygen saturation via pulse oximetry . change the reservoir, oxygen cannula and tubing every 7 days . keep oxygen cannula and tubing used PRN in a plastic bag when not in use . wash filters from oxygen concentrators every 7 days in warm soapy water. rinse and squeeze dry .

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 2 of 20 resident's (Resident #7 and Resident #37) reviewed for a homelike environment.1. The facility failed to ensure Resident #7's wall was free from peeling paint at the head of her bed with approximately 4 different areas measuring approximately 1-2 inches wide and 2-3 inches long.2. The facility failed to ensure Resident #7's wall was free from peeling paint by her pillow that measured approximately 6-8 inches at the widest point and a foot long at the longest point.3. The facility failed to ensure Resident #7's air condition/heat unit was free from peeling paint and/or caulk around the unit leaving approximately half inch gaps around the top of the unit.4. The facility failed to ensure Resident #37's wall was free from peeling paint at the midway area of his bed that measured approximately 10 inches at the widest point and a foot long at the longest point.These failures could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life.Findings included:1. Record review of Resident #7's face sheet dated 6/30/25 indicated she was [AGE] years old and admitted to the facility on [DATE]. Resident #7 had diagnoses which included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), diabetes (high blood sugar), and hypertension (high blood pressure).Record review of Resident #7's quarterly MDS assessment dated [DATE], indicated she had a BIMS score of 13, which indicated she was cognitively intact. Resident #7 used a walker for mobility. Resident #7 was independent to needed supervision for most ADLs.During an observation and interview on 6/30/25 at 11:36 AM, Resident #7 was sitting in her chair in her room. Resident #7 said she wanted her room painted because the paint was peeling off the wall, and she did not like it, and it looked bad. There was peeling paint at the head of her bed with approximately 4 different areas measuring approximately 1-2 inches wide and 2-3 inches long and peeling paint by her pillow that measured approximately 6-8 inches at the widest point and a foot long at the longest point. There was peeling paint and/or caulk around the air condition/heating unit leaving approximately half inch gaps around the top of the unit.2. Record review of Resident #37's face sheet dated 6/30/25 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #37 had diagnoses which included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe), senile degeneration of the brain (decline in cognitive function associated with aging), lack of coordination, and nicotine dependence.Record review of Resident #37's annual MDS assessment dated [DATE], indicated he had a BIMS score of 9, which indicated he had moderate cognitive impairment. The MDS indicated Resident #37 had continuous inattention. The MDS indicated Resident #37 was independent or needed set-up/clean-up assistance for most ADLs.During an observation and interview on 6/30/25 at 12:01 PM, Resident #37 had peeling paint on the wall beside his bed, about midway down his bed, that measured approximately 10 inches at the widest point and a foot long at the longest point. Resident #37 said it did not bother him, and he had lived in worse.During an observation on 7/02/25 at 9:35 AM, Resident #37 was lying in bed asleep. Resident #37's room continued to have peeling paint beside his bed that measured approximately 10 inches at the widest point and a foot long at the longest point. During an interview on 7/02/25 at 9:51 AM, RCP A said Resident #7 had not said anything to her about not liking the peeling paint on her wall. RCP A said she would report any issues with repairs to the nurse or the maintenance man. RCP A said the nurse put needed repairs in the maintenance logbook. RCP A said the maintenance man was responsible for ensuring the rooms were in good repair. RCP A said peeling paint in the residents' rooms was not homelike. RCP A said she would not want her walls like that. RCP A said peeling paint in her room would not make her feel good and would bother her. RCP A said peeling paint on the resident's wall would bother the resident also.During an interview on 7/02/25 at 9:58 AM, RCP F said he had worked at the facility for about 2 years. RCP F said he would report any resident reports of needed repairs to the maintenance man and put it in the maintenance logbook. RCP F said the maintenance man was responsible for repairing and maintaining the residents' rooms. RCP F said peeling paint in a resident's room was not homelike and he would not want peeling paint in his house. RCP F said it would not make him feel good to have peeling paint and would make the resident not feel good and not happy. RCP F said it was important to provide a homelike environment to make sure the resident was happy, and the facility was their home.During an interview on 7/02/25 at 10:16 AM, RN B said peeling paint in a resident's room would not be homelike. RN B said she would not like to have peeling paint in her home. RN B said having peeling paint in their room probably would make the resident feel like they were nothing and nobody cared about them. RN B said the facility should provide a homelike environment so the resident felt comfortable since they had to leave their homes and it had to do with their total wellbeing, if they are not happy, they could not heal. RN B said she would place any needed repairs in the maintenance logbook and the maintenance reviewed it for any needed repairs.During an interview on 7/02/25 at 10:55 AM, the Director of Plant Operations said he was over the maintenance department and had worked at the facility for about one and half years. The Director of Plant Operations said the staff wrote in the logbook at the nurses' station, he reviewed and if he noticed something that needed addressed as he walked by, he would fix it. The Director of Plant Operations said he walked the halls and pretty much glanced in every room every day. The Director of Plant Operations said there was several rooms with peeling paint in the building, but he was only one person and he had to prioritize what needed to be fixed first. The Director of Plant Operations said the residents did not like peeling paint and it was not comfortable for the resident. The Director of Plant Operations said he felt the aides ran the beds up and down the walls and it made it hard to keep the walls looking nice. The Director of Plant Operations said he would not want to have peeling paint in his home. The Director of Plant Operations said the residents should feel safe, be comfortable, and have a homelike environment. During an interview on 7/02/25 at 11:52 AM, the ADCO said there was a maintenance book where they logged issues or needed repairs at the nurses' station and the maintenance man took care of it. The ADCO said he could not say how peeling paint in the resident's room affected the resident, but he was sure no one would prefer that. The ADCO said he would not want peeling paint in his home. The ADCO said it would be bothersome to the resident, but he had not had anyone report to him having an issue with peeling paint in the rooms. The ADCO said it was important to provide a homelike environment for the residents to have a good quality of life because when they entered into the nursing home it was toward the end of their life. During an interview 7/02/25 at 2:14 PM, the DCO said they had been doing repairs a little as they went and painting a room had to be approved because the building was old. The DCO said they had a maintenance logbook at the nurses' station for staff to log any needed repairs and then the maintenance man addressed them. The DCO said peeling paint in a resident's room was not homelike. The DCO said sometimes staff cause the peeling paint by accident due to the beds being against the wall. The DCO said she had not had any residents express concerns with the paint situation. The DCO said the resident's room was their home and they would not want chipped or peeling paint. The DCO said she would not want peeling paint in her home if she had the means to replace it. During an interview on 7/02/25 at 2:39 PM, the EDO said any staff could report an issue or a needed repair and they had partners assigned to each room who do check offs weekly and should report any needed repairs for the rooms. The EDO said the building was older and had a lot that needed to be done. The EDO said they just repainted the men's memory unit. The EDO said a work order would need to be created for any repairs. The EDO said repair of peeling paint was an easy fix and would need to be repaired quickly to contribute to a more home like environment for the residents. The EDO said it was important to promote a home-like environment because it was their home, you want them to be comfortable, and for their psychosocial needs. Record review of the Maintenance Logbook, dated 4/01/2024 through 7/02/2025, did not indicate any wall/paint repairs were needed for Resident #7's (room [ROOM NUMBER]) or Resident #37's (room [ROOM NUMBER]) rooms.Record review of the facility's undated policy titled Homelike Environment indicated . Residents' rooms: Ensure all resident rooms meet federal standards for space, privacy, and comfort . Housekeeping and Maintenance: implement regular cleaning and maintenance schedules to ensure a sanitary and orderly environment . involve residents in decisions about their care plans and living environment to align with their preferences and needs .

Based on observation, interview and record review the facility failed to ensure nurse aides were able to demonstrate competency in skills and necessary techniques to care for resident's needs, as identified through resident assessments and described in the plan of care for 1 of 2 RCPs (RCP E) reviewed for nurse aide competencies. The facility failed to ensure RCP E was competent in performing a safe mechanical lift (machine used to lift and transfer a resident from one surface to another, such as from chair to bed/bed to chair) transfer on Resident #2 when RCP E did not place the legs of the mechanical lift in the wide position when lowering or transferring the resident and did not lock the lift wheels while lifting or lowering the resident.This failure could place residents at an increased and unnecessary risk of injury.Findings included:Record review of Resident #2's face sheet dated 7/02/25 indicated she was [AGE] years old and admitted to the facility on [DATE] and re-admitted [DATE]. Resident #2 had diagnoses which included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), diabetes (high blood sugar), hypertension (high blood pressure), weakness, blindness in one eye and low vision in the other.Record review of Resident #2's quarterly MDS assessment dated [DATE], indicated she had a BIMS score of 13, which indicated she was cognitively intact. The MDS indicated Resident #2 was dependent to needed substantial assistance in most ADLs.Record review of Resident #2's undated Care Plan Report indicated she was at risk for falls related to poor vision, inability to bear weight, weakness, and decreased sense of safety. Resident #2 had an ADL self-care performance deficit related to weakness, inability to bear weight and loss of vision from a cerebrovascular accident (stroke) with interventions including the resident required total assistance of two staff to move between surfaces using a Hoyer mechanical lift.During an observation on 7/01/25 at 8:38 AM, RCP E performed a mechanical lift transfer from a wheelchair to bed on Resident #2. RCP E placed the mechanical lift legs in the wide position around Resident #2's wheelchair. RCP E and RCP A attached the lift pad that was already under Resident #2. RCP E then did not lock the mechanical lift wheels and lifted Resident #2 up out of the wheelchair. The mechanical lift rolled toward the resident while RCP E was raising Resident #2 up. RCP E pulled Resident #2 backwards while RCP A moved the wheelchair from under the resident. RCP E the moved the mechanical lift legs to closed/narrow position, pulled Resident #2 backwards, turned toward the bed and then pushed Resident #2 over the bed. RCP E then lowered Resident #2 onto the bed, as RCP A guided the resident, and RCP E did not open the mechanical lift legs to the wide position and did not lock the mechanical lift wheels when lowering Resident #2 onto her bed.During an interview on 7/01/25 at 1:52 PM, RCP E said she had worked at the facility for a week and had been training on different halls. RCP E said she had not been checked off on mechanical Hoyer lift transfers yet but had been a CNA for 35 years and had been doing Hoyer lifts all that time. RCP E said the mechanical lift should have the legs in the wide position so it would go around the wheelchair. RCP E said the mechanical lift legs should be closed (narrow position) during transferring the resident because the mechanical lift was easier to push. RCP E said the wheels on the lift should be locked as a safety thing at all times. RCP E said she did not put the mechanical lift wheel locks on because it allowed her to move the mechanical lift to keep the bars out of the resident's face. RCP E said the mechanical lift was more stable with the legs in the wide position. RCP E said the mechanical lift was safer when the mechanical lift legs were closed (narrow position) during a transfer, but the mechanical lift legs should be opened to the wide position when lowering the resident to the bed. RCP E said she did not remember if she put the mechanical lift legs in the wide position or locked the wheels when lowering the position onto the bed.During an interview on 7/01/25 at 2:02 PM, RCP A said she had worked at the facility for approximately three years. RCP A said the mechanical lift legs should be in wide position for stability and so it would fit around the wheelchair. RCP A said the mechanical lift wheels should be locked when lifting or lowering the resident, so the mechanical lift does not move. RCP A said the mechanical lift legs should be in the narrow position during transferring the resident and when lowering the resident onto the bed. RCP A said the lift was more stable with the legs opened wide. RCP A said the legs of the mechanical lift should be opened wide, because it was safer for the resident during transfers and the mechanical lift could tip over and injure the resident. RCP A said she had been checked off on doing safe mechanical lift transfers. RCP A said she was guiding the resident while RCP E performed the mechanical lift on Resident #2 on 7/01/25 and did not notice if RCP E locked the wheels or if the legs were in the wide position during transferring the resident.During an interview on 7/02/25 at 11:52 AM, the ADCO said the lift process should be 2 people, one managing the lift and one making sure to safely move the resident. The ADCO said the mechanical lift legs should be in the wide position when going around the resident's wheelchair. The ADCO said then staff should close the mechanical lift legs after clearing the wheelchair and moving the resident the legs should be in the closed position to keep from hitting the legs on something else. The ADCO said the legs in wide position was to create a larger opening and give a wider base of support when lifting the resident. The ADCO said the legs should be in the closed position when lowering onto the bed. The ADCO said the wheels of the lift should be locked before any lifting or lowering of the resident. The ADCO said the wheels should be locked for the safety of the resident. The ADCO said the resident could be injured or the lift could turn over if the wheels were not locked. The ADCO said he was responsible for doing the competencies with the RCPs and ensuring they were providing safe competent care to the residents. The ADCO said they did not have a policy on competent staff, but utilized the Competency Check Off form as a guide in training staff.During an interview on 7/02/25 at 2:14 PM, the DCO said the wheels should be locked on the mechanical lift during standing positions and the mechanical lift legs in wide position during transferring/moving for resident safety. The DCO said the resident could possibly fall if transferred/moved if the mechanical lift legs were not in the wide position or the wheels locked. The DCO said the legs in the wide position provides a wider surface for preventing falls. The DCO said the administration teams were responsible for ensuring the staff were checked off and were performing skills adequately. The DCO said the wheels of the mechanical lift should be locked so it did not lose positioning and should stay locked until ready to transfer/move the resident.During an interview on 7/02/25 at 2:39 PM, the EDO said the governing body, the DCO and ADCO, were responsible for ensuring staff were providing competent care. The EDO said they performed skill check offs with staff upon hire, annually, and as needed. The EDO said she would expect the supervising nurses to manage that system. The EDO said the legs of the mechanical lift should have been in the wide position during lifting, moving, and lowering the resident and the wheels locked when not in motion for the safety of the resident. The EDO said not locking the wheels during lowering and lifting and not putting the mechanical lift legs in the wide position during lifting, moving, and lowering the resident, could contribute to an accident due to misuse of the lift. The EDO said if the legs of the mechanical lift were not in the wide position, the lift could become off balance and the resident could fall.Record review of the facility's Mechanical Lift Competency (bed to chair) dated 6/27/25 had a P marked in each section of the procedure which indicated RCP E passed all components and performed the skill competently . procedure . 3. place sling under resident . 4. bring mechanical lift over resident and raise bed height to working level, ensuring legs of lift can fit under bedframe, open legs to the widest position possible . 10. one staff member controls and maneuvers the lift; the second staff member guides the resident's body . 11. ensure receiving surface is locked, open legs of the lift to fit on each side of the wheelchair . lower resident. The ADCO had signed the form indicating he had observed RCP E perform a mechanical lift and she had performed it competently. Record review of the facility's policy titled Safe Lifting and Movement of Residents, dated revised July 2017, indicated . to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents . resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents . staff responsible for direct resident care will be trained in the use of manual . and mechanical lifting devices . only staff with documented training on the safe use and care of the machines and equipment used in the facility will be allowed to lift or move residents . staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques .Record review of Patient Lifts by the U.S. Food and Drug Administration (FDA), (Patient Lifts | FDA) was accessed on 7/08/25 indicated . the FDA has compiled a list of best practices that, when followed, can help mitigate the risks associated with patient lifts . users should . keep the base (legs) of the patient lift at maximum open position and situate the lift to provide stability . Record review of Best Practices for Using Patient Lifts by the U.S. Food and Drug Administration (FDA), Best Practices For Using Patient Lifts (fda.gov) was accessed on 7/08/25 indicated . patient lifts were designed to lift and transfer patients from one place to another . found improper use of patient lifts have led to patient falls . resulted in head traumas, fractures, deaths . can mitigate risks by doing the following . receive training and understand how to operate the lift . keep the base (legs) of the patient lift in the maximum open position .

Based on observation, interview and record review, the facility failed to follow their own established smoking policy for 1 of 9 residents reviewed for smoking. (Resident #37)The facility failed to ensure Resident #37 followed the smoking policy and did not have smoking supplies (cigarettes and lighter) at his bedside. This failure could place residents at risk for injury or harm. Findings included:Record review of Resident #37's face sheet dated 6/30/25 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #37 had diagnoses which included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe), senile degeneration of the brain (decline in cognitive function associated with aging), lack of coordination, and nicotine dependence.Record review of Resident #37's annual MDS assessment dated [DATE], indicated he had a BIMS score of 9, which indicated he had moderate cognitive impairment. The MDS indicated Resident #37 had continuous inattention. The MDS indicated Resident #37 was independent or needed set-up/clean-up assistance for most ADLs. The MDS did not indicate Resident #37 was using tobacco at the time of the assessment.Record review of Resident #37's undated Care Plan Report indicated he had a behavior problem related to anxiety, low frustration tolerance with poor impulse control, and often refused to follow smoking rules and attempted to hide cigarettes and lighter. Interventions included to intervene as necessary to protect the rights and safety of others. Resident #37 had impaired cognition with poor judgement, sense of safety, decision making skills related to dementia, very poor memory and often thought staff were talking about him, keeping his money, and not following smoke break times. Resident #37 was a smoker of tobacco and had a history of not following smoking rules and was very anxious and aggressive if smoke breaks were late. Interventions included for resident to keep all lighters/matches with facility staff for safety, and resident would participate in supervised smoke breaks.Record review of Resident #37's Safe Smoking assessment dated [DATE] indicated Resident #37 required direct supervision while smoking, all smoking materials would be kept at the nurse's station, the evaluation had been discussed with the resident and explained to his family/responsible party.During an observation and interview on 6/30/25 at 12:01 PM, Resident #37 said he smoked. Resident #37 said he kept his smoking supplies in his room when he had them. Resident #37 said he had a lighter in his room, but said it was out of fluid, then Resident #37 demonstrated with his red zippo-like (refillable) lighter that it flicked and sparked but did not light. Resident #37 said he was out of cigarettes and would not have money to buy more until Thursday (7/03/25) when he got paid.During an observation and interview on 7/01/25 at 2:25 PM, Resident #37 was lying in his bed and still had a red zippo-like lighter on his nightstand and had an empty box of cigarettes. Resident #37 said he was out of cigarettes now, but he kept his cigarettes and lighter in his room when he had them. During an observation on 7/02/25 at 8:00 AM, upon arrival at facility, Resident #37 was observed outside in the smoking area smoking and the Director of Environment Services was supervising the smoke break. During an observation on 7/02/25 at 9:35 AM, Resident #37 was lying in bed asleep. There was a red zippo-like lighter and an almost full pack of cigarettes lying on top of his nightstand in plain view. During an interview on 7/02/25 at 9:41 AM, the Director of Environmental Services said Resident #37 smoked when he wanted to and often would tell her that he did not need a babysitter while she was supervising the smoke breaks. The Director of Environmental Services said they were supposed to stay with the residents during the smoke breaks, but Resident #37 would get mad, so they would watch him through the window of the dining room. The Director of Environmental Services said she guessed the EDO knew it and he kept his cigarettes in his room. The Director of Environmental Services said they were supposed to supervise the residents during smoke breaks to ensure they were safe, and they had to light their cigarettes for them. The Director of Environmental Services said the policy said the residents were not supposed to have cigarettes or lighters in their rooms. The Director of Environmental Services said they should not have smoking supplies in their rooms, because they could smoke in the rooms and start a fire and it was a big no, no. The Director of Environmental Services said she had reported it to EDO previously and they have had a meeting about it and took all the supplies from residents. The Director of Environmental Services said Resident #37 was upset about it but he gave his smoking supplies to her but now had them back in his room. The Director of Environmental Services said Resident #37 had told her that morning (7/02/25), his hospice nurse brought him cigarettes yesterday (7/01/25) and apparently left them with him in his room. The Director of Environmental Services said the Activity Director kept all the extra cigarettes locked up and they had the smoking supply box to take out during smoke breaks.During an interview on 7/02/25 at 9:58 AM, RCP F said he had worked at the facility for about 2 years and normally worked the 6 AM -2 PM shift. RCP F said he was the RCP for Resident #37. RCP F said he had not seen Resident #37 with smoking supplies in his room. RCP F said he would report to the nurse if he saw smoking supplies in a resident's room and explain the rules and safety of him having them. RCP F said smoking supplies should be kept in the smoke box and locked up. RCP F said the EDO and the Social Worker were responsible for ensuring the residents were following the smoking policy, but he guessed they all would be responsible for reporting it to the higher ups. RCP F said residents should not have smoking supplies in room, because they could cause a fire and cause harm to themselves or others. With surveyor intervention, RCP F went to Resident #37's room and retrieved his cigarettes and lighter.During an interview on 7/02/25 at 10:05 AM, the Director of Environmental Services said they had confirmed Resident #37 did not have any smoking supplies on his person and he was informed that he could not smoke without supervision and could not keep smoking supplies in his room.During an interview on 7/02/25 at 10:16 AM, RN B said smoking was a problem at the facility because they took the residents' lighters and they end up getting more on their person, and residents wanting to go out when it was not time. RN B said residents should follow the smoking policy because the resident could set themself or someone else on fire and they should always be supervised. RN B said the residents should not have smoking supplies at their bedside. RN B said the charge nurse, DCO, ADCO, and all employees were responsible for ensuring the smoking policy was being followed by the residents. RN B said when nursing staff enforce the smoking policy; the administration team should back them up. During an interview on 7/02/25 at 11:52 AM, the ADCO said residents should not have smoking supplies in their room to prevent harm to themselves and all the hazards that could happen, being flammable. The ADCO said smoking supplies should be kept in the locked tackle box in the medication room at the nurses' station. The ADCO said everyone was responsible for ensuring the residents were following the smoking policy, but the Social Worker was responsible for addressing any smoking violations. During an interview on 7/02/25 at 2:14 PM, the DCO said resident smoking supplies should be kept in the locked box at the nurses' station. The DCO said they all were responsible for ensuring the smoking policy was being followed by the residents and if they had an issue with a resident, they would send the Social Worker to talk to the resident. The DCO said smoking supplies in a resident's room was a hazard because they had oxygen throughout the building. During an interview on 7/02/25 at 2:37 PM, the Social Worker said she knew she had given Resident #37 some smoking violations, but she did not remember how long ago. The Social Worker said the last smoking violation he received was in February of 2025 for smoking outside the scheduled times.During an interview on 7/02/25 at 2:39 PM, the EDO said they were trying to revamp the smoking policy currently because they had residents with high BIMS and functional ability that would like to smoke unsupervised and at other times than what was scheduled. The EDO said residents should not have cigarettes and lighters at their bedside for the safety of all residents in the facility. The EDO said she would expect the facility's smoking policy to be followed, and it was the responsibility of all staff to ensure it was being followed.Review of the facility's policy titled Smoking dated 3/01/17 indicated . it was the policy of the community to accommodate residents who desired to smoke, including electronic cigarettes by taking reasonable precautions, providing a safe environment for them and protecting the non-smoking residents . residents and their families/responsible parties were informed of the policy prior to or during the admission process, Resident Council meetings, and care conferences . the community would develop a smoking schedule to ensure a safe environment . incendiary devices would be stored by the facility staff . residents would not be allowed to possess any lighters, cigarettes or other smoking material .

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents reviewed for enhanced barrier precautions (Resident #121) infection control practices.The facility failed to ensure RN C donned (put on) a gown prior administering medications and feeding to Resident #121 via g-tube. Resident #121 was on enhanced barrier precautions.These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections.Findings included: Record review of Resident #121's face sheet dated 07/07/25, indicated she was a [AGE] year-old female that admitted [DATE] with diagnoses that included: epilepsy (a disorder in which nerve cell activity in the brain disturbed, causing seizures), gastrostomy status (opening allows for a tube to be inserted, providing a direct route for administering food), muscle weakness and dysphagia (difficulty swallowing foods or liquids). Record review of Resident #121's physician's order indicated: dated 6/24/25 enteral feed order one time a day document start and stop times as they pertain to down time if ordered. If continuous during the shift, document 'not applicable' next to start/stop time. jevity 1.5 at 55mL/hr with 30mL/hr water flush for 20 hours. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #121 usually understood others and was usually understood by others. Resident #121 BIMS score was a 15 which indicated she was cognitively intact. She was dependent with ADL's. Resident #121 was always incontinent with bowel and bladder. Record review of the care plan dated 09/13/24 indicated Resident #121 was on EBP (Enhanced Barrier Precautions) due to feeding tube. Interventions (enhanced barrier precautions) sign will be placed inside resident room within close proximity to resident to inform staff of resident specific needs. EBP supplies (gown and gloves) will be readily available. EBP supplies will be discarded in regular trash receptacle unless soiled with blood or bodily fluids. Residents are not restricted to their rooms or limited from group activities, as they are not considered in isolation for EBP only. Staff will maintain EBP (Enhanced Barrier Precautions) during high contact resident care activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or toileting. Staff will maintain EBP will performing any type of device care such as but not limited to the following: central line care, tracheostomy care, urinary catheter care, feeding tube care, and wound care. Record review of the care plan dated 02/15/24 indicated Resident #121 required tube feeding related to dysphagia and recent vent/inability to swallow. I have pleasure feeding only with speech therapy supervision but am NPO (nothing by mouth) with nursing staff. I choose to sit in the dining room during meals even though I am NPO (nothing by mouth). On 6/24/25 Resident #121 failed the swallow study during hospital stay and am now NPO (nothing by mouth). Interventions: the resident needs the HOB (head of bed) elevated at least 30 degrees during and thirty minutes after tube feed. Check for tube placement and gastric contents/residual volume per facility protocol and record. Discuss with the resident/family/caregivers any concerns about tube feeding, advantages, disadvantages and potential complications. Listen to lung sounds. Monitor/document/report PRN (as needed) any signs and symptoms of: aspiration- fever, shortness of breath, tube dislodged, infection at tube site, self-extubating, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting and dehydration. Obtain and monitor lab/diagnostic work as ordered. Report results to medical director and follow-up as indicated. Provide local care to g-tube site as ordered and monitor for signs and symptoms of infection. Registered dietician to evaluate quarterly and PRN (as needed). Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. Speech therapy evaluation and treatment as ordered. During observation of med pass to Resident #121 on 7/01/25 at 12:15 P.M. revealed RN C checked for g-tube placement, gave medications and started feeding jevity 1.5 cal 55ml/hr via g-tube without donning a gown. During an interview on 7/01/25 at 12:21 P.M., RN C said this was her first day working with Resident #121. She said she was not sure if Resident #121 was on enhanced barrier precautions. She said she had not been wearing her gown when she gave Resident #121 her medications and feedings. She said she did not see the enhancement barrier precaution sign or the PPE material in the resident's room. She said enhanced barrier precautions prevented the spread of infection. During an interview on 7/01/25 at 12:28 P.M., the ADCO said there was an EBP (enhanced barrier precautions) sign in Resident #121's room under her light and the PPE supplies cart was in the resident's room next to her nightstand. He said he would do a one-on-one in-service with RN C and a general all staff in-service over EBP (enhanced barrier precautions). He said it was important for staff to wear their PPE to reduce the risk of infection to the device Resident #121 had. During an interview on 7/02/25 at 10:49 A.M., LVN H said when a resident was on enhancement barrier precautions staff should wear PPE such as their gown and gloves to prevent the nurse or RCP from coming in contact with the back splash from the resident g-tube. She said EBP (enhancement barrier precautions) was to prevent cross contamination when a resident had a g-tube. During an interview on 7/02/25 at 2:46 P.M., the DCO said she expected the staff to follow EBP (enhancement barrier precautions). She said ADCO did one-on-one in-service with RN C yesterday over EBP (enhancement barrier precautions). She said EBP (enhancement barrier precautions) was not only to protect the staff it was to protect the residents from infections as well. During an interview on 7/02/25 at 3:30 P.M., the EDO said she expected the staff to use the new enhancement barrier precautions guidelines, because Resident #121 did have a peg-tube. She said a negative effect of not using enhancement barrier precautions staff could pass on infections to other residents. Record review of the facility's sign, Enhanced Barrier Precautions sign, undated, indicated: Providers All Staff Must Also: Wear gloves and grown for the following high-contact resident care activities .Device care or use: Central line (a central venous catheter), urinary catheter, feeding tube and tracheostomy (an opening into the trachea from outside the neck) . Record review of the facility's policy, Enhanced Barrier Precautions, dated 04/01/2024, indicated: Enhanced Barrier Precautions (EBP) are a CDC guidance to reduce transmission of multidrug-resistant organisms (MDRO) in health care settings, including nursing homes. EBP require team members to wear a gown and glove while performing high-contact care activities with residents who are infected or colonized with a targeted MDRO, or who have open wound or indwelling medical device . 2. Determine if any of the following indwelling medical devises are in use: urinary catheter, g-tube, EBP will be implemented if any of the above wounds or invasive medical devices are present .3. Place signage on resident's closet door, maintain PPE in residents' room and assure all team members are aware of resident status and need for EBP during high contact care .4. High-contact resident care, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator . Record review of the facility's policy, Infection Control, revised date 10/25/2022, indicated: This communities' infection control policies and practices are intended to facilitate maintaining as safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections . Record review of the facility's policy, Personal Protective Equipment, dated 08/25/2021, indicated: Personal protective equipment appropriate to specific task requirements is always available .1. All personnel who performed tasks may involve exposure to blood/body fluids are provided appropriate personal protective equipment (PPE) at no charge .

Based on interview and record review the facility failed to ensure residents were free from abuse for 1 of 8 residents (Resident's #1) reviewed for resident abuse. The facility failed to ensure Resident #1 was free from physical abuse on 11/21/24, when Resident #2 hit Resident #1 numerous times with the foot pedal of a wheelchair. The physical assault on Resident #1 resulted in worsening of a brain bleed with a midline shift (increased pressure in the brain). The noncompliance was identified as PNC. The immediate jeopardy (IJ) began on 11/21/24 and ended on 11/21/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of serious injury, physical harm, serious impairment, or death. The findings included: 1. Record review of the face sheet, dated 06/23/25, reflected Resident #1 was a [AGE] year-old male who initially admitted to the facility on [DATE] and discharged from the facility on 01/17/25. The diagnoses included: Alzheimer's disease (a brain disorder that slowly destroys a person's memory and thinking skills), seizures, difficulty in walking, and arthritis (inflammation of the joints). Record review the quarterly MDS assessment, dated 10/25/24, reflected Resident #1 had unclear speech and was sometimes understood by others. Resident #1 was sometimes able to understand others. The MDS reflected a staff assessment was completed because Resident #1 was rarely/never understood. The staff indicated Resident #1 had poor short-term and long-term memory problems. The staff indicated Resident #1 had severely impaired decision making skills. The MDS reflected Resident #1 had physical behavioral symptoms directed toward others and wandering 4 to 6 days during the 7-day look-back period. Record review of the comprehensive care plan, initiated 05/23/22, reflected Resident #1 was on the secured unit for wandering and exit seeking behaviors. Record review of the order summary report, dated 06/23/25, reflected Resident #1 had an order for the secured unit due to exit seeking behaviors, which started on 10/11/23. Record review of the Physical Aggression Received incident report, dated 11/21/24, reflected Resident #1 wandered into another resident's room and was struck by a wheelchair leg rest. The injuries included the following: a laceration to the back of the right hand, a laceration to the back of the head, and a laceration to the right forearm. The incident report reflected Resident #1 was confused with impaired memory. The incident report reflected he was a wanderer. The incident report reflected a staff statement from LVN A, which reflected Resident #1 was laying on the floor between Resident #2's bed and Resident #2's wheelchair. Resident #1 was bleeding from multiple areas to the scalp, right hand, and right forearm. Resident #2 was holding a wheelchair leg rest in his hand stating he [Resident #1] came into my room, and I hit his f**king a**. The incident report reflected the DON and Administrator were notified on 11/21/24. Record review of the neurological assessment form, dated 11/21/24 at 8:45 PM, reflected Resident #1 was at the emergency room. The assessment was blank. The neurological assessments did not restart until 11/22/24 at 7:53 PM, when he returned to the facility. Record review of Resident #1's nursing progress notes reflected the following: 1. On 11/21/24 at 10:20 AM, LVN A documented 8:40 AM - Witnessed fall noted with 1 cm x 0.5 cm laceration to the right eyebrow. No further injuries noted. Hospice nurse was notified and received consent to send to the emergency room for evaluation and treatment . 2. On 11/21/24 at 7:57 PM, LVN A documented Returned to the facility at 6 PM from emergency room status post fall with a diagnosis of subdural hematoma (brain bleed). 3 sutures to the right eyebrow and remove in 7 days. 3. On 11/21/24 at 10:07 PM, LVN A documented sent back to the emergency room per ambulance at 8:20 PM for multiple skin tears, lacerations, and contusions to scalp, right hand/arm following altercations involving another resident. DON and Administrator notified. 4. On 11/21/24 at 10:38 PM, LVN A documented Resident #1 noted by this nurse to be laying on the floor between Resident #2's bed and Resident #2 sitting in his wheelchair. Resident #1 was bleeding from multiple areas to scalp, right hand and forearm. Resident #2 holding a wheelchair leg rest in his hand stated he came in my room, and I hit his f**king a**. 911 called and Resident #1 was transported to the emergency room. Record review of the emergency department records, dated 11/21/24, reflected Resident #1 arrived at the emergency room by ambulance on 11/21/24 at 8:41 PM. The provider notes history reflected Resident #1 was assaulted by another resident at a nursing facility. Resident #1 was struck in the head multiple times with a metal wheelchair leg .this is Resident #1's second visit for the day. Resident #1 had gone back to the nursing facility and was found by the staff with another resident striking him with a leg that had been removed from a wheelchair. Resident #1 sustained some skin tears to his hands . The physical exam reflected Head: sutured wound to right eyebrow from the fall earlier. Two 4-5 mm signs to right scalp which appear new. No active bleeding . Musculoskeletal: Resident #1 has some skin tears that are superficial to his right hand and a hematoma to his right lower triceps area no long bone deformity good movement at shoulder elbow and wrist bilaterally . A CT scan was completed of the head without contrast. The results reflected Increase in size and prominence of known left subdural hematoma as detailed above with small left right midline shift. The scans were compared to the ones completed earlier in the day on 11/21/24. The emergency department records reflected Resident #1 was transferred to another hospital for higher level of care on 11/22/24 at 1:02 AM by air flight. The diagnosis was subdural hematoma (brain bleeding). 2. Record review of the face sheet, dated 06/23/25, reflected Resident #2 was an [AGE] year-old male who initially admitted to the facility on [DATE] and discharged from the facility on 01/19/25. The diagnoses included: Alzheimer's disease (a brain disorder that slowly destroys a person's memory and thinking skills) and prostate cancer with metastasis to the bone. Record review of the quarterly MDS assessment, dated 12/14/24, reflected Resident #2 had clear speech and was sometimes understood by others. Resident #2 was sometimes able to understand others. The MDS reflected Resident #2 had a BIMS score of 3, which indicated severe cognitive impairment. The MDS reflected Resident #2 had inattention that was continuously present and did not fluctuate. The MDS reflected Resident #2 had verbal and other behavioral symptoms, rejection of care, and wandering 1 to 3 days during the 7-day look-back period. Record review of the comprehensive care plan, initiated on 01/24/24, reflected Resident #2 was on an antipsychotic medication for a history of aggression and aggressive behaviors which placed him at an increased risk for mood swings. The interventions included: administer medications per orders and monitor and record occurence of targeted behaviors and document per protocol. Record review of the Physical Aggression Initiated incident report, dated 11/21/24, reflected Resident #2 was sitting in his wheelchair holding the footrest in his right hand above his head with Resident #1 lying on the floor between Resident #2 and the bed. Resident #2 stated he was in my room, and I hit his f**king a**. The incident report Resident #1 and Resident #2 were immediately separated, and Resident #2 had no injuries. The incident report reflected Resident #2 was confused with impaired memory and was agitated. The DON, Administrator, and physician were notified on 11/21/24. Record review of Resident #2's nursing progress notes reflected the following: 1. On 11/21/24 at 10:09 PM, LVN A documented Sent to emergency room per the nurse practitioner orders for extreme agitation and threat to facility following altercation with another resident. Administrator and DON notified. 2. On 11/21/24 at 10:20 PM, LVN A documented This nurse heard a noise, and Resident #2 was noted sitting in his wheelchair holding the footrest in his right hand and above his head with Resident #1 lying on the floor between Resident #2 and the bed. Resident #2 stated he was in my room. Separated the residents while another nurse called 911. Notified Administrator, DON, and nurse practitioner. Resident #2 was ultimately sent to the ER due to extreme agitation and threat to facility. 3. On 11/22/24 at 5:28 PM, LVN BB documented Resident #2 returned from the emergency room due to behaviors/aggression; Resident #2 was transferred with a wheelchair to [a different room]; Resident #2 was awake, alert, skin and warm and dry, color good, respirations even/unlabored with no distress noted; resident was quiet, friendly, and talking with staff; Resident #2 transferred to bed and resting quietly . Record review of the after visit summary, dated 11/21/24, reflected Resident #2 was seen in the emergency room for aggressive behaviors and medical clearance for psychiatric admission. Record review of the provider investigation report, dated 11/28/24, reflected the resident to resident physical altercation occurred on 11/21/24 and was reported to the state agency on 11/21/24. The report reflected LVN A saw Resident #1 in Resident #2's room on the floor. LVN A saw Resident #2 strike Resident #1 with a wheelchair foot pedal. The injuries included skin tears to arms and head and Resident #1 was sent to the emergency room for evaluation of an existing subdural hematoma (brain bleed). The provider response included the separation of Resident #1 and Resident #2 by units. Resident #2 was placed in a private room with increased monitoring until moved to behavioral unit for an in-patient stay. The investigation summary reflected Resident #2 initiated contact with Resident #1 when he wandered into his room. Resident #1 felt it was his fault and apologized. Resident #2 apologized as well but understood his reaction was excessive. Record review of a Room Audit form, undated, reflected rooms 1 - 12, 20, and 23 were inspected for assistive devices to include: oxygen, splints, walking boots, heel elevators, catheters, intravenous or enteral pumps, restraints, side rails, suction machines, other equipment, and fall mats. Record review of the in-patient behavioral hospital records, dated 12/10/24, reflected Resident #2 was admitted to the hospital on [DATE] at 3:52 PM with a principal diagnosis of dementia (memory loss) with behaviors. The records reflected Resident #2 was discharged back to the facility on [DATE]. Record review of the in-service education An Activity-Based Approach to Memory Care, dated 10/27/24, reflected an outside company conducted dementia care training to include dementia definitions, different activities, and managing the environment. Record review of the invoice, dated 11/24/24, reflected an outside company requested payment for in-service education that was provided. During an interview on 06/23/25 at 9:31 AM, Resident #1's family member stated he was at the facility for a little over 2 years. The family member stated he was no longer residing in the facility. The family member stated in November of 2024, Resident #1 had a really bad fall and was sent to the emergency room with lacerations that had to be sutured (stitched). The family member stated Resident #1 also had a hematoma and bruising above his eye and a CT scan showed a subdural hematoma (brain bleed). The family member stated Resident #1 returned from the emergency room and was assaulted and beaten by another resident. The family member stated he was hit multiple times with a metal wheelchair leg and had bleeding on his brain which had gotten worse and bigger. The family member stated Resident #1 was air flighted to another hospital. During an interview on 06/23/25 at 3:21 PM, LVN A stated on 11/21/24 she was sitting at the nurses' station around 8 PM. She stated she heard a muffled noise, multiple times as she was charting and got up to investigate. LVN A stated she was unable to identify the noise and sat back down to start charting again. LVN A stated she heard the muffled noise again but was much louder and sounded like moaning. LVN A stated she walked out of the nurses' station toward the short hallway and saw Resident #2 sitting in his wheelchair in front of his bed as the door was open. LVN A stated Resident #2 had something in his hands, which was lifted above his head, so she hurried toward his room. She said as she walked into the room, Resident #2 had swung the object down, and then she noticed Resident #1 was laying on floor with his right arm up trying to deflect the hits. LVN A stated Resident #2 was saying something that she was unable to recall. She said Resident #2 was getting ready to hit Resident #1 again when she noticed he had a wheelchair foot pedal. LVN A stated Resident #2 had hit Resident #1 in the head and arms. LVN A stated there was blood everywhere. She stated she attempted to remove the wheelchair foot pedal from Resident #2, but he would not let go of it and remained extremely agitated. LVN A stated she was the only staff member in the secured unit and knew she was not able to leave Resident #1 and Resident #2 alone, so she pulled Resident #2 with the wheelchair foot pedal out of the room and down the hallway to the doors for the female secured unit. LVN A stated she opened the door and hollered for help. LVN A said when the other nurse arrived, she left the other nurse with Resident #2, instructed her to call 911 and went to check on Resident #1. LVN A stated she completed first aid on Resident #1 until emergency services arrived. LVN A stated Resident #2 was placed on one-to-one monitoring until he was sent to the emergency room per orders from the nurse practitioner. LVN A stated Resident #2 was territorial about his space and did not like other residents' in his room. During an interview on 06/23/25 at 4:34 PM, the DON stated she remembered receiving a phone call notification back in November 2024, in which Resident #2 had struck Resident #1 with a wheelchair foot pedal. The DON stated Resident #1 and Resident #2 were immediately sent to the emergency room after the incident. The DON stated Resident #1 was transferred to another hospital for a higher level of care for a subdural hematoma (brain bleed). The DON stated Resident #2 returned to the facility from the emergency room and then was sent to an in-patient behavioral hospital for approximately one month. The DON stated neurological assessments were in progress from a fall that Resident #1 had obtained earlier in the day. The DON stated the incident occurred in Resident #2's room, which was directly across from the nurses' station. The DON stated Resident #2 remembered Resident #1 entered his room but did not remember hitting him. The DON stated Resident #2 valued his space and was particular about his space. The DON stated Resident #2 was moved to a room close to the nurses' station, on the hallway with less traffic to try to prevent other residents from wandering into his room. The DON stated Resident #2 was moved off the secured unit and had no further issues. The DON stated Resident #2 had a private room and there was no residents who wandered into his room in the general population.The DON stated she was unable to locate the in-service education provided in November of 2024. The DON stated education on abuse and neglect was completed after the incident and the dementia training was re-done in December 2024. The DON stated she conducted a room audit to search for things that could have been used as weapons. During an interview on 06/24/25 at 10:38 AM, the DON stated the dementia care trainer reported that she did the initial training in October 2024, then provided additional education in November 2024 after the resident-to-resident altercation between Resident #1 and Resident #2, and again in December 2024. The DON stated the trainer did not complete the entire training, only the parts that were pertinent such as the dementia disease process and de-escalation techniques. During interviews completed on 06/25/25 between 9:53 AM and 1:29 PM, CNA B, CNA D, CNA S, CNA T, CNA U, CNA V, CNA W, CNA X, CNA Y, CNA Z, LVN E, LVN F, LVN G, LVN H, LVN K, RN L, RN M, LVN Q, Housekeeper N, Housekeeper O, Laundry Aide P, COTA R, ST AA, the MDS Coordinator, the Housekeeping Supervisor, the AD, the Medical Records Coordinator, the DOR, the Social Worker, and the ADON were able to verbalize the different types of abuse, the abuse coordinator, and when to report abuse. The facility staff were able to verbalize resident-to-resident altercations could have been considered physical abuse. The staff reported residents' should have been immediately separated, placed on monitoring, and reported to the abuse coordinator. Record review of the Abuse policy, last revised 01/01/23, reflected The purpose of this policy is to ensure that reach resident has the right to be free from any type of abuse .abuse is a willful infliction of injury .with resulting physical or emotional harm or pain to a resident .residents will not be subjected to abuse by anyone, including .other residents . The noncompliance was identified as PNC. The noncompliance began on 11/21/24 and ended on 11/21/24.

Based on observations, interviews, and record review the facility failed to ensure the resident environment remained free of accident hazards as possible, and each resident received adequate supervision to prevent incident and accidents for 2 of 8 residents (Resident #1 and Resident #3) reviewed for accident hazards and supervision. 1. The facility failed to ensure adequate supervision was provided to prevent a resident-to-resident physical altercation on 11/21/24. Resident #2 repeatedly hit Resident #1 with a metal wheelchair pedal, which resulted in worsening of a brain bleed with a midline shift (increased pressure in the brain). 2. The facility failed to ensure adequate supervision was provided to prevent Resident #3 from falling, which resulted in a nasal fracture on 06/02/25. An immediate jeopardy (IJ) was identified on 06/24/25 at 12:55 PM. The IJ template was provided to the facility on [DATE] at 1:30 PM. While the IJ was removed on 06/25/25 at 1:32 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been provided education on supervision of residents on the secured units, effective communication practices, reporting on/off duty, and fall management and response policies. These failures could potentially place residents at risk of further serious injury/harm, serious impairment, or death from inadequate supervision on the male secured unit. The findings included: 1. Record review of the face sheet, dated 06/23/25, reflected Resident #1 was a [AGE] year-old male who initially admitted to the facility on [DATE] and discharged from the facility on 01/17/25. The diagnoses included: Alzheimer's disease (a brain disorder that slowly destroys a person's memory and thinking skills), seizures, difficulty in walking, and arthritis (inflammation of the joints). Record review the quarterly MDS assessment, dated 10/25/24, reflected Resident #1 had unclear speech and was sometimes understood by others. Resident #1 was sometimes able to understand others. The MDS reflected a staff assessment was completed because Resident #1 was rarely/never understood. The staff indicated Resident #1 had poor short-term and long-term memory problems. The staff indicated Resident #1 had severely impaired decision making skills. The MDS reflected Resident #1 had physical behavioral symptoms directed toward others and wandering 4 to 6 days during the 7-day look-back period. Record review of the comprehensive care plan, initiated 05/23/22, reflected Resident #1 was on the secured unit for wandering and exit seeking behaviors. Record review of the order summary report, dated 06/23/25, reflected Resident #1 had an order for the secured unit due to exit seeking behaviors, which started on 10/11/23. Record review of the Physical Aggression Received incident report, dated 11/21/24, reflected Resident #1 wandered into another resident's room and was struck by a wheelchair leg rest. The injuries included the following: a laceration to the back of the right hand, a laceration to the back of the head, and a laceration to the right forearm. The incident report reflected Resident #1 was confused with impaired memory. The incident report reflected he was a wanderer. The incident report reflected a staff statement from LVN A, which reflected Resident #1 was laying on the floor between Resident #2's bed and Resident #2's wheelchair. Resident #1 was bleeding from multiple areas to the scalp, right hand, and right forearm. Resident #2 was holding a wheelchair leg rest in his hand stating he [Resident #1] came into my room, and I hit his f**king a**. The incident report reflected the DON and Administrator were notified on 11/21/24. Record review of the neurological assessment form, dated 11/21/24 at 8:45 PM, reflected Resident #1 was at the emergency room. The neurological assessments did not restart until 11/22/24 at 7:53 PM, when he returned to the facility. Record review of Resident #1's nursing progress notes reflected the following: 1. On 11/21/24 at 10:20 AM, LVN A documented 8:40 AM - Witnessed fall noted with 1 cm x 0.5 cm laceration to the right eyebrow. No further injuries noted. Hospice nurse was notified and received consent to send to the emergency room for evaluation and treatment . 2. On 11/21/24 at 7:57 PM, LVN A documented Returned to the facility at 6 PM from emergency room status post fall with a diagnosis of subdural hematoma (brain bleed). 3 sutures to the right eyebrow and remove in 7 days. 3. On 11/21/24 at 10:07 PM, LVN A documented sent back to the emergency room per ambulance at 8:20 PM for multiple skin tears, lacerations, and contusions to scalp, right hand/arm following altercations involving another resident. DON and Administrator notified. 4. On 11/21/24 at 10:38 PM, LVN A documented Resident #1 noted by this nurse to be laying on the floor between Resident #2's bed and Resident #2 sitting in his wheelchair. Resident #1 was bleeding from multiple areas to scalp, right hand and forearm. Resident #2 holding a wheelchair leg rest in his hand stated he came in my room, and I hit his f**king a**. 911 called and Resident #1 was transported to the emergency room. Record review of the emergency department records, dated 11/21/24, reflected Resident #1 arrived at the emergency room by ambulance on 11/21/24 at 8:41 PM. The provider notes history reflected Resident #1 was assaulted by another resident at a nursing facility. Resident #1 was struck in the head multiple times with a metal wheelchair leg .this is Resident #1's second visit for the day. Resident #1 had gone back to the nursing facility and was found by the staff with another resident striking him with a leg that had been removed from a wheelchair. Resident #1 sustained some skin tears to his hands . The physical exam reflected Head: sutured wound to right eyebrow from the fall earlier. Two 4-5 mm signs to right scalp which appear new. No active bleeding . Musculoskeletal: Resident #1 has some skin tears that are superficial to his right hand and a hematoma to his right lower triceps area no long bone deformity good movement at shoulder elbow and wrist bilaterally . A CT scan was completed of the head without contrast. The results reflected Increase in size and prominence of known left subdural hematoma as detailed above with small left right midline shift. The scans were compared to the ones completed earlier in the day on 11/21/24. The emergency department records reflected Resident #1 was transferred to another hospital for higher level of care on 11/22/24 at 1:02 AM by air flight. The diagnosis was subdural hematoma (brain bleeding). 2. Record review of the face sheet, dated 06/23/25, reflected Resident #2 was an [AGE] year-old male who initially admitted to the facility on [DATE] and discharged from the facility on 01/19/25. The diagnoses included: Alzheimer's disease (a brain disorder that slowly destroys a person's memory and thinking skills) and prostate cancer with metastasis to the bone. Record review of the quarterly MDS assessment, dated 12/14/24, reflected Resident #2 had clear speech and was sometimes understood by others. Resident #2 was sometimes able to understand others. The MDS reflected Resident #2 had a BIMS score of 3, which indicated severe cognitive impairment. The MDS reflected Resident #2 had inattention that was continuously present and did not fluctuate. The MDS reflected Resident #2 had verbal and other behavioral symptoms, rejection of care, and wandering 1 to 3 days during the 7-day look-back period. Record review of the comprehensive care plan, initiated on 01/24/24, reflected Resident #2 was on an antipsychotic medication for a history of aggression and aggressive behaviors which places him at an increased risk for mood swings. Record review of the Physical Aggression Initiated incident report, dated 11/21/24, reflected Resident #2 was sitting in his wheelchair holding the footrest in his right hand above his head with Resident #1 lying on the floor between Resident #2 and the bed. Resident #2 stated he was in my room, and I hit his f**king a**. The incident report Resident #1 and Resident #2 were immediately separated, and Resident #2 had no injuries. The incident report reflected Resident #2 was confused with impaired memory and was agitated. The DON, Administrator, and physician were notified on 11/21/24. Record review of Resident #2's nursing progress notes reflected the following: 1. On 11/21/24 at 10:09 PM, LVN A documented Sent to emergency room per the nurse practitioner orders for extreme agitation and threat to facility following altercation with another resident. Administrator and DON notified. 2. On 11/21/24 at 10:20 PM, LVN A documented This nurse heard a noise, and Resident #2 was noted sitting in his wheelchair holding the footrest in his right hand and above his head with Resident #1 lying on the floor between Resident #2 and the bed. Resident #2 stated he was in my room. Separated the residents while another nurse called 911. Notified Administrator, DON, and nurse practitioner. Resident #2 was ultimately sent to the ER due to extreme agitation and threat to facility. 3. On 11/22/24 at 5:28 PM, LVN BB documented Resident #2 returned from the emergency room due to behaviors/aggression; Resident #2 was transferred with a wheelchair to [a different room]; Resident #2 was awake, alert, skin and warm and dry, color good, respirations even/unlabored with no distress noted; resident was quiet, friendly, and talking with staff; Resident #2 transferred to bed and resting quietly . Record review of the after visit summary, dated 11/21/24, reflected Resident #2 was seen in the emergency room for aggressive behaviors and medical clearance for psychiatric admission. Record review of the provider investigation report, dated 11/28/24, reflected the resident to resident physical altercation occurred on 11/21/24 and was reported to the state agency on 11/21/24. The report reflected LVN A saw Resident #1 in Resident #2's room on the floor. LVN A saw Resident #2 strike Resident #1 with a wheelchair foot pedal. The injuries included skin tears to arms and head and Resident #1 was sent to the emergency room for evaluation of an existing subdural hematoma (brain bleed). The provider response included the separation of Resident #1 and Resident #2 by units. Resident #2 was placed in a private room with increased monitoring until moved to behavioral unit for an in-patient stay. The investigation summary reflected Resident #2 initiated contact with Resident #1 when he wandered into his room. Resident #1 felt it was his fault and apologized. Resident #2 apologized as well but understood his reaction was excessive. Record review of a Room Audit form, undated, reflected rooms 1 - 12, 20, and 23 were inspected for assistive devices to include: oxygen, splints, walking boots, heel elevators, catheters, intravenous or enteral pumps, restraints, side rails, suction machines, other equipment, and fall mats. Record review of the in-patient behavioral hospital records, dated 12/10/24, reflected Resident #2 was admitted to the hospital on [DATE] at 3:52 PM with a principal diagnosis of dementia (memory loss) with behaviors. The records reflected Resident #2 was discharged back to the facility on [DATE]. Record review of the in-service education An Activity-Based Approach to Memory Care, dated 10/27/24, reflected an outside company conducted dementia care training to include dementia definitions, different activities, and managing the environment. Record review of the invoice, dated 11/24/24, reflected an outside company requested payment for in-service education that was provided. During an interview on 06/23/25 at 9:31 AM, Resident #1's family member stated Resident #1 was at the facility for a little over 2 years. The family member stated he was no longer residing in the facility. The family member stated in November of 2024, Resident #1 had a really bad fall and was sent to the emergency room with lacerations that had to be sutured (stitched). The family member stated Resident #1 also had a hematoma and bruising above his eye and a CT scan showed a subdural hematoma (brain bleed). The family member stated Resident #1 returned from the emergency room and was assaulted and beaten by another resident. The family member stated he was hit multiple times with a metal wheelchair leg and had bleeding on his brain which had gotten worse and bigger. The family member stated Resident #1 was air flighted to another hospital. The family member stated the staff at the facility did not watch Resident #1. The family member stated multiples times when she visited the facility, the facility staff had to spend up to 5 minutes searching for Resident #1 because they did not know where he was. The family member stated Resident #1 was usually found in another resident's room. The family member stated the facility staff would be sitting behind the nurses' station, talking or no where to be found. The family member stated on several occasions there was only one staff member on the secured unit. During an observation on 06/23/25 on the male secured unit was as follows: 10:00 AM - Surveyor entered the secured unit. LVN C was sitting up at the nurses' station. CNA W followed the surveyor onto the secured unit from the DON's office. Resident #3 was sitting against the wall, leaned back in his wheelchair with his eyes closed. Resident #9 was standing up on the short hallway, walking toward the dining room. He pulled out a chair and sat down. LVN C walked out of the secured unit toward the DON office, approximately 2 minutes. 10:08 AM - Resident #9 stood up from the chair and started walking toward the exit doors, following the MDS Coordinator, who had exited her office. His gait was shuffled. When the exit door shut, Resident #9 turned, and started down the hallway. 10:10 AM - Resident #9 was at the door entrance to the female secured unit. He attempted to open the door and was hitting the door. CNA W redirected Resident #9 to the dining room and encouraged him to sit in the chair. 10:13 AM - Another male resident, sitting at the dining room table, yelled Shut up!, and stood up quickly from the dining room table with an unsteady gait. LVN C was walking out of a room with the hospice nurse, CNA B was coming out of the supply room, and the MDS Coordinator was walking back onto the secured unit. 10:14 AM - LVN C notified surveyor she was responsible for both sides of the secured unit, the male and female sides. LVN C stated she had check on the females and would be back. 10:16 AM - LVN C returned to the male secured unit. 10:17 AM - 2 male residents were wandering around the secured unit, stopping at different rooms, no assistive devices. CNA B exited the secured unit, LVN C was behind the nurses' desk, talking with the hospice nurse. 10:19 AM - CNA B returned to secured unit with coffee. During an interview on 06/23/25 at 3:21 PM, LVN A stated on 11/21/24 she was sitting at the nurses' station around 8 PM. She stated she heard a muffled noise, multiple times as she was charting and got up to investigate. LVN A stated she was unable to identify the noise and sat back down to start charting again. LVN A stated she heard the muffled noise again but was much louder and sounded like moaning. LVN A stated she walked out of the nurses' station toward the short hallway and saw Resident #2 sitting in his wheelchair in front of his bed as the door was open. LVN A stated Resident #2 had something in his hands, which was lifted above his head, so she hurried toward his room. She said as she walked into the room, Resident #2 had swung the object down, and then she noticed Resident #1 was laying on floor with his right arm up trying to deflect the hits. LVN A stated Resident #2 was saying something that she was unable to recall. She said Resident #2 was getting ready to hit Resident #1 again when she noticed he had a wheelchair foot pedal. LVN A stated Resident #2 had hit Resident #1 in the head and arms. LVN A stated there was blood everywhere. She stated she attempted to remove the wheelchair foot pedal from Resident #2, but he would not let go of it and remained extremely agitated. LVN A stated she was the only staff member in the secured unit and knew she was not able to leave Resident #1 and Resident #2 alone, so she pulled Resident #2 with the wheelchair foot pedal out of the room and down the hallway to the doors for the female secured unit. LVN A stated she opened the door and hollered for help. LVN A said when the other nurse arrived, she left the other nurse with Resident #2, instructed her to call 911 and went to check on Resident #1. LVN A stated she completed first aid on Resident #1 until emergency services arrived. LVN A stated Resident #2 was placed on one-to-one monitoring until he was sent to the emergency room per orders from the nurse practitioner. LVN A stated CNA B had left the secured unit on her break. LVN A she was unaware CNA B had left for break and did not recall CNA B reporting that she was leaving. LVN A stated Resident #2 was territorial about his space and did not like other residents' in his room. LVN A stated it had been reported that Resident #2 had spent a majority of his life in prison and his room was like his cell. LVN A stated he would become upset if anyone went into his room and Resident #2 had stated he did not want anyone in his room. LVN A stated Resident #1 was constantly wandering around the secured unit and went in and out of other resident's rooms. During an interview on 06/23/25 at 3:52 PM, the ADON stated he was responsible for completing the staffing schedule for the secured unit. The ADON stated during the week, he tried to schedule a CNA for the female secured unit, a CNA for the male secured unit, and nurse to go between the two secured units. The ADON stated during the week, management staff offices were located on the male secured unit. The ADON stated the management staff provided monitoring and supervision to the residents as well. The ADON stated on the weekends, he scheduled a nurse and a CNA for the female secured unit, and a nurse and a CNA for the male secured unit. The ADON stated the facility recently hired a weekend supervisor who also helped supervise the secured units. The ADON stated the census for the male secured unit had increased within the last few weeks. The ADON stated the facility was working on adding a CNA. The ADON stated he had 2 CNAs orientating this week. The ADON stated he started an action plan for the secured unit staff. The action plan was requested. Record review of the action plan, dated 06/10/25, reflected the following: 1. Issue/concern: secured unit staffing. 2. Measurable goal: with a rise in census facility to determine staffing needs. 3. Intervention: Montessori certification (program offered in a secured unit for dementia care residents) for current transport tech to transport to unit; daily review of admission/discharge with IDT to meet needs of residents; RN weekend supervisor hired. 4. Target date: 06/30/25 and ongoing. During an interview on 06/23/25 at 4:07 PM, the Regional [NAME] President stated the facility had no policy on staffing or supervision of the secured unit. The Regional [NAME] President stated he reviewed the facility assessment and stated the staff was no specified with a number that it was based on the needs of the facility. During an interview on 06/23/25 at 4:34 PM, the DON stated she remembered receiving a phone call notification back in November 2024, in which Resident #2 had struck Resident #1 with a wheelchair foot pedal. The DON stated Resident #1 and Resident #2 were immediately sent to the emergency room after the incident. The DON stated Resident #1 was transferred to another hospital for a higher level of care for a subdural hematoma (brain bleed). The DON stated Resident #2 returned to the facility from the emergency room and then was sent to an in-patient behavioral hospital for approximately one month. The DON stated neurological assessments were in progress from a fall that Resident #1 had obtained earlier in the day. The DON stated the incident occurred in Resident #2's room, which was directly across from the nurses' station. The DON stated Resident #2 remembered Resident #1 entered his room but did not remember hitting him. The DON stated Resident #2 valued his space and was particular about his space. The DON stated Resident #2 was moved to a room close to the nurses' station, on the hallway with less traffic to try to prevent other residents from wandering into his room. The DON stated Resident #2 was moved off the secured unit and had no further issues. The DON stated she was unable to locate the in-service education provided in November of 2024. The DON stated education on abuse and neglect was completed after the incident and the dementia training was re-done in December 2024. The DON stated she conducted a room audit to search for things that could have been used as weapons. The DON stated the typical census in the male secured unit was about 14 - 15 residents. The DON stated the census was currently 19 for the male secured unit. The DON stated the CNAs work 16 hours on the secured unit. The DON stated during the week one nurse was scheduled for both sides of the secured unit and during the weekend there was one nurse for the male side and one nurse for the female side. The DON stated one CNA was scheduled for each side. The DON stated usually the nurses will cover each other when they went on break, and the nurses covered the CNAs during breaks. The DON stated trends were identified with incidents on the secured unit within the last few weeks with the increase in census. The DON stated the facility was working on scheduling additional staff on the secured unit. During an interview on 06/24/25 at 10:38 AM, the DON stated the dementia care trainer reported that she did the initial training in October 2024, then provided additional education in November 2024 after the resident-to-resident altercation between Resident #1 and Resident #2, and again in December 2024. The DON stated the trainer did not complete the entire training, only the parts that were pertinent such as the dementia disease process and de-escalation techniques. During an interview on 06/24/25 at 10:54 AM, CNA B stated on 11/21/24 she was on break when the resident-to-resident altercation happened. CNA B stated she had told the charge nurse she was going on break but the charge nurse did not understand. CNA B stated a lot of things had happened during the day and she had to take a late break. CNA B stated they usually verbally reported when they were going on break or leaving the secured unit. CNA B stated Resident #2 did not like anyone in his room and Resident #1 was constantly wandering. CNA B stated she did not feel like one CNA and one nurse was enough staff to provide adequate supervision on the secured unit because of all the residents with combative and wandering behaviors. CNA B stated she felt like the incident with Resident #1 and Resident #2 could have been prevented because it would have been noticed with an extra set of eyes. 3. Record review of the face sheet, dated 06/25/25, reflected Resident #3 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (a brain disorder that slowly destroys a person's memory and thinking skills). Record review of the quarterly MDS assessment, dated 05/22/25, reflected Resident #3 had clear speech and was usually understood by others. The MDS reflected Resident #3 was usually able to understand others. The MDS reflected Resident #3 had a BIMS score of 0, which indicated severe cognitive impairment. Resident #3 had inattention that was continuously present and did not fluctuate. The MDS reflected Resident #3 had physical, verbal, and wandering behaviors that happened 1 to 3 days during the 7-day look back period. The MDS reflected Resident #3 used a wheelchair and was dependent on staff for most ADLs. The MDS reflected Resident #3 had fallen with no injuries since the prior assessment. Record review of the comprehensive care plan, updated 06/02/25, reflected Resident #3 fell forward from wheelchair. The interventions included: specialty chair utilized that tilts slightly backward for torso control and therapy to assess chair for safe positioning device. Record review of Resident #3's un-witnessed fall incident report, dated 06/02/25, reflected DON was summoned to the men secured unit by CNA related to Resident #3 falling from wheelchair. Upon arriving, Resident #3 was noted lying on his right side outside the nurses' station door with two puddles of blood noted directly under the resident. Resident #3's wheelchair noted in upright position at the foot of the resident with lift pad in place. Resident #3 confused according to baseline stated, someone was shooting at him, and he tried getting away. A statement from CNA D revealed she was redirecting a resident on the back side of the nurses' station when informed by another resident that Resident #3 was in the floor. Record review of the fall scale assessment, dated 06/02/25, reflected Resident #3 was at high risk for falls. Record review of the pain tool assessment, dated 06/02.25, reflected Resident #3 was complaining of pain to his nose and right side of ribcage, 5 out of 10 on the pain scale. Record review of the emergency record, dated 06/02/25, reflected Resident #3 arrived at the emergency room by ambulance on 06/02/25 at 5:42 PM. The provider history reflected Resident #3 had an unwitnessed ground level fall after falling out of wheelchair. Resident #3 landed on his face and was taking blood thinners. The CT results of Resident #3's face reflected an acute nasal fracture. Record review of Resident #3 order details report, dated 06/04/25, reflected an order to monitor nasal fracture for signs and symptoms of bleeding, increased pain, or labored every shift for 14 days. Record review of the MAR, dated June 2025, reflected Resident #3's nasal fracture was monitored every shift for 14 days. During an interview on 06/24/25 at 9:25 AM, LVN C stated she was not on the male secured unit at the time of Resident #3's fall incident. LVN C stated the ADON and DON handled the incident. LVN C stated Resident #3 was always leaning forward in his wheelchair. LVN C stated Resident #3 had a history of falling and was unable to catch himself during the falls. During an interview on 06/24/25 at 9:47 AM, the ADON stated he and the DON were notified by CNA D that Resident #3 was on the ground. The ADON stated when they entered the secured unit, Resident #3 was laying on the floor. The ADON stated Resident #3 was confused and did not specify what happened but stated oh my, I'm just hurting. The ADON stated the nurse practitioner was immediately notified and new orders were received to send Resident #3 to the emergency room for new onset of pain and bleeding from his nose. The ADON stated the nurse had stepped out of the male secured unit onto the female secured unit. The ADON stated CNA D had to come to the doors of the secured unit, office area, to alert the ADON and DON that Resident #3 was on the ground. The ADON stated Resident #3 received a new tilt wheelchair for his tendencies to lean forward. The ADON stated a medication adjustment was completed. The ADON stated when incidents occurred an incident report was completed with a fall assessment, pain assessment, and skin assessment as needed for injuries. The ADON stated the IDT came together during morning clinical meetings to determine what happened, what contributed to the incident, what could have been done better, and what education needed to be provided. The ADON stated the last two weeks the facility had identified trends on the secured unit related to incidents and the increased census. The ADON stated they had been discussing staffing. During an interview on 06/24/25 at 9:59 AM, CNA D stated she was on the other side of the nurses' station, the back side, passing snacks when Resident #3 had fallen out of his wheelchair. CNA D stated she was alert by another resident that Resident #3 was on the ground. CNA D stated LVN C was on the female secured unit when the incident happened, so she notified the DON. CNA D stated she normally worked on the secured unit and the nurse was responsible for supervising the residents when she was providing cares or giving showers. CNA D stated she communicated with the nurse if she had to leave so the residents had constant supervision. She stated if the nurse was unavailable, she would get the ADON. During an interview on 06/24/25 at 10:05 AM, the DON stated CNA D came and got her and the ADON from the north to assess Resident #3 who had fallen. The DON stated when she arrived on the secured unit, Resident #3 was face down with his cheek on the floor. He had some blood coming from his nose. The DON stated Resident #3 was assessed and his nose was hurting, so he was sent to the emergency room. The DON stated Resident #3 was unable to verbalize what had happened and stated someone was shooting and he dodged the bullets. The DON stated she and the ADON were in the lobby area looking at staffing when CNA D alerted them about Resident #3's fall. The DON stated LVN C was on the female secured unit at the time of the incident. The DON stated she obtained reports from some more with it residents and they reported that Resident #3 was asleep and had fallen forward out of his wheelchair. The DON stated when incidents occurred the nurses completed an incident report, completed assessments, evaluated the environment and causative factors. The DON stated after the incident, the nursing management reviewed the documentation, obtained witness statements, evaluated ways to prevent falls from happening again and to keep residents safe. The DON stated trends on incidents had been identified on the male secured unit related to increased census. The DON stated the facility were looking at staffing changes on the secured unit. This was determined to be an immediate jeopardy (IJ) on 06/24/25 at 12:55 PM. The DON and Regional [NAME] President were notified. The DON was provided the IJ template on 06/24/25 at 1:30 PM and the plan of removal was requested. The following plan of removal was submitted by the facility and accepted on 06/25/25 at 9:13 AM and included the following: The following is a plan of?removal, which has been immediately?implemented?[facility] to remedy the immediate jeopardy [IJ] as a result of alleged deficient practices, which?was imposed on 06/24/25 at 1:30 PM.? Resident #1 was discharged from the facility on 01/17/25. Resident #2 was discharged from the facility on 01/19/25. Resident #3 was sent to the emergency room for evaluation and treatment related to the nasal fracture. He returned to the facility the same day. The facility monitored Resident #3 for [signs and symptoms] of nasal fracture complications per physician orders. Resident #3's care plan was updated to reflect the change in condition on 06/02/25 to reflect interventions related to the fall. On 06/24/25, Clinical Management and IDT (interdisciplinary team) reviewed clinical staff schedule for staffing concerns. Assignments confirmed with staff to meet the needs of the residents. Meaning, a thorough review of the clinical staff schedule was conducted to identify any staffing concerns. Following this review, the facility will include one additional team member for resident supervision support to the secure unit populations from 6 AM - 10 PM, strictly dedicated to the secure unit populations, indicated on the assignment sheet collectively, to float between the memory care populations. Eff[TRUNCATED]

Based on observation, interview and record review the facility failed to ensure procedures were in place to document a resident's choice regarding CPR for 1 of 20 residents (Resident #114) reviewed for CPR. 1. The facility performed CPR on Resident #114 on [DATE], after failing to accurately assess Resident #114's representative's choice for DNR code status on or before admission. 2. The facility failed to have a system in place to ensure staff maintained accurate CPR certifications. The SW failed to accurately document Resident #1's code status on the social service assessment. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] . The IJ template was provide to the facility on [DATE] at 4:43 p.m. While the IJ was removed on [DATE] at 12:13 p.m., the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of receiving necessary life-saving measures when not desired. Findings included: Record review of a face sheet dated [DATE] indicated Resident #114 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of acute respiratory failure (life threatening disease when there is not enough oxygen in the blood or too much carbon dioxide in the blood stream) with hypoxia (low oxygen levels in the tissues), heart failure, severe kidney disease stage 4 (kidneys not damaged, not working well), and senile degeneration of the brain (loss of memory). The face sheet denoted Resident #114 as desiring to be a Full Code status. Record review of a hospital face sheet dated [DATE] Resident #114 Code Status displayed was a DNR (Do not resuscitate) with the diagnoses of Acute respiratory failure with hypoxia and hypercapnia (high levels of carbon dioxide in the blood), heart failure, and stage 4 kidney disease. Record review of a hospital History and physical dated [DATE] indicated Resident #114 was admitted for hypoxic respiratory failure, heart failure and hypertension. The note indicated EMS responded to the nursing facility due to reporting patient was minimally resposnive with cooncern for intermittent episodes of apena. The note indicated Resident #114 had severe decreased responsivness, and EMS was ready to intubate prior to arriving at the emergency room . The note indicated EMS attempted a breathing tube but was unsuccessful. The note indicated the nrusing home contacted the family who stated they wished for Resident #114 not to be intubated, and not be a DNR/DNI status. The note indicated Resident #114 was placed on a non-rebreather mask by EMS with midly improved arousal. The note indicated Resident #114 was seen on the reclining stretcher, she was wearing a non-rebreather mask in place, had an altered mental status with severly decreased responsiveness to voice and touch, was afebrile, nomostensive, tachypenic, and hypoxic receiving oxygen at 10 liters. The note indicated the neurologic assessment indicated Resident #114 was lethaargic. The note indicated critical care was necessary to treat or prevent imminent or life-threatning deterioration of respiratory failure. Record review of a 5-day MDS assessment dated [DATE] indicated Resident #114 was usually understood and usually understands others. The MDS indicated Resident #114's BIMS was an 8 indicating Resident #114's had moderate cognitive impairment. Record review of a Social Services assessment dated [DATE] but signed on [DATE] indicated in Section B Advanced Directives/Code Status indicated Resident #114 was a Full Code status. In the subsection 1A. the box checked indicated the code status had been verified as current, complete, accurate, and to coincide with the residents or resident representatives wishes. Record review of a Baseline Care plan dated [DATE] indicated Resident #114 required cardiopulmonary resuscitation and was considered a full code status e-signed by the ADON on [DATE]. Record review of a progress note dated [DATE] at 9:14 p.m., LVN T documented Resident #114 wishes to be a DNR (Do Not Resuscitate) status. LVN T said she notified social services and indicated Resident #114's responsible party would be at the facility on [DATE] to sign the documents. Record review of a progress note dated [DATE] at 10:29 a.m., indicated the SW documented Resident #114 was just finishing breakfast. The SW documented Resident #114 was a full code at this time. Record review of Emergency Medical Service Run Report dated [DATE] at 8:44 p.m., the report indicated the dispatch received their call at 8:44 p.m., dispatched at 8:44 p.m., was enroute at 8:45 p.m., at the patient at 8:51 p.m. and left the facility at 9:17 p.m. The narrative indicated the medic unit was dispatched for an unconscious patient. The note indicated upon arrival the medic unit found the staff at Resident #114's bedside with a bag valve mask (used in rescue breathing) assisting breathing. The medic unit said the nursing staff said when Resident #114's airway was repositioned she stopped breathing. The medic note documented Resident #114 was a Full Code status although the nursing staff was reaching out to the family. The note indicated Resident #114 had a strong pulse to her wrists, and assisted respirations continued after little to no respiratory effort was found. The note indicated the medic attempted an intubation of an artificial airway. The medic documented while continuing assisted breathing Resident #114 was transferred to the stretcher. The medic documented staff members had Resident #114's responsible party on the phone and the responsible party stated they wanted no invasive procedures such as intubation, no CPR, and the medic documented Resident #114's responsible party just wanted Resident #114 to pass. The emergency room physician advised if the responsible party does not want any measures done it was okay to leave Resident #114 at the facility. The medic documented upon reentering Resident #114's room she had increased breathing efforts, more responsive and was transferred to the hospital. The medic documented Resident #114 left the faciity on a non-rebreather mask at 15 liters of oxygen per minute. Record review of the hospital History and Physical dated [DATE] indicated Resident #114 had a history of hypoxic respiratory failure, heart failure, and high blood pressure. The note indicated the nursing home staff found Resident #114 minimally responsive with intermittent episodes of apnea (when you stop breathing or have no airflow). The note indicated Resident #114 had severe decreased responsiveness. The note indicated the facility contracted the responsible party who stated their wishes were for Resident #114 to be a DNR and a DNI (do not intubate). Record review of a nursing progress note dated [DATE] at 9:42 p.m., LVN T documented at approximately 8:47 p.m., Resident #114's nurse came for her assistance. LVN T documented Resident #114 had [NAME] Stoke respirations (abnormal breathing pattern which commonly occurs in patients with decompensated heart failure and neurologic diseases) and she was unable to obtain an oxygenation measurement. LVN T documented she applied a non-rebreather oxygen mask at 25 liters per minute. LVN T documented Resident #114's vital signs were heart rate 66, blood pressure ,d+[DATE]. LVN T documented shortly after placing the oxygen mask on Resident #114 she stopped breathing. LVN T documented she called a code and 911 was called by another nurse. LVN T documented as soon as the crash cart was in the room, she ambu-bagged Resident #114 with 25 liters of oxygen. The note indicated Resident #114's oxygen rose to 80% with a heart rate of 65. LVN T documented emergency medical services arrived and asked this nurse to continue bagging Resident #114. LVN T documented emergency medical services attempted the placement of an endotracheal tube (breathing tube placed in the trachea) but was unsuccessful. LVN T said she continued to bag Resident #114 with oxygen. LVN T stated a call was placed to Resident #114's responsible party. LVN T documented Resident #114's responsible party said to stop lifesaving efforts. LVN T documented she and the emergency medical services went hands off and after approximately 30 seconds, Resident #114 began breathing. LVN T documented Resident #114 was then transferred to the local emergency room . During an interview on [DATE] at 12:16 p.m., the SW said she left early on [DATE] and was unable to visit with Resident #114 and her responsible party on the day of admission. The SW said she had not since reached out to Resident #114's responsible party since her Resident #114's cognitive state was impaired. The SW said since she had not obtained any signed paperwork from Resident #114's responsible party she placed Resident #114 a Full Code. When asked about the SW assessment completed on [DATE] on admission she marked she validated with the responsible party the desires for their advance directive she said she had not actually spoke to the responsible party. The SW said she should have not documented she had confirmed Resident #114's code status when in fact she had not done so. The SW said when not validating a resident's code status a resident could receive life-sustaining measures when not desired. During an interview on [DATE] at 12:44 p.m., the DON said when the facility received referrals the information comes from the corporate care team. The DON said the Administrator received the referral information and the Administrator advised nursing a resident was a pending admission. The DON said she had not reviewed the clinical records of Resident #114 prior to her arrival and was not aware Resident #114 was a DNR status in the hospital. The DON said within ,d+[DATE] hours after admission nursing should have had the updated code status for Resident #114. Requested at this time from the DON all nurse competencies for CPR. During an interview on [DATE] at 12:59 p.m., the Assistant Administrator said she was informed of Resident #114 coming to the facility by the centralized admission team. The Assistant Administrator said the centralized admission team validated the admission's financial status, clinical status, and approved for coming. The Assistant Administrator said nursing should have been advised of the hospital code status and reached out to the family on admission. The Assistant Administrator said when a code status was not validated then someone could receive life saving measures when not wanted. During an observation and interview on [DATE] at 1:30 p.m., the DON said the CPR cards were obtained upon hire, but the nursing CPR status was not tracked or maintained after hire. The DON said she would bring the CPR certifications as she obtains them. During an interview on [DATE] at 3:30 p.m., LVN N said she was Resident #114's nurse on [DATE]. LVN N said she went in Resident #114's room to obtain her vital signs when she repositioned her and began checking her vital signs. LVN N said she called Resident #114's name and she opened her eyes, and her breathing as labored. LVN N said she called LVN T in the room and they assessed Resident #114's breathing and indicated she had [NAME] stoke respirations. LVN N said she called 911 and LVN T placed on a non-rebreather mask. Record review of the CPR cards provided indicated the facility failed to provide a current CPR card for anyone other than the DON, ADON, and the treatment nurse. Record review of the Advance Directive policy and procedure dated ,d+[DATE] indicated in accordance with current OBRA definitions and guidelines governing advance directives, our facility has defined advanced directions as preferences regarding treatment options and include, but not limited to: a. Advance Directives-a written instruction, such as a living will or durable power of attorney for health care, recognized by State law, relating to the provisions of health care when the individual is incapacitated e. Do Not Resuscitate-indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used . h. Life-sustaining Treatment-treatment that, based on reasonable medical judgement, sustains an individual's life and without it the individual will die. This includes medications and interventions that are considered life-sustaining, but not those that are considered palliative or comfort measures. k. Other Treatment Restrictions-indicates that the resident, legal guardian, health care proxy, or representative does not wish for the resident o receive certain medical treatments. Examples include, but are not restricted to, blood transfusions, tracheotomy, respiratory intubations, etc. 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 2. Written information will include a description of the facility's policies to implement advance directives and applicable state law. 3. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative 6. Prior to or upon admission of a resident, the Director of Resident Support Services or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives . 18. The Director of Clinical Operations or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care 20. Staff will be educated on the advanced directives process and resident's rights annually and as needed. https://www.aclsmedicaltraining.com/respiratory-arrest/ accessed on [DATE] revealed: Respiratory arrest is a condition that exists at any point a patient stops breathing or is ineffectively breathing. It often occurs at the same time as cardiac arrest, but not always. In the context of advanced cardiovascular life support, however, respiratory arrest is a state in which a patient stops breathing but maintains a pulse. Importantly, respiratory arrest can exist when breathing is ineffective, such as agonal gasping. We often think of cardiac arrest leading to respiratory arrest, but the respiratory system may shut down without the heart's involvement. If the nerves and/or muscles are not capable of supporting respiration, a patient may enter respiratory arrest. One example of this is in the disease amyotrophic lateral sclerosis (Lou Gehrigsdisease). If the area of the brain that controls respiration becomes depressed, as might occur in an opioid overdose, the brain does not drive respiration. Another example is a state in which the chest might not be able to physically support respiration. This might occur externally (e.g., with a crush injury to the chest) or internally (e.g., in acute respiratory distress syndrome or tension pneumothorax). It is important to keep these possible causes of respiratory arrest in mind during resuscitation. The first goal is to establish an open airway in the patient. The rescuer should use the tools available to them according to a given situation and as appropriate. For instance, if the patient is found in respiratory arrest in a non-hospital setting, the rescuer may only be able to use basic airway techniques such as head tilt/chin lift or jaw thrust maneuver. Incidentally, the head tilt/chin lift is used when cervical spine injury is not an issue and the jaw thrust maneuver is used when an injury to the cervical spine is suspected or feared. If an oropharyngeal or nasopharyngeal airway device is available, consider using these means to assist in airway maintenance (see A Review of Airways). When you are administering artificial respiration, you are breathing for the patient. Avoid excessive ventilation and make sure that you see the chest rise and fall with breaths. Are you providing sufficient oxygenation? If you have access to supplemental oxygen, use it. You may use 100% oxygen initially, but it is best to titrate the level of supplemental oxygen necessary to achieve blood oxygen levels of 94% or higher (based on pulse oximetry). Likewise, if you have access to quantitative waveform capnography, you can use it to monitor end tidal carbon dioxide. Remember that a person who is in respiratory arrest may enter cardiac arrest at any moment. Therefore, it is important to check for pulses to assess circulation. If the patient enters cardiac arrest at any moment, you should follow the cardiac arrest resuscitation algorithm immediately.J https://www.ncbi.nlm.nih.gov/books/NBK526127/ accessed [DATE] revealed: The respiratory system allows gas exchange between the environment and the body, facilitating the process of aerobic metabolism. Specifically, the respiratory system provides oxygen and removes carbon dioxide from the body. The inability of the respiratory system to perform either or both of these tasks results in respiratory failure. Type 1 respiratory failure occurs when the respiratory system cannot adequately provide oxygen to the body, leading to hypoxemia. Type 2 respiratory failure occurs when the respiratory system cannot sufficiently remove carbon dioxide from the body, leading to hypercapnia. Respiratory failure can be classified based on chronicity (i.e., acute, chronic, and acute on chronic). A thorough understanding of respiratory failure is crucial to managing this disorder. If either type of respiratory failure is not identified and addressed early, it will become life-threatening and lead to respiratory arrest, coma, and death. The approach to adult patients with suspected respiratory failure (both hypercapnia and hypoxic), as well as the diagnosis and treatment of acute and chronic respiratory failure, are discussed in this article. Hypercapnic respiratory failure is defined as an increase in arterial carbon dioxide (CO2) ([NAME])> 45 mmHg with a pH < 7.35 due to respiratory pump failure and/or increased CO2 production. In general, according to the modified alveolar ventilation equation, the PaCO2 level is proportionally related to the rate of CO2 production (VCO2) and inversely associated with the rate of CO2 elimination (i.e., alveolar ventilation) (PaCO2 =VCO2 /VA). The relationship between minute ventilation and CO2 production in response to exercise can be affected by age and pregnancy . Respiratory failure is a syndrome caused by a multitude of pathological states; therefore, the prognosis of this disease process is difficult to ascertain. In 2017, in the United States of America, however, the in-hospital respiratory failure mortality rate was 12%. The case definition used in this study included all diagnosis codes, which included respiratory failure.[2] In-hospital mortality rates for patients requiring intubation with mechanical ventilation for asthma exacerbation, acute exacerbation of chronic obstructive pulmonary disease, and pneumonia were found to be 9.8%, 38.3%, and 48.4%, respectively.[37][38][39] Lastly, the in-hospital mortality rate for acute respiratory distress syndrome was found to be 44.3% http://www.nci.nlm.nih.gov/[NAME]/NBK448165/ accessed on [DATE] revealed: Cheyne-Stokes respiration is a type of breathing disorder characterized by cyclical episodes of apnea and hyperventilation. Although described in the early 19th century by [NAME] and [NAME] Stokes, this disorder has received considerable attention in the last decade due to its association with heart failure and stroke, two major causes of mortality, and morbidity in developed countries. Despite increasing recognition and growing knowledge, Cheyne-Stokes respiration remains elusive, and patients have very limited treatment options. This activity highlights the role of the interprofessional team in caring for patients with [NAME] Stokes respiration. Objectives: o Review the etiology of Cheyne-Stokes breathing. o Identify the clinical features of Cheyne-Stokes breathing. o Summarize the evaluation of a patient with Cheyne-Stokes breathing. o Describe the role of the interprofessional team in caring for patients with Cheyne-Stokes respiration. Access free multiple-choice questions on this topic. Go to: Introduction Cheyne-Stokes respiration is a type of breathing disorder characterized by cyclical episodes of apnea and hyperventilation. Although described in the early 19th century by [NAME] and [NAME] Stokes, this disorder has received considerable attention in the last decade due to its association with heart failure and stroke, two major causes of mortality, and morbidity in developed countries. Unlike obstructive sleep apnea (OSA), which can be the cause of heart failure, Cheyne-Stokes respiration is believed to be a result of heart failure. The presence of Cheyne-Stokes respiration in patients with heart failure also predicts worse outcomes and increases the risk of sudden cardiac death. Despite increasing recognition and growing knowledge, Cheyne-Stokes respiration remains elusive, and patients have very limited treatment options . Prognosis The presence of this pattern indicates a bad prognosis unless attended promptly. Cheyne-Stokes respiration in the upright position can be an ominous sign of cardiovascular dysregulation . This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 4:43 p.m. The Assistant Administrator was informed of the Immediate Jeopardy. The Assistant Administrator was provided with the IJ template on [DATE] at 4:46 p.m. and a Plan of Removal was requested, The facility's plan of removal was accepted on [DATE] at 10:11 AM and included the following: Plan of Action o Social Service Director reviewed clinical records for all residents to ensure that all residents have their code status documented Beginning on [DATE] to be completed by [DATE]. o Social Service Director or Administrative nurses will continue monitoring to begin [DATE]. o Treatment Nurse and ADON will ensure all residents that are able to make independent decisions have their wishes appropriately documented. Beginning on [DATE] to be completed by [DATE]. o Social Service Director, Director of Nurses, Administrator and Regional Nurse will contact responsible party of those resident that are unable to make independent decision and ensure that the residents wishes were appropriately documented. Beginning on [DATE] to be completed by [DATE]. o Social Service Director will be provided In-service education on [DATE] by Regional Director of Clinical Operations to include: 1. Advanced Directive policy 2. Validation of code status on or before admission o All Licensed Nursing staff will be provided in-service education beginning on [DATE] by DCO or designee which includes: 1. Validation of code status on or before admission 2. How/where to locate code status in PCC 3. Documentation of Out of Hospital Do Not Resuscitate order. o All Education/In servicing will be done by [DATE]. o Newly hired nurses will receive in-service covering Code Status/Resident wishes action plan. o An audit of current CPR status of Licensed Nursing staff has been conducted by Director of Nurses and Business Office Manager on [DATE]. o Director of Nurses will create a binder that has all Nurses CPR certification and a tracker to indicate when certifications are due to be renewed by [DATE]. o Medical Director notified of IJ [DATE]. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: o Record review of the CPR audit report revealed it was completed on [DATE] to ensure all advanced directive wishes were being implemented, followed, and documented in electronic charting system. o Record review of the in-service dated [DATE] conducted by the Regional Nurse revealed The Social Worker was provided education on the policy for advance directive to include validating code status before or on admission. o During an interview on [DATE] at 11:03 a.m., the SW said upon admission she would verify with the family member or the resident when applicable their code status wishes. The SW said if the decision was for a DNR status then the SW would provide the appropriate paperwork then for the resident or responsible party to complete. The SW said she would then upload the DNR in the computer system after the completion, have a nurse obtain the physician's order, and ensure the computer system reflected the code status. The SW said then quarterly she would evaluate with the resident or family member the desired code status. o Record review of the in-service dated [DATE] conducted by the DON revealed all nursing staff were provided education on the DNR policy which included All admissions code status will be validated prior to or upon admission; Resident who are out of hospital DNR must have an order written for DNR; and how to find code status in the electronic charting system. o During interviews on [DATE] between 10:59 AM and 12:08 PM revealed LVN C, LVN E, LVN K, LVN L, LVN O, LVN P, LVN U, LVN Z, LVN AA, RN B, RN S, RN BB, MDS Coordinator, ADON, and DON were able to verbalize the process for validating code status on new admission residents and whom to report changes in code status. The nurses were able to verbalize were to find the current code status in the electronic charting system. o Record review of the Nurse CPR sheets dated January - December, revealed an audit of CPR status for the nurses were completed and tracking sheets were started. o During an interview and record review on [DATE] at 10:57 a.m., the DON said prior to and upon admission she would verify the code status of a new resident and ensure the code status was properly placed in the electronic record. The DON said even after hours and on weekend admissions she would ensure the code status was validated and placed in the computer system. The DON said there was a tracking binder created to ensure all nurses remained CPR compliant. Record review of the CPR binder included the nursing current CPR cards and monthly tracking sheets. During an interview [DATE] at 11:03 a.m., the Medial Director stated he was made aware of the immediate jeopardy situation regarding advance directives. During an interview on [DATE] at 11:14 a.m., the ADON said she would verify code status of a new admission prior to or on the day of the admission. The ADON said she would ensure the out of hospital DNR was uploaded, there was a physician's order to reflect the desires of the resident/family, and then ensure the computerized system accurately reflected the desired code status. The ADON said she was now keeping a binder with a tracking method to ensure all nurses had their CPR training current. During an interview on [DATE] at 11:26 a.m., the Assistant Administrator said she was monitoring the advanced directive follow up by the DON and ADON. The Assistant Administrator said as soon as the resident referral was obtained, and the resident was approved for admission the process was to ensure the code status was obtained by reaching out to the family or resident. The Assistant Administrator said a tracking binder had been made to ensure the nurses remained up to date on their CPR certifications, and the facility maintained a copy of the certification. During an interview on [DATE] at 11:30 a.m., the Administrator said he was in constant communication with the Assistant Administrator and the code statuses, and the CPR monitoring would be discussed at least weekly. The Administrator said when he was on-site, he would do random checks to ensure compliance. On [DATE] at 12:13 PM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to provide residents with personal privacy and confidentiality of his or her personal and medical records for 1 of 20 (Resident #40) residents reviewed for resident rights. 1. LVN A video recorded Resident #40 on [DATE] when he was in an emergent situation using her personal device and then shared the video with RN B on [DATE]. 2. RN B shared the [DATE] video recording with the ADON, and the BOM on [DATE]. 3. Resident #23 overheard LVN A having a telephone discussion on her personal cell phone of the video recording on [DATE] of Resident #40 while in a common area on her personal cell phone. 4. LVN A and RN B were in possession of the video recording on their personal devices from [DATE] - [DATE]. 5. RN B continued to have a screen shot of the video recording of Resident #40 on her personal cellular device on [DATE]. 6. The facility failed to notify Resident #40 of the video obtained of him during his emergent situation, and the distribution to RN B. An Immediate Jeopardy (IJ) situation was identified on [DATE] 10:38 a.m. While the IJ was removed on [DATE] at 5:55 p.m., the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failure could place residents at risk for diminished quality of life, loss of dignity and self-worth. Findings included: Record review of a face sheet dated [DATE] indicated Resident #40 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with diagnoses of heart failure, depressive disorder, anxiety disorder, and morbid obesity. Record review of the comprehensive care plan dated [DATE] indicated Resident #40 had a diagnosis of depression which placed him at risk for isolation and mood swings. The goal of the comprehensive care plan indicated Resident #40 would be free from discomfort. The interventions included to allow Resident #40 to voice his feelings and validate them. The comprehensive care plan dated [DATE] indicated Resident #40 uses anti-anxiety medications related to having anxiety. The goal of the care plan was Resident #40 would be free from discomfort. The interventions for Resident #40 included to monitor and record occurrences for target behavior symptoms and document according to the facility protocol. Record review of the Quarterly MDS dated [DATE] indicated Resident #40 understood and was understood by others. The MDS indicated Resident #40's BIMs score was 15 indicating he had no cognitive deficits. The MDS indicated Resident #40 sometimes felt lonely or isolated. Record review of a nursing note dated [DATE] at 2:10 p.m., LVN A documented she entered Resident #40's room to deliver groceries he had ordered. LVN A documented she found Resident #40 sitting in his bed unresponsive to verbal stimuli, or tactile stimuli. LVN A documented a sternal rub was performed but Resident #40 remained unresponsive. Resident #40's documented vital signs were temperature of 96.8, heart rate 87, oxygen saturation 84%, and blood pressure of ,d+[DATE]. The note indicated Resident #40 received an injection of Narcan (opioid reversing medication) and called 911. The note indicated upon EMS arrival Resident #40 was verbally responsive and refused transport to the local hospital. The note indicated the physician was notified at 2:41 p.m. LVN A documented while she was removing the fentanyl patch Resident #40 become unresponsive and was shaking as if he had a seizure. The physician advised to call 911. Record review of a Grievance/Complaint form dated [DATE] indicated RN B documented, resident came to charge nurse at start of shift and asked how resident from across the hall was doing. Charge nurse asked resident what she was talking about, and resident stated that during the smoke break, LVN A was outside with her computer charting and talking on phone and stated while resident was unresponsive that she took a video of resident after medication was given before EMS came back and that she made the resident go to the hospital after the resident refused to go. The resident said that the nurse told the residents outside smoking that she saved his life and that the resident had taken too much medication that he ordered online. The charge nurse again asked this resident what was said during lunch in her room she stated the resident refused to go to the hospital and that a video was taken during the time before the resident was taken to the hospital. Record review of a Resident Grievance/Complaint Investigation Report Form dated [DATE] at 8:10 a.m., indicated RN B was the complainant. The form indicated an unnamed resident had approached her stating a video recording without permission was illegal and asked how she could know this was not happening with other residents. The unnamed resident said a resident was videoed unconscious. The form indicated to describe your findings of the incident and the response was the video was present. The form indicated the recommendations/corrective actions were to in-service all staff on HIPPA, and abuse/neglect. The form indicated the ADON completed and signed this form, and the assistant administrator signed the form [DATE]. Record review of a witness statement form dated [DATE], RN B's telephone statement was obtained and witnessed by the Regional Director of Clinical Services. The form indicated LVN A made the video to allow the physician to visualize how Resident #40 was behaving. The form indicated LVN A initially indicated she had not sent the video to RN B but then she said she may have sent it to a dayshift nurse. The witness statement form indicated LVN A was asked to delete the video and then was informed a formal investigation was in effect and that she was suspended pending investigation. Record review of a Disciplinary Action Record dated [DATE] indicated LVN A was suspended on [DATE] related to the occurrence on [DATE]. The form indicated the facts regarding the incident were listed as a video taken of an unconscious resident while waiting on emergency medical services and discussing circumstances surrounding other residents' episode and condition with other residents during the resident's smoke time. The form indicated the expectations for the team member was LVN A would not violate HIPPA and a HIPPA violation was not tolerated. The form indicated the corrective action taken was LVN A was suspended pending investigation, HIPPA violations were not tolerated, and pending findings of the investigation termination could occur. The form also had written based on the results of the investigation it had been confirmed that LVN A violated HIPPA for Resident #40. Record review of an in-service dated [DATE] indicated the DON provided training regarding the policy and procedure related to Abuse, Neglect, Mistreatment, Exploitation, Involuntary Seclusion, and Misappropriation of resident property. The in-service also covered employee standards 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. The in-service also included HIPPA and HIPPA violations. Review of the in-service revealed RN B, BOM, and ADON were among the employees in-serviced. Record review of the in-serviced policy named Abuse dated 2017 indicated the purpose of this policy was to ensure that each resident had the right to be free from any type of Abuse, Neglect, Intimidation, involuntary seclusion/confinement, and or Misappropriation of Property .Residents will not be subjected to abuse by anyone, including, but not limited to community staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members or legal guardians, care taker, friends, or other individuals. Training: All employees are required to be trained in issues related to abuse prohibition practices. Prevention: .Each employee receives the standards of conduct which includes the standards for prohibiting abuse or neglect of a resident, and the reporting of any suspected abuse or neglect of a resident. Reporting: The law requires the abuse coordinator/designee, or employee of the facility who believes 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 All events that involve an allegation of abuse or involve a suspicious serious bodily injury of unknown origin must be reported immediately or not later than 2 hours of alleged violation. If the allegation does not involve abuse and the event does not result in serious bodily injury the allegation should be reported within 24 hours. Protection: It is utmost important that residents suspected of being abused, and all other residents must be protected ruing the initial identification, and investigation process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm. The in-service included the undated, New Hire Orientation Education HIPAA education. The education included HIPAA a federal law that protects individuals' health information and provides privacy rights. The law also describes steps that must be taken to secure confidential electronic protect health information for unintended disclosure through security breaches. A breach is an unacceptable, impermissible, use or disclosure of PHI (personal health information) that comprises the security of privacy of PHI 3. No matter how interesting it seems to you, do not share anyone's PHI with friends or family . 8. Never send any PHI electronically Record review of a witness statement dated [DATE] indicated the Regional Director of Clinical Services wrote she spoke to RN B by phone conversation in the DON's office. The Regional Director of Clinical Services asked RN B to provide a written statement regarding how she was informed Resident #40 discharged to the hospital. RN B indicated she had received a video from LVN A. RN B said Resident #40 was lying in his bed with an oxygen mask on. RN B said she had deleted the video, notified the ADON, and she felt uncomfortable about having the video. RN B said she felt uncomfortable about the video because Resident #40 was not awake and could not have consented to the video recording. During an interview on [DATE] at 6:22 p.m., the DON said she was aware of the video recording of Resident #40 taken by LVN A. The DON said honestly, she had never had anything of this nature happen before, so she reached out to her supervisor the Regional Director of Clinical Services. The DON said upon the arrival of the Regional Director of Clinical Services they had RN B erase the video recording from her phone, they called corporate, and was advised to suspend LVN A during the investigation. The DON said when LVN A came to the facility to work her shift she was advised to come to the office where she was interviewed regarding the videoing of Resident #40 and then sending the video to RN B. The DON said LVN A was suspended, and then terminated. The DON said the incident was not reported because corporate failed to advise to report to HHSC. The DON said the facility completed an in-service that indicated to report allegations of abuse. The DON said RN B was not suspended although she failed to report timely to the abuse coordinator. DON said she did not tell Resident #40 of the video because he was in the hospital and when he returned, she had not thought to tell him. The DON said if this had of happened to her, she would want to know. The DON said she should have told Resident #40 of the video. During an interview on [DATE] at 6:25 p.m., the Regional Director of Clinical Services said she had advised the DON and Assistant Administrator how to handle the video recording incident performed by LVN A regarding Resident #40. The Regional Director of Clinical Services said she had requested and observed each LVN A and RN B erase the video recordings from their personal cell phones on [DATE]. The Regional Director of Clinical Services said she had not watched a second deletion of the video from the cell phones deleted sections of photos. The Regional Director of Clinical Services said she was not advised by the [NAME] President of Clinical Services to report this incident to HHSC. During an interview on [DATE] at 6:27 p.m., Resident #23 said she had heard LVN A talking on her personal cell phone about the video. Resident #23 said she did not know who LVN A was talking to on the cell phone. Resident #23 said she was concerned this happened, and voiced she believed the videoing of Resident #40 was not an appropriate choice. During an observation and interview on [DATE] at 6:28 p.m., Resident #40 was sitting up in his bed. Resident #40 was informed by this writer there was sensitive information to discuss with him. Resident #40 agreed to the conversation. Resident #40 after learning there was an employee who videoed him using her personal cell phone on [DATE] when he was unresponsive sat quietly for a moment. Then, Resident #40's eye welled with tears, and he said, I feel violated, this was the first I had heard of the video recording taking place during my emergent situation. Resident #40 said, I was not in control of myself, and I was taken advantage of without my permission. During a telephone interview and an observation on [DATE] at 6:40 p.m., RN B said she was aware of the video recording made by LVN A on Saturday [DATE]. RN B said in the video Resident #40 was not in a condition to be video recorded. RN B said although Resident #40 had a gown on, his gown only went to his upper thigh level, and the video was recorded facing Resident #40 and to his left side. RN B said LVN A sent the video recording to her while she was off duty at her personal residence. RN B said she was unsure why LVN A felt as though she needed to view a video of Resident #40's emergent situation. RN B said she had not shared the video with any until on [DATE] when she informed the ADON, and the BOM of the video recording. RN B said she no longer had the video, but she had a screen shot of the video remaining on her personal cell phone. RN B provided this screen shot. During an observation of this screen shot, in the center of the screen shot was the circled arrow indicating there was a video, the video was sent on Saturday, and Resident #40 was sitting upright in his bed, his head was back, and he had a non-rebreather oxygen mask on his face. During a telephone interview on [DATE] at 7:14 a.m., LVN A said she was in the habit of using her personal cell phone to record videos and take photographs of residents to send to the physician. LVN A said she had video recorded Resident #40 with the intent to send to his physician in so that the physician could visualize Resident #40's situation. LVN A said she never sent Resident #40's physician the video although this was the purpose. LVN A said she sent the video of Resident #40 to RN B thinking because she was Resident #40's daytime nurse she should be aware of what happened to Resident #40. LVN A said the video was deleted when she was called in the DON's office on [DATE]. LVN A said she would not feel anything if she was video recorded during an emergency. LVN A said when asked why she was acting as a videographer instead of a nurse in an emergency she said she had done what she could for Resident #40, and she was waiting on the EMS to arrive. LVN A said she had never thought of the video again, and she said she does not feel as though she had done anything wrong. LVN A said the video taping of a resident was not considered abuse. During an interview on [DATE] at 7:30 a.m., the BOM said she was made aware of the video of Resident #40 on [DATE]. The BOM said the ADON shared with her the existence of the video of Resident #40. The BOM said she viewed the video with the ADON and then said to the ADON that they would have to reach out to a higher management level to instruct how to handle the incident. The BOM said although she does not actually handle HR matters now the staff tend to still come to her for these matters and this was her reasoning behind viewing the video. The BOM said she had RN B screenshot the video of Resident #40 for the DON to have to use for her investigation. The BOM manager said she did advise the DON the videos should be deleted from the recently deleted files as well. The BOM said there was a risk the video was spread on social media platforms that disappear in minutes, and since the video was on personal cell phone devices these devices were in the employees' personal homes and could have been viewed there as well. The BOM said Resident #40's rights were violated, and she would feel violated if this happened to her. During an interview on [DATE] at 7:42 a.m., the ADON said she was working the day Resident #40 was in an emergent situation [DATE]. The ADON said she left her duties and come to help LVN A with the situation. The ADON said she notified the DON and then the DON reached out to the Regional Director of Clinical Services. The ADON said the DON was informed by the Regional Director of Clinical Services she was in route to the facility and would arrive in 3 hours. The ADON said when LVN A arrived at the facility to start her shift she was called to the DON's office. The ADON said LVN A was then suspended on [DATE]. The ADON said she had viewed the video on RN B's cellular device on [DATE]. The ADON said there was not a reason for LVN A to make a video of Resident #40. The ADON said as nurses we were not taught to video during an emergent situation. The ADON said she was aware the nurses at times had sent pictures of resident's wounds to the physician's cell phone to evaluate. The ADON said she would not feel safe in this environment and if this happened to Resident #40 it could happen to anyone. During an interview on [DATE] at 9:48 a.m., the floor tech said there was never a time videoing a resident would be appropriate. The floor tech said videoing a resident against their knowledge was a privacy issue. During an interview on [DATE] at 9:50 a.m., the transportation driver said she had heard about the video of Resident #40. The transportation driver said she believed videoing recording a resident was a HIPPA violation. During an interview on [DATE] at 9:53 a.m., LVN C said she had made photographed a resident's wounds or a leg and sent the pictures to the physician. LVN C said she used her personal cell phone, but she said her personal cell phone has a lock on it and could not be accessed by others. LVN C said she had never made a video of a resident in an emergent situation, and she would never make such a video saying, I know better. LVN C said she had not been informed not to take photographs of residents. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 10:38 a.m. The Assistant Administrator was informed of the Immediate Jeopardy. The Administrator was provided with the IJ template on [DATE] at 10:39 a.m. The facility's plan of removal was accepted on [DATE] at 3:48 PM and included the following: Action: LVN A who recorded Resident #40 with her personal phone was suspended on [DATE] and terminated [DATE]. Allegations for Residents #40 were self-reported on [DATE] by the Assistant Administrator and will be investigated. Resident #40 has been notified as part of the investigation. Safe Surveys will be conducted by Social Service Director and AD. Any negative findings have been reviewed and acted on accordingly. Completed [DATE]. Self-report that was completed for Resident #40 will be reviewed by RVP/RDCO for areas of further need. Completed [DATE]. Regional Nurse provided education to the MDS nurse/designee on abuse, neglect, exploitation policy and procedure, HIPPA, not utilizing personal cell phones to record residents in vulnerable situations because this could be considered abuse therefore she was allowed to train other staff. The MDS nurse/designee will in-service Staff prior to the next shift worked. Staff will not be allowed to work until education has been completed. All staff expected to be in service by [DATE]. Any staff member not in serviced by completion date will be in serviced prior to their next scheduled shift. a. Abuse neglect exploitation policy and procedure. b. HIPPA c. Not utilizing personal cell phones to record residents In-service provided to Administrator/DON by Regional Nurse on when to report abuse, what could be considered abuse such as recording residents in vulnerable situations. Resident #40 was physically assessed by Treatment Nurse. No adverse finding. Completed [DATE]. RN B provided with 1:1 in service on reporting any incident that could be considered reportable immediately to the Abuse Coordinator/designee provided by Regional Nurse. Licensed Clinical Social Worker from counseling services has evaluated Resident #40. Completed [DATE]. Daily Focus Care rounds will be completed by management staff and Weekend Manager on Duty to ensure residents are receiving appropriate care and treatment. Focus Care rounds reviewed with department heads/Manager on Duty. Completed [DATE]. The Medical Director has been notified by DON of the immediate jeopardy and reviewed current policy and procedures for abuse/neglect. Plan of action reviewed with Medical Director with no changes to the current policy. This practice will be reviewed monthly with the QA committee to ensure we are in compliance with the abuse/neglect policy and procedures. [DATE] On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: o Record review of LVN A's personnel file, accessed on [DATE], revealed she was suspended pending investigation on [DATE] and terminated on [DATE]. o Record review of self-report from the facility, undated, revealed the incident was reported to the state agency on [DATE]. o Record review of the safe survey interviews, dated [DATE] at 1:15 PM, revealed no concerns of abuse or further incidents of staff recording residents on their personal phone. o Record review of Resident #40's progress notes, dated [DATE] at 12:11 PM, revealed the Treatment Nurse completed an emotional and physical assessment on Resident #40. o Record review of an in-service, dated [DATE], revealed the RDCO conducted an in-service training with RN B, which included all incidents that can be considered reportable to the state must be reported to the administrator immediately. If you are unsure always err on the side of caution and notify the administrator. o Record review of the written statement dated [DATE], from the Licensed Clinical Social Worker revealed Resident #40 was provided services. o Record review of the In-service and education record, dated [DATE], conducted by the RDCO revealed the MDS Coordinator was provided education on the abuse and neglect policy and procedure to included: abuse, neglect, exploitation, HIPPA. The description of training revealed Residents will not be videoed or have pictures taken without consent. No exceptions. Staff will not use personal phones to capture, video, or picture image of any resident in vulnerable conditions as this could be considered abuse. o Record review of the in-service and education record, dated [DATE], revealed the RDCO completed training with the Administrator and DON on when to report abuse and video recording of resident in a vulnerable condition could be reportable. o Record review of the in-service and education record, dated [DATE], revealed the RDCO conducted training with the department heads to review the focused partner program (daily rounds made with residents to address needs). o Record review of the in-service and education record, dated [DATE], revealed staff were provided education on abuse, neglect, exploitation, and HIPPA policy and procedures. The description of training revealed Residents will not be videoed or have picture taken without consent, no exceptions. Staff will not use personal phones to capture video or picture images of any residents in vulnerable condition as this could be considered abuse. o During an interview on [DATE] at 3:58 p.m., the Medical Director stated he was made aware of the IJ situation regarding abuse. The Medical Director stated the plan of removal was discussed and no changes to the policy and procedures were made. o During an interview on [DATE] at 5:46 p.m. with Regional Director of Clinical Operations said she provided in-servicing to the Administrator, Assistant Administrator, DON, ADON, and the MDS coordinator regarding the provider regarding abuse and neglect and HIPPA. The in-service covered when to report and what to report including video recordings. The Regional Director of Clinical Operations said she also assisted with the monitoring tool for the CPR certifications, focus rounds weekly, and other monitoring tools. o During an interview with RN B on [DATE] she indicated she was able to verbalize the different types of abuse, when to report abuse, and whom to report abuse. RN B was able to verbalize refresh training was provided on focused partner rounding on assigned residents. The department heads (DON, ADON, ADM, MDS, BOM, Maintenance, DM, and SW stated videoing a resident in a vulnerable situation could have been a form of abuse. The department heads were able to verbalize no video recording or picture image should have been obtained without a resident's consent and personal cell phones should not be used to take photos or videos of residents. o During department head interviews on [DATE] between 4:56 PM and 5:38 PM, the Assistant Administrator, DON, ADON, Treatment Nurse (LVN K), BOM, Social Worker, Maintenance Supervisor, Dietary Manager, MDS Coordinator, and AD were able to verbalize the different types of abuse, when to report abuse, and whom to report abuse. They were able to verbalize refresh training was provided on focused partner rounding on assigned residents. The department heads stated videoing a resident in a vulnerable situation could have been a form of abuse. The department heads were able to verbalize no video recording or picture image should have been obtained without a resident's consent and personal cell phones should not be used to take photos or videos of residents. During staff interviews on [DATE] between 4:56 PM and 5:38 PM, DA V, [NAME] W, Housekeeper G, CNA D, CNA H, CNA M, CNA Q, CNA R, CNA X, CNA Y, MA F, LVN C, LVN E, LVN L, LVN N, LVN P, and RN B were able to verbalize the different types of abuse, when to report abuse, and whom to report abuse. The staff were able to verbalize no video recording or picture image should have been obtained without a resident's consent and personal cell phones should not be used to take photos or videos of residents. The staff stated videoing a resident in a vulnerable situation could have been a form of abuse and should have been reported immediately to the abuse coordinator, which was the Administrator. On [DATE] at 5:55 PM, the Administrator and the Assistant Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview, and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (a medication used in excessive doses and including duplicate therapy or for excessive duration; or without adequate monitoring, or without adequate indications for its use; or in the presence of adverse consequences which indicated the dose should be reduced or discontinued) for 1 of 5 residents reviewed for unnecessary medications. (Resident #5) The facility failed to ensure Resident #5 had behavior monitoring for with the use of anti-psychotic medications. These failures could place residents at risk for receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications. Findings included: Record review of a face sheet dated 2/21/2024 indicated Resident #5 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of Alzheimer's disease (memory loss disease), high blood pressure, and diabetes. Record review of a progress note dated 7/04/2023 reviewed from the electronic record from the facility indicated this was provided from the local behavior health hospital indicated Resident #5 was struggling with her lability (rapid, often exaggerated changes in mood) with frequent episodes of yelling and tearfulness. The progress note indicated the physician adjusted her medications to control her symptomology but continues to struggle with hallucinations requiring frequent redirection. Record review of discharge orders from the local behavioral health hospital indicated Resident #5 was planned for readmission to the facility on [DATE] with the discharge medications of acetaminophen-codeine (pain medication) 300 milligrams 1 tablet twice daily started on 6/15/2023, clozapine (anti-psychotic) 125 milligrams nightly started on 7/03/2023, divalproex EC (anti-seizure) 500 milligrams three times daily started on 7/03/2023, Aricept (dementia treatment) 5 milligrams nightly started on 6/21/2023, melatonin (herbal sleep aide) 6 milligrams nightly started on 6/23/2023. Record review of a physician's order dated 7/10/2023 at 4:40 p.m., Resident #5 was ordered Lorazepam 1 milligram twice daily for Preventative by her physician. Record review of an Admission MDS dated [DATE] indicated Resident #5 was rarely understood, and rarely understands. The MDS indicated Resident #5 had a long-term and short-term memory problem. The MDS indicated Resident #5 was moderately impaired in decision making tasks, had changes in mental status indicating delirium. The MDS indicated Resident #5 had inattention, and disorganized thinking that was continuously present. The MDS did not have any results entered for Resident #5's BIMS score. The MDS indicated Resident #5 required extensive assistance with two staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS indicated Resident #5 required extensive assistance on one staff with walking in her room, locomotion on the unit and off the unit, and eating. The MDS indicated Resident #5 required total assistance of two staff for bathing. The MDS indicated Resident #5 was always incontinent of bowel and bladder. The MDS Section I had no psychiatric/mood disorders coded for Resident #5. The MDS Section J indicated Resident #5 had a fall in the last month and had a fall since admission. The MDS in Section J1900 indicated Resident #5 had two falls with no injury, and 1 fall with injury except a major injury, and no falls with major injury. The MDS in section N Medications indicated Resident #5 had received antipsychotic medications during the last 7 days of the assessment period, had 6 days of anti-anxiety medications used over the last 7 days, and she received an anti-depressant 1 day out of the 7 days. The MDS indicated Resident #5 received anti-psychotic medications routinely since admission. The MDS indicated in Section O the physician had made no examinations but there were 5 physician order changes over the last 14 days. Record review of the consolidated physician orders dated 6/01/2023 - 8/31/2023 indicated Resident #5 was ordered Aricept (dementia medication) 10 milligrams one tablet one time a day on 7/17/2023 and started on 7/18/2023, Aricept 5 milligrams one tablet daily on 7/17/2023 and started on 7/18/2023, Ativan (Anti-anxiety) 1 milligram three times a day ordered on 7/13/2023 and started on 7/13/2023, Ativan 1 milligram one tablet two times a day ordered on 7/10/2023 and started on 7/11/2024, benztropine (Cogentin) mesylate 1 milligram one tablet at bedtime ordered on 7/28/2023 and started on 7/28/2023, Celexa (anti-depressant) 10 milligrams one tablet daily for anxiety and depression ordered on and started on 7/06/2023; Clozaril (Anti-psychotic) 100 milligrams one tablet by mouth at bedtime ordered on and started on 7/06/2023; Cogentin (anti-Parkinson's medication)1 milligram one time a day ordered on 7/13/2023 and started on 7/14/2023, Depakote (anti-convulsant medication) delayed release 500 milligrams three times a day ordered and started on 7/06/2023, Gabapentin (anti-seizure medication)100 milligrams give 2 capsules three times daily ordered on 7/06/2023, started on 7/11/2023 and ended on 7/13/2023; Gabapentin 100 milligrams one capsule three times a day ordered on 7/06/2023, started on 7/07/2023 and stopped on 7/10/2023, Gabapentin 300 milligrams daily ordered on 7/06/2023 and started on 7/07/2023, Gabapentin 300 milligrams one capsule three times a day ordered and started on 7/08/2023; Haldol injection (anti-psychotic) 5mg/ml inject 1 ml intramuscularly one time for restless, aggressive ordered on, started on, and ended on 7/14/2023, Lorazepam (Anti-anxiety) concentrate 2 milligrams/milliliter give 1 milliliter every 4 hours as needed for agitation ordered and started on 7/08/2023, Lorazepam tablets 0.5 milligrams one tablet every 4 hours as needed for restlessness or agitation ordered on and started on 7/08/2023; Lorazepam 1 milligram tablet every 4 hours as needed for anxiety and agitation ordered on and started on 7/17/2024, Lorazepam 1 milligram every 6 hours as needed for anxiety and agitation ordered on and started on 7/27/2023, Lorazepam 1 milligram every 6 hours as needed for anxiety for 14 days ordered on and started on 8/15/2023 and ended on 8/29/2023, Seroquel (anti-psychotic) 100 milligrams twice daily for dementia/delirium ordered on and started on 7/08/2023, Seroquel 100 milligrams, twice daily for insomnia ordered on and started on 7/13/2023, Seroquel 50 milligrams one time only ordered on, started on and ended on 8/09/2023, Seroquel 50 milligrams twice daily for insomnia ordered on and started on 7/13/2023; Zyprexa (anti-psychotic) 2.5 milligrams as needed for agitation for 14 days ordered on, started on 8/28/2023 and stopped on 9/11/2023, and Zyprexa 5 milligrams by mouth at bedtime ordered on and started on 8/28/2023. Record review of the comprehensive care plan dated 7/20/2023 indicated Resident #5 used anti-depressant medications related to the diagnosis of depression. The goal of Resident #5's care plan was she should be free from discomfort or adverse reactions related to the use of anti-depressant therapy. The interventions for Resident #5 included administer the anti-depressant as ordered, educate the family on the risks, monitor, and report adverse reactions. The comprehensive care plan indicated Resident #5 used as needed anti-anxiety medications related to agitation from end stage dementia. The goal of Resident #5's care plan indicated she would be free from discomfort or adverse reactions related to anti-anxiety therapy. The interventions for Resident #5 included the administration of the anti-anxiety medications as ordered, monitor the resident for safety due to Resident #5 was at an increased risk of confusion, amnesia, loss of balance, increased falls, broken hips, and legs. Record review of the fall care plan indicated Resident #5 was at risk for falls related to poor balance, decreased safety awareness. The goal of Resident #5's fall care plan indicated she would be free from preventable injury from preventable falls. Resident #5's interventions failed to reflect any new interventions or a review during the time period of 7/09/2023, 7/10/2023 when she had multiple falls when she sustained substantial facial bruising, and on 9/13/2023 when she sustained a skin tear. Record review of an Unwitnessed Fall Report indicated on 7/09/2023 at 5:22 p.m., Resident #5 had a fall and was sitting on her buttocks in front of the glass doorway entrance. The incident report indicated Resident #5 was alert and crying. The report indicated there were no environmental factors, predisposing factors included confused, incontinence, gait imbalance, and impaired memory. The fall report indicated Resident #5's nurse practitioner was notified. Record review of a Witnessed Fall Report indicated on 7/10/2023 at 5:23 p.m., Resident #5 was sitting in the blue chair, staff was standing nearby, Resident #5 leaned over forward in chair and rolled out of chair on to the floor. The report indicated Resident #5 had not hit her head and had no injuries. The report indicated there were no environmental factors, predisposing physiological factors included confused, impaired memory, recent change in cognition, and weakness. Record review of a Witness Fall Report indicated on 7/10/2023 at 11:21 p.m., Resident #5 had fallen forward out of the chair in the lobby, after she had been sleeping in the chair and wrapped in a blanket because she would not stay in bed in the room. No injuries were noted other than Resident #5 had small swelling to right forehead. The report indicated no environmental factors noted, predisposing physiological factors included confused, drowsy, incontinent, recent changes in medications, and gait imbalance. The fall report indicated Resident #5 had recently readmitted from the behavioral hospital, admitted to hospice care, declined, and was a high risk for falls. Record review of a physician's visit note dated 7/12/2023 and signed by the nurse practitioner and physician as of 7/30/2023 indicated Resident #5 was seen for a routine monthly visit. The note indicated Resident #5 had bruise over her right eye being status post a fall. The note indicated Resident #5 was in a wheelchair but just sitting here with her head down and she did not communicate with us. The physician's note indicated Resident #5's medications were reconciled and included Lorazepam 0.5 milligrams one tablet by mouth three times daily as needed, and Seroquel 150 milligrams nightly. The physician's visit note indicated Resident #5 received the Lorazepam and Seroquel for anxiety disorder. Record review of a weekly skin assessment dated [DATE] indicated Resident #5 had bruising on her face. Record review of Resident #5's MAR dated July 2023 indicated on July 22, 2023, at 1:18 p.m., Resident #5 was administered Lorazepam 1 milligram tablet. The MAR failed to indicate behaviors demonstrated for the use of this medication for Resident #5. Record review of Resident #5's MAR dated July 2023 indicated she received: Aricept 5 milligrams 1 tablet by mouth daily started on 7/18/2023 noted administered remainder of the month. Cogentin (Benztropine mesylate) 1 milligram by mouth daily started on 7/14/2023 and discontinued on 7/28/2023. Benztropine Mesylate 1 milligram by mouth at bedtime was started on 7/28/2023 and administered the remainder of the month and discontinued on 8/10/2023. Celexa 10 milligrams one tablet daily was administered starting on 7/18/2023 through the remainder of the month. Gabapentin 300 milligrams one capsule by mouth daily was ordered on 7/07/2023 and discontinued on 7/08/2023. Seroquel 100 milligrams once every evening for dementia with behaviors was ordered on 4/11/2023 and discontinued on 7/06/2023. The MAR had no behavior monitoring for the use of this medication. Seroquel 50 milligrams 1 tablet daily started on 7/06/2023 and stopped on 7/08/2023. The MAR had not behavior monitoring for the use of this medication. Ativan (Lorazepam) 1 milligram twice daily for preventative was ordered on 7/11/2023 and administer each day then discontinued on 7/13/2023. The MAR had no behavior monitoring for the use of this medication. Gabapentin 300 milligrams 1 capsule twice daily for dementia was ordered on 7/06/2023, administered once and then discontinued. The MAR had no behavior monitoring for the use of this medication. Seroquel 100 milligrams ordered twice daily starting and administered 7/08/2023 and ended on 7/13/2023. The MAR had no behavioral monitoring for this medication use. Seroquel 100 milligrams ordered twice daily started on 7/13/2023 and administered as ordered until 8/28/2023. The MAR had no behavior monitoring for this medication use. Seroquel 50 milligrams ordered twice daily starting 7/13/2023 and administer until 7/17/2023. The MAR had no behavior monitoring for this medication use. Ativan 1 milligram tablet by mouth three times daily started on 7/13/2023 and stopped on 7/17/2023. The MAR had no behavior monitoring for this medication use. Depakote 500 milligrams one tablet three times daily for preventative ordered on 7/06/2023 one dose administered then discontinued on 7/06/2023. The MAR had no behavior monitoring for this medication use. Gabapentin 100 milligrams three times daily ordered on 7/07/2023 and to stop of 7/10/2023. Resident #5 received 3 doses of this medication before discontinued on 7/08/2023. Gabapentin 300 milligrams 1 capsule three times daily started on 7/08/2023 for preventative and continued administration until discontinued on 8/09/2023. The MAR had no behavior monitoring for this medication. Haldol Injection 5 milligrams/milliliter inject 1 milliliter one time only for restlessness, aggression dated 7/14/2023. The MAR had no behavior monitoring entry for this medication. Lorazepam 2 milligrams give 1 milligram every 4 hours as needed was ordered on 7/08/2023 administer on 7/14/2023, 7/17/2023, 7/18/2023, 7/23/2023, and 7/27/2023 and discontinued on 7/27/2023. The MAR had no behavior monitoring entry for this medication. Record review of a Witnessed Fall Report dated 8/07/2023 at 10:15 a.m., Resident #5 was being showered by the hospice aide when Resident #5 began to slide down. The report indicated Resident #5 did not fall but was assisted down to her knees. The report indicated the hospice staff failed to notify the nurse on the same day of the occurrence. The report indicated there were no injuries. Record review of a physician's visit note dated 8/08/2023 and signed on 8/23/2023 at 9:46 p.m., the Nurse Practitioner and the physician indicated Resident #5 was seen on this day and was asleep in a chair. The note indicated the staff voiced her spouse was very unrealistic about her outcome and has threatened to take her home. The note indicated the physician had spoken to the spouse and indicated home would have not been the best situation for Resident #5. The note indicated Resident #5's medication regimen included gabapentin 300 milligrams by mouth two times daily, Lorazepam 0.5 milligrams three times daily as needed, Seroquel 150 milligrams by mouth daily at bedtime. The plan of the note indicted the physician and nurse practitioner was treating Resident #5's anxiety with lorazepam and Seroquel. Record review of an Un-witnessed fall report dated 8/13/2023 at 6:06 p.m., the report indicated Resident #5 was sitting on the floor. The report indicated Resident #5 had gotten out of her bed, safety mat beside the bed, and scooted on buttocks to the door entry. The report indicated Resident #5 was alert and confused. The note indicated Resident #5 was transferred in her specialty chair with her legs elevated and taken to the lobby to be observed. The report indicated Resident #5 was confused, incontinent, had impaired balance, and impaired memory. The report indicated Resident #5 was clean, dry, room was well lit, and the floor was clean and dry. Record review of an un-witnessed fall report dated 8/21/2023 at 7:10 p.m. indicated Resident #5 was found sitting on her buttocks in another resident's room, alert, no complaints of pain or discomfort. The mental status on the report indicted Resident #5 was confused, aggressive at times, continued to walk fast and unsteady gait, and tries to get out of the Broda chair (reclining chair) at times. The report indicated there was predisposing factors of noise. The predisposing physiological factors included confusion, incontinence, gait imbalance, and impaired memory. The report indicated the situation factors were Resident #5 was an exit seeker, had improper footwear, and ambulated without assistance. The other information on the report indicted Resident #5 had no safety awareness and was not wearing her safety socks. Record review of an Un-witnessed fall report dated 9/02/2023 at 5:03 p.m. indicated Resident #5 was found on the floor in the hallway near the exit door. Resident #5 was noted to be lying predominantly on her right side. The report indicated the predisposing physiological factors included confused, incontinent, gait imbalance, and impaired memory. Record review of an un-witnessed fall dated 9/03/2023 at 5:54 p.m., indicated Resident #5 was in another resident's room and was found sitting on her buttocks in an upright position. The report indicated the predisposing physiological factors included Resident #5 was confused, incontinent, gait imbalance, and impaired memory. Record review of a physician's visit note dated 9/05/2023 and signed on 9/17/2023 by the Nurse Practitioner and the physician indicating he agreed with the assessment and plan of care indicated Resident #5 was seen for her advanced dementia disease. The note indicated Resident #5's medications regimen was reconsolidated and included Gabapentin 300 milligrams twice daily, Ativan 0.5 milligrams three times daily as needed, Seroquel 150 milligrams at bedtime. The physician's note indicted Resident #5 was taking the Lorazepam and Seroquel for anxiety disorder. Record review of an Un-witnessed Fall report indicated Resident #5 had a fall on 9/07/2023 at 10:14 a.m. The note indicated Resident #5 was found sitting on her buttocks between two chairs with dining table behind her. The report indicated Resident #5 had the physiological factors of confused, incontinent, gait imbalance, and impaired memory. The report indicated Resident #5 possibly missed the dining room chair and sat on the floor on her buttocks. Record review of a Witnessed Fall Report indicated on 9/08/2023 at 11:15 a.m., Resident #5 had a fall. The report indicated Resident #5 was walking in another resident room with her eyes closed, she bumped her forehead on the door facing of the bathroom, and then she turned and slid down the wall to the floor. The report indicated there was no injuries noted. The predisposing physiological factors included incontinent, impaired memory, and weakness. Record review of an Un-witnessed fall report indicated on 9/08/2023 at 11:38 p.m., Resident #5 had slid off the chair in the lobby. The report indicted Resident #5 was lying on the left side with her head up, on the floor next to low chair in lobby. The report indicated Resident #5 was alert, and confused speech, denied pain at the time. The report indicated the physiological factors were confused, drowsy, incontinent, gait imbalance, and impaired memory. The section other information indicated Resident #5 had been aggressive, cussing at the staff, refused to stay in her broad chair to relax. Record review of an Unwitnessed Fall report dated 9/13/2023 at 5:31 p.m., Resident #5 was heard falling. Resident #5 was found on her buttocks in front of a chair. The report indicated Resident #5 had a skin tear to left arm. The report indicated Resident #5 had predisposing physiological factors of confused, and impaired memory. Record review of a progress note dated 9/13/2023 at 5:37 p.m., LVN E indicated Resident #5 had a fall and was found sitting on her bottom in front of the chair. Record review of a progress note dated 9/13/2023 at 5:23 p.m., LVN E documented Resident #5 had a bruise to her right hand and forehead. Record review of a progress note dated 9/14/2023 at 5:16 p.m., Resident #5 was ordered Depakote sodium 250 milligrams one tablet twice daily for behaviors. Record review of a progress note dated 9/14/2023 at 5:43 p.m., LVN F documented Resident #5 was ordered by the hospice nurse Depakote 250 milligrams twice daily for behaviors, Mobic 15 milligrams daily for pain, and one dose of Morphine sulfate 0.25 milliliters. The note indicated Resident #5 was sitting in the day areas in a wheelchair at this time. Record review of a progress note dated 9/16/2023 at 12:12 a.m., LVN G documented Resident #5 was gotten out of bed and put into the lobby area in a chair due to multiple attempts of trying to get out of bed by herself, resident is a high fall risk and recently recovered from one. LVN G documented Resident #5 was swaying back and forth moaning, unlabored breathing with signs and symptoms of distress mentally. LVN G documented the as needed orders for anxiety and pain followed. Record review of a progress note dated 9/19/2023 at 4:30 a.m., LVN H documented Resident #5 had been resting quietly all night, during rounds this morning Resident #5 had noted audible gurgling, repositioned in high fowlers with her head up and suctioned Resident #5 three times with approximately 30 milliliters of clear mucous, oral care was given, lungs had bilateral wheezing. LVN H indicated she would notify Resident #5's hospice provider. Record review of a progress note dated 9/19/2023 at 5:59 a.m., LVN H documented she notified Resident #5's hospice provider reporting the gurgling and bilateral wheezing. LVN H documented she reported suctioning Resident #5 with some improvement. LVN H documented hospice would make a visit and check Resident #5. Record review of a progress note dated 9/20/2023 at 6:15 a.m., LVN K documented she notified the family Resident #5 was not breathing, she documented Resident #5 had no pulse, and hospice was notified to come and assess Resident #5. During an interview and record review on 2/13/2024 at 8:15 a.m., Resident #5's family members had voiced concern over the bruising Resident #5 sustained during falls on 7/10/2023. The family members reported they were not notified of the falls and was alarmed when they arrived at the facility for a visit on 7/12/2023. The family member provided picture dated from 7/12/2023 documentation of Resident #5 sitting in the dining area with dark purple bruising to both of her eye lids and the brow on both sides. The pictures include the right eye was a very deep purple color and the entire right forehead had varying colors of purple throughout the bruised area. A review of the pictures provided dated July 14, 2023, indicated Resident #5 had deep purple bruising on the right side of her face extending down below the eye, the left eye lid remained a deep purple color. Resident #5's forehead had various colors of purple and yellow colors. During an interview on 2/14/2024 at 10:02 a.m., LVN L said she had administered Resident #5 the newly ordered Ativan 1 milligram prior to her falls on 7/10/2023 at 5:23 p.m. and 11:21 p.m. LVN L said the Ativan should have indications for use where this medication said preventative. LVN L said the anti-anxiety medications should be used after non-pharmacological interventions were tried. LVN L said before the nurses administers an as needed medication the resident should be offered food, sweets, and incontinent care. LVN L said she should have documented those interventions prior to the administration. During an interview on 2/14/2024 at 10:37 a.m., the DON said she was not the DON when Resident #5 was residing in the facility but indicated Resident #5 was on all kinds of medications that required monitoring and documentation of behaviors. The DON said, this was horrible. The DON said she searched the electronic medical record and could not provide the any evidence Resident #5 was being monitored for behaviors indicating use of these medications. The DON said these medications required monitoring of behaviors and side effects. During an interview on 2/14/2024 at 11:00 a.m., the previous Administrator said she was not aware Resident #5's behaviors were not being monitored. The previous Administrator said behaviors should be monitored for the use of anti-psychotic medications. The Administrator said this was the responsibility of the DON. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7048860 accessed on 2/22/2024 indicated: Along with cognitive decline, 90% of patients with dementia experience behavioral and psychological symptoms of dementia, such as psychosis, aggression, agitation, and depression. Atypical antipsychotics are commonly prescribed off-label to manage certain symptoms, despite warnings from the regulatory agencies regarding the increased risk of mortality associated with their use in elderly patients. Moreover, these compounds display a limited clinical efficacy, mostly owing to the fact that they were developed to treat schizophrenia, a disease characterized by neurobiological deficits. Thus, to improve clinical efficacy, it has been suggested that patients with dementia should be treated with exclusively designed and developed drugs that interact with pharmacologically relevant targets. Within this context, numerous studies have suggested druggable targets that might achieve therapeutically acceptable pharmacological profiles. Based on this, several different drug candidates have been proposed that are being investigated in clinical trials for behavioral and psychological symptoms of dementia. We highlight the recent advances toward the development of therapeutic agents for dementia-related psychosis and agitation/aggression and discuss the relationship between the relevant biological targets and their etiology. In addition, we review the compounds that are in the early stage of development (discovery or preclinical phase) and those that are currently being investigated in clinical trials for dementia-related psychosis and agitation/aggression. We also discuss the mechanism of action of these compounds and their pharmacological utility in patients with dementia Currently, a specifically approved pharmacotherapy for BPSD remains elusive. The most troublesome psychiatric events such as aggression and the remaining symptoms psychosis and agitation are addressed with atypical antipsychotics administered off-label [6]. However, the clinical efficacy of these drugs is unsatisfactory because a large percentage of patients do not respond or respond partially to the drugs [7]. Moreover, atypical antipsychotics are not actually recommended for elderly patients because they pose a risk of many side effects [8]. Elderly patients seem to be particularly sensitive to severe adverse reactions induced by atypical antipsychotics such as excessive sedation, orthostatic hypotension and related complications such as falls, extrapyramidal symptoms, cognitive slowing, cardiovascular complications, and anticholinergic side effects [9]. Notably, the use of currently available antipsychotics in patients with dementia has been associated with an increased risk of death. Consequently, in April 2004, the US Food and Drug Administration (FDA) issued a black-box warning against the use of atypical antipsychotics in elderly patients [10, 11]. The American and British clinical guidelines [12-14] state that antipsychotics can be used only if the patient constitutes a threat to self or others and should be administered after evaluating the benefit/risk ratio of the treatment [15]. If the physician decides to prescribe antipsychotics, clinical guidelines recommend the exclusive usage of the following drugs: risperidone, olanzapine, quetiapine, and aripiprazole [12]. Nevertheless, several reviews in this subject emphasized that prior to treatment with antipsychotics, one should always consider that these drugs exert detrimental effects and provide limited efficacy [6, 7, 16]. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5840911 accessed on 2/22/2024 indicated: Treatment of geriatric anxiety actually involves more of non-pharmacological approaches which are first recommended rather than pharmacological approaches. The usual non-pharmacological measures advised are: 1. Lifestyle modification: Sleep, diet, exercise, socialization -all in moderation. Eliminate medical and non-medical triggers. Structured daily activities are one of the mainstays of elder care. The premise behind the same being, that activities provide some stimulation and interaction with the environment, give a sense of control and reduce overall anxiety. Apart from managing one's own daily routine, the following are commonly advocated. Physical Exercise: Regular physical exercise, even for just a few minutes daily, improves cerebral blood flow and metabolism. Sedentary individuals who are bound to their beds have a distinct reduction in cerebral blood flow. Exercise need not be strenuous in the form of aerobic exercises or gym-based exercises. A simple walk in the garden or outdoors should suffice, that too at the pace of the individual concerned. If wheelchair bound, then upper body can be exercised with simple stretches, use of a ball and hand exercises. Other forms of physical exercise could include: - Walking in the house if too frail - Swimming or aqua exercises or playing around in a large tub to mobilize the limbs - Physical games like playing ball, carrom, table tennis, etc. Sleep: We are aware that the sleep architecture gets altered with advancing age, hence a shorter night time sleep, phase advancement and more fragmented sleep are all seen in the elder. Hence while teaching about sleep hygiene, it is also important to counsel the elder individual about lowering their expectations about sleep duration. Nutrition: By virtue of decreasing appetite and increasing social isolation, elderly often have compromised nutrition and imbalanced electrolytes. Minor changes in blood levels of sodium, potassium, chloride, vitamin D etc. could give rise to anxiety symptoms. Monitoring through a simple nutrition chart, helps maintain basic parameters, and at times is the only intervention required to manage the anxiety. Behavior Therapy: Relaxation Therapy: Classical Jacobson's technique of progressive muscle relaxation can be taught to the individual with anxiety. This can also be coupled with guided imagery or practiced alone.b) Systemic desensitization: This works particularly for phobias and unspecified fears for eg. fear of falling. Creating a hierarchy and controlling the response helps. Exposure and Response Prevention: For OCD Eye Movement Desensitization and Reprocessing (EMDR): For PTSD. Cognitive Therapy: Cognitive Behavior Therapy: The aim of CBT in older adults is to target cognitive symptoms, physical symptoms as well as behavioral symptoms. First and foremost, psychoeducation is a must -about the anxiety in general and management of the same. Acceptance that the symptoms may not be suggestive of a medical emergency, at the same time being vigilant of associated co-morbidities, becomes a tricky issue to deal with and require a lot of awareness and self-monitoring. The principles of relaxation and hierarchal construction may also be used. The core of CBT, however, remains cognitive restructuring using the ABC model(antecedents-behavior-consequences), wherein cognitive errors and maladaptive behavior are identified and worked upon. The pace may have to be a little slow, as with age new learning takes time, and the template of old learned behaviors is hard to change. Mindfulness: Mindfulness as a therapeutic intervention is finding applicability in a wide range of disorders. Mindfulness is inculcating the ability to focus on 'the now'. It involves focusing initially on indiv [TRUNCATED]

Based on observations, interviews, and record reviews 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 5 of 5 residents (Residents #1, #2, #3, #4 and #5) and 6 out of 11 nondedicated and contracted staff (MA A, CNA B, CNA F, CNA CC, Hospice Aide and X-ray Technician) in the facility reviewed for infection control practices and transmission-based precautions. 1. The facility failed to report the COVID-19 outbreak to both the local health department and HHSC. 2. The facility failed to ensure facility staff had readily available access to appropriate PPE supplies when caring for Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5. 3. The facility failed to ensure Resident #3, and Resident #4 were separated after Resident #3 tested positive for COVID and Resident #4 did not. 4. The facility failed to ensure Resident #5 was placed on isolation precautions for COVID. 5. The facility failed to ensure non-dedicated facility staff and contracted staff wore appropriate PPE when entering COVID positive residents' room. (Resident #1, Resident #3, and Resident #5) 6. The facility failed to ensure staff was trained on current COVID-19 protocols and interventions. 7. The facility staff failed to follow facility infection prevention policies to prevent the spread of infections. An Immediate Jeopardy (IJ) was identified on 10/07/23 at 2:10 PM. While the IJ was removed on 10/09/23, the facility remained out of compliance at no actual harm with the potential for more than minimal harm with a scope identified as widespread because the facility needed to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at increased risk for serious complications from a communicable disease that could diminish the resident's quality of life. The findings included: 1. Record review of the e-mail submitted to the state agency on 10/06/23 revealed an outbreak occurred at the facility on 09/21/23. It was reported to the state agency 15 days after the outbreak occurred. Record review of the e-mail submitted to the local health department on 10/07/23 revealed the outbreak was reported to the epidemiologist 16 days after the outbreak occurred. During an interview on 10/06/23 beginning at 1:56 PM, the Administrator stated she did not submit a self-report to the state agency regarding the recent COVID-19 outbreak at the facility. The Administrator stated she had talked to the corporate managers who said the incident was not considered an outbreak because it was contained to the secured unit. The Administrator stated she submitted the self-report to the state agency on 10/06/23 after surveyor entrance to the facility. During an interview on 10/07/23 beginning at 4:20 PM, the DON stated the whole facility had gone into outbreak status on 10/04/23. The DON stated prior to 10/04/23, only the secured unit was considered outbreak status per the facility policy. The DON stated the positive residents were contained to the secured unit, so it was not considered an outbreak which needed to be reported to the state agency, until 10/04/23. The DON stated the Administrator was responsible for reporting outbreaks to the state agency and local health department. The DON stated she believed the Administrator had reported the incident on 10/04/23 but was unsure. During an interview on 10/08/23 beginning at 10:37 AM, the Administrator stated after reviewing the guidance and current COVID-19 situation at the facility, the incident should have been considered an outbreak. The Administrator stated it should have been reported to the state agency and the local health department when the first resident tested positive on 09/21/23. The Administrator stated it was important to ensure the state agency and local health department was notified of outbreaks of communicable disease to ensure protocol was followed to prevent the spread of infection. Record review of the COVID-19 Reporting Guidance for NF Providers provider letter, issued 07/26/22, revealed nursing facilities should report to state agency within 24 hours of the first confirmed positive case of COVID-19 staff or residents and any new confirmed case of COVID-19 in staff or residents after a facility has been without new cases for 14 days or longer. 2. During an observation on 10/06/23 beginning at 10:00 AM, room [ROOM NUMBER] and #62 had no isolation supply carts readily available outside the doors to access PPE supplies before entering the residents' rooms. room [ROOM NUMBER] and #62 had signage on the doors that stated STOP Airborne precautions, see nurse before entering. During an interview on 10/06/23 beginning at 10:17 AM, RN D stated she had been asking for isolation kits to have been placed outside of room [ROOM NUMBER] and room [ROOM NUMBER] since 10/04/23, when the residents had tested positive for COVID-19. RN D stated she notified the DON the isolation supplies were needed. RN D stated no comment when asked what the DON did with the provided information. RN D stated you can see we still don't have the supplies. RN D stated the supplies were in the big supply closet that was locked. RN D stated she did not have access to the supply closet to obtain the PPE herself . RN D stated the DON had access to the big supply closet but was unaware of everyone who had a key. RN D stated it was important to ensure the appropriate PPE was readily accessible and worn in COVID-19 positive residents' room to prevent transmission of infections and to protect the residents. During an observation on 10/06/23 beginning at 10:28 AM, Resident #5's room (room [ROOM NUMBER]) had no isolation supply carts readily available outside the doors to access PPE supplies before entering the resident's room. During an interview on 10/06/23 beginning at 10:36 AM, MA A stated the facility had PPE supplies. MA A stated the women's unit kept an isolation cart behind the locked nurses' station. MA A stated an isolation cart should have been placed in front of Resident #5's door (room [ROOM NUMBER]). MA A stated it was everyone's responsibility to place an isolation cart outside resident's room who were on transmission-based precautions. MA A stated it was important to ensure PPE supplies were readily available for use prior to entering a resident's room to protect the staff and residents from the spread of infection. During an interview on 10/06/23 beginning at 11:47 AM, LVN E stated he worked with the COVID-19 positive resident's on 10/05/23. LVN E stated he was not provided isolation gowns. LVN E stated he only wore the N-95 mask and a face shield or goggles when he went into the COVID-19 positive resident rooms. LVN E stated he tried to find the isolation gowns and was able to find a few but it was scattered and not readily accessible. LVN E stated the nursing management was aware the staff did not have access to the isolation gowns because it was on the 24-hour report sheet. LVN E stated the facility had a big isolation supply room that was locked, and he did not have access to it. LVN E stated it was important to ensure the staff had PPE supplies readily available and wore the recommended PPE to prevent the spread of infection. During an observation and interview on 10/06/23 at 1:42 PM, CNA M took the surveyor to the big supply closet where the PPE was kept. CNA M stated himself and the DON had a key to the supply closet . CNA M stated he believed there was another key but was unsure who had it. The PPE supply closet had several rows of boxes that were 4 boxes high that contained isolation gowns. The PPE supply closet had several boxes of N95 masks, hand sanitizer, face shields, goggles, purple-top wipes, and shoe covers. CNA M stated he usually placed the isolation carts outside of the residents' rooms who tested positive for COVID-19. During an interview on 10/07/23 beginning at 10:50 AM, CNA B stated isolation supplies should have been readily accessible outside the resident's door. CNA B stated it was important to ensure PPE supplies was readily accessible for the safety of the staff and residents. During an interview on 10/07/23 beginning at 4:20 PM, the DON stated the staff had not reported that they had no access to PPE supplies. The DON stated she expected the facility staff to call her or the administrator if they had no PPE supplies. The DON stated CNA M and nursing management was responsible for ensuring PPE supplies were located outside COVID-19 positive resident's room. The DON stated it was important to ensure the PPE supplies were readily accessible for use by the staff to protect other residents from the spread of infection . During an interview on 10/08/23 beginning at 10:37 AM, the Administrator stated when a resident tested positive for COVID-19, an isolation cart should have been placed outside the door with the appropriate PPE supplies. The Administrator stated if there was more than one COVID-19 positive resident room, then one cart could have been placed if it was easily accessible to both rooms. The Administrator stated she expected the staff to notify nurse management staff if they did not have access to PPE supplies. The Administrator stated she was unaware the facility staff had no access to the PPE supplies. The Administrator stated an in-service had been conducted with CNA M to ensure isolation carts were placed outside resident's room who tested positive for COVID-19 or had been exposed. The Administrator stated it was important to ensure facility staff had easily accessible PPE supplies for COVID-19 positive residents to prevent the spread of infectious disease. 3. A. Record review of the face sheet, dated 10/07/23, revealed Resident #3 was a [AGE] year-old female who readmitted to the facility on [DATE] with a current diagnosis of COVID-19 (an acute communicable disease caused by a coronavirus, which is characterized mainly by fever and cough and can progress to severe symptoms and in some cases death, especially in older people with underlying health conditions). Resident #3 also had diagnoses of acute diastolic (congestive) heart failure (condition in which your heart's main pumping chamber (left ventricle) becomes stiff and unable to fill properly), polyneuropathy (damage to multiple peripheral nerves), and history of cerebral infarction without residual deficits (stroke). Record review of the MDS assessment, dated 09/13/23, revealed Resident #3 had clear speech and was usually understood by staff. The MDS revealed Resident #3 was usually able to understand others. The MDS revealed Resident #3 had a BIMS of 12, which indicated moderately impaired cognition. The MDS revealed Resident #3 had no behaviors or refusal of care. The MDS revealed Resident #3 required an extensive, one-person physical assistance with bed mobility and a total dependence, two-person physical assistance with transfers. Record review of the comprehensive care plan, updated on 10/04/2023, revealed Resident #3 was COVID-19 positive with no symptoms. The interventions included isolate per facility protocol. Record review of the order summary report, dated 10/07/23, revealed Resident #3 had an order, which started on 10/04/23, for Isolation, droplet precautions for COVID-19 positive. During an interview on 10/06/23 beginning at 4:53 PM, Resident #3 stated facility staff only wore a mask when entering her room. Resident #3 stated she thought the staff was supposed to wear the full gear. B. Record review of the face sheet, dated 10/07/23, revealed Resident #4 was an [AGE] year-old female who readmitted to the facility on [DATE] with diagnoses of pulmonary fibrosis (disease in which the lungs become scarred (fibrosed) and damaged causing difficulty in breathing), legal blindness, COPD (characterized by persistent respiratory symptoms like progressive breathlessness and cough), PVD (narrowed arteries reduce blood flow to the arms or legs), and a history of CVA (stroke). Record review of the MDS assessment, dated 08/04/23, revealed Resident #4 had clear speech and was sometimes understood by staff. The MDS revealed Resident #4 was sometimes able to understand others. The MDS revealed Resident #4 had a BIMS of 8, which indicated moderately impaired cognition. The MDS revealed Resident #4 had no behaviors or refusal of care. The MDS revealed Resident #4 required an extensive, one-person assistance with transfers. Record review of the comprehensive care plan, revised 08/01/23, revealed Resident #4 had no care plan to address her exposure to COVID-19 or potential risk for infection. Record review of the order summary report, dated 10/07/23, revealed Resident #4 had no order for isolation precautions related to exposure. The order summary report revealed no monitoring for signs or symptoms of COVID-19. Record review of the progress notes, dated 09/07/23 to 10/08/23, revealed Resident #4 had no monitoring for signs or symptoms of COVID-19 and no nurse documentation that indicated the physician was notified of her exposure to COVID-19. During an observation on 10/06/23 beginning at 10:17 AM, Resident #3 and Resident #4 were in room [ROOM NUMBER]. The door was open and the signage on the door indicated STOP: airborne precautions .before entering room, perform hand hygiene, put on gown, put on gloves, apply N-95 mask and perform fit check of mask . During an interview on 10/06/23 beginning at 10:17 AM, RN D stated Resident #3 was positive for COVID-19 but Resident #4 was not. RN D stated she spoke with the Medical Director regarding Resident #4 remaining in the room with a COVID-19 positive roommate. RN D stated she was behind on charting and had not charted the conversation. RN D stated the Medical Director said it was okay to keep Resident #4 in the room with Resident #3 because Resident #4 was exposed anyways. RN D stated Resident #4 had remained COVID-19 during the testing that had been performed. During an observation and interview on 10/06/23 beginning at 4:53 PM, upon entrance into the room [ROOM NUMBER] f ull PPE was applied to include an isolation gown, N-95 mask, goggles, and gloves. The door was opened, and a biohazard box was in front of the door. Resident #3 was laying in the bed with the head of the bed elevated at approximately 80 degrees. Resident #3 was watching television and placed it on mute during the interview. Resident #3 stated she started out having allergy type symptoms with fatigue. Resident #3 stated she was COVID-19 tested on [DATE] and it was positive. Resident #3 stated she was tested again on 10/04/23 and it was still positive. Resident #3 stated the facility staff did not attempt to move her roommate and she was worried about her because she did not want her to get COVID-19. Resident #3 stated facility staff had not tried to place a barrier between her and her roommate, such as keeping the curtain pulled. During an observation and interview on 10/06/23 beginning at 4:57 PM, Resident #3 was sitting up in her recliner leaning on her left side with her feet reclined. Resident #3 was not wearing a mask or face covering. Resident #3 stated the facility staff had not attempted to move her to another room. Resident #3 had a wet, congested cough during the interview. Resident #3 stated she always had a cough because she smoked. During an interview on 10/07/23 beginning at 4:14 PM, the Medical Director stated Resident #4 had been exposed to COVID-19 from her roommate, Resident #3. The Medical Director stated technically speaking the policy was to separate the resident's and isolate them if one tested positive for COVID-19 and the other one did not. The Medical Director stated both residents were doing well, and he felt like the risk was low for Resident #4. The Medical Director stated the facility staff were continuing to monitor both residents and were to notify him of any changes. During an interview on 10/07/23 beginning at 4:20 PM, the DON stated the Medical Director was aware that Resident #3 had tested positive for COVID-19 and Resident #4, her roommate had tested negative. The DON stated the Medical Director was notified and he was okay with them staying in the same room. The DON stated Resident #4 had been exposed to COVID-19 from Resident #3. The DON stated the residents should have been separated when Resident #3 was suspected of having COVID-19. The DON stated the failure to Resident #4 was exposure to a communicable disease that could cause serious complications. During an interview on 10/08/23 beginning at 10:37 AM, the Administrator stated Resident #3 and Resident #4 refused to move rooms. The Administrator stated when the residents refused to move rooms the doctor was notified, and he stated it was okay to keep them in the same room. The Administrator stated it should have been documented by facility staff. The Administrator stated she was unsure why the refusal was not documented. The Administrator stated after reviewing current CDC guidelines and the facility policy, Resident #3 and Resident #4 should have been separated to prevent the spread of infection and lower the risk of transmission of COVID-19 for Resident #4. Record review of the CDC Guidelines Interim Infection Preventions and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 05/08/23, revealed Only patients with confirmed SARS-CoV-2 infection should be cohorted together. 4. Record review of the face sheet, dated 10/07/23, revealed Resident #5 was a [AGE] year-old-female who admitted to the facility on [DATE] with a current diagnosis of COVID-19 (an acute communicable disease caused by a coronavirus, which is characterized mainly by fever and cough and can progress to severe symptoms and in some cases death, especially in older people with underlying health conditions). Record review of the MDS assessment, dated 09/04/23, revealed Resident #5 had clear speech and was usually understood by staff. The MDS revealed Resident #5 was usually able to understand others. The MDS revealed Resident #5 had a BIMS of 10, which indicated moderately impaired cognition. The MDS revealed Resident #5 had no behaviors or refusal of care. The MDS revealed Resident #5 required partial to moderate assistance with transfers, indicated the helper does less than half the effort. Record review of the comprehensive care plan, initiated on 10/05/23, revealed Resident #5 was positive for COVID-19. The interventions included: isolate per facility policy. Record review of the order summary report, dated 10/07/23, revealed Resident #5 had no order for isolation precautions. Record review of the progress note, completed on 10/07/23 at 11:41 AM, revealed Resident #5 remained on isolation precautions due to positive for COVID. During an observation on 10/06/23 beginning at 10:28 AM, Resident #5 was sitting up in a Geri chair with her legs elevated and an N-95 down around her neck. Resident #5 had a wet, congested cough with a crusted substance around her nose and mouth. Resident #5 was sitting in the dining room with 8 other residents and was within arm's reach of 2 of the residents. COTA GG was sitting at a dining room table with other residents. MA A and CNA B were behind the nurses' desk with the half door. No attempts were made by facility staff to ensure Resident #5 was isolated to her room. During an interview on 10/06/23 beginning at 10:36 AM, CNA B stated Resident #5 was positive for COVID-19. CNA B stated Resident #5 should have been isolated to her room. CNA B stated Resident #5 was not isolated to her room because the night shift had gotten her up. During an interview on 10/07/23 beginning at 9:36 AM, LVN C stated Resident #5 should not have been sitting in the dining room because she was positive for COVID-19. LVN C stated she was unsure the exact date Resident #5 tested positive, but she was on isolation when she returned to work on 10/04/23. LVN C stated it was hard to ensure the residents on the secured unit understood they needed to isolate to their room because of their cognitive status. LVN C stated it was important to ensure residents were isolated to prevent the spread of infection. During an interview on 10/07/23 beginning at 10:21 AM, MA A stated Resident #5 should have been isolated to her room MA A stated she was nervous with the state surveyor watching her. MA A stated it was important to ensure residents were isolated to prevent the spread of infection to other residents. During an interview on 10/07/23 beginning at 4:20 PM, the DON stated residents who were positive for COVID-19 should have been isolated in their room. The DON stated she expected staff to isolate residents who were positive for COVID-19. The DON stated Resident #5 should not have been sitting at the dining room table. The DON stated isolation was monitored by random observations. The DON stated it was important to ensure residents were isolated to their room to prevent the spread of infection. During an interview on 10/08/23 beginning at 10:37 AM, the Administrator stated she expected facility staff to ensure COVID-19 positive residents were isolated to their room. The Administrator stated nursing management was responsible for monitoring to ensure residents were isolated in their room. The Administrator stated it was important to ensure residents were isolated when they tested positive for COVID-19 to prevent the illness from spreading. 5. During an observation on 10/06/23 beginning at 10:13 AM, the Hospice Aide was in room [ROOM NUMBER] providing care for Resident #1. The Hospice Aide was wearing a surgical mask and gloves. There was a sign on the door that stated STOP: Airborne Precautions and listed the required PPE needed to be worn in the room, which included N-95 mask, face shield or goggles, isolation gown, and gloves. The Hospice Aide remained in the room for approximately 15 - 20 minutes. The Hospice Aide left the room, did not perform hand hygiene, and was observed walking down the hallway toward another resident's room. During an interview on 10/06/23 beginning at 10:17 AM, RN D stated hospice staff was instructed to wear appropriate PPE. RN D stated the Hospice Aide might not have been aware Resident #1 was positive for COVID-19 because the isolation carts were not outside the door. RN D stated the Hospice Aide might not have seen the sign on the door. RN D stated the required PPE for entering a COVID-19 positive room was isolation gown, gloves, shoe covers, N-95 mask, and either face shield or goggles. RN D stated it was important to wear the recommended PPE to protect other residents and staff. During an observation and interview on 10/06/23 beginning at 12:38 PM, the X-ray Technician entered Resident #3 and Resident #4's room. The X-ray Technician wheeled his x-ray machine into the room. The X-ray Technician was wearing a KN-95 mask and gloves. The X-ray Technician asked the surveyor which resident was positive for COVID-19, and he was redirected to the nurse. The X-ray Technician stated, oh okay and proceeded with x-ray without checking with the nurse or applying the required PPE. The X-ray Technician completed the x-ray with his gloved hands and then touched the biohazard box, Resident #4's wheelchair footrests and placed them on top of her personal refrigerator, and then wheeled his x-ray machine out of the room and wheeled it down the hallway without removing his gloves. The X-ray Technician stopped in the hallway with his x-ray machine within arms-reach of the tray cart, and them removed his gloves. The X-ray Technician did not perform hand hygiene and immediately started typing on his keyboard. No sanitization was performed on the x-ray machine that was used in the COVID-19 positive room. The X-ray Technician stated he was aware one of the residents in the room he went into was COVID-19 positive, which was why he was wearing a KN-95 mask. The X-ray Technician stated he did not notice the sign on the door. The X-ray Technician stated the facility staff did not ask him to wear the full PPE. During an observation on 10/06/23 beginning at 12:53 PM, CNA F and CNA CC were passing meal trays. CNA CC entered Resident #3 and Resident #4's room to bring them a meal tray. CNA CC did not put on the required PPE prior to entering Resident #3 and Resident #4's room. CNA CC wore an N-95 mask only. CNA F followed CNA CC into Resident #3 and Resident #4's room to bring the other meal tray without donning the required PPE. CNA F wore an N-95 mask only. CNA CC went into a COVID-19 negative residents' room to assist with feeding. CNA F went into Resident #1 and Resident #2's room to pass meal trays without the required PPE. CNA F wore an N-95 mask only. During an observation on 10/06/23 beginning at 1:03 PM, Resident #5 was isolated in her room with the door open. Signage was observed on the door indicated resident was isolation precautions and listed the required PPE. MA A entered the room without donning the required PPE and assisted Resident #5 with repositioning in her chair. MA A had on an N-95 mask only with both straps located at the base of her neck. MA A left Resident #5's room and did not perform hand hygiene. MA A immediately went into the dining room, grabbed the back of a chair, and scooted it under the table. MA A then grabbed a resident's wheelchair and pushed her under the dining table. MA A went back into Resident #5's room without donning the required PPE and took a fall mat out of her room and placed it in room [ROOM NUMBER]. Resident #5 was sitting in up in the Geri chair with the head elevated at approximately 85 degrees. MA A did not sanitize the fall mat and did not perform hand hygiene. MA A came out of room [ROOM NUMBER], grabbed another resident by the hands and led her to a blue recliner in the dining room. MA A opened the half door to the nurse's station, sat down at the desk, and started typing on her computer. A big gallon bottle of hand sanitizer was observed on the counter to the nurses' desk. During an interview on 10/06/23 beginning at 1:23 PM, the Hospice Aide stated she was aware Resident #1 was positive for COVID-19. The Hospice Aide stated the required PPE was a facemask or shield and gloves. The Hospice Aide stated she was new to the facility and had only been seeing Resident #1 for a few weeks. The Hospice Aide said the nurse handed her a surgical mask off the cart and stated that was the only required PPE. The Hospice Aide stated she was unsure of the nurse's name. The Hospice Aide stated when she left Resident #1's room, she had another resident to see at the facility and she went into his room, but he refused care. The Hospice Aide stated she had no access to the required PPE because there were no isolation carts outside the resident's room. The Hospice Aide stated it was important to ensure the required PPE was worn in a COVID-19 positive resident's room to protect the staff and other residents from obtaining COVID-19. During an interview on 10/07/23 beginning at 936 AM, LVN C stated the required isolation precautions when entering a COVID-19 positive resident's room was a face shield, N-95 mask, isolation gown, and gloves. LVN C stated facility staff or contracted staff should wear the required PPE when entering the COVID-19 positive room. LVN C stated it was important to ensure the required PPE was worn to prevent the spread of infection and protect the staff and residents. During an interview on 10/07/23 beginning at 10:21 AM, MA A stated all required PPE should have been applied prior to entering a COVID-19 positive resident's room. MA A stated the required PPE was an isolation gown, N-95 mask, face shield or goggles, shoe covers, and gloves. MA A stated hand hygiene should have been performed between rooms. MA A stated she did not apply the required PPE or perform hand hygiene because she was nervous the state surveyor was watching. MA A stated it was important to apply the required PPE and perform hand hygiene to protect the staff and residents from getting COVID-19. During an interview 10/07/23 beginning at 10:50 AM, CNA B stated the required PPE to put on prior to entering a COVID-19 positive residents' room was isolation gown, N-95 mask, face shield or goggles, and gloves. CNA B stated she had only been wearing an N-95 mask and gloves because she was not thinking about it. CNA B stated it was important to wear the appropriate PPE when caring for someone who was COVID positive to protect the staff and other residents. 6. Record review of the COVID/Infection Control Policy and Procedure in-service, dated 09/21/23 and reviewed on 10/06/23, revealed only 6 staff signatures. Only one direct care staff had signed the in-serviced. Record review of the PPE Competency Check Off Form, dated 10/07/23, revealed only 11 check-off had been completed. The form was dated after surveyor entrance to the facility. During an interview on 10/07/23 beginning at 11:19 AM, CNA F stated he had been working at the facility for approximately one week. CNA F stated he had not been in-serviced on infection control or checked off on donning or doffing PPE. During an interview on 10/07/23 beginning at 3:50 PM, the ADON stated the Administrator gave her a form for PPE check offs the morning of 10/06/23. The ADON stated she had only been hired at the facility for a few weeks. The ADON stated it was important to ensure that training and competencies were performed to education staff on policy and procedures, current COVID-19 guidelines, and to prevent the spread of infections. 7. Record review of the Strategies to Prevent the Spread of Respiratory Diseases in Long-Term Care Facilities policy, revised 05/11/23, revealed report any possible . COVID-19 illness in residents and employees to the local health department, including your state coordinator. The policy revealed j. provides the right supplies to ensure easy and correct use of PPE .l. make PPE, including facemasks, eye protection, gowns, and gloves, available immediately outside of the resident room. The policy did not address cohorting residents. The policy revealed .use Mask, eye protection, isolation gown and gloves. Record review of the Transmission-Based Precautions for Infections policy, revised 10/24/22, revealed 7. PPE cart should be hung on door or rolling cart placed outside door in hallway. The policy did not address cohorting residents. The policy revealed Resident's on transmission-based precautions should remain in their room expect for medically necessary care. Record review of the Infection Control policy, revised 10/25/22, revealed Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The policy further revealed assure that outbreaks of infections are investigated and take appropriate steps to diagnoses and manage cases, implement appropriate precautions, and prevent further transmission of disease. The policy revealed . oversee implementation of infection control policies and practices and help department heads and managers ensure that they are implemented and followed. The policy revealed all personnel will be trained on our infection control policies and practices upon hire and periodically thereafter . The Administrator was notified on 10/07/23 at 2:49 PM that an immediate jeopardy situation was identified due to the above failures. The Administrator was provided the immediate jeopardy template on 10/07/23 at 2:53 PM. The facility's plan of removal was accepted on 10/08/23 at 12:48 PM and included the following: Alleged Issues: The facility failed to: 1. Report current COVID-19 outbreak to both the local health department and HHSC. 2. Ensure facility staff had access to appropriate PPE supplies. 3. Ensure Resident #3 and Resident #4 were separated after Resident #3 tested positive for COVID and Resident #4 did not. 4. Ensure Resident #5 was placed on isolation precautions for COVID. 5. Ensure non-dedicated facility staff and contrac [TRUNCATED]

Based on observations, interviews and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to ensure staff who drove the transportation van were trained to properly secure Resident #1 in his wheelchair during transport. Resident #1 fell backwards on the van when the driver made a turn and hit his head which resulted in his death. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 12:15 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm because (e.g.) the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place other residents at risk for decreased quality of life and injury/death from a vehicle accident by not being secured properly during transport. Findings Include: Record review of the face sheet dated [DATE] indicated Resident #1 was a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses including Senile Degeneration of Brain (the loss of intellectual ability related to age), Chronic Respiratory Failure (occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), Bilateral Above Knee Amputee, Peripheral Vascular Disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), Dysphagia (difficulty swallowing), COPD (Chronic Obstructive Pulmonary Disease - disease making it difficult to breath) Muscle Wasting and Atrophy, Ataxia (impaired coordination), Hypertension (high blood pressure). Record Review of Physician Orders on [DATE] include: Eliquis 5 mg BID for anticoagulation started on [DATE]. Record review on [DATE] of the comprehensive MDS dated [DATE] indicated Resident #1 was usually understood by others and usually understood others. The MDS indicated Resident #1 had a BIMS of 08 (moderately impaired cognitive status). The MDS indicated Resident #1 required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Record review of the care plan last revised on [DATE] indicated Resident #1 had potential for physically aggression, delusions, and at risk for ADL self-care deficit related to Dementia (memory loss). The care plan indicated Resident #1 had alteration in cardiovascular status related to atrial fibrillation (rapid heart rate causing poor blood flow) with physician orders for Eliquis (anticoagulant). The Care plan indicated the interventions of monitoring vital signs, monitor labs, report abnormal to physician. Record Review of the Autopsy dated [DATE] indicated cause of death as Blunt Craniocervical (the junction where the skull meets the first two bones of the spine) Trauma. Record review of the provider investigation report dated [DATE] indicated Resident #1 was being transported by the facility van and accompanied by facility staff when the driver of the van turned a corner and Resident #1 fell backwards and hit his head on the lift. CNA A called 911 while the van driver provided aide until the paramedics arrived. The provider investigation report indicted Resident #1 was transferred from the scene of the incident to the emergency department by ambulance for assessment. The provider investigation report indicated the facility was notified by the hospital on [DATE] that Resident #1 had expired. The provider investigation report indicated Resident #1 was secured in the wheelchair with all straps securely latched. During an interview on [DATE] at 009:24 a.m., the DON said he did not witness the wheelchair being strapped in after the appointment was completed. The DON said the maintenance worker was driving the van at the time of the incident. The DON said CNA A was accompanying the maintenance worker on the transports on [DATE]. The DON stated the driver of the van involved in the incident was not at work today and was not doing well. During an interview on [DATE] at 09:31 a.m., CNA A said ton [DATE] the Resident #1 hit his head on the lift when the driver turned the corner . CNA A stated this [DATE] was her first time on a transport. CNA A said the maintenance worker was taking an extended time in the back of the van securing Resident #1 after the appointment. CNA A stated she got out of the van and the maintenance worker stated he was buckling Resident #1 in straps. CNA A stated she had not been trained on securing the wheelchair in the van. During an interview on [DATE] at 09:34 a.m., the DON said the facility did not have a transport driver. The DON stated the maintenance worker transported the residents. The DON stated the maintenance worker had not received training from this facility but had experience from a previous facility . The DON said he had not been trained by the facility on how to secure a wheelchair in the van, and he would not be able to do it. When asked for a demonstration of securing the wheelchair in the van, the DON stated he had been trained a very long time ago but had not been trained by this facility. The DON stated he would not be able to do it. During an interview on [DATE] at 10:25 a.m., the Administrator said there was not a police report for the incident. The Administrator said the police officer directed traffic following the incident. The Administrator stated transport was being outsourced by a 3rd party company at this time. The Administrator She stated there had not been a QAPI meeting regarding the incident. Record Review on [DATE] of an undated list of van drivers at facility provided by Administrator showed two names, CNA A and MA 1. Record Review on [DATE] of personnel files of maintenance worker, CAN 1, and the MA indicated a valid Texas Driver's License. During an interview on [DATE] at 11:00 a.m., the Administrator said there was no transport driving training for the maintenance worker, CNA A, or MA 1. Record Review the Monthly Vehicle Inspection indicated [DATE] as the last documented inspection. During an interview on [DATE] at 11:00 a.m., the Director of Facility Operations said he worked at a sister facility. The Director of Facility Operations said a weekly log should be completed for the transport van to ensure the restraints, lift, and seatbelts are in proper working order. The Director of Facility Operations said the importance of weekly inspection logs was to ensure resident safety when transporting. Record review of the facility's undated Driver and Vehicle Safety Manual indicated, .The objective of this policy is to implement safe driving policies and practices so that the following goals are met .No employee or resident injuries in or around a vehicle .Residents are properly secured at all times .Employees drioving the company vehicle shall also: Know how to safely load and unload residents/passengers and properly secure wheelchairs and other equipment if responsible for transporting residents .be CPR certified .Team members who drive the company vehicle for residents must watch the following videos: SURE-LOK Wheelchair Restraints by NW Bus Sales, Commercial Wheelchair Operators Video, and Wheelchair Lift Overview Video . The Administrator was notified on [DATE] at 12:15 p.m. that an immediate jeopardy situation was identified due to the above failures. The Administrator was provided the immediate jeopardy template on [DATE] at 12:20 p.m. The facility's plan of removal was accepted on: [DATE] at 09:15 a.m. and included: o All appointments scheduled for residents have been outsourced to qualified 3rd party transportation services or sister facility transportation with approved drivers. This was completed on [DATE] at approximately 3:00pm for transportation. o There's going to be approved qualified staff that will conduct all transports. o Transport staff will be educated by director of maintenance if the lift equipment, straps, seat belts, or anchors appear to be malfunctioning that they are to stop and not transport the resident. They will then contact the DON or EDO to report the malfunction at which point the van will be inspected and if needed repairs will be made before another resident is transported, if transportation aide and/or assistant know the van lift and/or straps are not working properly to stop, report and do not transport. o Facility van will not be used for transportation until inspection has been completed. o Transport staff will be educated by facility director of maintenance. o Training will be completed before first use of van operation. o Anyone not on duty, training will be completed prior to operation of transportation vehicle. o Transport driver will not operate van prior to passing the training and return demonstration. * The facility failed to ensure the resident and their wheelchair was properly secured during transport. o The weekly Driver's Vehicle Safety Inspection will be completed weekly by the facility director of maintenance by each Friday. It will be located in the facility van binder inside the van. o Maintenance Director or designee will check the van lift every month to ensure proper functioning. The facility will conduct biweekly maintenance checks on seatbelts, anchors, lift, and all internal operational parts to ensure that community van complies and validated by EDO. * The facility failed to properly train the maintenance worker and CNA on transporting residents safely. o Staff that will be allowed to operate the facility van have performed a return demonstration on loading and unloading residents who use wheelchairs and securing residents in wheelchairs. This training was completed on [DATE] 1:00pm, Director of Maintenance. o The EDO (Executive Director of Operations)/Administrator, DON, and perspective van drivers were educated by facility director of maintenance on the Driver and Vehicle Safety Policy Checklist, Vehicle Safety Acknowledgement, Driver Inservice Log, and Securing Residents in Van Competency Demonstration and was completed on [DATE] at 11:30am. o Facility Director of Maintenance will be educated prior to returning to work on van policy and procedure, loading and unloading of residents, and securement of residents to include all safety checks, videos, and van checklists per policy, by the EDO. *The facility failed to have a staff properly trained to transport residents safely or train new drivers. o 1:1 in-service with facility administrator completed by corporate nurse, regarding van policy and procedure, manual reviewed, and forms reviewed on [DATE] at 4:10pm o QAPI meeting was held [DATE] at 1:30 p.m. with the medical director, EDO, Director of Nursing, social worker, therapy director, CRC, corporate nurse, and prospective van driver. o At least one staff member present during transportation will be CPR certified. At least one staff member will be CPR certified or the transport will be outsourced. o The facility will address corrective action by training and Inservice all new employees who will operate the facility van, on the skill check off for securing wheelchair. o Administrator, Director of Nurses, SW and (potential) van driver(s) completed van safety videos that were relevant to our van on [DATE] 3:30pm. o 'Safe Driving, a Shared Responsibility', o 'Braun Commercial Wheelchair Operators', o 'Surelok Wheelchair Restraints by Schetky NW Bus Sales' o The EDO and DON and perspective van drivers were educated on the Driver and Vehicle Safety Policy Checklist, Vehicle Safety Acknowledgement, Driver Inservice Log, and Securing Residents in Van Competency Demonstration and was completed on [DATE] 11:30am. o Facility Director of Maintenance and/or any trained administrative designee will in-service and train staff that will be providing transportation. Quarterly in-services will be conducted on transportation. Staff will be trained and in-serviced on proper inspection of transportation van, proper loading and unloading of residents, attendants will be in-serviced and trained on their role during loading/unloading and during transport. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of potential drivers (Administrator, DON, CNA A, and Social Worker) completed Inservice's and trainings dated [DATE]. During an interview 10:15 a.m. on [DATE] with the Administrator, she stated all transport staff will have CPR training prior to transporting residents. Observations on [DATE] indicated all potential drivers (Administrator, DON, CNA A, and Social Worker ) were able to properly demonstrate loading and securing a wheelchair in the transport van. Record review of the QAPI committee review indicated a QAPI meeting was held on [DATE] regarding the above failure. Record review of third-party transport contracts indicated all contracts up to date. On [DATE] at 01:50 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to consult with the physician regarding a change in condition for 1 of 12 residents (Resident #25) reviewed for notification of changes. The facility failed to consult the physician of Resident #25 having [CONDITION(S)] activity on 10/18/21, 11/29/21, and 12/08/21. The facility failed to consult the physician of Resident #25 having subtherapeutic [MEDICATION(S)] ([CONDITION(S)] medication) lab values on 02/03/21, 11/03/21, and 12/09/21. This failure resulted in an identification of an Immediate Jeopardy (IJ) at 3:32 p.m. on 12/14/21. While the IJ was removed on 12/15/21, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not receiving appropriate treatment, deterioration of their physical condition, and decreased quality of life due to the physician not being aware of changes Findings include: 1. Record review of the consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] indicated Resident #25 rarely understood others and rarely made herself understood. The MDS indicated Resident #25 did not indicated a BIMS score for Resident #25. The MDS indicated Resident #25 required extensive assistance with bed mobility, dressing, eating, and personal hygiene. The MDS indicated Resident #25 had total dependence for transfers and toileting. Record review of the care plan revised on 12/02/21 indicated Resident #25 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan indicated interventions included remove objects from the area that could cause injury, record precipitating factors, time, and progression, administer [MEDICATION(S)] (medication used to treat seizures) sprinkles as prescribed, monitor for side effects of medications, and monitor labs to maintain therapeutic level of [CONDITION(S)] medication if ordered. Record review of the order summary report for active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #25's EMR (electronic medical record) for lab results on 12/14/21 indicated Resident #25 had a [MEDICATION(S)] level of 30 ug/ml on 02/10/21. The lab results indicated Resident #25 had a [MEDICATION(S)] level of 38.9 ug/ml on 11/03/21. The lab results indicated resident #25 had a [MEDICATION(S)] level of 34.9 ug/ml on 12/09/21. The normal range for [MEDICATION(S)] level was 50-100 ug/ml. Record review of Resident #25's nursing notes from 10/18/21 to 12/15/21 indicated Resident #25 had seizures on the following dates and times; *10/18/21 at 9:05 a.m. (duration 30 seconds documented by LVN E; *11/29/21 at 12:31 p.m. (duration 30 seconds documented by LVN E); and *12/08/21 at approximately 9:44 a.m. (duration 30 seconds documented by LVN E). The nurse progress note dated 10/18/21 at 9:05 a.m. indicated, Resident up in wheelchair. Resident noted to have a [CONDITION(S)] [MEDICATION(S)] approximately 30 seconds. Vitals signs-blood pressure 97/68, heart rate 84, respirations 18, and temperature 97.7. Resident now sleeping. Respirations even and unlabored. Zero signs and symptoms of distress. The nurse progress noted dated 11/29/21 at 12:31 p.m. indicated, Resident sitting in wheelchair in day area. Resident noted to have a [CONDITION(S)] [MEDICATION(S)] approximately 30 seconds. Vital signs within normal limits. Zero signs and symptoms of distress. The nurse progress note date 12/08/21 at 9:44 a.m. indicated, Resident noted to have a [CONDITION(S)] [MEDICATION(S)] approximately 30 seconds. Vital signs within normal limits post [CONDITION(S)]. Zero signs and symptoms of distress. During an interview on 12/14/21 at 10:41 a.m. Resident #25's primary care physician said he had not been notified of her seizures or subtherapeutic lab levels. The physician said if he had been notified of Resident #25's subtherapeutic [MEDICATION(S)] levels he would have increased her medication. The physician said increasing Resident #25's [MEDICATION(S)] medication could have prevented her from having seizures. During an interview on 12/14/21 at 11:45 a.m. the nurse practitioner said he had not been notified of Resident #25 having a [CONDITION(S)] on October 2021, November 2021 or December 2021. The nurse practitioner said he had not been notified of Resident #25 having subtherapeutic labs levels. During an interview on 12/14/21 at 1:17 p.m. LVN E said she recalled being the nurse taking care of Resident #25 for seizures that occurred in October 2021, November 2021, and December 2021. LVN E said she was given orders from the physician to monitor Resident #25 following the seizures on 10/18/21 and 11/29/21. LVN E said she was given an order from the physician for a [MEDICATION(S)] level to be drawn following the [CONDITION(S)] on 12/08/21. LVN E said she had notified the physician regarding all 3 seizures. LVN E said she did not document notifying the physician or nurse practitioner. LVN E said she did not put the order for the [MEDICATION(S)] level she received on following the [CONDITION(S)] on 12/08/21. LVN E said residents should have vital signs monitored once 30 minutes after a [CONDITION(S)]. During an interview on 12/14/21 at 3:47 p.m. LVN F said the physician should be notified as soon as possible following a [CONDITION(S)]. LVN F said nurses should document duration of the [CONDITION(S)], characteristics of the [CONDITION(S)], physician notification, and post [CONDITION(S)] monitoring in the nurse's progress notes. LVN F said if the nurse does not document physician notification or monitoring of a resident post [CONDITION(S)] then there would be no proof these actions. During an interview on 12/14/21 at 3:00 p.m., the DON said she just started at the facility on 11/29/21. She said nurses should know if a physician has ordered labs for [CONDITION(S)] medications, they should have ensured the lab was drawn and results were reported to the physician. The DON said the nurses should know this because it's nursing knowledge. The DON said it was important for resident's on [CONDITION(S)] medications to have their lab levels monitored because the medication must be at therapeutic levels in order to prevent seizures. The DON said if Resident #25 low level of [MEDICATION(S)] had been reported to the physician he could have made adjustments in Resident #25's medication that may have prevented the subsequent seizures. She said it was also important to monitor these labs because some [CONDITION(S)] medications could cause toxicity. The DON said there had not been an administrative system in place to ensure residents on [CONDITION(S)] medications received lab monitoring and ensure appropriate physician notification occurred. She said the facility was correcting these issues. During an interview on 12/16/21 at 10:11 a.m. the Administrator said she expected staff to notify physician of any change in condition including abnormal lab values. Record review of an undated Change of Condition policy indicated, .It will be the policy that once the nurse has notified the physician for a change in condition the resident/patient will be monitored every hour until the physician has responded .If you are unable to reach the physician within 2 hours, repeat the call. If you are still unable to reach the physician, you may call the Medical Director. If the resident/patient condition appears emergent transfer to local emergency room can occur without physician order. The administrator was notified on 12/14/21 at 3:32 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The administrator was provided the Immediate Jeopardy template on 12/14/21 at 3:38 p.m. The facility's Plan of Removal was accepted on 12/15/21 at 2:24 p.m. and included: Director of Clinical Operations, Assistant Director of Clinical Operations, Clinical Reimbursement Coordinator and Treatment Nurse reviewed clinical records for residents receiving medications that require serum monitoring to ensure labs ordered as needed. Beginning on 12-14-21 to be completed by 12-14-21. Resident #1 received Stat orders for [MEDICATION(S)] level to ensure therapeutic level for [CONDITION(S)] medication by Assistant Director of Clinical Operations. Licensed Nurses will be provided in-service education related to Notification of Change in Condition beginning on 12-14-21 by Director of Clinical Operations or designee which includes: 1. Event/Change in condition. 2. Vital Signs 3. History of similar events 4. If resident is receiving a medication that requires therapeutic levels, this information will be conveyed to the physician at time of notification. All Education/In servicing will be done by 12-16-21 by Director of Clinical Operations or designee. Director of Clinical Operations or Designee will validate staff knowledge base through random questioning. Director of Clinical Operations or Designee will review records for any resident experiencing change in condition daily in clinical meeting to ensure physician notification and appropriate follow up. Beginning 12-16-21. The Administrator/Executive Director of Operations will review the action plan developed related to Physician Notification Issues in QA meeting quarterly. On 12/15/21 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Interviews of nursing staff (3-nurses on the 06:00 a.m.-02:00 p.m. shift; 3-nurses on the 08:00 a.m.-05:00 p.m. shift; 3-nurses on the 02:00 p.m.-10:00 p.m. shift; 1-nurses on the 10:00 p.m.-06:00 a.m.) were performed. During these interviews' nurses said physician notification should be made for all changes in condition and abnormal lab values. They said if a resident has a [CONDITION(S)] physician notification should be made as soon as possible after the [CONDITION(S)]. The nurses said if the resident was having a [CONDITION(S)] [MEDICATION(S)] longer than 5 minutes the physician should be notified immediately. They said not notifying the physician of changes in condition or abnormal lab values could delay resident care. On 12/15/21 at 6:30 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at isolated harm.

Based on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 2 of 11 (Resident #25 and Resident #30) residents reviewed for quality of care. The facility did not ensure Resident #25 was monitored following seizures on 10/18/21, 11/29/21, and 12/08/21. The facility did not monitor Resident #30 after her [CONDITION(S)]. This failure resulted in an identification of an Immediate Jeopardy (IJ) at 3:32 p.m. on 12/14/21. While the IJ was removed on 12/15/21, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk for not receiving care and services to meet resident needs. Findings included: 1. Record review of the consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] indicated Resident #25 rarely understood others and rarely made herself understood. The MDS indicated Resident #25 did not indicated a BIMS score for Resident #25. The MDS indicated Resident #25 required extensive assistance with bed mobility, dressing, eating, and personal hygiene. The MDS indicated Resident #25 had total dependence for transfers and toileting. Record review of the care plan revised on 12/02/21 indicated Resident #25 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan indicated interventions included remove objects from the area that could cause injury, record precipitating factors, time, and progression, administer [MEDICATION(S)] (medication used to treat seizures) sprinkles as prescribed, monitor for side effects of medications, and monitor labs to maintain therapeutic level of [CONDITION(S)] medication if ordered. Record review of the order summary report for active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #25's EMR (electronic medical record) for lab results on 12/14/21 indicated Resident #25 had a [MEDICATION(S)] level of 30 ug/ml on 02/10/21. The lab results indicated Resident #25 had a [MEDICATION(S)] level of 38.9 ug/ml on 11/03/21. The lab results indicated resident #25 had a [MEDICATION(S)] level of 34.9 ug/ml on 12/09/21. The normal range for [MEDICATION(S)] level was 50-100 ug/ml according to the laboratory reference range provided on the lab results. Record review of Resident #25's nursing notes from 10/18/21 to 12/15/21 indicated Resident #25 had seizures on the following dates and times; *10/18/21 at 9:05 a.m. (duration 30 seconds documented by LVN E); *11/29/21 at 12:31 p.m. (duration 30 seconds documented by LVN E); and *12/08/21 at approximately 9:44 a.m. (duration 30 seconds documented by LVN E). The nurse progress note dated 10/18/21 at 9:05 a.m. indicated, Resident up in wheelchair. Resident noted to have a [CONDITION(S)] [MEDICATION(S)] approximately 30 seconds. Vitals signs-blood pressure 97/68, heart rate 84, respirations 18, and temperature 97.7. Resident now sleeping. Respirations even and unlabored. Zero signs and symptoms of distress. The nurse progress noted dated 11/29/21 at 12:31 p.m. indicated, Resident sitting in wheelchair in day area. Resident noted to have a [CONDITION(S)] [MEDICATION(S)] approximately 30 seconds. Vital signs within normal limits. Zero signs and symptoms of distress. The nurse progress note date 12/08/21 at 9:44 a.m. indicated, Resident noted to have a [CONDITION(S)] [MEDICATION(S)] approximately 30 seconds. Vital signs within normal limits post [CONDITION(S)]. Zero signs and symptoms of distress. Record review of Resident #25's electronic medical record indicated vital signs were obtained on the following dates and time; * 10/18/21 at 9:40 a.m. * 11/29/21 at 2:25 p.m. * 12/08/21 at 12:40 p.m. During an interview on 12/14/21 at 10:41 a.m. Resident #25's primary care physician said he had not been notified of her seizures or subtherapeutic lab levels. The physician said if he had been notified of Resident #25's subtherapeutic [MEDICATION(S)] levels he would have increased her medication. The physician said increasing Resident #25's [MEDICATION(S)] medication could have prevented her from having seizures. During an interview on 12/14/21 at 11:45 a.m. the nurse practitioner said he had not been notified of Resident #25 having a [CONDITION(S)] on October 2021, November 2021 or December 2021. The nurse practitioner said he had not been notified of Resident #25 having subtherapeutic labs levels. During an interview on 12/14/21 at 1:17 p.m. LVN E said she recalled being the nurse taking care of Resident #25 for seizures that occurred in October 2021, November 2021, and December 2021. LVN E said she was given orders from the physician to monitor Resident #25 following the seizures on 10/18/21 and 11/29/21. LVN E said she was given an order from the physician for a [MEDICATION(S)] level to be drawn following the [CONDITION(S)] on 12/08/21. LVN E said she had notified the physician regarding all 3 seizures. LVN E said residents should have vital signs monitored once 30 minutes after a [CONDITION(S)]. During an interview on 12/14/21 at 1:26 p.m. with Resident #25's primary care physician he said he expected the facility to monitor residents closely following a [CONDITION(S)]. He said residents should be monitored a minimum of 2 hours after a [CONDITION(S)]. The physician said residents needed to be monitored closely following a [CONDITION(S)] due to the risk of aspiration, fall, or having another [CONDITION(S)]. During an interview on 10/14/21 at 3:47 p.m. LVN F said the physician should be notified as soon as possible following a [CONDITION(S)]. LVN F said after a [CONDITION(S)] a resident should have vital signs and neurological checks every 15 minutes for 1 hour. LVN F said residents should be monitored following a [CONDITION(S)] due to risk of death, a coma, or having another [CONDITION(S)]. LVN F said nurses should document duration of the [CONDITION(S)], characteristics of the [CONDITION(S)], physician notification, and post [CONDITION(S)] monitoring in the nurse's progress notes. LVN F said if the nurse does not document physician notification or monitoring of a resident post [CONDITION(S)] then there would be no proof these actions. During an interview on 12/14/21 at 3:00 p.m., the DON said she just started at the facility on 11/29/21. The DON said she was not yet familiar with the specifics of the facility's policy and procedure regarding evaluation after [CONDITION(S)] management but said it was nursing knowledge that a resident be monitored closely after a [CONDITION(S)]. The DON said vital signs should be taken at least every 15 minutes for an hour. The DON said it was important to monitor residents closely after a [CONDITION(S)] because they could have repeated seizures, depressed respiratory function, airway issues, or have a fall during the post ictal state (the abnormal altered state of consciousness occurring between the end of an epileptic [CONDITION(S)] and return to baseline condition). The DON said there had not been an administrative system in place to monitor nursing staff and ensure residents were monitored appropriately after seizures. The DON said the facility was correcting these issues. During an interview on 12/16/21 at 10:11 a.m. the Administrator said nurses should monitor residents following a [CONDITION(S)] every 15 minutes for 2 hours, then follow physician orders. 2. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] indicated Resident #30 rarely/never understood others and rarely/never made herself understood. The MDS indicated she had severely impaired cognitive status. The MDS indicated Resident #30 required extensive assistance with bed mobility, transfers, dressing, toilet use personal hygiene and bathing. The MDS indicated she required limited assistance with locomotion in her wheelchair and supervision with eating. The MDS indicated Resident #30 was always incontinent of bladder and frequently incontinent of bowel. The MDS indicated she had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The active physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan revised on 11/26/21 indicated Resident #30 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the nursing note dated 6/29/21 at 4:32 p.m. indicated Resident (#30) had a [CONDITION(S)] while she sat in her wheelchair. The nursing note indicated the nurse ensured patient safety during the 60 second [CONDITION(S)] and remained with Resident #30 during the [CONDITION(S)]. The note stated Resident #30 was monitored after and she was back to normal. Will monitor at table. Will notify the physician. Vital signs 98.1, 133/78, 74, 22, and oxygen saturation 96% on room air. This nursing note was signed by LVN J. Record review of the nursing notes on 6/29/21 indicated there was no additional documentation regarding Resident #30's status (assessment/vital signs) after her [CONDITION(S)] for over 5 hours. Record review of the vital sign record on 6/29/21 for Resident #30 indicated vital signs were not obtained for Resident #30 again until 9:43 p.m. (over 5 hours after her [CONDITION(S)]). The vital sign record indicated Resident #30's vital signs at that time were; temperature-98.1 degrees Fahrenheit; respiration rate-20 breaths per minute; pulse 74 beats per minute; blood pressure- 118/74 and oxygen saturation 96%. This nursing note was signed by LVN J. Record review of the nursing note on 6/29/21 at 9:44 p.m., indicated Resident #30 had no further signs or symptoms of [CONDITION(S)] activity. This nursing note was signed by LVN J. During an observation and interview at 12/14/21 at 9:00 a.m., Resident #30 was sitting in her wheelchair near the nurses' station. She appeared to be in no distress and was talking to other residents. Resident #30 said she did not have seizures. During an interview on 12/14/21 at 1:26 p.m., Resident #30's primary physician said he expected the facility to monitor residents closely following a [CONDITION(S)]. He said residents should be monitored a minimum of 2 hours after a [CONDITION(S)]. The physician said residents needed to be monitored closely following a [CONDITION(S)] due to the risks of aspiration; falls due to the post-ictal state; and/or subsequent seizures. During an interview on 12/14/21 at 3:00 p.m., the DON said she just started working at the facility on 11/29/21. The DON said she was not yet familiar with the specifics of the facility's policy and procedure regarding resident evaluation/assessment after a [CONDITION(S)] but said it was nursing knowledge that a resident should be monitored closely after a [CONDITION(S)]. The DON said vital signs should be taken every 15 minutes for at least an hour. She said it was important to monitor residents closely after a [CONDITION(S)] because they could have repeated seizures, depressed respiratory function, airway issues, or have a fall during the post ictal state. The DON said there had not been an administrative system in place to monitor nursing staff and ensure they (nursing staff) monitored residents appropriately after seizures. She said the facility was working to correct these issues. During an interview on 12/14/21 at 3:35 p.m., LVN J said she did take care of Resident #30 when she had [CONDITION(S)] during the summer but could not remember the exact date. LVN J said nurses should monitor residents after a [CONDITION(S)] every 15 minutes for at least an hour. She said on the secure unit residents are usually watched closely as they are usually in the dining area around the nurses' station. LVN J said the day Resident #30 had the [CONDITION(S)] she kept her in the in that area so she (LVN J) could watch her (Resident #30). LVN J said she did monitor Resident #30's vital signs every 15 minutes. LVN J said the vital signs would be recorded in the EMR in the nurses notes or vital sign record. She said there was no other place the vital signs would be recorded. During an interview at 12/16/21 at 10:00 a.m., the ADON said nurses were responsible to ensure residents were monitored/assessed every 15 minutes for at least 2 hours after a [CONDITION(S)] event. The ADON said vital signs should be obtained and documented in the EMR in a nursing note or the vital sign record. The ADON said the facility had not had a system in place to ensure appropriate monitoring/assessments were done by nursing staff after a resident had a [CONDITION(S)]. The ADON said she had been at the facility for 5 months and in that time had been dealing with multiple issues and trying to ensure staffing needs were met. The ADON said there was a lot of instability in the DON position until the current DON started in November. The ADON said she believed these issues combined was what caused the monitoring issues with Resident #25 and Resident #30 to fall through the cracks. The ADON said had there been more stability in the DON role, she believed the DON would have discovered the issue in a chart audit. During an interview on 12/16/21 at 10:04 a.m., the Administrator said she expected nursing staff to follow the facility policy and procedure with regard to monitoring after [CONDITION(S)] events. She said it was the DON and ADON's responsibility to ensure nurses appropriately monitored residents after [CONDITION(S)] events. The Administrator said the DON just started at the facility and the ADON had been with the facility for 5 months. The Administrator said she felt the instability in nursing administration played a role in the facility's failure to identify and correct the post-[CONDITION(S)] monitoring issues identified by the survey team. The Administrator said the facility had no system in place prior to surveyor identification of these issues but were working quickly to correct them. The facility policy and procedure titled Emergency Procedure-[CONDITION(S)] Management, revised March 2011 stated, . (13) If the tonic/clonic convulsions (tonic means stiffening, and clonic means rhythmical jerking) last longer than 5 minutes, or are followed by subsequent seizures, this may constitute status epilepticus ( dangerous condition in which epileptic seizures follow one another without recovery of full consciousness between them) which is a medical emergency. If this is suspected, notify the physician. If the physician is not immediately available to discuss the situation, initiate emergency transfer. (14) Monitor the resident's vital signs every 15 minutes for at least two hours following the [CONDITION(S)] activity, and then as ordered by the physician. (15) Notify the physician during or as soon as possible after the [CONDITION(S)] . The Administrator was notified on 12/14/21 at 3:32 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 12/14/21 at 3:38 p.m. The facility's Plan of Removal was accepted on 12/15/21 at 2:24 p.m. and included: Director of Clinical Operations, Assistant Director of Clinical Operations, Clinical Reimbursement Coordinator and Treatment nurse reviewed all clinical records for all residents receiving medications that require serum monitoring to ensure current lab orders to ensure therapeutic levels are maintained. Beginning on 12-14-21 to be completed by 12-14-21. Assistant Director of Clinical Operations to review all residents who have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Beginning on 12-14-21 to be completed by 12-14-21. Executive Direction Operations, Director of Clinical Operations, Assistant Director Clinical Operations will provide in-service education to Licensed Nurses beginning on 12-14-21 which includes: 1. Signs/Characteristics of [CONDITION(S)] activity 2. Preparation for managing residents with history of [CONDITION(S)] activity. 3. Emergency Procedures/[CONDITION(S)] management 4. Monitoring of vital signs and follow up assessments. 5. Notification of Physician and family 6. Documentation to include description of [CONDITION(S)] activity, including characteristics, length of time the activity lasted and necessary interventions. All Education/In servicing will be done by 12-16-21 Newly hired nurses will receive in-service on [CONDITION(S)] management action plan. Director of Clinical Operations or designee will review any documented [CONDITION(S)] activity daily in clinical meeting to ensure physician notification and appropriate follow up. Beginning 12-16-21. Director of Clinical Operations or designee will review new admissions to ensure appropriate interventions initiated for residents with a history of seizures. The Administrator/Executive Director of Operations will review the action plan developed related to Quality of Care in QA quarterly On 12/15/21 the survey team confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the untitled facility document dated 12/15/21 indicated there were no new admissions to the facility but established a review tool was in place to ensure new admissions with a history of seizures had appropriate interventions in place. Interviews of nursing staff (3-nurses on the 06:00 a.m.-02:00 p.m. shift; 3-nurses on the 08:00 a.m.-05:00 p.m. shift; 3-nurses on the 02:00 p.m.-10:00 p.m. shift; 1-nurses on the 10:00 p.m.-06:00 a.m.) were performed. During these interviews' nurses were able to identify signs and symptoms of [CONDITION(S)], emergency management steps to be taken during a [CONDITION(S)]. The nurses said residents with [CONDITION(S)] activity should be monitored during the [CONDITION(S)] for duration, characteristics, and resident safety should be maintained (lowering the resident to the floor, provide pillow for residents head, pad any areas that may cause injury, lay the resident to the left side if possible, stay with the resident, do not restrain the resident, do not place anything in the residents mouth, notify the physician). The nurses said the physician should be notified immediately of seizures [MEDICATION(S)] 5 minutes or greater in duration or if subsequent seizures occurred. The nurses said residents should be closely monitored with vital signs obtained/documented every 15 minutes for two hours after a [CONDITION(S)] event. The nurses said the resident should continue to be monitored as ordered by the physician. The nurses said physician and family notification should be made as soon as possible after the [CONDITION(S)]. On 12/15/21 at 6:30 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to ensure that nursing staff had the appropriate competencies and skill sets necessary to provide nursing services to care for residents' health care needs safely for 1 of 7 residents reviewed for medication administration. (Resident #1). The LVN charge nurses did not ensure Resident #1's medication, Eliquis (a blood thinner), ordered by the physician to treat a potential life-threatening condition, was entered correctly in the electronic chart and administered as ordered. Resident #1 developed a blood clot requiring hospitalization after the facility failed to administer the blood thinner from 01/22/18 until a [DIAGNOSES REDACTED]. This failure could place the census of 64 residents at risk for adverse effects from not receiving the treatment and medications to prevent exacerbations and/or complications of disease processes. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The physician order [REDACTED]. The most recent MDS, a significant change assessment, dated 07/31/18 indicated Resident #1 made her needs known and understood others. The MDS indicated Resident #1 required extensive assistance with ADLs, and she was frequently incontinent of bowel and bladder. An entry in the electronic chart dated 01/22/18 at 2:13 p.m., indicated LVN A received a verbal order to discontinue Resident #1's medication Eliquis tablet 2.5 mg by mouth two times a day. A MAR dated (MONTH) (YEAR) indicated Resident #1's last dose of Eliquis 2.5.mg was administered at 9:00 a.m., on 01/22/18. A nurse progress note dated 01/29/18 at 2:10 a.m., indicated Resident #1 was scheduled for a colonoscopy on this date and her twice a day Eliquis 2.5 mg was on hold beginning 01/26/18 until after the colonoscopy procedure. There was no written order in Resident #1's medical record with a physician signature to hold or discontinue the medication Eliquis. During an interview on 08/14/18 at 10: 03 a.m., LVN A said Resident #1 was scheduled for a colonoscopy on 01/29/18 and she received a verbal order on 01/22/18 to hold her Eliquis 3 days prior and 2 days post procedure. LVN A said she was not familiar with electronic charting at that time and became confused when entering the hold order. She said it was change of shift and the oncoming nurse said she would enter the hold and resume order for Resident #1. LVN A said she was off the next two days and when she returned on 1/24/18 and she did not think to check Resident #1's orders. LVN A said she did not reorder or administer Resident #1's medication Eliquis. She said she did not remember if she wrote a telephone order on 1/22/18 to hold the medication on 01/26/18 and resume on 02/1/18. She said there was not an order found in Resident #1's medical record. The MARs for Resident #1 dated (MONTH) (YEAR) through 08/08/18 indicated Eliquis was not listed as a scheduled medication. A copy of fax order sheets indicated Resident #1's medication Eliquis 2.5 mg was reordered by a charge nurse on duty on the following dates; *03/13/18 *03/26/18 *04/09/18 *05/08/18 *05/18/18 *06/01/18 *07/01/18 A form titled shipping manifest pharmaceuticals indicated Resident #1's medication Eliquis 2.5 mg (28 tablets) was delivered and verified received by a charge nurse on duty on the following dates; *03/13/18 *03/26/18 *04/10/18 *05/08/18 *05/18/18 *06/01/18 *07/02/18 A nurse progress note dated 08/06/18 at 9:47 p.m., indicated an order was received for Resident #1 to have a venous doppler study of her right leg due to [MEDICAL CONDITION], appointment scheduled for 08/07/18 at 3:45 p.m. A nurse progress note dated 08/07/18 at 9:21 p.m., indicated Resident #1 was admitted to the hospital for 24 hour observation and treatment after findings of the doppler study revealed a [MEDICAL CONDITION] ([MEDICAL CONDITION]/ blood clot) in her right lower extremity. During an interview on 08/14/18 at 2:00 p.m., LVN B said she signed her name on a fax to reorder and receive medication for Resident #1. She said she signed it because it had to be signed by an LVN. LVN B said she signed verified receipt on medications received from the pharmacy, she said she did not remember if she saw Resident #1's Eliquis listed on the receipt. During an interview at 4:25 p.m., The DON said she was unable to determine if Resident #1 received the medication Eliquis because there was no documentation on her MAR after 9 a.m.,01/22/18 to date of admission to hospital after doppler study findings of a [MEDICAL CONDITION] to right leg. She said the medication should not have been discontinued on 01/22/18. The DON said the medication should have been held on 01/26/18 and resumed on 02/01/18. She said a physician order [REDACTED].#1's medical record to hold or resume the medication. She said Resident #1's medication Eliquis, was ordered from the pharmacy by fax because the medication was not active on the MAR and could not be ordered electronically. The DON said she expected the nurses to reorder medications electronically from the resident's MAR. The CMS 672 dated 08/14/18 indicated the census was 64.

Based on observation, interview, and record review, the facility failed to implement interventions based on the comprehensive assessment to prevent development of pressure sores and provide necessary treatment to promote healing of existing pressure sores for 1 of 3 residents sampled for pressure sores. (Resident #2) Resident #2 sustained a right lower leg fracture on 10/8/14. He was treated at the hospital and returned to the facility with a leg immobilizer on 10/8/14. On 10/20/14 an unstagable pressure sore was identified on the back of his right lower leg. The facility did not complete skin assessments or remove the leg immobilizer for 9 days. This failure contributed to the development of a new Stage IV pressure ulcer for Resident #2 and could place 3 residents with pressure sores at risk for decline in their pressure sores. Findings included: Physician orders [REDACTED].#2, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The emergency room record dated 10/8/14, did not indicate how the injury occured. The resident was transferred to the hospital and returned to the facility with a leg immobilizer on his right leg for a right lower leg fracture. The most recent MDS assessment dated [DATE] indicated Resident #2 was totally dependent with all ADLs. He was alert, oriented, and able to make his own decisions. The Braden scale assessment, for predicting pressure ulcer risk, was completed quarterly and the most recent assessment was dated 10/31/14. The assessment indicated Resident #2 was at high risk for skin breakdown. A pressure ulcer care plan dated 8/14/14 indicated the resident was at risk for pressure sores and staff were to provide Resident #2 pressure relieving devices for the bed and wheelchair. Staff were to assist the resident with turning/repositioning every two hours and as needed. An acute care plan dated 10/9/14 indicated Resident #2 had a "possible" lower right leg fracture. The staff were to assess for pain, administer pain medication as needed, refer to the orthopedic physician, provide two staff assistance with repositioning/turning, ADLs, and refer to physician, as needed. The care plan did not address the leg immobilizer including the assessment of the skin under the immobilizer. During an observation and interview on 11/19/14 at 8:45 a.m., Resident #2 was on a low air loss mattress with his legs offloaded (non-weight bearing on the wound) with pillows. A wound V.A.C. (vacuum assisted closure therapy) was attached to a pressure sore on the back of his right lower leg. The treatment nurse said the wound V.A.C. was not scheduled to be changed until 11/20/14. Resident #2 said on 10/8/14 when the CNA's transferred him to bed using a Hoyer lift; he heard a "popping sound" to his right leg. He said he did not say anything to the CNAs but told his sister who arrived about 5 minutes later. Resident #2 said he had no sensation to his extremities and did not feel any pain. He said a x-ray was obtained and he was transferred to the hospital on [DATE] for further evaluation. He was told he had a fracture and was returned to the facility with a leg immobilizer Resident #2 said the staff did not remove the immobilizer but did open it a couple of times. During an interview on 11/19/14 at 8:50 a.m., the treatment nurse said they did not have orders on how to monitor Resident #2's skin after he returned with the immobilizer on 10/8/14. She said she opened the immobilizer on 10/17/14 and applied lotion to his right leg and did not feel anything abnormal at that time. She said she did not visualize the back of the right leg. She said on 10/20/14 she opened the immobilizer to apply lotion and she felt the pressure sore. She assessed the pressure sore and described the wound as 6.5 cm x 5 cm unstageable pressure sore to his right lower leg. She said she notified the physician and Resident #2 was seen by the physician on 10/20/14. An appointment was made for the wound care clinic for 10/27/14. The treatment nurse did not consult the physician for clarification on assessing the resident's skin with the immobilizer. She said there were new orders to discontinue the immobilizer, and pressure sore treatment orders were given while waiting for the wound care appointment on 10/27/14. Skin assessment sheets for Resident #2, completed by the treatment nurse, indicated the following: 10/17/14 - Resident #2 had no skin problems. 10/20/14 - Resident #2 had a 6.5cmx5cm unstageable pressure sore to his right lower leg. A physician order [REDACTED].#2's right leg. A physician summary dated 10/20/14 indicated Resident #2 had a stage IV 6.5 x 5 x 0.1 cm pressure sore to the back of his right lower leg with a medium amount of serosanguineous drainage and eschar. There were no exposed tendons, muscle or bone. There was redness and [MEDICAL CONDITION] around the pressure sore. The treatment orders dated 10/20/14 indicated the wound required debridement, clean with normal saline, apply Santyl ointment, cover with hydrogel, and wrap with Kerlix daily. An appointment with the wound care clinic was scheduled for 10/27/14. A wound care clinic summary dated 10/27/14 indicated Resident #2 had a stage IV 6.5 x 5 x 0.4cm pressure sore on the back of the lower right leg . The pressure sore was debrided 6.6 x 5.1 x 1 cm. A wound V.A.C. was ordered continuously and to keep weight off area of the wound, at all times. During an interview on 11/19/14 at 11:00 a.m., RN C said he worked the weekend of 10/18-19/14, but he did not assess Resident #2's right leg or open the immobilizer. He said he did not know if there were orders to assess the skin under the immobilizer and did not know what the facility's protocol was regarding immobilizer removal and assessment of underlying skin. During an interview on 11/19/14 at 12:45 p.m., LVN A said she assessed Resident #2's right leg on 10/17/14. She said she opened the immobilizer and applied lotion to his leg and there were no pressure sores. She said they did not have instructions or orders on when or how often to remove his immobilizer to assess his skin. She said she did not open the immobilizer and assess his leg daily. She said the physician should have been notified to obtain clarification on removal of the immobilizer to assess his skin. LVN A said she was scared to remove the immobilizer and assess his leg because there were no orders to do that. During an interview on 11/19/14 at 1:00 p.m., the DON said if the staff were unsure of how and when to monitor Resident #2's skin under the immobilizer they should have spoken with her or called the physician for clarification. She said Resident #2's leg should have been assessed and documented on at least once daily. The DON said she was in Resident #2's room when the treatment nurse applied lotion to his leg on 10/17/14, but did not visualize the back of the right lower leg. During an interview on 11/19/14 at 2:30 p.m., LVN B said Resident #2 did not have orders to remove the leg immobilizer to assess his skin. She said she never assessed his skin under the immobilizer. She said she did not call the physician for clarification orders regarding assessment of the skin with the immobilizer. During an interview on 11/19/14 at 3:00 p.m., the DON said the facility did not have a policy/procedure for immobilizers; however, she provided a copy of an in-service she held on 10/20/14 for orthopedic devices and skin integrity. The NPAUP (National Pressure Ulcer Advisory Panel) proposed definition of a (DTI) deep tissue injury is " A pressure -related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. These [MEDICAL CONDITION] may herald the subsequent development of a Stage III - IV pressure ulcer even with optimal treatment. " (NPAUP, 2002) .....Deep tissue injury represents a dangerous lesion due to its potential for rapid deterioration. Proper labeling will afford clinicians a more accurate [DIAGNOSES REDACTED]. A problem with this approach is that the labeling of deep tissue injury as a stage I can reasonably be interpreted to mean that the lesion is relatively minor and healing is likely with offloading. However, if enough subcutaneous pressure damage has occurred prior to its identification, and if there is reperfusion injury, it is quite possible that no amount of pressure offloading will prevent further deterioration. The CMS Form 672 dated 11/19/14 indicated 4 residents had pressure sores.

Based on observation, interview, and record review, the facility failed to implement interventions based on comprehensive assessments to prevent development and worsening of pressure ulcers for 1 of 7 residents reviewed for pressure ulcers. Resident #9) Resident # 9 was admitted without pressure ulcers, but was at high risk for development of pressure ulcers. The resident developed 2 facility acquired pressures ulcers (unstageable and Stage III). The facility did not provide wound care treatment per physician orders, or complete skin assessments, use of supportive/protective devices to assist with positioning and encourage nutrition per the plan of care. These failures contributed to the development of new pressure ulcers for Resident # 9 and placed 5 residents with pressure ulcers at risk for development of new pressure ulcers and decline of existing pressure ulcers. Findings included: Physician orders [REDACTED].#9 was [AGE] years old and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. *4/2/14 - Float (elevate) left heel while in bed with wound care orders. *5/16/14 indicated DC (discontinue) dressing to left heel and Start monitor DTI (Deep Tissue Injury) every shift. *6/6/14 at 3:30 a.m., (taken from standing orders) Cleanse stage III to back right rib cage with wound cleanser, apply duoderm, and change every 3 days and as needed (PRN). May use air loss mattress. *6/6/14 at 9 a.m., Cleanse area to mid back with wound cleanser, apply Safegel and dressing every day. Add LAL (low air loss) mattress. * 6/10/14 (following surveyor intervention) indicated discontinue and Monitor DTI every shift to left heel and cleanse area with wound cleanser and apply Santyl and cover with dressing every day. The most recent MDS assessment dated [DATE] indicated Resident # 9 required total assistance with help of two persons with bed mobility, transfers, and extensive assistance with help of one person for eating. The resident was understood and usually understood others, had poor recall, and had moderately impaired decision making capabilities. Resident # 9 had no pressure ulcers, but was identified as a high risk for developing a pressure ulcer(s) at the time of this assessment. Dietary consults for Resident # 9 indicated the following: *on 3/19/14 resident ate at the assistant table in the dining room and could feed self with set-up. *on 5/14/14 resident has a gradual weight loss from 156.4 pounds to 153.6 pounds on 5/8/14. *on 6/5/14 resident was in dining room for meal and needed extensive assistance. A Braden scale assessment dated [DATE] indicated Resident # 9 was not a high risk for skin breakdown. A Braden scale assessment dated [DATE], following readmission for [MEDICAL CONDITION] indicated Resident # 9 was not a high risk for skin breakdown. A care plan dated 3/18/14 indicated Resident # 9 was a high risk for pressure ulcers and the following approaches were to be used: *encourage good nutritional intake *daily observation of skin with routine care *full skin evaluation weekly, and *pillows or other supportive/protective devices to assist with positioning. A weekly wound care plan for Resident #9's left heel indicated the following: 4/1/14 - float heel 4/8/14 - area drying out ...No open areas. 5/1/14 - Improving slowly 5/15/14 - Monitor every shift and DC treatment 5/28/14 - Continue POC - Blister Dry 6/4/14 - Continue POC - Float heels in bed 6/10/14 - Treatment change - area has drainage. The wound care plan did not indicate wound drainage from 5/15/14 through 6/10/14. A nurse's note written by RN G dated 5/18/14 at 8:45 a.m., indicated Resident # 9 had drainage to the top area of her left heel. RN G cleansed the heel and was going to apply a dressing, but the resident refused. It was documented Resident #9 said she was told the wound was to stay dry. A nurse's note dated 6/6/14 at 3:30 a.m. indicated, LVN H " ...noted a pressure ulcer stage III to right back rib cage ... " (according to a physician order [REDACTED]. During an observation on 6/9/14 at 2:00 p.m., Resident #9 was lying on her back on an air loss mattress. Her back and heels were against the mattress. Her left foot was not elevated (floated). During an observation on 6/9/14 at 3:26 p.m., Resident # 9 was lying on her back on an air loss mattress. Her heels were against the mattress. During an observation on 6/10/14 at 7:34 a.m., Resident # 9 was in the dining room and ate only 25% of her breakfast. Staff did not assist her to eat more. During an interview on 6/10/14 at 4:55 p.m., Resident #9's son said his mother had [MEDICATION NAME] degeneration and had difficulty seeing things. He said the resident had a good appetite and would eat 100% if assisted with meals. During an observation and interview with CNA K on 6/10/14 at 2:48 p.m., Resident #9 was lying in bed on her back on an air loss mattress and her heels were against the mattress surface. She had a wound to her left heel. The wound did not have a dressing and there was a large amount of yellow-brownish drainage to Resident #9's sock. The wound looked to be approximately 3 centimeters (cm) x 3cm pressure ulcer The wound bed had gray-yellow colored dead tissue in the center and a small amount of red at the bottom. CNA K said the wound had been draining and looked that way for several weeks. During a treatment observation and interview with LVN S on 6/10/14 at 4:45 p.m., Resident #9 was sitting in her wheelchair. LVN S performed wound care on Resident #9's left heel. She cleansed the wound using wound cleanser and applied Safegel to the wound bed. LVN S said Resident # 9 had a DTI (deep tissue injury) and not a pressure ulcer to her left heel. The wound bed exhibited brown dead tissue in the center of the wound with red edges and draining a reddish fluid. The left heel wound was measured at 1.7 cm x 1.4 cm. During a treatment observation and interview with LVN S and the ADON on 6/10/14 at 4:45 p.m. two surveyors were present during wound care to Resident # 9's left heel. Resident #9 was lying in bed on the air loss mattress and her heels were floated on a foam pillow. LVN S said Resident #9's left heel wound was 2.5 cm x 3.4 cm with necrotic tissue to the wound bed. The ADON said she was the treatment nurse the week before and the left heel wound had deteriorated since last week. During an observation and interview on 6/10/14 at 1:24 p.m. LVN S performed wound care to the pressure ulcer over the right, back rib cage. The wound was the size of a nickel, and had cream colored slough on a pink wound bed. LVN S said she did not know how the wound occured. An interview with Resident # 9 was not performed due to her confusion. During an interview on 6/11/14 at 3:40 p.m., the DON said Resident # 9's left heel was not a pressure ulcer. She said Resident # 9's left heel was a deep tissue injury (DTI) and was treated by floating the heel. She said no further treatment was needed. During an interview on 6/11/14 at 10:55 a.m., CNA R said she saw a quarter-sized amount of brownish drainage on Resident # 9's socks on several occasions in the last 2-3 weeks. CNA R said she told LVN S when she found the drainage. She could not remember if heels had been floated. During an interview on 6/11/14 at 11:10 a.m., the ADON said she expected when Resident #9's wound deteriorated the nurse would call the physician for wound care orders and notify the family. During a phone interview on 6/11/14 at 11:25 a.m., Resident # 9's physician said he had not been notified of the left heel drainage in the last 24 hours. He thought it was dry. Resident #9's physician said the wound needed debridement and culturing. During an interview on 6/11/14 at 2:00 p.m., CNA V said Resident #9's left heel had been draining for 2 to 3 weeks. CNA V said she reported to the treatment nurse and was told it was to be open to air During an interview on 6/11/14 at 2:04 p.m., RN G said on 6/7/14 she monitored the wound on Resident #9's left heel. She said the wound had some drainage and she informed the CNAs not to put shoes on Resident #9. RN G said she did not visualize Resident #9's wound to her left heel on 6/8/14 even though she had documented twice on the treatment sheets she had monitored it. During an interview on 6/11/14 at 2:15 p.m., CNA Q said she saw reddish-brown drainage, the size of a golf ball on Resident #9's socks for the last 2 weeks. She said Resident #9's heel drained daily. CNA Q said sometimes the drainage on her sock was dry and sometimes it was wet. She said she told the wound care nurse about the drainage. During an interview on 6/11/14 at 2:14 p.m., LVN H said she monitored and documented regarding Resident #9's wound on her heel on 6/7/14, 6/8/14, 6/9/14 and 6/10/14. She said she documented on Resident #9's treatment record. LVN H said monitoring to her meant she relied on her CNAs to tell her any skin issues. She said she had not actually looked at Resident #9's wound and did not know the current condition of the wound. LVN H said the wound was "coasting along." During an interview on 6/11/14 at 2:18 p.m., CNA N said on 6/7/14 she assisted Resident #9 to change clothes. She said she put shoes and socks on Resident #9, but RN G told her not to put a shoe on her left foot due to a wound. She denied seeing a bandage on her left foot During an interview on 6/11/14 at 2:20 p.m., CNA O said she had assisted Resident #9 to bed on 6/7/14. She said Resident #9 was wearing both shoes. She said RN G said to take Resident #9's left shoe off, due to a foot wound. CNA O said when she removed the shoe; Resident #9 yelled "OH!" Resident #9 said her left foot was tender. CNA O said she did not remove the resident's socks, so she did not know if there was any drainage. CNA O said no one told her to elevate/off-load Resident #9's feet in the bed or in her chair. CNA O said Resident #9 had worn shoes all day and her feet were not off loaded in bed or when she was up in her wheelchair. During an interview on 6/11/14 at 2:55 p.m., the treatment nurse said she had not been trained on wound care. She said she was supposed to attend wound care training later in the year. She said prior to being the wound nurse, she had done MDS assessments. During an interview on 6/11/14 at 3:40 p.m., the ADON said she trained the treatment nurse. The ADON could not find documentation of wound care training for herself or the treatment nurse. During an interview on 6/11/14 at 3:25 p.m., the DON said upon admission Resident #9 had a post-op ORIF (open reduction internal fixation) of her left hip, with orders for an abduction pillow to be used daily. She said this condition made her a high risk for pressure sore development. The DON said she did not know staff had documented Resident #9's Braden scale assessment as a mild risk for pressure sore development. The NPAUP (National Pressure Ulcer Advisory Panel) proposed definition of a (DTI) deep tissue injury is " A pressure -related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. These [MEDICAL CONDITION] may herald the subsequent development of a Stage III - IV pressure ulcer even with optimal treatment. " (NPAUP, 2002) .....Deep tissue injury represents a dangerous lesion due to its potential for rapid deterioration. Proper labeling will afford clinicians a more accurate [DIAGNOSES REDACTED]. A problem with this approach is that the labeling of deep tissue injury as a stage I can reasonably be interpreted to mean that the lesion is relatively minor and healing is likely with offloading. However, if enough subcutaneous pressure damage has occurred prior to its identification, and if there is reperfusion injury, it is quite possible that no amount of pressure offloading will prevent further deterioration. The CMS 672 Form dated 6/9/14 indicated 4 residents had pressure ulcers and a list dated on 6/12/14 indicated 5 residents had pressure ulcers.

Based on observation, interview, and record review the facility failed to ensure supervision to prevent accidents for 1 of 5 residents (Resident #6) and 7 of 19 resident rooms reviewed for accident/hazzards. (Room #s 42, 43, 45, 46, 47, 50,51) Resident #6 smoked unsupervised. He had a cigarette burn to his finger and multiple cigarette burn holes in his clothing. After surveyor intervention, Resident #6's smoking ability was re-assessed and he was determined to be an unsafe smoker. Being an unsafe smoker he must be supervised at smoking times and must wear a smoking apron. Resident Room #s 42, 43, 45,46, 47, 50,51 had multiple patient care equipment plugged into their entangled, electrical power strips. This failure could place 5 residents that smoked at risk for multilpe minor and major burn injuries and placed 17 residents with entangled, electric power strips used in their rooms at increased risk of overheating, fire risk and injury. Findings included: 1. Physician orders [REDACTED].# 6 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #6 was understood, understands others, had physical and verbal behaviors directed at others, put others at risk for physical injury, required supervision with his activities of daily living and used tobacco. The comprehensive care plan dated 4/7/14 indicated Resident #6 was at risk for potential injury related to his use of psychotropic medications and required intervention to keep the environment free of safety hazards. The care plan indicated Resident #8 was a safe smoker and would not be injured in the next 90 days. The interventions were to assess Resident #6's ability to smoke safely on admission and as needed. A safe smoking assessment dated [DATE] indicated Resident #6 was assessed to be a safe smoker. The assessment indicated Resident #6 had adequate memory/recall ability. According to the assessment if "yes" was checked to all areas then the resident was considered a safe smoker. During an observation and interview on 6/9/14 at 9:46 a.m., Resident #6 was sitting in his room. He had a burn on his left hand, second middle finger, with pink tissue to the wound bed. Resident #6 had two burn holes in his shirt. Resident #6 said he burned his finger while smoking about one month ago. A nurse note dated 5/26/14 indicated Resident #6 and another resident had an altercation while smoking. The nurse indicated she was called to the smoking area related to the altercation and saw Resident #6 tugging on the ashtray and nearly sitting on the other resident's lap attempting to obtain the ashtray of his choice. No injuries were noted in nurses' notes. Skin assessments, after surveyor intervention, dated 6/9/14 indicated Resident #6 had two open areas to the third finger of his left hand. Area #1- 0.5 x 1 cm with a depth of 0.2 cm, and Area #2 was .2 x 2 cm with a depth of 0.2 cm. Physician orders [REDACTED]. The treatment nurse flow sheet indicated on 6/7/14 Resident #6 had a head to toe skin check with the result of clear to all areas. During an interview on 6/9/14 at 10:10 a.m., the treatment nurse said Resident #6 had no skin issues. She said staff did not supervise the residents who smoke. She said Resident #6 did not use a smoking apron. During an observation on 6/9/14 at 3:00 p.m., Resident #6 obtained his cigarette from the nurse. Resident #6 obtained a lighter from another resident in the smoking area. His cigarette had long ashes before he put them in the ash tray. Resident #6 smoked his cigarette up to the filter, and did not extinguish it. He left the cigarette smoldering in the bottom of the ashtray. During an interview on 6/9/14 at 3:12 p.m., the DON saw the smoldering ashtray and commented that someone had left their cigarette burning. During an interview on 6/9/14 at 3:25 p.m., the DON looked at Resident #6's burned finger and clothing said he could have caught himself on fire. She said Resident #6 was considered a safe smoker, but that was not the case now. During an interview on 6/10/14 at 10:00 a.m., LVN B said she had not noticed the burn to Resident #6's finger. She said there had not been an assigned smoking schedule for staff to monitor smoking. She said there was no smoking apron provided to Resident #6. During an interview on 6/10/14 at 10:05 a.m., LVN M said she never supervised smoking at the facility. She said the residents came at the scheduled times, the nurses give them their cigarettes and lighters, and then the resident is on their own to smoke. LVN M said she was unaware of Resident #6's burns. During an interview on 6/10/14 at 10:15 a.m., the SW said Resident #6 was considered a safe smoker. She said the facility had not had an unsafe smoker in a, therefore not needing to use their smoking aprons. The SW said she was responsible for the smoking assessments. She said the smoking policy indicated the residents deemed safe smokers would not be supervised. The SW indicated that the smoking schedule would now have not only the times for smoking, but what department was responsible to monitor the unsafe smoker. During an interview on 6/11/14 at 2:01 p.m., RN G said she did not recall seeing a burn to Resident #6's finger during his skin assessment on 6/7/14. She was unable to recall really looking at his hands. A safe smoking assessment dated [DATE] (after surveyor intervention) indicated Resident #6 was re-assessed with [REDACTED]. He was not able to hold the smoking device safely, and could not safely dispose of ashes therefore, considered an unsafe smoker. A nurse note dated 6/9/14 (after surveyor intervention) indicated Resident #6 had a 1.5 cm x 1.0 cm open area with partial scabbing to left hand middle finger. The note indicated Resident #6 said he had smoked his cigarette too short causing the burn and had poor memory. An In-service dated 6/9/14, after surveyor intervention, indicated Resident #6 was considered an unsafe smoker. The unsafe smokers must be supervised at smoking times and must wear smoking aprons. During an observation on 6/10/14 at 8:00 a.m., following surveyor intervention Resident #6 was outside in the smoking area with a smoking apron to prevent ashes from falling on his clothing. A policy and procedure revised 2/17/12 indicated "...it was the responsibility of the facility to provide a safe and hazard free environment for those residents having been assessed as being safe for facility smoking privileges. The policy is to minimize the risks to residents who smoke, including possible adverse effects on treatment, passive smoke to others and fire. Residents wishing to smoke while at the facility will have a "safe smoking assessment " completed by the interdisciplinary team to determine the resident's ability to follow smoking policies safely. Residents who are deemed "safe "will be allowed to smoke unsupervised and may be permitted to keep cigarettes and /or lighters on their persons. If resident was deemed "unsafe", they will be required to surrender all smoking paraphernalia to facility. Staff will maintain/keep all smoking materials and distribute the materials to residents at smoking times. Furthermore, a smoking schedule will be posted and resident will be required to smoke with supervision only, according to schedule ..." 2. During observations on 06/09/14 at 10:15 a.m. and 3:34 p.m. in Room #47 A-bed a power strip was lying on the mattress at the foot of the bed. The resident's oxygen concentrator was connected to it. During an observation on 06/09/14 at 3:40 p.m., in Room #42, A-bed and air mattress was plugged into the power strip. During an observation on 6/9/14 the following was noted: * At 3:35 p.m., Room #43 electric bed and air mattress were plugged into the power strip. * At 3:36 p.m., Room #46 oxygen concentrator was plugged into the power strip. * At 3:37 p.m., Room #45 electric bed, air mattress, and feeding pump were plugged into the power strip. * At 3:38 p.m., Room #51 two electric beds were plugged into the power strip. * At 3:39 p.m., Room #50 an electric bed was plugged into the power strip. During an interview on 6/9/14 at 4:05 p.m., the maintenance supervisor said there was not enough electrical outlets for resident care equipment and personal electrical items, so they used power strips. He verified residents had care equipment including electric beds, oxygen concentrators, etc. connected to the power strips. A list provided on 6/11/14 indicated there were 5 residents who smoked. During an interview on 6/10/14 at 8:45 a.m., the administrator said she was only aware of two residents having power strips in their rooms. During observations on 6/9/14 from 3:34 p.m. thru 3:39 p.m., surveyors identified 17 residents with entangled, electric power strips used in their rooms