Every finding on record at Focused Care at Orange

Based on interviews and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress for 1 of 2 residents (Resident #1) reviewed for abuse, neglect, and misappropriation.The facility failed to thoroughly investigate and conduct sufficient interviews after Resident #1 alleged on 06/27/26 that CNA A punched or slapped (he used both terms at different times) the resident on his face between his two eyes.This failure could place residents at risk of not having allegations of abuse, neglect, exploitation, or misappropriation investigated properly to prevent re-occurrence.Findings included:Record review of Resident #1's face sheet, dated 08/12/26, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included severe intellectual disabilities, lack of coordination, and anxiety disorder. Record review of Resident #1's comprehensive MDS assessment, dated 06/22/26, indicated he was able to make himself understood and understood others. He was cognitively intact with a BIMS score of 15.Record review of Resident #1's care plan, no date, indicated Resident #1 had .a history/been noted to makeallegations regarding facility employees. I make these allegations when there are not witnesses present. 6/27/26: Resident #1 made an allegation that he received physical aggression from CNA. Date Initiated: 06/27/2026.Record review of the facility investigation, dated 07/02/26, and completed by the Administrator, indicated the incident occurred on 06/27/26 at 09:00 p.m. and was reported to HHSC on 06/27/26 at 10:03 p.m. The AP was identified and confirmed as CNA A. There were no identified witnesses. In the investigation summary it was reported. Resident gave interview to Administrator and stated that he did not like this aide and wanted her fired. Resident stated she is disrespectful to him because she is on her phone. He then stated he does not like the aide, so he said he she hit him to get her fired.unfounded. Part of the facility's investigation included a statement the administrator took from Resident #1. It was written as.interview with Resident #1: 1. Resident #1 reported CNA A was on phone while in room providing care. He does not like this aide because she is always on her phone. He was telling this aide to put the trashcan by the door. Aide responded no. Resident #1 got frustrated and called this aide a Bitch and shot the finger at her. 2. I asked Resident #1 if he told the nurse she hit him because he doesn't like the aide and he wants her fired, he said yes. Because she doesn't respect him cause she is on her phone.verbally given by Resident #1 6/29 @ 1:26 pm written by the Administrator. The facility 5-day report did not include safe survey (resident) interviews or staff interviews regarding abuse.During an interview on 08/12/26 at 11:40 a.m., Resident #1 stated, she slapped me and he pointed to the area between his eyes and said, it hurt. He denied recanting his statement. He stated I am fine now. I never saw that staff member again. Attempted to interview the roommate immediately after his interview, but she did not respond.During an interview over the phone on 08/12/26 at 11:46 a.m., CNA A denied the allegations. She confirmed she was suspended immediately, while the administrator completed an investigation. She was brought back after the investigation was completed. She confirmed prior trainings of abuse and neglect.During an interview on 08/12/26 at 12:04 p.m., the Administrator stated the incident was in Resident #1's room. There were no other witnesses. She interviewed Resident #1 and the roommate. She stated the roommate interview was unsuccessful due to cognition. The Administrator stated CNA A was suspended immediately. The Administrator stated she took Resident #1's response during his interview as the abuse never happened. The Administrator stated, I normally do the safe surveys (resident interviews) and staff interviews. She stated, I didn't make sure they were done. That was my fault. I take full responsibility. She stated the policy did not specifically state to do the safe surveys or staff interviews, that it was part of her investigation process. She stated the possible risk was the facility could miss she (CNA A) treated someone else this way as well.Record review of the facility's Abuse policy, revised 01/01/23 indicated .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.Reporting/Investigation:.will conduct interviews that include documented statement summaries from.any staff who worked prior to and during the time of the incident,.interviews may include employees of various departments and shifts.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 3 medication carts and 3 of 25 residents reviewed for pharmacy services (Residents #42, #61 and #64) (Medication cart for Rooms 109 - Rooms 120, Medication cart for Rooms 217 - Rooms 220 and Medication cart for Rooms 205 - Rooms 216 ).The facility failed to ensure expired medications were removed from 3 of 3 medication carts.These failures could place residents at an increased risk of receiving medications that were not at their intended potency and potential adverse reactions or side effects. Findings included:Record review of Resident #42's face sheet, dated 06/23/2026, indicated a [AGE] year-old female, admitted [DATE]. Resident #42 had diagnoses which included hypertension (high blood pressure) and hypothyroidism (thyroid does not produce enough hormones to meet the body's needs). Record review of Resident #42's quarterly MDS assessment, dated 04/21/2026, indicated Resident #42 had a BIMS score of 3, which indicated severely impaired cognition with diagnoses of hypertension and hypothyroidism. Record review of Resident #42's physician orders, dated 06/03/2026, indicated she was prescribed amlodipine besylate 2.5 mg every day for hypertension with a start date of 12/22/2022 and levothyroxine 50 mcg daily for low thyroid with a start date of 05/20/2023. Record review of Resident #42's care plan, with a target date of 07/12/2026, indicated Resident #42 had a diagnosis of hypothyroidism and was at risk of complications with interventions of administer medication as prescribed. Resident #42's care plan included a diagnosis of hypertension with a risk of complications and interventions that included administer medication as prescribed. Record review of Resident #61's face sheet, dated 06/03/2026, indicated a [AGE] year-old male, admitted [DATE]. Resident #61 had diagnoses which included Parkinsonism (group of neurologic disorders causing movement problems including tremors, slow movement, balance problems and rigid muscles). Record review of Resident #61's quarterly MDS assessment, dated 03/04/2026, indicated Resident #61 had a BIMS score of 13, which indicated intact cognition with a diagnosis of Parkinsonism. Record review of Resident #61's physician orders, dated 06/03/2026, indicated he was prescribed carbidopa/ levodopa 25 mg/ 100 mg every 8 hours for Parkinson's with a start date of 12/28/2020. Record review of Resident #61's care plan, with a target date of 08/11/2026, indicated Resident #61 was on an antiparkinsonian therapy with interventions administer medication as prescribed. Record review of Resident #64's face sheet, dated 06/03/2026, indicated a [AGE] year-old female, admitted [DATE]. Resident #64 had a diagnosis which included hypertension (high blood pressure). Record review of Resident #64's quarterly MDS assessment, dated 05/13/2026, indicated Resident #64 had a BIMS score of 7, which indicated severely impaired cognition with a diagnosis of hypertension. Record review of Resident #64's care plan, with a target date of 07/13/2026, indicated Resident #64 had a diagnosis of hypertension and interventions that included receive medication as ordered. Record review of Resident #64's physician orders, dated 06/03/2026, indicated she did not have current orders for clonidine 0.1 mg every 8 hours as needed. During an observation and interview on 06/03/2026 at 9:52 a.m., medication cart for Rooms 109 - Rooms 120 with LVN C revealed in the third drawer including medication overflow:*1 medication card with 30 of 30 pills Carbidopa/ Levodopa 25mg/ 100 mg every 8 hours for Parkinson's disease with a use by date of 02/07/2025 labeled for Resident #61. *2 medication cards with 30 of 30 pills Carbidopa/ Levodopa 25mg/ 100 mg every 8 hours for Parkinson's disease with a use by date of 04/18/2025 labeled for Resident #61. *2 medication cards with 30 of 30 pills Carbidopa/ Levodopa 25mg/ 100 mg every 8 hours for Parkinson's disease with a use by date of 09/26/2025 labeled for Resident #61. *1 medication card with 30 of 30 pills Carbidopa/ Levodopa 25mg/ 100 mg every 8 hours for Parkinson's disease with a use by date of 11/25/2025 labeled for Resident #61. *1 medication card with 25 of 30 pills Carbidopa/ Levodopa 25mg/ 100 mg every 8 hours for Parkinson's disease with a use by date of 01/03/2026 labeled for Resident #61. LVN C said the nurses that gave medication off this medication cart were responsible for ensuring all expired medications were removed from the medication cart. She said she was giving medication off this medication cart today (06/03/2026) and was educated on removal of expired medication. She said the other nurses giving medication off this medication cart were the backup to double check and ensure all expired medication was removed off the medication cart. LVN C said these expired medications were overlooked. She said the resident risk of expired medication left on a medication cart was they may not be as effective. She said she had not given any of the expired medication and the medication cart contained a card of the medication that was not expired. During an observation and interview on 06/03/2026 at 10:05 a.m., medication cart for Rooms 217 - Rooms 220 with RN D revealed in the third drawer including medication overflow:*1 medication card with 30 of 30 pills levothyroxine 50 mcg daily for low thyroid with a use by date of 03/17/2026 labeled for Resident #42. *1 medication card with 30 of 30 pills levothyroxine 50 mcg daily for low thyroid with a use by date of 05/12/2026 labeled for Resident #42. *1 medication card with 30 of 30 pills amlodipine besylate 2.5 mg daily for high blood pressure with a use by date of 12/31/2025 labeled for Resident #42. RN D said the nurses that gave medication off this medication cart were responsible for ensuring all expired medications were removed from the medication cart. She said she was giving medication off this medication cart today (06/03/2026) and was educated on removal of expired medication. She said the other nurses giving medication off this medication cart were the backup to double check and ensure all expired medication was removed off the medication cart. RN D said these expired medications were overlooked. She said the resident risk of expired medication left on a medication cart was they may not be as effective. She said she had not given any of the expired medication. During an observation and interview on 06/03/2026 at 11:05 a.m., medication cart for Rooms 205 - Rooms 216 with LVN E revealed in the third drawer including medication overflow:*1 medication card with 17 of 30 pills clonidine HCL 0.1 mg every 8 hours as needed for blood pressure with a use by date of 02/28/2025 labeled for Resident #64. LVN D said the nurses that gave medication off this medication cart were responsible for ensuring all expired medications were removed from the medication cart. She said she was giving medication off this medication cart today (06/03/2026) and was educated on removal of expired medication. She said the other nurses giving medication off this medication cart were the backup to double check and ensure all expired medication was removed off the medication cart. LVN D said these expired medications were overlooked. She said the resident risk of expired medication left on a medication cart was they may not be as effective. LVN D said she had not given any of the expired medication. During an interview on 06/03/2026 at 11:48 a.m., the DON said the charge nurses giving medication off the medication carts were responsible for removing all expired medication off the medication carts. She said the ADONs were responsible for weekly checks of the medication carts to remove expired medication. The DON said all nurses were educated to remove expired medication off the medication carts. She said the expired medications were overlooked. The DON said the potential resident risk of having an expired medication on a medication cart is that the medication potentially may not be as effective. She said her expectation was the nurses would check the dates on all medication and if expired remove them immediately from the medication cart. During an interview on 06/03/2026 at 11:56 a.m., ADON A said the nurses giving medication off the medication carts were responsible for removing all expired medications off the medication carts. She said she was not sure who was responsible for being the backup to ensure all expired medications were removed from the medication carts, but she would find out. ADON A said the expired medications were possibly overlooked. She said all the nurses were educated to remove expired medication from the medication carts. ADON A said the resident risk of expired medication not removed from a medication cart was the medication could be less effective. During an interview on 06/03/2026 at 12:04 p.m., the Administrator said the nurses giving medication off the medication cart were responsible for removing all expired medications off the medication carts. She said the ADON assigned to station A and ADON assigned to station B and DON were the backup to ensure all expired medications were removed off the medication carts. The Administrator said the expired medications were overlooked, the staff did not check the overflow medication for expired medications. She said the nurses were all educated to remove expired medication from the medication carts. She said the resident risk of expired medication on a medication cart was the medication could be less effective. The Administrator said her expectation was all medication carts be checked weekly to say up to date as best as possible including the overflow medication and all expired medication be removed and destroyed timely. During an interview on 06/03/2026 at 12:10 p.m., ADON A said she was now responsible for both nurses' stations until ADON B returned. She said she would check the medication carts weekly on Wednesdays starting today for expired medication and remove the expired medication from the medication cart. During an interview on 06/03/2026 at 3:27 p.m., ADON B said the charge nurses were responsible for removing expired medication off the nurses' medication carts and she was responsible for station A that included Resident #61's hall. ADON B said ADON A was responsible for Nurses Station B that included Resident #42 and #64's halls. She said she made weekly checks on the medication carts for her station on Wednesdays. ADON B said all the nurses were educated to remove expired medication off the medication carts. She said the expired medications were overlooked. ADON B said the potential resident risk of expired medication left on a medication cart was the medication could be less effective or could cause side effects. Record review of a facility policy, revised 08/2024, titled, Storage of Medications, indicated, . 8. Outdated, contaminated, or deteriorated medications . are immediately removed from inventory, disposed of according to procedures for medication disposal, . 1. Expiration dates (beyond-use dates) of dispensed medications shall be determined by the pharmacist at the time of dispensing. 4. Re-packaged drugs carry a beyond-use-date determined by the pharmacy based upon a number of factors in addition to applicable law and regulation.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in 1 of 1 kitchen reviewed for food safety requirements. 1. The facility failed to ensure there were paper towels at the handwashing station.2. The facility failed to ensure the Dietary Manager's hair was inside the hair restraint.3. The facility failed to ensure Dishwasher A wore a beard restraint.4. The facility failed to ensure [NAME] A wore his beard restraint correctly.5. The facility failed to ensure the Dietary Manager, and [NAME] A washed their hands upon entering the kitchen.6. The facility failed to ensure [NAME] B washed her hands after lifting her shirt up and pulling her pants up.7. The facility failed to ensure the floor and shelves of the walk-in coolers were free from green and brown colored debris and dark brown stains.8. The facility failed to ensure 2 log packs of ground beef meat were thawed with running water.9. The facility failed to ensure staff did not have open hydration drinks on preparation table. These failures could place residents at risk of foodborne illness, and food contamination. Findings included: During an observation of the kitchen on 06/01/2026 at 8:42 a.m. there were no paper towels in the paper towel dispenser, nor any paper towels near the handwashing station. During an observation on 06/01/2026 at 8:47 a.m., there were 2 log packs of ground meat thawing in the sink without running water. During an observation on 06/01/2026 at 9:00 a.m. there were 2 open drinks that belonged to [NAME] A on the preparation table near serving plates and food. During an observation and interview on 06/01/2026 at 9:00 a.m., the Dietary Manager, and [NAME] A, did not wash their hands upon entering the kitchen from outside. The Dietary Manager's hair restraint covered the top of her head leaving the bottom of her hair outside of the hair restraint while in the meal preparation section. During an interview with the Dietary Manager, she said she should have washed her hands when she entered the kitchen. She said all hair must be in the hair restraint while in the kitchen. She said she was rushing and forgot to wash her hands and put all her hair in the hair restraint. She said the potential risk was hair falling in the food and cross contamination. During an interview with [NAME] A, he said he went outside to smoke then came back inside to finish cooking. He said he did not wash his hands because there were no paper towels to dry his hands. He said he had been trained on handwashing, and the potential risk was cross contamination if hands were not washed. During an observation and interview on 06/01/2026 at 9:10 a.m. Dishwasher A was not wearing a beard restraint while in the kitchen. He said he was educated to have a beard restraint on while in the kitchen. He said he forgot to put it on. Dishwasher A said not wearing a beard restraint could place residents at risk for getting hair in their food. During an observation and interview on 06/01/2026 at 9:30 a.m. [NAME] B was observed lifting her uniform shirt up and pulling her pants up. [NAME] B did not wash her hands after pulling her pants up before touching kitchen seasonings. During an interview [NAME] B said she did not immediately wash her hands after pulling up her pants because she was going to go wash the dishes after she put the seasonings up. She said she had been trained on washing her hands and the potential risk was cross contamination. During an observation on 06/01/2026 at 9:50 a.m. the floor and shelves of the walk-in coolers had green and brown colored debris and dark brown colored stains.During an observation on 06/01/2026 at 12:00 p.m., there were 2 logs of ground meat thawing in the sink without running water. During an observation and interview on 06/01/2026 at 12:30 p.m. there were 2 open drinks that belonged to [NAME] A on the preparation table near serving plates and food. During an interview [NAME] A said 2 of the drinks belonged to him. He said he knew not to consume and store his drinks on the preparation counter because of the potential of cross contamination. He said he was busy preparing and serving food and forgot. During an interview on 06/01/2026 at 1:15 p.m., the Dietary Manager said she was responsible for ensuring kitchen staff adhered to all required regulations regarding food safety. She said she expected all kitchen staff, including herself, to wash hands upon entering the kitchen and for paper towels to be at the handwashing station so staff could dry their hands. She said she did not know who took the ground meat out of the freezer to thaw. She said the meat was thawing since approximately 6:00 a.m. She said the Administrator intervened and told her to discard the ground meat due to it thawing without water running. She said staff had been educated on thawing meat with running water to ensure meats were held at proper temperatures to prevent food borne illnesses. The Dietary Manager said all staff must wash their hands after adjusting any clothing to prevent cross contamination. She said she expected the walk- in cooler to be clean and free of debris and residue to prevent food borne illnesses and cross contamination. The Dietary Manager said staff should only consume and store drinks at the hydration station to prevent contamination. During an interview with the Administrator on 06/03/2026 at 4:00 p.m., she said her expectations were for staff to wash their hands before and after break, between duties, and upon entering the kitchen. She said she expected staff to know their role and execute it. She said the Dietary Manager was responsible for the staff in the kitchen. The Administrator said she was responsible for making rounds and ensuring they were following regulations. She said she goes to the kitchen every day to watch the serve out process and when the food truck comes in. She said the potential risks of sanitation failures were food borne illness, and cross contamination. Record review of the facility's policy titled Hand Washing/Glove Use Last revised date: 03/2026, indicated: POLICY: Handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses. Food and Nutrition Services team members should clean their hands in a handwashing sink or approved handwashing facility. Hands should not be washed in a sink used for food preparation, ware washing, or in a service sink used for the disposal of mop water or similar waste.PROCEDURE1. Hands and exposed portions of their arms should be kept clean.5. Frequency of Handwashing:a. Clean hands and exposed portions of armsb. Before engaging in food preparation including working with exposed food,c. Before using clean equipmentd. Before handling clean utensilsf. After entering the kitcheng. At the beginning of the shifth. After returning from breakk. After hands have touched bare human body parts other than clean hands (such as face, nose, hair).l. After coughing, sneezing, or blowing your nose, using tobacco products, eating or drinking. Record review of the facility's policy titled Kitchen Sanitation Effective date: 03/2026, indicated: POLICYEquipment should be maintained in a clean, sanitary condition and free from spills, to minimizethe risk of cross contamination.PROCEDURE1.Clean and sanitize food preparation areas and equipment after use.6. Maintain restrooms with toilet paper, soap and paper towels.10. Sweep and mop floors including under the shelves routinely. Record review of the facility's policy titled Personnel Guidelines Last revised date: 03/2026, indicated: POLICY: Food and Nutrition Services team members will follow hygiene and sanitary practices to preventcontamination. PROCEDURE3. Hands and Fingernailsa. Wash hands prior to beginning work.b. Wash hands after using the restroom, eating or drinking, using tobacco products,coughing, sneezing, blowing nose, before putting on gloves, after removing gloves, andafter engaging in other activities that contaminate the hands.4. Hair Restraintsa. Wear hair restraints that are designed to effectively keep hair from contacting exposedfood; clean equipment, utensils, and linens; and unwrapped single-service or single-usearticlesb. Hair restraints may include items such as hair bonnets and nets, beard restraints, andclothing that covers body hair. Hair should be fully covered with hair restraints withinthe department. Hair coverings should completely restrain hair, should not be wornoutside the community and remain clean.7. Eating and drinking are not permitted in food service, food storage, or preparation areas. Record review for thawing meat facility policy was unavailable due to the facility not providing one.

Based on observation, interview and record review, the facility failed to provide a safe, clean and comfortable homelike environment for 1 of 3 halls (Hall 100) and 1 of 22 occupied rooms on Hall 100 (room [ROOM NUMBER]) reviewed for a homelike environment. 1.The facility failed to provide a comfortable home-like living room area at the end of Hall 100 with unbroken end table and chairs without stains. 2.The facility failed to ensure the 2 over bed tables in an occupied resident room (#101) were in good repair and did not have lose trim on 1 over bed table and areas of missing laminate on the other over bed table. The failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life. Findings included:During an observation on 06/01/2026 at 9:30 a.m., the living room at the end of Hall 100 had 2 fabric chairs with discolored stained areas on the seat cushion approximately 5 inches on the first chair and the next chair had several 2-inch discolored spots on the seat cushion. In between the 2 chairs was an end table with the front leg leaning to the left at the bottom of the leg.During an observation on 06/01/26 at 9:35 a.m., room [ROOM NUMBER] had an overbed table with lose trim on 1 over bed table and areas of missing laminate on the other over bed table.During an interview on 06/01/2026 at 9:50 a.m., the maintenance supervisor said the chairs needed to be cleaned, and the end table and said the overbed tables needed to be replaced. He said the environment should be free of broken tables to promote safety and overbed tables should have smooth finish to be able to sanitize the surface. He said the end table must have been broken during the past weekend and said it had not been reported to him. He said he attempted to reattach the trim on the overbed table in room [ROOM NUMBER], however he should have replaced both overbed tables. He said he did not notice the other overbed table was worn and missing laminate last week.During an interview on 06/03/2026 at 3:45 p.m., the Administrator said she expected the overbed tables and furniture, to be free of stains and to be in good repair for a safe homelike environment for the residents. She said the furniture should have been reported to maintenance and was not reported. Record Review of the Maintenance Service Policy dated 02/01/2017 indicated Maintenance service shall be provided to all areas of the building, grounds, and equipment.PROCEDURE The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 1.Functions of maintenance personnel include but are not limited to: A. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. B. Maintaining the building in good repair and free from hazards.No policy on homelike environment was provided.

Based on observation, interview and record review, the facility failed to ensure that residents who need respiratory care were provided with such care, consistent with professional standards of practice for 1 of 25 residents (Resident #5) reviewed for respiratory care. The facility did not ensure Resident #5's oxygen concentrator was set at 3 LPM on 06/02/26 at 8:43 a.m. as ordered. This failure could place residents who required respiratory care at risk of not receiving proper care and treatment and decreased quality of life. Findings included:Record review of the admission record indicated Resident #5 was admitted on [DATE] and was [AGE] years old with diagnoses of chronic obstructive pulmonary disease (a disease which makes it hard to breathe in and out) and high blood pressure. Record review of physician orders dated May 2026 indicated Resident #5 had an order for oxygen at 3 LPM per concentration via nasal cannula continuous. Record review of care plan dated 03/06/2026 indicated Resident #5 had oxygen therapy related to COPD (Chronic Obstructive Pulmonary Disease), shortness of breath, Hypoxia (body's tissues do not receive an adequate supply oxygen), respiratory failure (occurs when respiratory system cannot adequately supply oxygen or remove carbon dioxide), pulmonary hypertension (high blood pressure which affects the arteries in the lungs).During an observation on 06/02/2026 at 8:43 a.m., Resident #5 was in her bed and was receiving oxygen and the concentrator was set on 5 LPM. During an interview and observation on 06/02/2026 at 8:53 a.m., LVN F checked the physician's orders and said the oxygen was ordered at 3 LPM per concentrator for Resident #5. LVN F walked down the hall to Resident #5's room and said this concentrator should not be on 5 LPM. Resident #5 said a nurse came in at night and turned the knob; however, she did not know who she was. Resident #5 said she felt ok. LVN F said for residents with COPD; too much oxygen can cause respiratory issues. LVN F checked Resident #5 O2 saturation and it was 99 % and LVN F said she would report the concentrator being on the wrong setting to the physician, family and DON. During an interview on 06/03/2026 at 1:00 p.m., the DON said her expectation was for the nurses to follow the physician's orders. The DON said the nurses are to check the concentrator at least daily however when the nurse enters room with resident on concentrator they were to check concentrators. DON said to much oxygen can slow respiratory rate.During an interview on 06/03/2026 at 3:45 p.m., the Administrator said she expected the nurses to follow the physician's orders or call the physician for new orders. She said the DON was responsible for the nurses to follow physician orders. She said maybe we should monitor closer in case the resident is changing concentrator. Record review of the Oxygen Therapy policy dated 04/2021 indicated It is the policy of this community to ensure all oxygen administration is conducted in a safe manner. Procedure 1. Verify there is an order for Oxygen administration to include: a. Method of Delivery b. Flow rate.

Based on interview and record review, the facility failed to ensure it's free of any significant medication errors for 1 of 8 residents (Resident #1) reviewed for significant medication errors. The facility failed to identify Resident #1 medication allergy to Hydrocodone and Resident #1 was administered 10 doses of Hydrocodone. This failure could place residents at risk for having allergic reactions such as skin rashes, itching, or swelling if given medications they are allergic to. Findings included: Record Review of Resident #1's face sheet dated 10/6/2025 indicated Resident #1 was a 78- year- old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Pain, Hyperlipidemia (high levels of fat in the blood.), and Primary Hypertension (high blood pressure). Record review of Resident #1's Care plan dated 04/22/2025 indicated Resident #1 had Codeine, Diazepam, Sulfa Antibiotics, Tramadol, Caffeine, Adhesive listed as her allergies with Review listed allergies prior to administering new medications, and Give MD a list of allergies when receiving orders to new medications listed as interventions. Record review of Resident #1's nurse's notes and progress notes from the dates 04/23/2025- 05/05/2025 indicated there were no notes related to the administration of Hydrocodone and any negative outcomes. Record review of Resident #1's Physician orders dated 04/17/2025 indicated Hydrocodone was ordered by the hospital physician. Record Review of Resident #1's Medication Record dated April 2025 indicated Resident # 1 had Codeine, Diazepam, Sulfa Antibiotics, Tramadol, Caffeine, Adhesive listed for her allergies. Resident #1 received 10 doses of PRN (as needed for pain) Hydrocodone -Acetaminophen Oral Tablet 5-325 MG related to pain. Dates & Times of administration:- April 24, 2025 at 11:50 a.m. (administered by: LVN E)- April 25, 2025 at 3:45 p.m. (administered by: LVN F)- April 25, 2025 at 10:43 p.m. (administered by: LVN F)- April 27, 2025 at 2:51 a.m. (administered by: LVN G)- April 28, 2025 at 12:32 a.m. (administered by: LVN G)- April 28, 2025 at 12:24 p.m. (administered by: LVN E)- April 28, 2025 at 8:44 p.m. (administered by: LVN F)- April 29, 2025 at 11:50 a.m. (administered by: LVN E)- April 30, 2025 at 10:57 a.m. (administered by: LVN E)- April 30, 2025 at 8:00 p.m. (administered by: LVN F) Record review of nurse report sheet dated: 04/22/2025 retrieved by LVN A indicated Resident #1 was allergic to Hydrocodone, Valium, Codeine, Clindamycin, Sulfa, and Tramadol and adhesive tape. Record review of Resident #1's Hospital discharge paperwork dated 04/17/2025-04/22/2025 (length of hospital stay) indicated Hydrocodone was listed as an allergy. Record review of default progress note entered by Nurse Practitioner B dated: April 30,2025 indicated Resident #1 had Hydrocodone listed as one of her allergies. Record review of Residents with No Recommendations dated: 05/1/2025 thru 05/13/2025 indicated Resident #1 was reviewed by the pharmacy consultant with no recommendation made. An interview on 10/07/2025 at 11:23 a.m. with Resident #1's family member indicated Family Member A said she was not present during any time when Resident #1 received Hydrocodone. She said she did not know how many doses were administered. Family Member A said she was told Resident #1 was allergic to Hydrocodone by Family Member B. She said Resident #1 wanted her to make the complaint to State. Family Member A said she wanted all investigation findings and communications to be given to Resident #1 and Family Member B. An interview on 10/07/2025 at 11:50 a.m. with Resident #1's family member indicated Family Member B said when Resident #1 was admitted on [DATE] she reported to the staff that Resident #1 was allergic to Hydrocodone. Family Member B said she was aware that Resident #1 had a urinary tract infection during her stay at the facility. Family Member B could not recall the name of the staff member she reported Resident #1 allergies too. She said Resident #1 reported to her that she was not forced to take the Hydrocodone but was told the Hydrocodone would not affect her because she would be sleeping. Family Member B said she was not present at any of the times Hydrocodone was administered. An interview on 10/07/2025 at 12:07 p.m. indicated Nurse Practitioner C said a person with a true medication allergy could have a skin rash, itching, hives, and or shortness of breath. She said people sometimes list medications they did not like taking under allergies, so they would not be given the medication even though it was not a true allergy. She said she would not have approved a resident with an allergy to Hydrocodone to receive Codeine to prevent a potential allergic reaction. Nurse Practitioner C said Resident #1 was given Hydrocodone first during her 04/17/2025 hospital stay before admitting to facility. and was not ordered Hydrocodone by the facility. Nurse Practitioner C said she cannot prescribe Hydrocodone, only the Physician can. She cannot recall if Resident #1 had any skin rashes, itching, hives, or shortness of breath, or negative effects from receiving 10 doses of Hydrocodone. An interview on 10/07/2025 at 2:00 p.m. indicated Pharmacist #1 said a true medication allergy is different from a side effect. He said most common symptoms of drug allergy are hives, rash, itching and fever. Pharmacist #1 said if a resident has a true drug allergy, they could potentially experience hives, rash, and itching. He said he would not recommend residents with a Codeine or Hydrocodone allergy to receive a dose of Hydrocodone. An interview on 10/07/2025 at 2:45 p.m. indicated the ADON said Resident #1's Medication administration record showed she was given 10 doses of Hydrocodone Oral Tablet 5-325 MG. The ADON said she reviewed Resident #1's allergies and said she should not have been given Hydrocodone. She said the potential harm to Resident #1 receiving Hydrocodone could be her having skin hives, skin rashes, and or itching. An interview on 10/07/2025 at 2:55 p.m. indicated the Administrator said Resident #1 had an allergy to Hydrocodone and should not have been given any Hydrocodone. She said Resident #1 could have had an allergic reaction causing her itching, skin rashes, and or skin hives. An interview on 10/08/2025 at 1:00 p.m. indicated Resident #1 said she did not know she had received a dose of Hydrocodone in the hospital. She said she didn't know she had received 10 doses of Hydrocodone at the facility. Resident #1 said staff did inform and educate her on medications before administering them to her. Resident #1 said she had a lot of allergies and had an active urinary tract infection during her 04/23/2025 stay at the facility. Resident #1 said she was not forced to take Hydrocodone. Resident #1 said she didn't know she had mental disturbances when she took the Hydrocodone. She said Family Member B told her she had mental disturbances when she took Hydrocodone. Resident #1 said when she was admitted to the facility, Family Member B told staff she was allergic to Hydrocodone. Resident #1 could not recall which staff her family member reported her allergies to. Record review of In- service training report on the topic of Allergies dated: 05/13/2025 indicated When getting new medication orders make sure to check the residents' allergies. If resident is allergic ask for alternative medication. Conducted by the Director of Nurses. Record review of the facility's policy General Guidelines for Medication Administration. revision dated: 08/2020 indicated (in part):Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer.7. a.- Working with the resident or their representative and appropriate clinicians (i.e., the consultant pharmacists, attending physician, medical director, etc.) the facility should determine the most appropriate method for administering medications that considers each resident's safety, needs, medications, schedule, preferences, and functional ability.

Based on observation interview, and record review, the facility failed to ensure correct installation, use, and maintenance of bed rails, for 3 of 7 residents (Residents #70, #87, and #102) reviewed for bed rails. The facility did not have the manufacturers' recommendations and specifications to follow for installing and maintaining the bed rails to prevent large gap in Resident #70's bed rail. The facility failed to develop care plans to address the risk of entrapment and interventions to prevent entrapment due to the use of bed rails for the residents who had histories of falling out of the bed for Residents #70, #87, and #102 The facility did not follow their Bed Mobility Assessments indicating the bed rails were not recommended for use for Residents #70, #87, and #102. The facility did not provide maintenance and monitoring of the bed rails per the manufacturer specifications/recommendations for residents with bed rails. The facility failed to maintain a copy of a manufacturer manual available for reference. An Immediate Jeopardy (IJ) was identified on 04/23/25. The IJ template was provided to the facility on [DATE] at 6:43 p.m. While the IJ was removed on 04/25/25, the facility remained out of compliance at a scope of a pattern and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on bed rails and reporting broken rails. These failures placed residents at risk for entrapment with serious injury or death. Findings included: 1. Record review of a face sheet for Resident #70 dated 04/23/25, indicated she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses including dementia, anxiety, and hereditary ataxia (group of neurological disorders caused by genetic mutations and characterized by progressive decline in coordination of movement and speech). Record review of Physician Orders, dated 04/23/25, indicated Resident #70 had 1/2 bed rails x 2 on the bed to facilitate with turning and repositioning every shift for bed mobility with a start date of 11/08/23. Review of Resident #70's quarterly MDS, dated [DATE], indicated she had a BIMS score of 11 indicated moderately impaired cognitive skills for daily decision making. Resident #70's functional status indicated she was non-ambulatory and required a one person assist for bed mobility. Review of Resident #70's care plan, revised 04/08/25, indicated the resident had a history of falls and was at a high risk for fractures from the falls. The care plan indicated Resident #70 required extensive assistance for bed mobility and required 2 persons with the mechanical lift for transfers. The care plan addressed the use of bed rails with interventions to evaluate and reevaluate for 1/2 bed rails quarterly on the quarterly assessment. The interventions included monitor for proper positioning and circulatory concerns any significant changes to physician promptly. The care plan did not include the risk of entrapement. Record review of Resident #70's Bed Rail Mobility Device Assessment, dated 10/14/24, indicated no concerns for risks of entrapment and bed rails were installed for bed mobility post falls following prior interventions of a floor mat and bed in low position. Record review of Resident #70's Bed Rail Mobility Device Assessment, dated 04/14/25, indicated bed rails were not recommended. Record review of Resident #70' consent for bed rails had been signed on 08/02/21 by her family. During an observation on 04/06/25 at 08:38 a.m., Resident #70 was in her with the bed rails on the left side of Resident #70's bed had a gap approximately 14 inches - 18 inches between the scoop mattress on the bed and the rail. During an observation and interview on 04/06/25 at 09:00 a.m., CNA A grabbed the left bed rail on Resident #70's bed and wiggled the rail. She said the left rail had been loose for 2-3 months. She said she thought the loose bed rail was reported 2-3 months ago but said she did not report. She said the bed rail would need to be reported to maintenance. She said the risk of the bed rail being loose and having a gap was the resident could fall from the bed. During an interview on 04/06/25 at 09:30 a.m., the DON said Resident #70 bed rails were used to assist during care with turning and repositioning the resident. She said the rails needed to be fixed to prevent falls. The DON said she was not aware of the bed rail for Resident #70 was loose and a large gap. During an interview on 04/07/25 at 10:30 a.m., the Director of Plant Operations said he was not aware Resident #70 bed rails were loose yesterday (04/06/25). He said after surveyor intervention, he had tightened the bed rails which fixed the gap in Resident #70 bed rails. He said he was responsible to check the bed rails in the facility and keep them secure. He said the bed rails should not have large gaps between the bed rail and the mattress. During an interview on 4/8/25 at 11:00 a.m., the Executive Director of Operations said the Director of Plant Operations was responsible to check the side rails every quarter for need of repairs or gaps. He said they were checked last in February 2025. The Executive Director denied knowing that Resident #70 bed rail was loose and had a large gap. During an observation and interview on 04/23/25 at 8:30 a.m., the Director of Plant Operations said he was responsible for checking bed rails quarterly. He said after surveyor intervention, he tightened the loose rail, and the rail had no gap on Resident #70's bed on 04/06/24. He said yesterday (04/22/25) a staff member had reported the bed rail was loose again. He said he did not remember which staff had told him the bed rail was loose again. He said he was going to work on the bed rail for Resident #70 and said he had forgot. He said he did not have work order documentation and he did not use a log of any needed repair. He said most of the time the staff just tells him what needs to be fixed. Resident #70 was in her bed and there was 9-inch gap between the mattress and the left bed rail. He looked at Resident #70's bed rail and said there should not have that large of gap between the rail and the mattress. He got underneath Resident #70's bed and he said the bolts were stripped out on the bed rails. He said he would have to get new bed rails, or he would have to replace Resident #70's bed. During an observation on 04/23/25 at 9:45 a.m. Resident #70 was in a new bed with assist bar and with her scoop mattress in low position with fall mats. Record review of the incident report dated 05/15/24 indicated Resident #70 had an unwitnessed fall at 3:45 p.m., she told nurse she had fell from her bed. Record review of the incident report dated 06/04/24 incident Resident #70 had an unwitnessed fall at 8:00 p.m., She was found bedside her bed and said she slid off the bed. During an interview on 4/23/25 at 10:00 a.m., the Director of Plant Operations said he did not maintain records of what he had fixed before. He said he did not keep any documentation of the maintenance requests made by staff or residents. He said he did not use a log or documented when he repaired items. He said Resident #70's bed and bed rails were the property of the facility. He said he did not have the manuals for the bed or bed rails. 2. Record review of face sheet for Resident #87, dated 04/23/25, indicated she was a [AGE] year-old female admitted on [DATE] and had diagnoses hemiplegia (weakness on one side of the body), muscle wasting (muscles thinning and loss of strength), and anxiety disorder. Record review of Resident #87's Significant Change MDS assessment, dated 01/21/25, indicated she was severely cognitively impaired with a BIMS score of 03. Resident #87's functional status indicated she was non-ambulatory and the assistance of 2 or more helpers was required for bed-to-chair transfer. Record review of Physician Orders, dated 04/23/25, indicated Resident #87 had 1/2 bed rails x 2 on the bed to facilitate with turning and repositioning every shift for bed mobility with a start date of 03/12/25. Record review of Resident #87's care plan, revised 12/18/24, indicated she had an ADL self-care performance deficit. She required extensive assistance of 2 persons with bed mobility. Interventions included the half siderails to be in the up position for safety during care provision and to assist with bed mobility, and to observe for injury or entrapment related to siderail use. Staff were to reposition the resident as necessary to avoid injury. Record review of Bed Mobility Device Assessment for Resident #87, dated 11/27/24, indicated the resident was totally dependent on staff for bed mobility and the use of a bedrail, grab/assist bar was not recommended. Record review of Bed Mobility Device Assessment for Resident #87, dated 02/27/25, indicated the resident was totally dependent on staff for bed mobility and the use of a bedrail, grab/assist bar was not recommended. Record review of an incident report dated 11/23/24 at 4:40 p.m., indicated Resident #87 fell from her bed. Record review of an incident report dated 11/26/24 at 8:48 p.m., indicated Resident #87 fell from her bed. Record review of an incident report dated 12/12/24 at 12:30 a.m., indicated Resident #87 fell from her bed. Record review of an incident report dated 12/19/24 at 1:30 a.m., indicated Resident #87 fell from her bed. Record review of an incident report dated 12/22/24 at 7:00 a.m., indicated Resident #87 fell from her bed. Record review of an incident report dated 12/25/24 at 4:08 p.m., indicated Resident #87 fell from her bed. Record review of an incident report dated 01/13/25 at 9:35 a.m., indicated Resident #87 fell from her bed. Record review of Resident #87' consent for bed rails indicated the form had been signed on 03/12/25 by her family. During an observation on 04/23/25 at 11:10 a.m., Resident #87 had two 1/2 bed rails, which were fitted with no gap greater than 4 inches. 3. Record review of face sheet for Resident #102, dated 04/23/25, revealed he was a [AGE] year-old male admitted on [DATE] and had diagnoses of intracranial injury (brain dysfunction due to injury), contractures to bilateral lower extremities (when muscles and tendons shorten), and was a functional quadriplegic (paralysis of all four extremities). Record review of Physician Orders, dated 04/23/25, indicated Resident #102 bed rails to assist with bed mobility with a start date of 04/02/24. Record review of Resident #102's Annual MDS assessment, dated 04/11/25, indicated he had severe cognitive impairment with a BIMS score of 03. Resident #102's functional status indicated he was non-ambulatory and dependent on 2 or more staff for ADLs. Record review of Resident #102's care plan, revised 06/07/24, indicated the resident required the use of 1/2 side rails to assist with bed mobility. The intervention was to evaluate and re-evaluate for 1/2 siderail use quarterly and as needed. The care plan did not address the resident's risk of entrapment. The care plan addressed the falls was revised on 01/23/25 indicated Resident #102 was high risk for increased falls and fractures and the goal was for resident to be free from falls. Record review of Resident #102's consent for bed rails indicated the form had been signed on 04/02/24 by his family. Record review of Bed Mobility Device Assessment for Resident #102, dated 01/04/25, indicated the use of a bed rail, grab/assist bar was not recommended. Record review of Bed Mobility Device Assessment for Resident #102, dated 04/04/25, indicated the use of a bed rail, grab/assist bar was not recommended. Record review of an incident report dated 05/10/24 at 4:00 p.m., indicated Resident #102 fell from his bed. Record review of an incident report dated 05/12/24 at 11:00 p.m., indicated Resident #102 fell from his bed. During an observation on 04/23/25 at 10:45 a.m., Resident #102 was in his bed and had 1/2 bed rails to both sides of the bed with no gaps. During an interview on 04/23/25 at 11:00 a.m., the DON said if the bed mobility assessment indicated the resident was not recommended for the use bed rails. The DON said the nurse should have reported it to her (the DON) and the maintenance to remove the bed rails. Review of facility policy, titled Bed Safety, effective 04/2021, indicated the following: Policy will strive to provide a safe sleeping environment for the resident. PROCEDURE 1.The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. 2. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: a. An inspection should be done by the Director of Plant Operations at installation/before use and quarterly thereafter of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; b. Review that gaps within the bed system are within the dimensions established by the FDA (Note: The review shall consider situations that could be caused by the resident's weight, movement, or bed position. c. Ensure that when bed system components are worn and need to be replaced, they are replaced with compatible components that meet manufacturer specifications; d. Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, ensure proper distance from the headboard and footboard, etc.); and . 10. When using side rails for any reason, the staff shall take measures to reduce related risks. The Executive Director of Operations was notified of the Immediate Jeopardy on 04/23/25 at 6:43 p.m. and was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal was accepted on 04/24/25 at 5:36 p.m. and reflected the following: On 04/23/2025 The Director of Plant Operations changed the bed for resident #70 with properly operating bed rails. On 04/23/2025 The Charge Nurse reassessed resident #70 for bed mobility and the bed mobility assessment for resident #70 was updated. The use of side rails was recommended per assessment. On 04/23/2025 The Charge Nurse reassessed resident #102 for bed mobility and the bed mobility assessment for resident #102 was updated. The use of side rails was not recommended per assessment. The Director of Plant Operations removed the assist bar for resident #102 per recommendations from assessment. On 04/23/2025 The Charge Nurse reassessed resident #87 for bed mobility and the bed mobility assessment for resident #87 was updated. The use of one bed rail for turning and repositioning recommended per assessment. The Director of Plant Operation removed the right bed rail from resident #102's bed. Bed Rail Entrapment Assessment on 4/24/2025 The Director of Plant Operations was educated according to Manufacturers Guidelines on proper installation of bed rails. The Director of Plant Operations conducted a Bed Rail Entrapment Assessment throughout the building to identify any bed rail posing a risk of entrapment. The Executive Director of Operation obtained the manufacturer's guidelines for each type of bedrail in the facility, and they are compatible for use with the beds that we have. The bed rails are not universal they are made for the model of bed we have. Any non-compliant bed rail was either fixed or replaced to meet assessment standards and proper installation according to the manufactures guide. The Director of Plant Operations will complete the Bed Rail Entrapment Assessment weekly x 4 weeks and quarterly thereafter. Completion date: 4/23/2025 Clinical Audits, The Director of Clinical Operations and/or designee will conduct a 100% audit of bed mobility assessments to ensure proper evaluation and documentation. If the bed mobility assessment indicated that bed rails were not needed, they were removed by the Director of Plant Operations. Completion date: 4/24/2025 Staff Education & In-Service Training. The Director of Clinical Operations and/or designee will lead training sessions to ensure team members understand proper procedures for identifying and addressing bed rail concerns. Topics included: Equipment Maintenance & Reporting, Team members must immediately report malfunctioning, broken, or non-working equipment to their Supervisor and the Director of Plant Operations via phone and on maintenance log. New team members will be educated regarding reporting any broken equipment during orientation. 1.The Executive Director completed educational training with the Director of Plant of Operations regarding the completion of the Bed Rail Entrapment Assessment quarterly per company policy. The assessment details what gaps in zones of the bed are acceptable. Zone 1 FDA recommended space is less that-less than 4-3/4 and Zone 3 FDA recommended space is less that 4-3/4. Zone 2, 4, and 5 are not used at our facility due to no bottom rails on any of our beds. Nursing staff and department managers educated on acceptable gaps for zone 1 and zone 3. Nursing staff will document on the licensed medication administration record daily the checks have been completed. Any gaps larger than 4-3/4 will be reported to the on-call phone and the maintenance log. Documentation will be completed on the company form for the assessment. The Assessment was previously completed on 2/10/2025 and 4/23/2025 by the Director of Plant Operations. The Executive Director of Operations completed educational training with the Director of Plant Operations on the manufacturer's guidelines on bed rails installation for the Medline (FCE1232RSRN) and Joerns beds (F14SC). Completion date: 4/24/2025 2. Proper Bed Rail Assessment Procedures Charge nurses must accurately complete bed rail assessments and determine if rails are suitable for resident use. Charge Nurses educated on how to accurately complete bed rail assessments. New charge nurses will be educated regarding completing an accurate bed rail assessment during orientation according to manufacturers' recommendation. If an assessment indicates bed rails are recommended, the team member must notify both the Director of Clinical Operations and the Director of Plant Operations immediately. New charge nurses will be educated regarding immediate notification to the Director of Clinical Operations and the Director of Plant Operations during orientation. Completion date: 4/24/2025 Accident/Incident Prevention: The Director of Clinical Operation and/or Designee will complete training on accident/incident prevention, including types of interventions put into place to prevent any further fall. Completion date: 4/24/2025 Care Plan Updates & Compliance The Clinical Reimbursement Coordinator will conduct a 100% audit of resident care plans, ensuring appropriate documentation of bed rail concerns. Care plans will be updated to specify bed rail risks and potential entrapment hazards. Completion date: 4/24/2025 Medical Director Notification On 4/23/2025 The Director of Clinical Operations notified the Medical Director of immediate jeopardy and reviewed bed rail policy and procedure. Plan of action reviewed with the Medical Director with no changes to the current policy. This practice will be reviewed monthly with the QA Committee to ensure no changes are needed to the current policy. Commitment to Resident Safety All actions outlined in this plan will be monitored for ongoing compliance, reinforcing our commitment to providing a safe environment for residents. On 04/25/25 at 1:45 p.m., the surveyor confirmed the facility implemented their Plan of Removal sufficiently to remove the Immediate Jeopardy (IJ) by: During an observation on 04/23/25 at 1:00 p.m., Resident #70 was on new low bed with just the grab bars with less than a 4-inch gap between each side of the mattress. During an observation on 4/23/25 at 1:30 p.m., Resident #102 was in his bed with left bed rail removed. Record review of the in-service dated 04/23/25 indicated all licensed staff were trained on care plans updates and included entrapment risk for residents with assist bars and bed rails indicated all licensed staff were trained. Record review of the in-services dated 04/23/25 indicated all licensed staff were trained which included assessments and the training included demonstration and staff demonstrating knowledge and location of bed mobility assessments in the electronic record. Record review of the in-service dated 04/24/25 indicated all staff were trained on bed mobility zone gap recommendations and reporting broken or loose bed rails. During an interview and record review on 04/25/25 at 8:35 a.m., the Executive Director of Operations said the interdisciplinary team (the DON, MDS Coordinators, Activity Director, Social Worker, Director of Therapy, and the ADONs and himself) were retrained on the manufacturer's guidelines for the bed rails. The Executive Director of Operations said he downloaded the manufacturer's guidelines for the bed rails for the two types of beds in used in the facility and pulled the online manual up on his computer to review. He said the Director of Plant Operations was in-serviced on the recommendations of the mattress to bed rail gap in Zone 3 (the area on each side of the bed between the side rail and the mattress) of the mattress being less than 4 and 5/8 inches as he pointed to the diagram of a bed on his computer with bed rails and measurements. The Executive Director of Operations said it was important for staff to report any concerns with the assist bars/bed rails to the Director of Plant Operations and the DON. The Executive Director of Operation said the facility reassessed residents who had assist bars/bed rails to determine which residents were able to use assist bar/bed rail based on their ability to use the bar for bed mobility and if bed rails were not recommended due to entrapment risks. He said for the residents who no longer needed the bed rail/assist bar, which included Resident #70 who was using 1/2 bed rails, was placed in a new bed with just the grab bars. He said education was provided to all residents and representatives with side rails on the bed and risk of using them. He said the residents, families and physicians were notified prior to removing or changing the type of bed rails. He said physicians' orders and consent would be obtained by the nurses before applying bed rails. The Executive Director of Operations said all staff were trained on the recommendations of the mattress to bed rail gap in Zone 3 of the mattress being less than 4 and 5/8 inches. During an interview on 04/25/25 at 9:10 a.m., the Director of Plant Operations said he received one-on-one in-services regarding the completion of the Bed Rail Entrapment Assessment quarterly per company policy. The assessment details what gaps in zones of the bed are acceptable. Zone 1 FDA recommended space is less that-less than 4-3/4 and Zone 3 FDA recommended space is less that 4-3/4. The Zone 2, 4, and 5 were not used at our facility due to no bottom rails on any of our beds He voiced a clear understanding of the risks related to gaps in the bed rails, on how to properly install the assist bars, and ensure the resident's safety. He said the facility would follow the manufacturer's guidelines. The Director of Plant Operations said he was checking beds weekly for proper installation and the need for repairs and all bed rails x 4 weeks to make sure the bed rails were not loose and there were no gaps greater than 4 and 5/8 inches from the mattress to the bed rail. During an interview and record review on 04/25/25 at 10:00 a.m., the DON said she completed an audit of all the residents to obtain a list of which residents used an assist bar or bed rails and if their assessment to determine if were safe to use the bed rail. The DON said the MDS nurses updated the residents with assist bars/bed rails care plans to include the risk of entrapment. She said the bed rails/assist bars were removed from the beds of the residents who were identified as not recommended for using a bed rail for safety. Record review with the DON reflected the audit was performed for all residents with assist bars/bed rails to include the list of resident care plans that were updated to reflect the use of the bed rails. The residents' physician orders were updated to reflect the use of the bed rails on those residents identified in the audit. Record review of the bed rail assessments had been updated for Residents #70, #87 and #102. She said Resident #70's bed rail assessment was not correct. She said the nurses have been retrained completing the bed rails assessement. She said all residents who have bed rails have consents, orders and correct assessments. During an interview on 04/25/25 at 10:30 a.m. MDS J said she was retrained and had completed updating care plans on all the residents who have or had bed rails. She said she included the risk of entrapment for the residents who remained with bed rails. During an interview on 04/25/25 at 10:50 a.m., the Medical Director said the facility notified him of the IJ related to bed rails and he confirmed the Administrator had notified him. Record review of in-services, dated 04/24/25, indicated the licensed nursing staff were trained on the proper use of assist bars/bed rails to include assessments for assist bars on care plan prior to usage. Record review of the in services dated 04/24/25 indicated all staff were trained on reporting broken equipment and included the gap recommendation of less than 4-5/8 for Zone 3 located between bed rail and mattress. During interviews on 04/25/24 from 10:30 a.m. to 11:30 a.m. indicated RN L, LVN L, LVN M, LVN N, LVN O, LVN P, LVN Q, LVN R, LVN S, LVN T, LVN U, LVN B, AND LVN V were trained on bed mobility assessments, care plans and how to report broken or bed rails with gaps. They were able to voice the dangers of improperly used or broken bed rails. They were knowledgeable about the consent, orders, and care plans. They all voiced if the bed rail needed repair or replaced and maintenance was not there, they would place the resident in a new bed if the bed rail could not be repaired would and notify the DON and the Executive Director of Operations. The LVNs were able to voice the space between the mattress and the bed rails could not be more than 4 and 5/8 inch. During interviews on 04/25/24 from 11:35 a.m. to 12:30 p.m., indicated CNA G, CNA W, CNA X, CNA Y, CNA Z, CNA A, CNA AA, CNA BB, CNA CC, CNA DD, CNA EE, CNA FF, CNA GG, CNA HH, CNA JJ, CNA KK, CNA LL, CNA MM, CNA PP, CNA QQ, CNA F, CNA RR, CNA SS, AND CNA TT were trained on reporting broken or gapping bed rails. They were able to voice the positive uses for bed rails as to enable the resident to participate with turning and maintain their mobility and the staff were aware of the dangers of bed rails. They all said they would report to the charge, if they saw the bed rails not being appropriate for the residents or problems with the bed rails. The CNA staff said the bed rails should be no more than 4 and 5/8 inch away from the mattress and the rail should fit snug and not wiggle. During an interview on 4/25/25 at 1:00 p.m., the DON said all staff who had not received the in-services and trainings, would be trained prior to their next shift and new hires would be trained as part of the new hire training. She said new admissions would be assessed for bed rails before they were placed in a bed with rails. The Executive Director of Operations was informed the Immediate Jeopardy was removed on 04/25/25 at 2:15 p.m. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 24 residents reviewed for range of motion. (Resident #48) The facility failed to maintain Resident #48's contractures of the left hand. The resident did not have a palmar cushion (a soft, padded device used to support and protect the palm of the hand and reduce finger flexion contractures) in place to his left hand daily to maintain ROM and prevent a decline on 04/07/25 at 9:30 a.m and 2:30 p.m. and on 04/08/25 at 8:00 a.m This failure could place the residents at risk for not receiving the care and services to maintain their highest level of well-being. Findings included: Record review of a face sheet dated 04/08/25 indicated Resident #48 was [AGE] years old and admitted to the facility on [DATE]. His diagnoses included hemiplegia (paralysis on one side of body) and hemiparesis (muscle weakness on one side of the body, often affecting the arms, legs, or face) following cerebral infarction (a pathological process that results in an area of necrotic tissue in the brain) affecting his left non-dominant side and contracture (a shortening and hardening of muscles, tendons, and other tissue, often leading to deformity and rigidity of joints) of multiple sites. Record review of a physician order for Resident #48 dated 10/27/24 indicated: Apply palmar cushion to left hand at all times to prevent further contractures - worn daily except for hygiene with skin checks for redness every shift and frequent nail trims. Record review of an annual MDS dated [DATE] indicated Resident #48 had a BIMS score of 11 indicating he had moderately impaired cognition, he had functional limitation of ROM of upper and lower extremities on one side and required maximal assistance for most ADLs. Record review of a care plan revised 03/17/25 indicated Resident #48 was to have a [NAME] cushion to his left hand at all times to prevent further contractures to be worn daily except for hygiene with skin checks for redness every shift and frequent nail trims. Interventions indicated to monitor/document/report and signs of complications related to arthritis, joint pain, joint stiffness, usually worse on wakening; selling; decline in mobility; decline in self-care ability; and contraction formation/joint shape changes. During an observation and interview on 04/06/25 at 10:33 a.m., Resident #48's fingers on his left hand were curling toward the palm of his hand. He demonstrated that he was unable to move his left arm, hand, or fingers. He said he had not had a hand roll in his hand for weeks, but that his hand always felt better with a cushion in it. During the following observations Resident #48 was without a palmar cushion to his left hand: 04/07/25 at 9:30 a.m. 04/07/25 at 2:30 p.m. 04/08/25 at 8:00 a.m. During observation and interview on 04/08/25 at 8:05 a.m., LVN B she was not aware of an order Indicating Resident #48 required a palmar cushion for his left hand and she had never observed him with one in his hand or applied one to his left hand. Resident #48 said he had a palmar cushion, but he did not know where it was. LVN B searched his bedside table, found his palmar cushion, and placed it into his left hand. Resident #48 said he was glad to have it back and his left hand felt comfortable. LVN B said the purpose of the palmar cushion was to prevent further contractures of the resident's left hand. LVN B said therapy was responsible for applying the palmar cushions to Resident #48's left hand and for making sure he had it in place every day. After checking Resident #48's orders she said he had an order to have the palmar cushion every day, but the therapist had not entered the order so that it would appear on the MAR. During an interview on 04/08/25 at 8:29 a.m., PT C said she entered the order for Resident #48's palmar cushion to his left hand because he was no longer receiving physical therapy and she wanted nursing to apply the [NAME] cushion daily on every shift. She said Resident #48 was to have the palmar cushion every day on every shift except during bathing to prevent further contracture and improve his ROM to his left hand. She said possible negative outcome of not utilizing the palmar cushion was worsening contractures and decreased ROM. During an interview on 04/08/25 at 8;44 a.m., the DON said she had been informed nursing had not been applying Resident #48's palmar cushion daily on every shift to his left hand. She said she was in the process of entering Resident 48's therapy order into the system so they would appear on his MAR. She said the purpose of the palmar cushion was to increase mobility, prevent further contractures, and decrease pain. She said not using them as ordered could cause decreased mobility, increased pain, and worsening contractures. During an interview on 04/08/25 at 11:40 a.m., the Administrator said the facility did not have a current policy that addressed resident contractures and their prevention and treatment.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen reviewed for dietary services. The facility failed to ensure all staff wore hair restraints while working inside the kitchen. The facility failed to ensure the fryer was clean and free from brown crusty particles in the fryer baskets above the open cooking oil and brown and black particles along the side ledges and large front ledge surrounding the open oil. These failures could place residents who ate meals prepared in the kitchen at risk of foodborne illnesses. Findings included: During observation and interview on 04/06/25 during initial tour of the kitchen at 08:30 a.m. the following was observed: * [NAME] H was observed standing between the stove and counters without a hair restraint covering her hair. She reached into her pocket and got her hair covering and began putting it on while tucking stray strands of hair underneath the covering. She said she had been washing dishes and had gotten hot and sweaty and took her hair restraint off and forgot to put it back on. She said a hair restraint should be worn at all times while in the kitchen to keep hair from falling into the food being prepared for the residents. * Dishwasher I was in the dishwashing area inside the kitchen without a hair restraint. She said she had just forgotten to put on a hair restraint. She said she had been instructed by the facility to always wear a hair restraint while in the kitchen to keep hair from falling into the food or equipment. * The facility deep fryer had 2 baskets sitting above the open cooking oil. The baskets had dime to quarter size pieces of dried brown crusty substances. What appeared to be smaller size pieces of the same brown crusty substance missed with black particles were covering the side ledges and the wide front ledge of the fryer. [NAME] H said the particles were probably left over from the lunch service on 04/04/25 when the facility served fried fish for lunch. She said the fryer baskets and ledges should have been cleaned after frying the fish. During an interview on 04/06/25 at 08:57 a.m., the Dietary Manager (DM) said hair restraints were always to be worn by staff when inside the kitchen. She said they had all been trained to wear hair restraints. She said not wearing hair restraints in the kitchen could result in food falling into food being prepared or into equipment and contaminating food served to residents. She said the fryer baskets should have been cleaned and not left with food particles in them. She said the ledges should have been cleaned of the food debris left on them. She said the possible negative outcome of not cleaning the fryer baskets and ledges could be cross contamination of food served to residents. She said the fryer was on the weekly cleaning schedule and she had witnessed staff change the oil in the fryer and clean the fryer on 04/03/25. She said the particles on the fryer and baskets were most likely from the fried fish served for lunch on 04/04/25. During an interview on 04/07/25 at 7:55 a.m., the Administrator said he was the DM's direct supervisor. He said he expected all kitchen staff to wear hair restraints while in the kitchen. He said hair restraints were worn to prevent cross contamination of food with hair falling into food being prepared. He said he could not comment on the condition fo the fryer during initial tour because he did not see it before it had been cleaned. He said he expected the fryer to be kept clean and without food debris to prevent cross contamination. Record review of a facility policy titled Sanitation - Personnel Hygiene last revised October 2023 indicated . Food and Nutritional Services staff will follow hygiene and sanitary procedures to prevent the spread of foodborne illness. 13. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Record review of a facility policy titled Sanitation - Kitchen Cleaning Schedule last revised November 2023 indicated . Food and Nutritional Services Personnel will be responsible to maintaining the cleanliness and sanitation of kitchen. According to the US Food and Drug Administration Food Code dated January 18, 2023: . 2-402.11 (A) . Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers the body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens, and unwrapped single-serve and single-use articles. . 6-601.11 (B) . The food contact surfaces of cooking equipment and pans shall be kept from encrusted grease deposits and other soil accumulations.

Based observation, interview, and record review, the facility failed to ensure residents who were incontinent of bowel and bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #100) reviewed for incontinent Care. The facility failed to ensure that CNA F did not wipe Resident #100's perineal (area between the legs) area from back to front while providing incontinent care on 04/07/2025. This failure could place the residents at risk of cross-contamination and development of urinary tract infections. Findings included: Record review of face sheet, dated 04/07/2025, indicated Resident #100 was a [AGE] year-old female admitted on [DATE] with a urinary tract infection. Record review of quarterly MDS assessment dated [DATE] indicated Resident #100 was cognitively intact with a BIMS score of 15 and was always incontinent for bladder and bowel. Record review of comprehensive care plan dated 01/27/2025 indicated Resident #100 required extensive assistance of 1 person for personal hygiene and toilet use. Resident #100 care plan was revised on 04/07/25 she was receiving Cipro 500 mg BID for 7 days for a urinary tract infection. During an observation on 04/07/25 at 10:30 a.m. CNA F and CNA G was performing incontinent care on Resident #100. CNA F cleaned the peri area with wiping towards the rectum. CNA G assisted CNA F and they turned Resident #100 on her right side. Then CNA F cleaned the rectal area and she wiped towards the vaginal area x 1. During an interview on 4/7/25 at 10:45 a.m., CNA F said she had been trained on incontinent care. She said she should have wiped from clean to dirty. She said the resident did not have stool, but she should have wiped the back side away from the frontside. During an interview on 4/7/25 at 11:15 a.m., the DON said the facility used the check off sheet as their policy for incontinent care. She said her expectation was for the staff to wipe from the front to the back to prevent infections. Record review of the Skill / Procedure: Peri / Incontinent Care dated 06/2013 indicated . 18. Clean rectal area. Use tissue or brief to remove any fecal matter present. Cleaned front to the back using separate section of the wipe for each individual stroke.

Based on observation, interview, and record review, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles on 1 of 3 medication carts observed. (Hall 100 Rooms 109 - 120 medication cart) observed in that: LVN B was not aware of a loose pill and scattered debris, powdery and sticky substance in the bottom of the Hall 100 medication cart drawers and did not remove the loose pill or clean scattered debris, powdery and sticky substance in the medication drawers. These failures could place residents at risk of not receiving prescribed drugs or contaminated medication. Findings included: During an observation and interview on 04/08/25 at 8:45 a.m., during review of the Hall 100 medication cart with LVN B, she said she was giving patient medication off this cart today. The cart review revealed the 3rd drawer contained 1 loose unidentified pill that was not labeled and not sealed in packaging, scattered debris from medication card pill packs, and a whitish brown powdery substance with sugar like crystals scattered about 1/2 inch width along the back of the drawer with a sticky brown substance in the bottom crease of the drawer containing resident's prescribed medications. The 4th drawer contained debris from medication card pill packs, a whitish brown powdery substance with sugar like crystals about 1/4 inch width along the back of the drawer with a sticky brown substance in the bottom crease of the medication drawers containing resident's prescribed medications, and a sticky pinkish/ brown substance sticking a box of insulin syringes to the bottom of the drawer. LVN B said the cart should be cleaned and no loose pills should be in the drawers. She said Maintenance pressure washes the carts sometimes and the nurses that use the cart were responsible for wiping down the bottles on the cart. She said she was educated to keep the cart clean. She said the resident medication was not at risk due to the medication was sealed with no holes in the packages, but the medication cart should be wiped down. During an interview on 04/08/25 at 9:46 a.m., the DON said the ADON's were responsible for ensuring the medication carts were clean and all expired medication and loose pills removed. She said the nurse's giving medication off the medication cart were the back up to ensure the medication carts were clean and no loose pills were on the cart. She said the dirty medication cart was possibly overlooked. The DON said the nurses were all educated to ensure the medication carts were clean and the ADONS reviewed and cleaned them weekly and as needed. She said the resident risk of a dirty medication cart was a possible risk of resident infection. The DON said her expectation was all medications carts were cleaned weekly and as needed. During an interview on 04/08/25 at 10:30 a.m., ADON D said she was responsible for station A and ADON E was responsible for station B that included the Hall 100 medication cart. She said the ADONs were supposed to check and clean the medication carts for their stations weekly. She said the dirty medication cart was possibly missed or overlooked. ADON D said ADON E had worked nights and were unavailable for interview at this time. She said the nurses giving medication off the medication cart were the back up to ensure the medication carts were clean with no expired medications on them. ADON D said the resident risk of a dirty medication cart was possible spread of infection. During an interview on 04/08/25 at 11:00 a.m., the Administrator said the charge nurse's providing medication off the medication cart were responsible for ensuring the medication cart was clean. He said the ADON's were the backup, they were responsible for weekly audits to ensure the medication carts were clean. The Administrator said the medication cart was possibly overlooked. He said the resident risk of a medication cart that was not clean was possible cross contamination. The Administrator said his expectation was for all medication carts to be clean. Record review of a policy revised August 2024, titled, Storage of Medications indicated, .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.9. Medication storage areas are kept clean, .

Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 4 (Resident #1) residents reviewed for medication errors. 1. The facility failed to administer Resident #1 the appropriate dose of morphine. Resident #1 was administered 1ml (20mg) of morphine every 3 minutes from 11:15 a.m. to 11:39 a.m. (180mg) instead of 1ml (20mg) every 30 minutes. 2. The facility failed to ensure Resident #1's morphine order was properly transcribed. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on [DATE] and ended on [DATE]. The facility had corrected the non-compliance before the survey began. This failure could place residents at risk for harm or death relating to being administered too much medication. Finding Include: 1. Record review of Resident #1's face sheet dated [DATE] indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe), epilepsy (brain condition that causes reoccurring seizures), diabetes with neuropathy (nerve damage that occurs as a complication of diabetes), paranoid schizophrenia (intense paranoia and delusional thinking), legally blind (severely impaired vision), and pain. Record review of Resident #1's physician orders dated [DATE] through [DATE] indicated she had an order morphine sulfate (concentrate) oral solution 100mg/5ml give 1ml by mouth every 2 hours as needed starting [DATE]. Record review of Resident #1's quarterly MDS dated [DATE] indicated she usually understood others and was usually understood by others. The MDS indicated she had a BIMS of 7 (severely impaired cognitively). The MDS indicated she required total dependence with self-care, bed mobility, transfers, and dressing. The MDS indicated she received scheduled pain medication regimen, and she is taking high-risk drug of opioid. Record review of Resident #1's care plan last revised [DATE] indicted she was at risk for experiencing discomfort or pain with interventions including administer medication to relieve pain as ordered and discuss with the physician and review medications as indicated to ensure she was on the least amount of medication at the lowest dose to treat her pain. Record review of Resident #1's MAR dated [DATE] indicated Resident #1 had been administered 1ml (20mg) of morphine on [DATE] at 10:30 a.m. and 2:00 p.m. by LVN A. Record review of Resident #1's morphine sulfate prescription label dated [DATE] indicated morphine sulfate 100mg/5ml give 1ml by mouth or under tongue every 30 minutes as needed until comfortable and then every 2 hours for pain or shortness of breath. Record review of Resident #1's Nurse Progress Note dated [DATE] at 11:58 a.m. authored by LVN A indicated Resident #1's sitter approached the nurse's station with the resident's family member on the phone stating Resident #1 was in pain. Resident #1 had received routine Norco 7.5mg/325mg one tablet at 7 a.m. and prn morphine 1ml at 10:30 a.m. LVN A assessed the resident to have increased respirations and heart rate, and she was noted to be with sounds of distress, grimacing and stating she was hurting and saying Lord Help Me. LVN A contacted Hospice RN and received orders to administer morphine 1ml (20mg) every 3 minutes until the resident was at comfort level and pain subsided, then start morphine 1ml (20mg) every 2 hours routinely around the clock. The note indicated morphine 1ml every 3 minutes was initiated. Morphine was administered every 3 minutes for 9 doses with the resident's subjective and objective signs and symptoms of pain resolved after the 9th dose. Hospice RN notified of morphine on hand and status of resident needing more morphine. Record review of Resident #1's undated Narcotic Count Sheet for morphine sulfate 100mg/5ml bottle indicated the dosage was give 1ml by mouth/under tongue every 2 hours as needed for pain or shortness of breath. The Narcotic Count Sheet indicated the initial amount of morphine received was 45ml. The Narcotic Count Sheet indicated Resident #1 received 1ml of morphine on [DATE] at 10:30 a.m., 1ml of morphine on [DATE] at 11:15 a.m., 1ml of morphine on [DATE] at 11:18 a.m., 1ml of morphine on [DATE] at 11:21 a.m., 1ml of morphine on [DATE] at 11:24 a.m., 1ml of morphine on [DATE] at 11:27 a.m., 1ml of morphine on [DATE] at 11:30 a.m., 1ml of morphine on [DATE] at 11:33 a.m., 1ml of morphine on [DATE] at 11:36 a.m., 1ml of morphine on [DATE] at 11:39 a.m., 1ml of morphine on [DATE] at 12:00 p.m., and 1ml of morphine on [DATE] at 2:00 p.m. all doses administered by LVN A. During an interview on [DATE] at 3:51 p.m., LVN A said on [DATE] around 11:00 a.m. Resident #1's sitter, who was on the phone with Resident #1's family member, notified her of Resident #1 being in pain. She said Resident #1 received her dose of Norco 7.5mg/325mg earlier that morning at 7:00 a.m. and prn morphine 1ml (20mg) at 10:30 a.m. She said Resident #1, remained tensed, crying, moaning, grimacing and stating she was hurting. She said she contacted Hospice RN and received new orders to administer morphine 1ml (20mg) every 3 minutes until the resident was comfortable and then start morphine 1 ml (20mg) every 2 hours routinely around the clock. She said she clarified and confirmed the order 2 or 3 times with Hospice RN. She said she initiated the morphine 1ml (20mg) every 3 minutes and administered a total of 9 doses over a 24-minute period to Resident #1 with pain resolved. She said she remained in Resident #1's room at her bedside and set an alarm on her cell phone to monitor her pain every 3 minutes and administered the morphine when she continued to complain of pain. She said after the 9th dose of morphine, Resident #1 was resting comfortably with no complaints of pain or signs of discomfort. She said she notified Hospice RN at around 12:00 p.m. of Resident #1's morphine supply running low, and Hospice RN told her she would deliver more morphine when she came to assess the resident. She said she administered Resident #1 morphine 1ml (20mg) again at 12:00 p.m. for complaints of pain with effectiveness. She said she administered another dose of morphine at 2:00 p.m. to follow the ordered routine dosing of morphine to be given every 2-hours. She said around 2:30 p.m., Hospice RN arrived at the facility during report, identified the morphine order was transcribed wrong. She said Resident #1 was supposed to have received morphine 1ml (20mg) every 30 minutes not every 3 minutes. She said Hospice RN notified Resident #1's RP and family of the incident and offered Narcan to reverse the effects and/or transfer to the ER for evaluation, but the RP and family denied the treatment. She said Hospice RN assessed Resident #1 with no abnormal findings and directed her and LVN D to hold all medications for 4 hours and assess the resident's vital signs every 30 minutes for 4 hours and to notify hospice with any changes. She said she notified the DON of the incident with Resident #1's morphine dosage, and she was instructed to complete a medication error incident. She said she received 1:1 training from the DON and ADON regarding if orders received did not seem correct or if she was uncomfortable with administering a medication, she needed to contact the DON for clarification before administering. She said she clarified the order with Hospice RN ,d+[DATE] times, and Hospice RN was communicating with the physician via text while on the phone with her and she administered what the physician ordered. She said LVN B was at the nurses' station when she received the orders and heard the conversation. She said she was not familiar with the hospice service company providing Resident #1's care and thought the morphine dose was a new pain management treatment plan specific to this hospice. She said she was alarmed with the dosing which was why she clarified the order with the hospice nurse ,d+[DATE] times. She said she was aware of signs of overdose of morphine to include decrease respirations, decrease heart rate, drowsiness, and confusion. Record review of Resident #1's Nurse Progress Note dated [DATE] at 3:20 p.m. late entry authored by LVN A indicated Resident #1 was being fed by sitter at this time, no concerns noted, resident stable, staff will continue to monitor. Weekend Supervisor aware of events. At 1:00 p.m. family member arrived, resident reassessed and VS WNL. The resident was alert, and the family member fed the resident. Resident #1 had no verbal complaints of pain/ discomfort or non-verbal signs and symptoms of pain/discomfort. The resident was resting at this time and the nurse would continue to monitor. At 2:30 p.m., Hospice RN arrived to deliver Resident #1's Morphine, and assessed the resident indicating the vital signs were WNL. Hospice RN gave orders to hold all medications for 4 hours and assess vital signs every 30 minutes for 4 hours. Hospice RN offered Resident #1's family member to administer Resident #1 Narcan or send to the ER for accidental overdose of morphine and the family member declined. During an interview on [DATE] at 2:22 p.m., Hospice RN said she received a report from LVN A Resident #1 was having a pain crisis and she had already had her Norco 7.5mg/325mg around 7:00 a.m. and a dose of morphine 1ml (20mg) around 10:30 a.m. She said she contacted the hospice physician with the report and assessment and was given new orders to administer morphine 1ml (20mg) every 30 minutes until pain subsides or comfortable and then every 2 hours as needed. She said LVN A repeated back the order and instead of every 30 minutes she said every 3 minutes and she corrected LVN A and instructed the medication needed to be provided every 30 minutes not 3 minutes. She said she received a call from LVN A regarding Resident #1's morphine supply was low. She said when she arrived at the facility around 2:15 p.m. to drop of the morphine prescription and assess Resident #1, during conversation and narcotic count, she discovered Resident #1 was administered morphine 1ml (20mg) every 3 minutes starting at 11:15 a.m. through 11:39 a.m. totaling 9 doses (180mg) in 24 minutes and additional morphine 1ml (20mg) given and 12:00 p.m. and 2:00 p.m. She said when she learned of the morphine overdose, she assessed Resident #1 and contacted the hospice physician. She said the hospice physician provided options of the antidote of Narcan and/or send the resident to ER for evaluation. She said she informed Resident #1's RP of the accidental overdose and the options suggested by the hospice physician. She said the RP stated she felt Resident #1 was comfortable and did not want an antidote administered. She said the RP was informed of the potential effects if antidote not given and she verbalized understanding. She said facility staff was notified to contact hospice of any changes. She said she was contacted by LVN D around 5:00 p.m., indicating Resident #1's respirations were more labored and decreased, and family was requesting hospice to reassess the resident. She said she returned to the facility and completed an assessment on Resident #1 and reported findings of respiratory rate of 6 breaths per minute to the hospice physician. She said she rediscussed the antidote and ER evaluation options and effects if administered and RP declined. She said she provided end of life counseling with RP and family. She said she was contacted around 4:30 a.m. on [DATE] Resident #1 had no signs of life and requested RN to facility and pronounce time of death. Record review of Resident #1's hospice assessment dated [DATE] time in at 2:15 p.m. authored by Hospice RN indicated the resident's facility nurse called indicating the resident was having pain after already receiving Norco 7XXX,d+[DATE] mg two hours ago around 8:00 a.m. and a dose of morphine 1ml (scheduled every two hours) 30 minutes ago at 10:35 a.m., Hospice MD was notified, and new orders were received for morphine 1ml to be given every 30 minutes as needed for pain or shortness of breath until patient was comfortable and then every two hours. LVN A was given new orders and verbalized understanding. LVN A called back and stated Resident #1 would not have enough medication of morphine to last through the day and new orders/directions were sent to pharmacy. The morphine prescription would be picked up and delivered to the facility (by Hospice RN). Upon arriving to the facility, Resident #1's pain status and morphine doses given was verified when LVN A reported she had given 9 doses of morphine and last dose given was at 2:00 p.m. Hospice RN reviewed the resident's Morphine Narcotic Count Sheet and the times it was administered, and morphine had been given every 3 minutes and not every 30 minutes. The note indicated LVN A stated she had transcribed the order incorrectly for every 3 minutes. Resident #1 was assessed (by Hospice RN), and vital signs were taken, and Hospice MD was notified of the medication error and patient status. New orders given for the facility to hold the resident's pain medications for four hours, to obtain vital signs every 30 minutes, and to call Hospice if any changes occurred. The note indicated Hospice RN spoke with the resident's family member as well as the facility staff nurse with additions to the plan of care with verbalization of understanding. Record review of Resident #1's hospice assessment dated [DATE] time in at 5:00 p.m. authored by Hospice RN indicated LVN D called around 4:45 p.m. and Resident #1's family member requested for Hospice RN to return to the facility and assess Resident #1 because her respirations had changed and were more labored. Hospice nurse returned to reassess Resident #1. Family members were notified of options at the facility or send the resident to ER since this was not related to the Hospice diagnosis, but for treatment for symptoms from facility nurse giving incorrect frequencies of morphine Hospice RN discussed with Resident #1's family members regarding what happened if Narcan was administered to reverse the medication and the resident's pain could return and pain medications would still be held until patient was stable prior to resuming pain medication or send the resident to ER where they would likely give the Narcan as treatment. Hospice RN informed family members at bedside if Narcan was not given she could very well pass soon. Family member asked why Narcan would be given, and other family member responded because the morphine given was too much. Family members said she looked comfortable and would rather her be comfortable and pass rather than give her medications could cause her to be in pain again. Hospice RN gave direction for family members to contact additional immediate family because with her decreased respirations and pauses between breaths as the resident may soon pass. During an interview on [DATE] at 12:53 p.m., LVN D said she worked the ,d+[DATE] p.m. shift on [DATE] and during shift change she was made aware the Resident #1 had received an accidental overdose of morphine during the previous shift. She said Resident #1 was monitored throughout her shift and obtained vital signs every 30 minutes starting around 3:30 p.m. for 4 hours ending around 7:30 p.m. She said she did contact the hospice RN at the request of Resident #1's family because her respirations were labored and decreased at around 5:00 p.m. She said Resident #1's alertness and respiratory rate decreased throughout the shift. She said when she made her last rounds with oncoming nurse LVN C around 10 p.m. Resident #1's respiratory rate was down to 3 breaths per minute. Record review of Resident #1's Nurse Progress Note dated [DATE] at 5:05 a.m. authored by LVN C indicated nurse was called to resident room by Resident #1's sitter and no signs of life was present this nurse called hospice nurse, she arrived, assessed Resident #1, and pronounced time of death. During an interview on [DATE] at 2:18 p.m., LVN C said she worked the 10 p.m.-6 a.m. shift on [DATE] - [DATE] and during shift change she was made aware the Resident #1 had received an accidental overdose of morphine during the morning shift and she was being monitored. She said Resident #1 was not responding to verbal or tactile stimuli during her assessments and respiratory rate was at 3 -4 breathes a minute with periods of apnea. She said Resident #1's RP and family was at bedside most of the night. She said around 4:15 a.m., Resident #1's family member reported the resident was not breathing and had no signs of life. She said she went to assess Resident #1 and found no signs of life and contacted Hospice RN. She said Hospice RN arrived at the facility and pronounced Resident #1 deceased around 4:30 a.m. Record review of Resident #1's hospice assessment dated [DATE] time in at 4:38 a.m. authored by Hospice RN indicated Resident #1 expired on [DATE] at 4:38 a.m., death was pronounced by Hospice RN, after no pulse, respirations or other signs of life noted for 2 full minutes. During an interview on [DATE] at 2:13 p.m., LVN B said she was present at the nurses' station when LVN A was receiving the morphine orders for Resident #1, but she only heard LVN A's side of the conversation and heard her verify morphine 1ml every 3minutes until pain subsided and ask for the nurse's name and prescribing MD's name. She said she did acknowledge to LVN A this order for morphine seemed to be a lot. She said she left the nurses' station during the phone call but if she was transcribing the order she would have questioned the order or contacted the weekend supervisory before administering. During an interview on [DATE] at 10:20 a.m., the Hospice Physician said Hospice RN called her on [DATE] at 11:08 a.m. reporting Resident #1 was having a pain crisis and had received Norco 7.5mg and 1ml of morphine (20mg) over the last 2 hours with no relief. She said she gave orders for Resident #1 to have Morphine 1ml (20mg) every 30 minutes until her pain subsided or comfortable and then continue Morphine 1ml (20mg) every 2 hours for pain. She said around 2:57 p.m. Hospice RN contacted her and reported facility nurse (LVN A) transcribed the order incorrectly and had administered Resident #1's morphine 1ml (20mg) every 3 minutes for 9 doses (total of 180 mg in 24 minutes) instead of every 30 minutes. She said Hospice RN reported vital signs, assessment, and last dose of morphine 1ml (20mg) was at 2:00 p.m. and resident's vital signs were stable. She ordered for Narcan to be administered or to transfer the resident to the ER for evaluation which was declined by RP. She said she ordered for facility staff to continue to monitor Resident #1 and report to hospice with any changes. She said Hospice RN notified her around 4:30 p.m. of Resident #1's respiratory rate decreasing, and she returned to the facility to complete an assessment. She said Hospice RN reported the resident's decrease in responsiveness and respiratory rate. She said she advised Hospice RN to offer the resident's family the Narcan to be administered or sending the resident to the ER for evaluation, again the RP declined. She said morphine should never be given every 3 minutes because with liquid morphine it takes ,d+[DATE] minutes to take affect which is why it was ordered every 30 minutes during a pain crisis. She said the morphine could remain in the body's system for up to 6 hours depending on the body's metabolism. She said she had never ordered morphine 1ml (20mg) every 3 minutes as it would cause respiratory distress or failure if multiple doses given which could lead to death. During an interview on [DATE] at 12:42 p.m., the Attending NP said she was not contacted regarding Resident #1's morphine accidental overdose/medication error. The Attending NP said if she had been notified of the morphine overdose, she would have ordered for an antidote like Narcan to be administered and to monitor respirations or given an order for Resident #1 to be sent to the hospital due to her being on hospice. The Attending NP said she had never heard of morphine 20mg be given every 3 minutes and a large dose administered would cause respiratory distress or failure leading to death if antidote was not administered. During an interview on [DATE] at 2:30 p.m., RN E said she was the RN supervisor during the previous weekend (time of the incident), and she was not notified of the medication discrepancy until around 2:15 p.m. when she was asked for the DON's phone number to discuss the incident with her. She said if she was made aware of the medication discrepancy, she would have contacted Hospice RN or the hospice physician for clarification because the transcribed dose was not within the standard morphine prescribing guidelines. During an interview [DATE] at 2:47 p.m., the facility contracted Pharmacist said the effects of morphine overdose was respiratory depression, confusion, disorientation, fatigue, and sleepiness. She said she had never heard of morphine 20mg be given every 3 minutes and that was a concerning high dosage. The Pharmacist said the order should have been clarified before administering. During an interview on [DATE] at 5:00 p.m., the DON said she was not made aware of the incident with Resident #1's morphine incorrect dosage until [DATE] around 2:45 p.m. She said she contacted the consulting pharmacy, had LVN A complete medication error incident, verified hospice was aware, took statements, interviewed involved staff, and visited with Resident #1 and family. The DON said if licensed staff received an order that did not seem correct, outside of prescribing guidelines, or if they were not comfortable giving a medication, they should contact her, for further discussion and clarification from the pharmacist and the ordering or attending physician. The DON said the morphine overdose could have caused respiratory depression and death. The DON said Resident #1's RP was offered an antidote but declined. The DON said vital signs would be monitored more often or longer if an order was given by the physician. The DON said she contacted their pharmacist consultant regarding the overdose and was advised to complete a medication error incident report. She said the facility pharmacy consultant scheduled an in-person training for all licensed facility staff next week for continued training and the consultant would be providing staff a resource to have available for narcotic minimal and maximal dosage (not to exceed). The DON said she had provided training on [DATE] to licensed staff about clarification of verbal orders, completed medication pass competency checks with scheduled staff since the incident, and performed a chart audit of all residents on pain medication verifying adequate frequency/duration. The DON said she was performing medication pass review competency checkoffs on the licenses staff as they return to work and will not allow them to work if competency check not passed. The DON said she expected the licensed staff to use their professional judgement and not to provide medications they did not feel comfortable administering or to contact her prior to administering for additional clarification. Record review of the facility's Preventing and Detecting Adverse Consequences and Medication Error policy- dated [DATE] indicated, 2. When a resident receives a new medication the medication order is evaluated for the following a. the dose route of administration duration and monitoring are in agreement with the current clinical practice clinical guidelines and or manufacturers specifications for use Record review of an In-Service training report dated [DATE], with LVN A one on one training, with contents or summary of the training session included: if you receive a verbal order from MD or nurse that you do not feel comfortable following through with contact the DON immediately to discuss the orders received and MD or nurse will be contacted after discussion of order to verify or clarify order received. Record review of an In-Service training report dated [DATE], with facility charge nurses with contents or summary of training session included: if you receive a verbal order from MD or nurse that you do not feel comfortable following through with contact the DON immediately to discuss the orders received and MD or nurse will be contacted after discussion of order to verify or clarify order received, indicated 26 charge nurses signed the in-service record or received the training via phone conversation. Record review of Medication Pass Review Competency Checkoffs dated [DATE] -[DATE] indicated 8 charge nurses had completed and passed medication pass competency check off. Record review of a facility audit dated [DATE] at 9:30 a.m. indicated all residents with pain medication were reviewed for correct frequency and/duration of pain medications. Record review of Incident logs from [DATE] through [DATE] indicated there were no other medication error incidents at the facility. During interviews on [DATE] from 11:30 a.m. - [DATE] to 5:00 p.m., 2 RNs (RN E, RN F), and 9 LVNs (LVN A, LVN B, LVN C, LVN D, LVN G, LVN H, LVN I, LVN J, and LVN K) were able to identify correct protocol for receiving verbal orders, clarifying and repeating the order back to the prescriber and if orders were not within the prescribing guidelines or if they did not feel comfortable following or administering the orders, they were to contact the DON immediately to discuss the issues and the DON would contact the MD or nurse to verify/clarify the order received. All staff were able to identify the signs and symptoms of accidental overdosing of morphine and protocols to follow. On [DATE] at 05:25 p.m., the Administrator was informed of the Immediate Jeopardy. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before survey began.

Based on observation, interview, and record review, the facility failed to coordinate assessments with the PASRR program, including incorporating the recommendations from the PASRR evaluation report into a resident's care planning for 1 of 2 residents reviewed for PASRR assessments. (Resident #1) The facility did not provide and arrange for a specialized customized manual wheelchair for Resident #1 as recommended and agreed upon by the IDT within the time frame set by PASRR. This failure could place residents who are PASRR positive at risk of not receiving the necessary services/DME that would enhance their quality of life. Findings included: Record review of a face sheet dated 03/24/2025 indicated Resident #1 was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included moderate intellectual disabilities (condition that affects a person's ability to learn and function at an expected level), developmental disorder of speech and language (communication disorder that interferes with learning, understanding, and using language), hypertension (condition in which the force of the blood against the artery walls is too high), hypertensive chronic kidney disease (a long-standing kidney condition that develops over time due to persistent or uncontrolled high blood pressure), chronic kidney disease (condition impairs kidney function, causing kidney damage), and benign prostatic hyperplasia (noncancerous enlargement of the prostate gland) with lower urinary tract symptoms. Record review of a PCSP dated 01/16/2025 for Resident #1 indicated the IDT recommended and agreed on continued Habilitation coordination and a CMWC. Record review of a care plan last revised 01/16/2025 indicated Resident #1 was PASRR positive (screening to identify if resident has PASRR conditions serious mental illness, intellectual disability, developmental disability or related conditions) for intellectual disability. He is visited by a PASRR service coordinator and will specialized services. On 01/16/2025 Quarterly PCSP meeting held with Habilitation Coordinator and IDT team. The Habilitation Coordinator explained to the IDT that PASRR's decision regarding the CMWC overrules the facility therapy's determination regarding the CMWC. The Patient will continue to receive habilitation services, patient measured for customized manual wheelchair per DME company. Goals included for Resident #1 to maintain highest level of practicable wellbeing through the review date. Record review of a quarterly MDS dated [DATE] indicated Resident #1 had severe cognitive impairment. He had unclear speech and was usually understood and usually understood verbal communication. He required substantial or maximal assistance for most activities of daily living and used a wheelchair for mobility. He was considered by the state level II PASRR process to have serious mental illness and intellectual disability. During an observation on 03/25/2025 at 10:30 a.m., Resident #1 was sitting in his standard wheelchair in his room. Resident #1 reported that he was pleased with care provided by the facility and used his standard wheelchair to move about the facility without difficulty. Resident #1 acknowledged that he is to receive a custom wheelchair, but it has not been delivered. During an interview on 3/24/2025 at 4:05 p.m., the Clinical Reimbursement Coordinator said PASRR requirements mandate that the facility complete an accurate request for NF specialized services recommended (CMWC) and agreed upon at the IDT meeting into the online portal within 20 business days and DME or a CMWC must be ordered within 5 business days after receiving notification of the approval through the LTC Online Portal. She said Resident #1 refused a CMWC during quarterly meetings up until 01/16/2025 and even though the facility physical therapist did not recommend a CMWC for Resident #1, the Habilitation Coordinator explained to the IDT that PASRR's decision regarding the CMWC overrules the facility therapy's determination regarding the CMWC and the facility initiated the request for NF specialized services in the LTC Online Portal. She said she completed the facility section of the request and forwarded it to the DME company for them to complete their section and they entered the information into the LTC Online Portal. She said the quarterly IDT meeting for Resident #1 was on 01/16/2025, and she entered the information into the LTC Online Portal on 01/30/2025. She said on 02/05/2025 she received multiple alerts from the LTC Online Portal which identified the CMWC request had errors or sections that needed to be reviewed and completed. She said that she reviewed the document on the Online Portal on 02/05/2025 and made the requested corrections and resubmitted the CMWC request. She said the CMWC request was approved on 02/12/2025. She was unsure when she notified the DME company Resident #1's CMWC request was approved. During an interview on 03/25/2025 at 3:15 p.m., the office manager with the DME company said they received the approval for Resident #1's CMWC on 02/24/2025 via email from the facility Clinical Reimbursement Coordinator with a screen shot of the LTC Online Portal attachment indicating that the CMWC request was approved on 2/12/2025. She said they ordered the Customized Wheelchair for Resident #1 on 02/24/2025 and the equipment should be delivered to the facility 3/26/2025. During an interview on 3/25/2025 at 5:30 p.m., the DON said the Clinical Reimbursement Coordinator was responsible for coordinating all things PASRR related. She said she was familiar with the PASRR process and what documents were required to be completed but not the timelines for completion. She said she was aware that Resident #1 was PASRR positive and evaluated for a CMWC and was waiting for the delivery from the DME company. She said during the quarterly IDT meeting on 01/16/2025 the Habilitation Coordinator explained to the IDT that PASRR's decision regarding the CMWC overrules the facility therapist's determination regarding the CMWC and the CMWC process was initiated at that time. She said a possible negative outcome of not meeting the PASRR timeframes for completing the CMWC request and ordering the CMWC could be residents not receiving services as approved through PASRR. During an interview on 3/25/2025 at 6:10 p.m., the Administrator said the Clinical Reimbursement Coordinator was responsible for any updates for PASRR and submitting the specialized services/DME request on the LTC Online Portal. He said he was aware that Resident #1 was approved for a CMWC and was waiting for the equipment to be delivered. The Administrator said he received calls from PASRR staff and provides the requested documents. He said residents might not get the services/DME that PASRR provided if requests were not submitted in the required timeframes. He said he expected the facility staff to follow the PASRR policy and meet the required timelines for submitting the request for specialized services or DME and notifying the DME company when facility notified of the DME approval. Record review of an undated facility policy titled PASRR indicated . Policy: the purpose of this policy is to ensure PASRRs are being obtained and completed timely and accurately. Procedure: 1. PASRRs are obtained from referring entity by the admissions department. 2. PL1s are put into LTC online portal by the facility CRC within 72 hours of resident admitting to facility. The completed PL1 must also be uploaded into the resident's EMR. 3. Communicate with LIDDA/LMHA to ensure all active positive PL1s have a completed PE and upload the PE into the resident's EMR. 4. Review recommended specialized services on the PE once the PE is submitted. 5. When discharging a resident to another NF, the facility is responsible for completing PASRR for the NF. 6. Follow Texas PASRR policy for all mandatory meetings and care coordination including any changes that may require a change in resident's PASRR status.

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 the resident rights, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 17 residents (Resident #5) reviewed for care plans. The facility failed to ensure Resident #5's care plan ADL interventions were implemented on 09/22/24 resulting in serious injury. An Immediate Jeopardy (IJ) situation was identified on 01/23/25 at 3:23 p.m. While the IJ was removed on 01/24/25 at 6:37 p.m., the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for staff not being aware of the resident needs and not receiving the care and services to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Record review of Resident #5's face sheet indicated a [AGE] year old female, admitted to the facility on [DATE] (initially admitted on [DATE]). Resident #5 had diagnoses which included unspecified convulsions (seizures), displaced intertrochanteric fracture of left femur (thigh bone), dysphagia (swallowing difficulty), gastrostomy (feeding tube access), contracture of muscle (permanently shortened muscles), cervicalgia (neck pain), traumatic brain injury (usually results from a violent blow or jolt to the head or body), other abnormalities of gait and mobility (gait disorder), unilateral primary osteoarthritis of left hip (degenerative joint condition that primarily affects one side of the body), need for assistance with personal care, scoliosis (spine deformity) and muscle wasting and atrophy (loss of muscle mass). Record review of Resident #5's quarterly MDS assessment, dated 08/16/24, indicated she sometimes was able to make herself understood and understood others, she had severe cognitive impairment with a BIMS of 1, she had impairment on both sides of upper and lower extremities, and she was dependent (Helper does all the effort. Resident does none of the effort to complete the activity, or, the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for all ADLS. Resident #5 was always incontinent of bladder and bowel. Record review of Resident #5's quarterly MDS assessment, dated 12/26/24, indicated she sometimes was able to make herself understood and understood others, she had severe cognitive impairment with a BIMS of 1, she had impairment on both sides of upper and lower extremities, and she was dependent (Helper does all the effort. Resident does none of the effort to complete the activity, or, the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for all ADLS. Resident #5 was always incontinent of bladder and bowel. Record review of Resident #5's care plan, dated 02/27/18 revised 09/15/19, indicated she had an ADL performance deficit. Interventions indicated Resident #5 was totally dependent on 2 staff to provide bed bath, required extensive assist by 2 staff for bed mobility, and required total assistance by 2 staff for toileting. Record review of Resident #5's care guide, dated 01/13/25, indicated Resident #5 was totally dependent on 2 staff to provide bed baths, she required extensive assist by 2 staff to turn and reposition in bed as necessary and she required total assistance by 2 staff for toileting. Record review of Resident #5's progress note, dated 09/22/24 at 10:50 p.m., completed by the DON indicated Resident #5 rolled off the bed. Resident #5 was o.k. PRN pain medication administered. On-call notified and an order for left leg and hip x-ray was received. Record review of Resident #5's care record, for 09/22/24, indicated CNA C provided care without a second staff. Record review of progress note, dated 09/23/24 at 3:03 a.m., competed by LVN H, indicated CNA C informed LVN H she needed help with Resident #5 because she rolled out of the bed when CNA C was adjusting her in the bed at 10:50 p.m. on 09/22/24. Upon entering Resident #5's room, LVN H noted Resident #5 on the floor beside her bed. Resident #5 did not give a description. Resident #5 stated, My leg hurts. Resident had her hand resting on her left leg. LVN H did not see any impairment. LVN H, CNA C, LVN I and LVN J assisted Resident back to bed. Record review of Resident #5's x-ray, dated 09/24/24, indicated no acute fracture or dislocation. Record review of a progress note, dated 10/03/24 at 3:04 p.m., and completed by the DON, indicated PT G informed the DON of Resident #5 sometimes crying, she was not sure if Resident #5 was crying due to her roommate constantly hollering out or if it was due to her being in pain. The DON informed PT G that Resident #5 could tell staff when she was in pain. PT G agreed with the DON and that Resident #5 informed her she was hurting, and she was going to apply a cold pack to Resident #5's leg to see if it helped. PT G stated Resident #5 even told her (PT G) about the fall she had. The DON contacted NP F and order was given for repeat X-ray. Record review of Resident #5's x-ray, dated 10/03/24, of left hip indicated age indeterminate, transverse, comminuted, mildly displaced intertrochanteric fracture femur with varus deformity (hip fracture where the bone is broken across its width (transverse) in multiple pieces (comminuted) slightly shifted out of place (mildly displaced) and angled inwards at the fracture site creating a varus deformity typically seen in the area between the greater and lesser trochanters of the femur (the inter trochanteric region). Record review of hospital records, dated 10/07/24, indicated Resident #5 had surgical repair of left hip fracture. Record review of Resident #5's fall assessment ,dated 06/27/24, indicated she was a moderate fall risk. Record review of Resident #5's fall assessment, dated 09/23/24, indicated she was a high fall risk. Record review of Resident #5's Admit/Readmit Screener, dated 10/08/24, completed by LVN A, indicated Resident #5 was totally dependent for all ADLS. Record review of the facility investigation, dated 10/11/24, indicated the facility determined Resident #5 had a fall on 09/22/24 and the fractured hip was most likely to have occurred at that time. During an interview on 01/13/25 at 10:56 a.m., CNA C said she was providing toileting care to Resident #5 on 09/22/24. She said she rolled Resident #5 over to remove the soiled brief and Resident #5 rolled off the bed onto the floor. She said she always provided care to Resident #5 without a second staff. She said Resident #5 did not have hold of the side rail for repositioning. She said Resident #5 complained of pain to her left leg after she fell . She said she was trained to provide care for Resident #5 without a second staff. She could not recall who had trained her. She said she did not check Resident #5's care guide and had not seen the care guide which indicated Resident #5 required 2 staff for bed bath bed mobility, or toileting. She said residents were at risk of injury if they did not receive care as required. During an interview on 01/13/25 at 11:15 a.m., the DON said Resident #5 fell from the bed during care. She said she was assessed with no injury. She said Resident #5 required only 1 staff to provide care because Resident #5 could assist with turning and repositioning by holding on to the side rails. She said the care plan should say 1 person and not 2 persons for care. She said residents were at risk of injury if their care guide was not accurate or if staff did not follow the care guide. She said the care guide was dated 10/08/24 on Resident #5's readmission from hospital. During an interview on 01/13/25 at 11:36 a.m., MDS LVN E said Resident #5's MDS dated [DATE] and 12/26/24 were completed using the previous 7 days of documentation by staff. She said if there were two staff providing care one time in the previous 7 days then the MDS would indicate 2 staff were required. She said the care plan was based on the MDS. She said the care plan populated the resident care guide. She said the care plan was not revised to indicate 1 staff could provide Resident #5's care. She said she did not update Resident #1's care plan when she returned from the hospital. She said residents were at risk of injury if they did not receive care as required. During an interview on 01/14/25 at 9:20 a.m., CNA P said Resident #5's care guide indicated 2 staff were required for bed bath, bed mobility, and toileting. She said she would ask a second aide or nurse to assist if she was providing care when she (Resident #5) fell out of the bed. During an interview on 01/14/25 at 11:15 a.m., CNA ZZ said he provided Resident #5's care without a second staff. He said Resident #5 assisted with repositioning and turning during care by holding the side rail. He said she was never in distress or exhibited signs of pain when he provided care. He said he did not see she was 2-person assist on the care guide. He said he was trained to provide her care without a second staff. He said was able to access the care guide to determine the level of care a resident required. During an interview on 01/14/25 at 11:24 a.m., RN B said Resident #5 was normally a 1-person assist with care because she (Resident #5) could assist with repositioning and turning and would hold the side rail. She said she did not know why the care plan or care guide indicated 2 person assist. During an interview on 01/14/25 at 11:30 a.m., Resident #5 said no when asked if she had hold of the rail for repositioning when she fell off the bed. Resident #5 said yes when asked if only 1 staff provided care when she fell out of the bed and said yes when asked if usually 1 staff provided her care. During an interview on 01/15/25 at 9:48 a.m., LVN Q said she did not know why 1 staff would provide care for any resident if the care guide said 2 staff were required. She said she would assist any aide who requested assist with Resident #5. During an interview on 01/15/25 at 10:11 a.m., NP F said it was her opinion Resident #5 required 2 staff for care due to Resident #5's physical condition and being immobile in bed. During an interview on 01/15/25 at 1:30 p.m., CNA O said she would take care of Resident #5 without a second staff. She said she did not know Resident #2's care guide indicated she required 2 staff for care. She said she never noticed the indication for 2 staff. She was able to to access resident care guide but never noticed the required two staff. During an interview on 01/15/25 at 1:50 p.m., the DON said staff looked at the resident care guide to know how to care for residents. Staff should check the care guide to know if the residents' care was changed. Residents were at risk of potential harm or injury if 1 person did their care and 2 staff were required. During an interview on 01/23/25 at 12:00 p.m., the DON said on 09/22/24, Resident #5's care plan indicated she required 2 staff for bathing, repositioning and toileting. She said she was responsible for implementing interventions post incident. She said she would review the incident report and if interventions were decided on, she would get an order and implement the interventions. She said fall mats were implemented after Resident #5 fell out of her bed on 09/22/24. She said she did not evaluate the need for 2 staff for resident safety because CNA C reported she was walking past Resident #5's room and saw her leg hanging out of the bed. She said CNA C attempted to reposition Resident #5 and Resident #5 continued to roll out of the bed. During an interview on 01/23/25 at 12:35 p.m., CNA C said she did not remember exactly what happened on 09/22/24 when Resident #5 fell out of the bed. She said she assumed it was because she was changing Resident #5 but when asked about repositioning Resident #5's leg she said Resident #5 fell out of the bed when she pulled the draw sheet. She said she may have put Resident #5's leg up and checked her for wetness and that was when Resident #5 rolled out of the bed. Record review of the facility's Comprehensive Care Plan Policy, dated 01/20/21, indicated the resident will have an individualized interdisciplinary plan of care in place . 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. Record review of the facility's Incident and Accident Policy, dated 03/01/17, indicated . 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training, as necessary; Ensuring that interventions are implemented; and documenting interventions. 5. Monitoring the effectiveness of interventions shall include the following: a. Ensuring the interventions are implemented correctly and consistently. Record review of the facility's Safety and Supervision of Residents policy, dated 2001 (revised July 2017), indicated . 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. This was determined to be an Immediate Jeopardy (IJ) on 01/23/25 at 3:23 p.m. The facility's Administrator and DON were notified. The Administrator was provided the IJ template on 01/23/25 at 3:23 p.m. The following Plan of Removal (POR) submitted by the facility was accepted on 01/24/25 at 4:27 p.m.: Plan of Action Immediate action taken by staff: Physical Therapy evaluated Resident #5 to ensure appropriate staff assist to prevent further accidents. The Director of Clinical Operations implemented floor mats for Resident #5 on 9/22/2024. The MDS nurse updated the level of assist to 1-2 person for ADL's for Resident #5 to prevent further injuries on 1/13/2025. Physical Therapy determines the level of assistance required. The MDS Nurse implemented scoop mattress for Resident #5 to prevent further injuries on 1/24/2025. The above change in care is discussed in the morning clinical meeting with the update being added to the Kardex to keep staff informed. The MDS Nurse is responsible for making the update on a quarterly basis, or as needed if a change occurs, after the IDT has discussed the resident. The IDT determines the number of staff (increase/decrease) that is needed for ADL's. On 1/24/2025 at 3:30 pm the EDO had the therapist go re-evaluate Resident #5 for ADL care. The evaluation showed that Resident #5 was a 1 person assist for bed mobility. The IDT met and are in agreeance will make the change on the care plan effective 1/24/2025. The Director of Clinical Services will perform an in-service education to the staff immediately on the level of care during of this assessment of Resident #5. The MDS Nurse and/or designee will review fall care plans on all residents to ensure that they are appropriate and will help prevent injuries by ensuring the appropriate level of assistance needed for ADL's by team members. Completion date 1/24/2025 by 10:00am. All care plans will be reviewed to ensure the appropriate level of assistance for ADL's by staff is accurate by the MDS Nurse and/or designee. The care plan will update the Kardex to show the level of assistance needed to all nursing staff. Completion date 1/24/2025 by 10:00am. All incidents/accidents will be reviewed in the morning clinical meeting by the Director of Clinical of Operations and/or designee to ensure that care plan is updated to reflect any changes in level of care and appropriate interventions are in place after each fall. Completion date 1/24/2025 by 10:00am and ongoing. In-service Education will be provided to all nursing staff by the Director of Clinical Services and/or designee. Staff will not be allowed to work until in-service education has been provided which includes: 1. How to use the Kardex to determine the level of staff assistance needed to care for the residents. The change in level of assistance will be communicated in the morning clinical meeting and the Kardex is updated at that time. Completion Date of all in-service 1/24/2025 by 10:00am. The Director of Clinical Services and/or the Assistant Director of Clinical Services will randomly monitor two nurse aides weekly times 10 weeks to ensure that they are utilizing the Kardex for resident care. Any aide that is not utilizing the Kardex system will be re-trained immediately. Completion date 1/24/2025 at 12:00 pm and on-going. The Regional Clinical Reimbursement Coordinator will perform in-service education with the MDS Nurses on personalizing the care plan for falls with interventions and level of care provided by team members. The Director of Clinical Services and/or the Assistant Director of Clinical Services will monitor during the morning clinical meeting, during the review of incidents/accidents, that the interventions and level of care provided by team members are being reviewed and care plan changed as needed. Completion date 1/24/2025 by 10:00am. The incident/accident care plans will be monitored by the Director of Clinical Services and/or by the Assistant Director of Clinical Services in the morning clinical meeting with the IDT to ensure appropriate fall interventions are in place for the resident's care plan. The fall interventions will be monitored for 72 hours by the Director of Clinical Operation and/or designee to ensure that the intervention is effective. If the fall intervention is not effective the IDT will make other recommendations for a new approach and the care plan will be updated. Completion date by 1/24/2025 by 10:00am and ongoing. Monitoring of the Plan of Removal included the following: Observations conducted on 01/24/25 between 4:27 p.m. and 6:37 p.m. indicated staff (CNA W and CNA C) were able to access the Kardex (resident care guide) to determine level of staff require as required. Resident #5 had a scoop mattress, floor mats, low bed, and call light in reach. There were no observed concerns. Interviews with staff (DON, ADON DD, ADON EE, RN B, RN CC, MDS LVN E, LVN A, LVN H, LVN I, LVN J, LVN K, LVN L, CNA C, CNA M, CNA N, CNA O, CNA P, CNA W, CNA X, CNA Y, and CNA Z), who represented all shifts (6:00 a.m.-2:00 p.m., 2:00 p.m. -10:00 p.m., and 10:00 p.m.-6:00 a.m.) indicated they were aware of and able to give examples of how to use the Kardex/care guide (level of care required for ADLS included bed mobility, incontinent care/toileting, and bathing). Nursing staff indicated they observed and monitor staff every shift to ensure care was provided per each resident's care plan and care guide and would immediately intervene and retrain staff if necessary. During an interview on 01/24/25 at 5:22 p.m., MDS LVN E indicated she was responsible for making the care plan updates on a quarterly basis or as needed if a change occurred. She said the IDT determined the number of staff (increase/decrease) that were needed for ADLS. Record review of Resident #5's PT assessment dated [DATE] indicated she used both hands to help with rolling and only required 1 staff to provide safe hygiene, ADLS, bathing and repositioning. Record review of Resident #5's care plan indicated a scoop mattress was implemented as of 01/24/25 and she required 1 person staff assist for ADLS. Record review of incident and accident reports from 12/24/24 through 01/24/25, indicated care plans were appropriate and personalized for 7 of 7 residents (Residents #13, #14 #15, #16, #17, #18, #19) reviewed. Record review of Incidents and accident reports from 12/24/24 through 01/24/25, indicated there was adequate staff assistance as indicated in the care plan recommendations for 7 of 7 residents (Residents #13, #14 #15, #16, #17, #18, #19) reviewed. Record review of the facility's monitoring indicated the Director of Clinical Operation and/or designee reviewed incident/accident reports in the morning clinical meeting with the IDT to ensure appropriate interventions were in place for the resident. There were no concerns noted. Record review of incidents/accidents reviewed in the morning clinical meeting on 01/24/25 by the Director of Clinical Operations and/or designee indicated care plans were updated to reflect any changes in the level of care and appropriate interventions were in place. Record review of readmissions on 01/24/25 from the hospital indicated there was no re-admission to the facility. Record review of staff training dated 01/24/25 indicated staff training included how to use the Kardex/care guide to determine level of staff assistance needed to care for the residents, the change in level of assistance would be communicated in morning meeting and the resident Kardex/care guide updated during the morning meeting. Record review of staff training dated 01/24/25 indicated the MDS nurse was trained on personalizing resident care plans for falls with interventions and level of care required for ADLS. The Administrator was informed the Immediate Jeopardy was removed on 01/24/25 at 6:37 p.m. The facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation , interview and record review the facility failed to provide supervision and assistance devices to prevent accident for 1 of 17 (Resident #5) residents reviewed for accidents/supervision. The facility failed to ensure CNA C provided ADL care with 2 person assistance. Resident #5 fell out of her bed and sustained a fractured left femur during care on 09/22/24. An Immediate Jeopardy (IJ) situation was identified on 01/23/25 at 3:23 p.m. While the IJ was removed on 01/24/25 at 6:37 p.m., the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of accidents and injuries. Findings include: Record review of Resident #5's face sheet indicated a [AGE] year old female, admitted to the facility on [DATE] (initially admitted on [DATE]). Resident #5 had diagnoses which included unspecified convulsions (seizures), displaced intertrochanteric fracture of left femur (thigh bone), dysphagia (swallowing difficulty), gastrostomy (feeding tube access), contracture of muscle (permanently shortened muscles), cervicalgia (neck pain), traumatic brain injury (usually results from a violent blow or jolt to the head or body), other abnormalities of gait and mobility (gait disorder), unilateral primary osteoarthritis of left hip (degenerative joint condition that primarily affects one side of the body), need for assistance with personal care, scoliosis (spine deformity) and muscle wasting and atrophy (loss of muscle mass). Record review of Resident #5's quarterly MDS assessment, dated 08/16/24, indicated she sometimes was able to make herself understood and understood others, she had severe cognitive impairment with a BIMS of 1, she had impairment on both sides of upper and lower extremities, and she was dependent (Helper does all the effort. Resident does none of the effort to complete the activity, or, the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for all ADLS. Resident #5 was always incontinent of bladder and bowel. Record review of Resident #5's quarterly MDS assessment, dated 12/26/24, indicated she sometimes was able to make herself understood and understood others, she had severe cognitive impairment with a BIMS of 1, she had impairment on both sides of upper and lower extremities, and she was dependent (Helper does all the effort. Resident does none of the effort to complete the activity, or, the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for all ADLS. Resident #5 was always incontinent of bladder and bowel. Record review of Resident #5's care plan, dated 02/27/18 revised 09/15/19, indicated she had an ADL performance deficit. Interventions indicated Resident #5 was totally dependent on 2 staff to provide bed bath, required extensive assist by 2 staff for bed mobility, and required total assistance by 2 staff for toileting. Record review of Resident #5's care guide, dated 01/13/25, indicated Resident #5 was totally dependent on 2 staff to provide bed baths, she required extensive assist by 2 staff to turn and reposition in bed as necessary and she required total assistance by 2 staff for toileting. Record review of Resident #5's progress note, dated 09/22/24 at 10:50 p.m., completed by the DON indicated Resident #5 rolled off the bed. Resident #5 was o.k. PRN pain medication administered. On-call notified and an order for left leg and hip x-ray was received. Record review of Resident #5's care record, for 09/22/24, indicated CNA C provided care without a second staff. Record review of progress note, dated 09/23/24 at 3:03 a.m., competed by LVN H, indicated CNA C informed LVN H she needed help with Resident #5 because she rolled out of the bed when CNA C was adjusting her in the bed at 10:50 p.m. on 09/22/24. Upon entering Resident #5's room, LVN H noted Resident #5 on the floor beside her bed. Resident #5 did not give a description. Resident #5 stated, My leg hurts. Resident had her hand resting on her left leg. LVN H did not see any impairment. LVN H, CNA C, LVN I and LVN J assisted Resident back to bed. Record review of Resident #5's x-ray, dated 09/24/24, indicated no acute fracture or dislocation. Record review of a progress note, dated 10/03/24 at 3:04 p.m., and completed by the DON, indicated PT G informed the DON of Resident #5 sometimes crying, she was not sure if Resident #5 was crying due to her roommate constantly hollering out or if it was due to her being in pain. The DON informed PT G that Resident #5 could tell staff when she was in pain. PT G agreed with the DON and that Resident #5 informed her she was hurting, and she was going to apply a cold pack to Resident #5's leg to see if it helped. PT G stated Resident #5 even told her (PT G) about the fall she had. The DON contacted NP F and order was given for repeat X-ray. Record review of Resident #5's x-ray, dated 10/03/24, of left hip indicated age indeterminate, transverse, comminuted, mildly displaced intertrochanteric fracture femur with varus deformity (hip fracture where the bone is broken across its width (transverse) in multiple pieces (comminuted) slightly shifted out of place (mildly displaced) and angled inwards at the fracture site creating a varus deformity typically seen in the area between the greater and lesser trochanters of the femur (the inter trochanteric region). Record review of hospital records, dated 10/07/24, indicated Resident #5 had surgical repair of left hip fracture. Record review of Resident #5's fall assessment, dated 06/27/24, indicated she was a moderate fall risk. Record review of Resident #5's fall assessment, dated 09/23/24, indicated she was a high fall risk. Record review of Resident #5's Admit/Readmit Screener, dated 10/08/24, completed by LVN A, indicated Resident #5 was totally dependent for all ADLS. Record review of the facility investigation, dated 10/11/24, indicated the facility determined Resident #5 had a fall on 09/22/24 and the fractured hip was most likely to have occurred at that time. During an interview on 01/13/25 at 10:56 a.m., CNA C said she was providing toileting care to Resident #5 on 09/22/24. She said she rolled Resident #5 over to remove the soiled brief and Resident #5 rolled off the bed onto the floor. She said she usually provided care to Resident #5 without a second staff because she was trained to provide care to Resident #5 without a second staff. She said Resident #5 did not have hold of the side rail for repositioning. She said Resident #5 would usually hold the side rail and assist with repositioning. She said an unnamed nurse assessed Resident #5 with no injuries then the nurse and other aides picked Resident #5 up and put her back in bed. She said Resident #5 complained of pain to her left leg. She said she was trained to provide care for Resident #5 without a second staff. She could not recall who trained her. She said she did not check Resident #5's care guide and did not realize the care guide indicated Resident #5 required 2 staff for bed bath bed mobility, or toileting. She said if she needed a second staff, she would ask an aide or a nurse for assistance. She said she was not aware of Resident #5 having any history of falling from the bed during care. She said residents were at risk of injury if they did not receive care as required. During an interview on 01/13/25 at 11:15 a.m., the DON stated Resident #5 fell from the bed during care. She said she was assessed with no injury. She said the physician was notified and ordered an x-ray of the left hip and leg. She said the first x-ray completed on 09/24/24 indicated no injury. She said on 10/03/24, PT G notified her (the DON) of Resident #5 being in pain during therapy. She said she notified the physician and N/O were obtained for a repeat x-ray. She said the x-ray completed on 10/3/24 indicated Resident #5 had a fractured left femur. She said Resident #5 was sent to the hospital for further evaluation and treatment. She said Resident #5 had surgical repair of her left hip. She said it was likely caused from the fall on 09/22/24 since there was no other identified cause of the fracture. She said Resident #5 required only 1 staff to provide care because Resident #5 could assist with turning and repositioning by holding on to the side rails. She said Resident #5 did not have any history of falling from the bed during care. She said residents were at risk of injury if their care guide was not accurate or if staff did not follow the care guide, or if they did not receive care as required. During an interview on 01/13/25 at 11:36 a.m., MDS LVN E said Resident #5's, MDS dated [DATE] and 12/26/24, were completed using the previous 7 days of documentation by staff. She said if there were two staff providing care one time in the previous 7 days then the MDS would indicate 2 staff were required. She said the care plan was based on the MDS. She said the care plan populated the resident care guide. She said the care plan was not revised to indicate 1 staff could provide Resident #5's care. She said residents were at risk of serious injury if they did not receive care as required. During an interview on 01/14/25 at 9:20 a.m., CNA P said Resident #5's care guide indicated 2 staff were required for bed bath, bed mobility, and toileting. She said she would ask a second aide or nurse to assist if she was providing care when she fell out of the bed. During an interview on 01/14/25 at 11:15 a.m., CNA ZZ said he provided Resident #5's care without a second staff because he was trained to provide care without a second staff. He said he could not recall who trained him to provide Resident #5's care. He said Resident #5 assisted with repositioning and turning during care by holding the side rail. He said she was never in distress or exhibited signs of pain when he provided care. He said he did not see she was 2-person assist on the care guide. He said he was trained to provide her care without a second staff. During an interview on 01/14/25 at 11:24 a.m., RN B said Resident #5 was normally a 1-person assist with care because she (Resident #5) could assist with repositioning and turning and would hold the side rail. She said she did not know why the care plan or care guide indicated 2 person assist. During an interview on 01/14/25 at 11:30 a.m., Resident #5 said no when asked if she had hold of the rail for repositioning when she fell off the bed. Resident #5 said yes when asked if only 1 staff provided care when she fell out of the bed and said yes when asked if usually 1 staff provided her care. She did not respond when asked who was the staff who provided care. She said yes when asked if her left leg hurt after the fall. During an interview on 01/14/25 at 1:55 p.m., PT G said it was her opinion 1 staff could provide Resident #5's care if Resident #5 was in the correct position and had hold of the side rail. She said Resident #5 sometimes could move her arm and her hand would grab the bed rail but sometimes the staff would have to move her arm and place her hand on the rail. She said she screened Resident #5 after her fall on 09/22/24 and was informed there was no fracture. She said she instructed the unnamed CNAs to be aware of Resident #5's position before rolling her in the bed. She said she attempted therapy on 10/03/24 with Resident #5 but Resident #5 was in pain and crying. During an interview on 01/15/25 at 9:48 a.m., RN B said she did not know why 1 staff would provide care for any resident if the care guide said 2 staff were required. She said she would assist any aide who requested assist with Resident #5. During an interview on 01/15/25 at 10:11 a.m., NP F said it was her opinion Resident #5 required 2 staff for care due to Resident #5's physical condition and being immobile in bed. She said it was probable the fractured femur occurred when Resident #5 fell from her bed on 09/22/24 but did not show in the first x-ray. She said the fractured femur became pronounced and visible on the second x-ray due to normal ADLS and physical therapy. During an interview on 01/15/25 at 1:30 p.m., CNA O said she would take care of Resident #5 without a second staff. She said she was trained to take care of her with 1 staff. She said Resident #5 would hold the side rail to assist with turning and repositioning. She said if she needed a second staff, she would ask an aide or a nurse for assistance. She said she did not realize Resident #2's care guide indicated she required 2 staff for care. She said she was not aware of Resident #5 having any history of falling from the bed during care. During an interview on 01/15/25 at 1:50 p.m., the DON said staff look at the resident care guide to know how to care for residents. Staff should check the care guide to know if the residents' care was changed. Residents were at risk of potential harm or injury if 1 person did their care and 2 staff were required. During an interview on 01/23/25 at 10:18 a.m., PT G said residents dependent for care or required 2 staff for ADLS did not always mean the resident was supposed to have 2 staff at all times. She said having two staff would make completing ADLS easier and require less time. She said staff would have to ensure the resident was in the correct position and centered in the bed at all times to ensure the resident was safe and not in danger of falling out of the bed during ADLS or repositioning. During an interview on 01/23/25 at 12:00 p.m., the DON said on 09/22/24, Resident #2's care plan indicated she required 2 staff for bathing, repositioning and toileting. She said she was responsible for implementing interventions post incident. She said she would review the incident report and if interventions were decided on, she would get an order and implement the interventions. She said fall mats were implemented after Resident #5 fell out of her bed on 09/22/24. She said she did not evaluate the need for 2 staff for resident safety because CNA C reported she was walking past Resident #5's room and saw her leg hanging out of the bed. She said CNA C attempted to reposition Resident #5 and Resident 5 continued to roll out of the bed. During an interview on 01/23/25 at 12:35 p.m., CNA C said she did not remember exactly what happened on 09/22/24 when Resident #5 fell out of the bed. She said she assumed it was because she was changing Resident #5 but when asked about repositioning Resident #5's leg she said Resident #5 fell out of the bed when she pulled the draw sheet. She said she may have put Resident #5's leg up and checked her for wetness and that was when Resident #5 rolled out of the bed. Record review of the facility's Incident and Accident Policy, dated 03/01/17, indicated Our facility strives to make the environment as free from hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . 2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training, as necessary; Ensuring that interventions are implemented; and documenting interventions. 5. Monitoring the effectiveness of interventions shall include the following: a. Ensuring the interventions are implemented correctly and consistently. Record review of the facility's Safety and Supervision of Residents policy, dated 2001 (revised July 2017), indicated Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . 1. Our individualized, resident-centered approach to safety addressed safety and accident hazards for individual residents. 2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. This was determined to be an Immediate Jeopardy (IJ) on 01/23/25 at 3:23 p.m. The facility's Administrator and DON were notified. The Administrator was provided with the IJ template on 01/23/25 at 3:23 p.m. The following Plan of Removal (POR) submitted by the facility was accepted on 01/24/25 at 4:27 p.m.: Plan of Action Immediate action taken by staff: The nurse entered the room after being notified by aide that Resident #5 was on the floor beside her bed. The resident was assessed by the nurse and assisted back to bed with four staff members. The resident complained of pain to the left leg. The nurse did not see any impairment at this time. The nurse administered pain medication, notified attending physician, and family of fall. Attending physician ordered X-ray to the left hip and left leg. The nurse left the room with the bed in low position and call light within reach. X-ray results showed no fracture. The nurse will continue to assess and monitor for pain. Physical Therapy evaluated Resident #5 to ensure appropriate staff assist to prevent further accidents. The Director of Clinical Operations implemented floor mats for Resident #5 on 9/22/2024. The MDS Nurse implemented scoop mattress for Resident #5 to prevent further injuries on 1/24/2025. The above change in care are discussed in the morning clinical meeting with the update being added to the Kardex to keep staff informed. The MDS Nurse is responsible for making the update on a quarterly basis, or as needed if a change occurs, after the IDT has discussed the resident. The IDT determines the number of staff (increase/decrease) that is needed for ADL's. On 1/24/2025 at 3:30 pm the EDO had the therapist go re-evaluate Resident #5 for ADL care. The evaluation showed that Resident #5 was a 1 person assist for bed mobility. The IDT met and are in agreeance will make the change on the care plan effective 1/24/2025. The Director of Clinical Services will perform an in-service education to the staff immediately on the level of care during of this assessment of Resident #5. The Director of Clinical Operations and/or the Assistant Director of Clinical Operations will review incidents and accidents within the last 30 days with a focus on falls to ensure care plans were appropriate and personalized with interventions after each fall. Completion date 1/24/2025 by 10:00am. The Director of Clinical Operations and/or designee will review incident/accidents reports in the morning clinical meeting to ensure that there was adequate staff assistance as indicated in the care plan recommendations. Completion date 1/24/2025 by 10:00am and ongoing. The Director of Clinical Operation and/or designee will review incident/accident reports in the morning clinical meeting with IDT to ensure appropriate intervention in place for the resident. The intervention will be monitored for 72 hours by the Director of Clinical Operation and/or designee to ensure that the intervention is effective. If the intervention is not effective the IDT will make other recommendations for a new approach. Completion date 1/24/2025 by 10:00am. Morse fall risk assessments were reviewed on all residents by the Director of Clinical Operations and/or the Assistant Director of Clinical Operations. Residents identified as having a high fall risk will have care plans and Kardex updated with interventions and reflect any changes to their personalized plan of care. Completion date 1/24/2025 by 10:00am. All incidents/accidents will be reviewed in the morning clinical meeting by the Director of Clinical Operations and/or designee to ensure that care plan is updated to reflect any changes in level of care and appropriate interventions are in place. Completion date 1/24/2025 by 10:00am and ongoing. All readmissions from the hospital will be reviewed in the morning clinical meeting by the Director of Clinical Operations and Assistant Director of Clinical Operations for any changes in the level of care. The care plan will be updated for any noted changes in the level of care. Completion date 1/24/2025 by 10:00am and ongoing. In-service Education will be provided to all nursing staff by the Director of Clinical Services and/or designee. Staff will not be allowed to work until in-service education has been provided which includes: 1. Fall interventions (referral to therapy, fall mats, low bed, change in level of assistance, etc.) and prevention of falls. 2. Appropriate interventions based on the resident's individualized assessment that are added to care plan after each fall. 3. How to use the Kardex to determine fall interventions put in place to ensure interventions are followed. Completion Date of all in-service 1/24/2025 by 10:00am. The Director of Clinical Services and/or the Assistant Director of Clinical Services will randomly monitor two nurse aides' weekly times 10 weeks to ensure that they are utilizing the Kardex for resident care. Any aide that is not utilizing the Kardex system will be re-trained immediately. Completion date 1/24/2025 at 10:00am and on-going. The Regional Director of Clinical Operations performed in-service education with DCO and ADCO's on personalizing of interventions put into place to prevent falls. Completion date 1/24/2025 by 10:00am. The Director of Clinical Services and/or Assistant Director of Nursing will refer any resident that exhibits pain or injury related to a fall to be screen/evaluated by physical therapy for changes in ADL care. The care plan will be updated with therapy recommendations. Completion Date on 1/24/2025 at 10:00am and ongoing. Monitoring of the Plan of Removal included the following: Observations conducted on 01/24/25 between 4:27 p.m. and 6:37 p.m. indicated staff were able to access the Kardex (resident care guide) to determine the level of staff require as required. There were no observed concerns. Observation conducted on 01/24/25 at 5:00 p.m. indicated Resident #5 laid on a scoop mattress. Her bed was in the low position and the fall mats were on each side of her bed. There were no observed concerns. Interviews on 01/24/25 from 4:27 p.m. through 6:35 p.m. with staff (DON, ADON DD, ADON EE, RN B, RN CC, MDS LVN E, LVN A, LVN H, LVN I, LVN J, LVN K, LVN L, CNA C, CNA M, CNA N, CNA O, CNA P, CNA W, CNA X, CNA Y, and CNA Z), who represented all shifts (6:00 a.m.-2:00 p.m., 2:00 p.m. -10:00 p.m., and 10:00 p.m.-6:00 a.m.) indicated they were aware of and able to give examples of how to use the Kardex/care guide (level of care required for ADLS included bed mobility, incontinent care/toileting, and bathing). Staff were aware of Resident #5's level of assistance needs. Nursing staff indicated they observed and monitor staff every shift to ensure care was provided per each resident's care plan and care guide and would immediately intervene and retrain staff if necessary. During an interview on 01/24/25 at 5:22 p.m., MDS LVN E indicated she was responsible for making the care plan updates on a quarterly basis or as needed if a change occurred. She said the IDT determined the number of staff (increase/decrease) that were needed for ADLS. Record review of Resident #5's PT assessment dated [DATE] indicated she used both hands to help with rolling and only required 1 staff to provide safe hygiene, ADLS, bathing and repositioning. Record review of Resident #5's care plan indicated a scoop mattress was implemented as of 01/24/25 and she required 1 person staff assist for ADLS. Record review of incident and accident reports from 12/24/24 through 01/24/25 indicated care plans were appropriate and personalized for 7 of 7 residents(Residents #13, #14 #15, #16, #17, #18, #19) reviewed. Record review of Incidents and accident reports from 12/24/24 through 01/24/25 indicated there was adequate staff assistance as indicated in the care plan recommendations for 7 of 7 residents (Residents #13, #14 #15, #16, #17, #18, #19) reviewed. Record review of the facility monitoring date 01/24/25 indicated the Director of Clinical Operation and/or designee reviewed incident/accident reports in the morning clinical meeting with the IDT to ensure appropriate intervention in place for the resident. There was no concerns noted. Record review of residents' Morse fall risk assessments reviewed on 01/24/25on all residents by the Director of Clinical Operations and/or the Assistant Director of Clinical Operations. 7 of 7 residents (Resident #3, #13, #14, #15, #19, #20, and #21) identified as high fall risk care plans and Kardex were updated with interventions and reflected any changes to their personalized plan of care. Record review of incidents/accidents reviewed in the morning clinical meeting on 01/24/25 by the Director of Clinical Operations and/or designee indicated care plans were updated to reflect any changes in the level of care and appropriate interventions were in place. Record review of readmissions on 01/24/25 from the hospital indicated there was no re-admission to the facility. Record review of staff training dated 01/24/25 indicated staff training included: 1. Fall interventions (referral to therapy, fall mats, low bed, change in level of assistance, etc.) and prevention of falls. 2. Appropriate interventions based on the resident's individualized assessment that are added to care plan after each fall. 3. How to use the Kardex to determine fall interventions put in place to ensure interventions are followed. Record review of staff training dated 01/24/25 indicated the DCO and ADCO's were trained on personalizing of interventions put into place to prevent falls. The Administrator was informed the Immediate Jeopardy was removed on 01/24/25 at 6:37 p.m. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of property, and exploitation for 4 of 17 residents (Residents #1, #2, #3, and #4) reviewed for abuse. 1. The facility failed to ensure Resident #3 did not hit Resident #4 on 10/05/24. 2. The facility failed to ensure Resident #1 did not hit and push Resident #2 on 11/11/24. The noncompliance was identified as PNC. The noncompliance began on 10/05/24 and ended on 11/11/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for emotional distress, fear, decreased quality of life and further abuse. Findings included: 1. Record review of Resident #3's face sheet dated 01/14/25 indicated she was a [AGE] year -old female, admitted on [DATE], and her diagnoses included dementia (group of symptoms that affects memory, thinking and interferes with daily life), COPD (Chronic obstructive pulmonary disease is an ongoing lung condition caused by damage to the lung), anxiety (emotion characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events) and bipolar disorder (a mental disorder characterized by periods of depression and periods of abnormally elevated mood that each last from days to weeks). Record review of Resident #3's annual MDS dated [DATE] indicated she was able to make herself understood, usually understood others, was cognitive (BIMS-15), exhibited no behaviors, and utilized a wheelchair for mobility. She required supervision to moderate assistance for all ADLS. Record review of Resident #3's progress note, dated 10/05/24 at 12:30 p.m., completed by LVN K, indicated Resident #3 slapped Resident #4 in the face. Resident #3 stated [Resident #4] slapped me on the back of the head and scratched me so I defended myself. Small skin tear noted on Resident #3's left forearm. On-call notified and gave a new order for treatment of skin tear. Record review of Resident #3's psychiatric visit report, dated 10/08/24, completed by NP D, indicated Resident #3 agreed to restart Abilify (used to treat agitation and bipolar disorder). Record review of Resident #3's care plan, dated 10/24/24, indicated she was on medication for bipolar and interventions included administer medications as ordered and monitor/record occurrence of targeted behavior. 2. Record review of Resident #4's face sheet dated 01/14/25 indicated she was an [AGE] year old female, admitted on [DATE], and her diagnoses included Alzheimer's (brain disorder that causes problems with memory, thinking and behavior) Record review of Resident #4's quarterly MDS assessment, dated 10/23/24, indicated was usually able to make herself understood and understood others, had moderate cognitive impairment (BIMS 11), had no behaviors, utilized a wheelchair for mobility, and required partial to maximum assist for all ADLS. Record review of Resident #4's care plan dated 07/06/24 indicated she had the potential to be physically aggressive related to Alzheimer's. Interventions included communication and to provide physical and verbal cues to alleviate anxiety and redirect to nurse's station. Record review of Resident #4's progress note dated 10/05/24, completed by LVN N, indicated Resident #4 pushed Resident #3. Resident #3 slapped Resident #4 on the right side of her face. Bruise noted to the right side of the face, Resident #3 denied pain. Resident refused pain medications and stated, I am not a baby it was just a slap. Record review of Resident #4's psychiatric visit report dated 10/16/24, completed by NP D, indicated Resident #4 did not recall who hit her, said she had memory problems, and did not want to talk about the incident. There were no medication changes. Record review of the facility investigation, dated 10/11/24 and completed by the Administrator, indicated the facility confirmed the incident occurred. The facility indicated the incident occurred on 10/5/24 at 11:30 a.m. The facility reported the incident to HHS on 10/06/24 at 10:19 a.m. On 10/05/24 the facility in-serviced staff on the abuser/neglect policy and keeping Resident #3 and Resident #4 separated. During an interview on 01/10/25 at 9:00 a.m., the DON said Residents #3 and #4 used their wheelchairs for mobility. She said Resident #4 sometimes had difficulty and bumped into others. It was alleged Resident #3 slapped Residents #4's face and left a bruise. She said the bruise was actually an age spot. The residents were separated, and staff were in-serviced to keep residents separated. Both residents were seen by psych services and Resident #3's medications were adjusted. There was no history of aggression between the residents and there has been no issues since the incident. During an interview on 01/13/25 at 1:00 p.m., Resident #3 said she had no recollection of any issues or physical altercations with any other resident. She said she was not afraid of any residents. She said she had no complaints of her care of staff. She said she would report any abuse to the DON or Administrator . During an interview on 01/14/25 at 11:00 a.m., Resident #4 said she did not remember any issues or physical altercations with any other resident. She said she was not afraid of any residents. She said she had no complaints of her care of staff. She said she would report any abuse to the DON or Administrator. 3. Record review of Resident #1's face sheet dated 01/13/25 indicated he was an [AGE] year old male, admitted on [DATE], and his diagnoses included spondylosis (degeneration of the vertebral column from any cause) and acute kidney failure (sudden decline in kidney function). Record review of Resident #1's MDS assessment (discharge) dated 11/15/24 indicated he had moderate cognitive impairment (BIMS of 11) required set up/supervision or partial assist for ADLS, had physician behavioral symptoms directed at others and verbal behavioral symptoms directed at others. Record review of Resident #1's care plan, dated 09/20/24, indicated no behavioral focus or interventions. Record review of a progress note, dated 11/11/24 completed by LVN A, indicated LVN A was notified by an unidentified aide that Resident #1 hit Resident #2. LVN A observed Resident #1 lying on his bed. Resident #1 smiled and stated [Resident #2] wouldn't shut up. I sat up on my side of the bed. I walked over to him, and [Resident #2] shoved me in my face. Then I pushed him back. LVN A observed Resident #1 for bruising that was located on the left side of his head. Family and physician notified. Resident #1 moved to another room. Record review of a progress note, dated 11/15/24, indicated Resident #1 was discharged to home. 4. Record review of Resident #2's face sheet dated 01/13/25 indicated he was a [AGE] year old male, admitted on [DATE], and his diagnoses included Parkinson's (disease is a movement disorder of the nervous system that worsens over time) and Alzheimer's (brain disorder that causes problems with memory, thinking and behavior) Record review of Resident #2's quarterly MDS assessment, dated 12/11/24, indicated he was able to make himself understood and usually understood others, he was cognitively intact with a (BIMS of 15), had no behaviors, utilized a wheelchair or walker for mobility, and required set up or supervision for some ADLS. Record review of Resident #2's care plan, dated 10/30/24, indicated Resident #2 was verbally aggressive. Interventions included positive feedback for good behavior . Record review of Resident #2's care plan dated 11/11/24 indicated he received physical aggression from another resident. Interventions included physician notification, separation of residents and the other resident moved to a different room to prevent further incidents. Record review of Resident #2's progress note, dated 11/11/24 ,and completed by LVN A, indicated Resident #2 was on the floor. Resident #2 stated Resident #1 pushed him. Resident #2 had a skin tear on his left forearm and left elbow. During an interview on 01/13/25 at 9:47 a.m., Resident #2 said Resident #1 came over to his side of the room and Resident #1 popped him on his head. He said he pushed Resident #1 away and then Resident #1 pushed him (Resident #2) and he fell over his bed to the floor. He said he hurt his shoulder. He said Resident #1 was taken out of the room right away and moved to another room. He said he could not recall why Resident #1 hit him or pushed him. He said it was abuse to be hit and pushed but he was not afraid of Resident #1 . During an interview on 01/13/25 at 8:45 a.m., the DON said she did not know the reason the incident between Resident #1 and Resident #2 was not reported. She said she was notified of the incident and notified the Administrator immediately. She said resident to resident abuse was reportable to the state. She said Resident #1 and Resident #2 were immediately separated with Resident #1 being moved to a different room. She said staff were trained prior to the incident and after the incident on abuse, neglect, and reporting. During an interview on 01/13/25 at 9:00 a.m., the Administrator said he was the abuse coordinator. He said he did not report the incident between Resident #3 and Resident #4 within 2 hours because there was no serious injury. He said he did not report the incident between Resident #1 and Resident #2 as resident to resident abuse because it was two residents going back and forth and there was no serious injury. He said Resident #1 was moved immediately to another room. He said there was no history of incidents between Resident #1 or Resident #2. He said allegations or incidents of abuse were reportable within 2 hours. He said the facility followed the facility policy and most recent provider letter regarding reporting abuse. He said residents were at risk of continued abuse if allegations of abuse was were not reported as required . During an interview on 01/16/25 at 12:31 a.m., LVN A said she was not in the room when Resident #1 pushed and hit Resident #2. She said Resident #2 was yelling that he had stood up and Resident #1 pushed him to the floor. She said she immediately separated the two residents to different rooms and notified the DON. She said there was no history of aggression between Resident #1 and Resident #2 . She said there was no further incidents after they were separated. Interviews conducted on 01/10/25 from 8:30 a.m. through 3:30 p.m., 01/13/25 from 8:30 a.m. through 3:30 p.m., 01/14/25 from 8:30 a.m. through 3:30 p.m. and 01/15/25 from 8:30 a.m. through 2:30 p.m. with the Administrator, the DON, 1 RN (RN B), 6 LVN (LVN A, LVN H, LVN I, LVN J, LVN K, LVN L), 9 CNA (CNA C, CNA M, CNA N, CNA O, CNA P, CNA W, CNA X, CNA Y, CNA Z), 2 housekeeping staff (HSK Q, HSK S), 2 dietary staff (DT AA, DT BB), and 1 maintenance staff (MS R who represented all shifts (6:00 a.m.-2:00 p.m., 2:00 p.m. -10:00 p.m., and 10:00 p.m.-6:00 a.m.) indicated they were able to give examples of abuse (physical, sexual, emotional, psychological) and neglect (not providing services) and would report immediately to the abuse coordinator or designee. Interviews conducted with 12 residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #12) on 01/10/25 from 8:30 a.m. through 3:30 p.m., 01/13/25 from 8:30 a.m. through 3:30 p.m., 01/14/25 from 8:30 a.m. through 3:30 p.m. and 01/15/25 from 8:30 a.m. through 2:30 p.m. indicated there were no concerns of abuse and they would report any abuse to the administrator and DON immediately. They were not afraid of any staff or other residents. They had no complaints of staff or fear of any resident . Record review of in-service, dated 10/05/24, 11/02/24, and 11/22/24 indicated staff who represented all shifts were retrained on abuse and neglect prevention and reporting. Record review of the facility's abuse policy, dated 02/01/17 (revised 01/27/20), indicated The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion, Confinement, and or Misappropriation of property. The facility staff will adhere to the policies and procedures and will follow the guidelines in the written policy and procedure. Residents will not be subjected to abuse by anyone, including but not limited to community staff other residents The noncompliance was identified as PNC. The noncompliance began on 10/05/24 and ended on 11/11/24. The facility had corrected the noncompliance before the survey began.

Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported, immediately but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or bodily injury, to the administrator of the facility and to other officials, including the State Survey Agency in accordance with State law through established procedures for 4 of 17 residents (Residents #1, #2, #3 and #4) reviewed for reporting allegations of abuse. 1. The facility failed to report an allegation of abuse within 2 hours after Resident #3 slapped Resident #4's face on 10/05/24. 2. The facility failed to report an allegation of abuse within 2 hours after Resident #1 hit and pushed Resident #2 on 11/11/24. These failures could place residents at risk of abuse, physical harm, mental anguish and emotional distress. Findings include: 1. Record review of Resident #3's face sheet, dated 01/14/25, indicated a [AGE] year old female, admitted to the facility on [DATE]. Resident #3 had diagnoses which included dementia (group of symptoms that affects memory, thinking and interferes with daily life), COPD (an ongoing lung condition caused by damage to the lung), anxiety (emotion characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events) and bipolar disorder (a mental disorder characterized by periods of depression and periods of abnormally elevated mood that each last from days to weeks). Record review of Resident #3's annual MDS, dated [DATE], indicated she was able to make herself understood, usually understood others, was cognitive evidenced by a BIMS 15, exhibited no behaviors, and utilized a wheelchair for mobility. She required supervision to moderate assistance for all ADLS. Record review of Resident #3's progress note, dated 10/05/24 at 12:30 p.m., completed by LVN K, indicated Resident #3 slapped Resident #4 in the face. Resident #3 stated [Resident #4] slapped me on the back of the head and scratched me so I defended myself. A small skin tear noted on Resident #3's left forearm. On-call notified and gave a new order for treatment of skin tear. Record review of Resident #3's psychiatric visit report, dated 10/08/24, completed by NP M, indicated Resident #3 agreed to restart Abilify (used to treat agitation and bipolar disorder). Record review of Resident #3's care plan, dated 10/24/24, indicated she was on medication for bipolar and interventions included administer medications as ordered and monitor/record occurrence of targeted behavior. 2. Record review of Resident #4's face sheet, dated 01/14/25, indicated an [AGE] year old female, admitted to the facility on [DATE]. Resident #4 had a diagnosis which included Alzheimer's (brain disorder that causes problems with memory, thinking and behavior.) Record review of Resident #4's quarterly MDS assessment, dated 10/23/24, indicated the resident was usually able to make herself understood and understood others, had moderate cognitive impairment with a BIMS of 11, had no behaviors, utilized a wheelchair for mobility, and required partial to maximum assist for all ADLS. Record review of Resident #4's care plan, dated 07/06/24, indicated she had the potential to be physically aggressive related to Alzheimer's. Interventions included communication and to provide physical and verbal cues to alleviate anxiety and redirect to the nurse's station. Record review of Resident #4's progress note, dated 10/05/24, completed by LVN N, indicated Resident #4 pushed Resident #3. Resident #3 slapped Resident #4 on the right side of her face. A bruise noted to the right side of the face, Resident #3 denied pain. The Resident refused pain medications and stated I am not a baby it was just a slap. Record review of Resident #4's psychiatric visit report, dated 10/16/24, completed by NP D, indicated Resident #4 did not recall who hit her, she said she had memory problems, and did not want to talk about the incident. There were no medication changes. Record review of the facility investigation, dated 10/11/24 and completed by the Administrator, indicated the facility confirmed the incident occurred. The facility indicated the incident occurred on 10/5/24 at 11:30 a.m. The facility reported the incident to HHS on 10/06/24 at 10:19 a.m. On 10/05/24 the facility in-serviced staff on the abuser/neglect policy and kept Resident #3 and Resident #4 separated. During an interview on 01/10/25 at 9:00 a.m., the DON said Residents #3 and #4 used their wheelchairs for mobility. She said Resident #4 sometimes had difficulty and bumped into others. It was alleged Resident #3 slapped Residents #4's face and left a bruise. She said the bruise was actually an age spot. The residents were separated and staff were in-serviced to keep residents separated. Both residents were seen by psych services. There was no history of aggression between the residents and there had been no issues since the incident. 3. Record review of Resident #1's face sheet, dated 01/13/25, indicated an [AGE] year old male, admitted to the facility on [DATE]. Resident #1 had diagnoses which included spondylosis (degeneration of the vertebral column from any cause) and acute kidney failure (sudden decline in kidney function). Record review of Resident #1's Discharge MDS assessment, dated 11/15/24, indicated he had moderate cognitive impairment with a BIMS of 11, required set up/supervision or partial assist for ADLS, had physician behavioral symptoms directed at others and verbal behavioral symptoms directed at others. Record review of Resident #1's care plan, dated 09/20/24, indicated no behavioral focus or interventions. Record review of a progress note, dated 11/11/24, completed by LVN A, indicated LVN A was notified by an unidentified aide that Resident #1 hit Resident #2. LVN A observed Resident #1 lying in his bed. Resident #1 smiled and stated Resident #2 wouldn't shut up. I sat up on my side of the bed. I walked over to him and Resident #2 shoved me in my face. Then I pushed him back. LVN A observed Resident #1 for bruising that was located on the left side of his head. Family and physician notified. Resident #1 moved to another room. Record review of a progress note, dated 11/15/24, indicated Resident #1 was discharged to home on 11/15/24. 4. Record review of Resident #2's face sheet, dated 01/13/25, indicated a [AGE] year old male, admitted to the facility on [DATE]. Resident #2 had diagnoses which included Parkinson's (disease is a movement disorder of the nervous system that worsens over time) and Alzheimer's (brain disorder that causes problems with memory, thinking and behavior. This is a gradually progressive condition.) Record review of Resident #2's quarterly MDS assessment, dated 12/11/24, indicated he was able to make himself understood and usually understood others, he was cognitively intact with a BIMS 15, had no behaviors, utilized a wheelchair or walker for mobility, and required set up or supervision for some ADLS. Record review of Resident #2's care plan, dated 10/30/24, indicated Resident #2 was verbally aggressive. Interventions included positive feedback for good behavior. Record review of Resident #2's care plan 11/11/24 indicated he received physical aggression from another resident. Interventions included physician notification, separation of residents and other resident moved to a different room to prevent further incidents. Record review of Resident #2's progress note, dated 11/11/24 and completed by LVN A, indicated Resident #2 was on the floor. Resident #2 stated Resident #1 pushed him. Resident #2 had a skin tear on his left forearm and left elbow. During an interview on 01/13/25 at 8:45 a.m., the DON said she did not know the reason the incident between Resident #1 and Resident #2 was not reported. She said she was notified of the incident and notified the Administrator immediately. She said resident to resident abuse was reportable to the state. She said Resident #1 and Resident #2 were immediately separated with Resident #1 being moved to a different room. She said staff were trained prior to the incident and after the incident on abuse, neglect and reporting. During an interview on 01/13/25 at 9:00 a.m., the Administrator said he was the abuse coordinator. He said he did not report the incident between Resident #3 and Resident #4 within 2 hours because there was no serious injury. He said he did not report the incident between Resident #1 and Resident #2 as resident to resident abuse because it was two residents going back and forth and there was no serious injury. He said Resident #1 was moved immediately to another room. He said there was no history of incidents between Resident #1 or Resident #2. He said an allegation or incidents of abuse were reportable within 2 hours. He said the facility followed the facility policy and most recent provider letter regarding reporting abuse. He said residents were at risk of continued abuse if allegations of abuse were not reported as required. During an interview on 01/16/25 at 12:31 a.m., LVN A said she was not in the room when Resident #1 pushed and hit Resident #2. She said Resident #2 was yelling that he had stood up and Resident #1 pushed him to the floor. She said she immediately separated the two residents to different rooms and notified the DON. She said there was no history of aggression between Resident #1 and Resident #2. She said there was no further incidents after they were separated. She said all resident-to-resident abuse was reportable immediately to the DON and Administrator. Record review of the facility's abuse policy, dated 02/01/17 (revised 01/27/20), indicated . Reporting and Investigating: The law requires the abuse coordinator/designee, or employee of the facility who believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect, or exploitation caused by another person to report the abuse, neglect or exploitation. 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.

Based on interview and record review the facility failed investigate and report the findings of the investigation to the State Survey Agency within 5 working days of the incident for 2 of 17 residents (Residents #1 and #2) reviewed for abuse. The facility failed to investigate and submit the results of their investigation within 5 days after Resident #1 hit and pushed Resident #2. These failures could place residents at risk of abuse, physical harm, mental anguish and emotional distress. Findings included: Record review of Resident #1's face sheet, dated 01/13/25, indicated an [AGE] year old male, admitted to the facility on [DATE]. Resident #1 had diagnoses which included spondylosis (degeneration of the vertebral column from any cause) and acute kidney failure (sudden decline in kidney function). Record review of Resident #1's Discharge MDS assessment, dated 11/15/24, indicated he had moderate cognitive impairment with a BIMS of 11, required set up/supervision or partial assist for ADLS, had physician behavioral symptoms directed at others and verbal behavioral symptoms directed at others. Record review of Resident #1's care plan, dated 09/20/24, indicated no behavioral focus or interventions. Record review of a progress note, dated 11/11/24, completed by LVN A, indicated LVN A was notified by an unidentified aide that Resident #1 hit Resident #2. LVN A observed Resident #1 lying in his bed. Resident #1 smiled and stated Resident #2 wouldn't shut up. I sat up on my side of the bed. I walked over to him and Resident #2 shoved me in my face. Then I pushed him back. LVN A observed Resident #1 for bruising that was located on the left side of his head. Family and physician notified. Resident #1 moved to another room. Record review of a progress note, dated 11/15/24, indicated Resident #1 was discharged to home on 11/15/24. Record review of Resident #2's face sheet, dated 01/13/25, indicated a [AGE] year old male, admitted to the facility on [DATE]. Resident #2 had diagnoses which included Parkinson's (disease is a movement disorder of the nervous system that worsens over time) and Alzheimer's (brain disorder that causes problems with memory, thinking and behavior. This is a gradually progressive condition.) Record review of Resident #2's quarterly MDS assessment, dated 12/11/24, indicated he was able to make himself understood and usually understood others, he was cognitively intact with a BIMS 15, had no behaviors, utilized a wheelchair or walker for mobility, and required set up or supervision for some ADLS. Record review of Resident #2's care plan, dated 10/30/24, indicated Resident #2 was verbally aggressive. Interventions included positive feedback for good behavior. Record review of Resident #2's care plan 11/11/24 indicated he received physical aggression from another resident. Interventions included physician notification, separation of residents and other resident moved to a different room to prevent further incidents. Record review of Resident #2's progress note, dated 11/11/24 and completed by LVN A, indicated Resident #2 was on the floor. Resident #2 stated Resident #1 pushed him. Resident #2 had a skin tear on his left forearm and left elbow. A record review of TULIP inidcated there was no facility-self report and 5th day report submitted by the facility During an interview on 01/13/25 at 8:45 a.m., the DON said she did not know the reason the incident between Resident #1 and Resident #2 was not reported. She said she was notified of the incident and notified the Administrator immediately. She said resident to resident abuse was reportable to the state. She said Resident #1 and Resident #2 were immediately separated with Resident #1 being moved to a different room. She said staff were trained prior to the incident and after the incident on abuse, neglect and reporting. During an interview on 01/13/25 at 9:00 a.m., the Administrator said he was the abuse coordinator. He said he did not report the incident between Resident #1 and Resident #2 as resident to resident abuse because it was two residents going back and forth and there was no serious injury. He said Resident #1 was moved immediately to another room. He said there was no history of incidents between Resident #1 or Resident #2. He said an allegation or incidents of abuse were reportable within 2 hours. He said the facility followed the facility policy and most recent provider letter regarding reporting abuse. He said residents were at risk of continued abuse if allegations of abuse were not reported as required. Record review of the facility's abuse policy, dated 02/01/17 (revised 01/27/20), indicated . The abuse coordinator with the Director of Nursing/designee will investigate all allegations and use the appropriate forms to document the investigation. And turn it into HHS within 5 calendar days

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 1 of 12 dietary staff (DA J) reviewed for food and nutrition services. The facility failed to ensure DA J had a current Food Handler's Certificate while working in the facility's kitchen. This failure could place residents who consumed food prepared in the facility kitchen at risk of foodborne illness due to being served by improperly trained staff. Findings included: Record review of 12 dietary staff food handlers' certificates indicated DA J's certificate had an expiration date of [DATE]. During an interview on [DATE] at 11:47 a.m., DA J said she did not realize her food handler's certification had expired last year. She stated, I was trying to get on the computer to complete the food handler training today. During an interview on [DATE] at 11:52 a.m. the DM said she noticed the Food Handlers Certificate for DA J was expired. During an interview on [DATE] at 12:30 p.m., the Administrator said the DM had just started recently but she would be the one responsible to monitor the certificates. He said the dietary staff were to have current food handler's certification to prevent food borne illness and the food handler certification was required. Reference obtained from the Texas Food Establishment Rules dated 2015 indicated .Certified Food Protection Manager and Food Handler Requirements. (e) The food establishment shall maintain on premises a certificate of completion of the food handler training course for each food employee. The requirement to complete a food handler training course shall be effective [DATE]

Based on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 preparation kitchen. * The facility did not ensure baking sheets did not have brown and/or black baked on build up. * The facility did not ensure steam table pans did not have brown and/or black baked on build up. * The facility did not ensure muffin pans did not have brown and/or black baked on build up. * The facility did not ensure skillets did not have black build up on the outer and inner surface. * The facility did not ensure staff leave their shoes in the kitchen. * The DM and Cook G did not ensure food was at a safe temperature prior to serving food to residents. These failures could place residents who eat from the kitchen at risk of foodborne illnesses. Findings included: During observations on 03/04/24 during initial tour of the kitchen at 08:36 a.m. indicated: * There were 3 large deep baking sheets, 7 large baking sheets, 3 half size baking sheets, and 5 muffin pans all with black/brown build up inside the corners and the outside edges; * There were 2 large shallow steam table pans with brown build up on the outside edges. * There was 1 large skillet on the stove being used had black build up on the outer and inner surface. During an interview on 03/04/24 at 09:00 a.m. the DM said she had only been working at the facility for 2 weeks and had not been able to do anything yet about the buildup. During observations and interviews of the lunch meal service on 03/05/24 indicated: * at 11:46 a.m. there were slide shoes under the prep table next to the steam table. * at 12:01 p.m. the DM acknowledged the slide shoes under the preparation table and said the slide shoes should not be there and removed them. * at 12:18 p.m. Cook G pulled two deep steam table pans with 2 turkey breasts roasts out of the oven. Cook G conducted a temperature check with the temperatures ranging from 169-171 degrees. Cook G sliced up two turkey breast roasts, placed them in a steam table pan, then placed the pan on the steam table. The other pan with 2 turkey breast roasts were left on the preparation table. * at 12:30 p.m. the DM removed the lids from the foods on the steam table. She did not check the temperatures of the food at that time. * at 12:35 p.m. the DM was pulling serving utensils and did not have all the correct ones. She said she would have to adjust how much was given with the ones she had to ensure the residents received the right amount. The temperatures of the food was not checked at that time. * at 12:38 p.m. the DM placed a turkey slice on a plate without checking the temperature. * at 12:40 p.m. the DM started to serve the a turkey slice on a plate without checking the temperature. Surveyor asked what was the temperature of turkey being served since it had been sitting out of the oven and not on the steam table. Cook G said the temperature was checked when she took them out of the oven. Surveyor asked the DM and Cook G when should the temperatures of food to be checked and the DM said when taken out of the oven and before serving. The DM checked the temperature of the turkey slices and it was 154 degrees. She then started to serve and surveyor asked what the temperatures were of the other food on the steam table. She said she did not know and started checking the temperatures. The temperatures were above the required holding temperature. According to the US Food and Drug Administration Food Code dated January 18, 2023: 2-103.11 Person in Charge. The PERSON IN CHARGE shall ensure that: (I) EMPLOYEES are properly maintaining the temperatures of TIME/TEMPERATURE CONTROL FOR SAFETY FOODS during hot and cold holding through daily oversight of the EMPLOYEES' routine monitoring of FOOD temperatures; 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; or (2) At 5 C (41 F) or less. .4-6 Cleaning of Equipment and Utensils 4-601 Objective 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris

Based on observation, interview, and record review, the facility failed to ensure nurse aides demonstrated competency in skills and techniques necessary to care for residents needs as identified by the resident assessment and plan of care for 2 of 4 CNAs (CNA A and CNA B) reviewed for nurse aid proficiency and for 1 of 2 residents reviewed for transfers. (Resident #1) The facility did not transfer Resident #1 with a proper technique. CNA A and CNA B did not use a gait belt to transfer Resident #1; they transferred Resident #1 by lifting her under her arms and holding by her pants. Resident #1 sustained a nondisplaced greater tuberosity (prominent area of bone at the top of the arm) fracture on 09/16/19. This was determined to be past non-compliance with actual harm due to the facility having implemented actions to correct the non-compliance prior to the beginning of the survey. This failure could place residents who required transfers at risk of injury. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 had severely impaired cognition and required extensive assistance of one staff for bed mobility and transfers. The most recent MDS dated [DATE] indicated Resident #1 had severely impaired cognition and required extensive assistance of two staff for bed mobility and transfers. A Care Plan History with a revision dates of 12/6/18 and 09/15/19 indicated Resident #1 required extensive assistance of 2 staff to move between surfaces. A nursing note dated 09/17/19 indicated the hospice aide reported to the nurse, Resident #1 had bruising to the right upper chest and under her right arm. Resident #1 was unable to describe what happened due to her dementia. The nurse reported to the DON and hospice nurse. A hospital radiology report dated 09/17/19 of Resident #1's right shoulder indicated a suspected nondisplaced greater tuberosity fracture (shoulder fracture). During an interview on 09/25/19 at 9:10 a.m., the administrator said CNA A and CNA B transferred Resident #1 on 09/16/19 by lifting under Resident #1's arms and without a gait belt. She said the hospice aide noticed the bruise on Resident #1's right shoulder on the morning of 09/17/19 after she removed Resident #1's shirt to give her a bath. During an interview on 09/25/19 at 9:10 a.m. the DON said the bruise on Resident #1's right shoulder area was a light bruise and was not discovered until the hospice aide removed her shirt. She said the night staff did not notice any bruising and Resident #1 did not display any signs or symptoms of pain. She said Resident #1's physician was notified and ordered an x-ray and Resident #1 was sent to the hospital for evaluation and treatment. She said Resident #1 returned to the facility with new orders for an ice pack to right chest wall every 4 hours for 15 minutes and a sling. She said physical therapy reevaluated Resident #1 and suggested a Hoyer (mechanical) lift for transfers. During an observation on 09/25/19 at 1:00 p.m., Resident #1 was sitting in her bed with her knees drawn to her chest and a sling was around her right arm and shoulder. She did not respond to questions. During an interview on 09/25/19 at 2:00 p.m., CNA B said she worked until 8:00 p.m. on 09/16/19. She said she was on her way out of the facility when CNA A requested assistance to transfer Resident #1 to bed. She said she reached under Resident #1's right arm and CNA A reached under Resident #1's left arm and they held on to the back of Resident #1's pants, counted to 3, and simultaneously lifted Resident #1 from her wheelchair to the side of her bed. She said she did not have her gait belt and CNA A did not have her gait belt. She said she knew she was supposed to use the gait belt to transfer Resident #1. She said she was previously trained to use the gait belt to transfer residents. During an interview on 09/25/19 at 2:12 p.m., CNA A said she transferred Resident #1 with assist from CNA B. She said she reached under Resident #1's left arm and CNA B reached under Resident #1's right arm, they grabbed the back of Resident #1's pants, counted to 3 and lifted Resident #1 to the side of the bed. She said CNA B left the room and she resumed Resident #1's care. She said she did not use a gait belt. She said she knew she was supposed to use the gait belt to transfer Resident #1. She said she was previously trained to use the gait belt to transfer residents. The facility's policy for Safe Lifting and Movement of Residents revised 07/2017 indicated In order to protect the safety and wellbeing of staff and residents, and promote quality of care, this facility uses appropriate techniques and devices to lift and move residents. 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible. 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. The surveyor determined the facility was in non-compliance from 09/16/19 to 09/23/19. The facility took the following actions to correct the non-compliance: * Resident #1's physician was notified on 09/17/19, and orders were obtained for a radiological exam of the right arm and transfer to the emergency room for evaluation and treatment. * Resident #1 was reassessed by the physical therapist for transfer needs and the care plan was updated to reflect the need for a mechanical lift on 9/23/19. *A transfer care plan updated 09/23/19 indicated Resident #1 required the use of a Hoyer lift (mechanical lift) with 2 staff total assistance for transfers. * CNA A and CNA B were re-educated on the use of gait belt and Hoyer lift transfer techniques on 09/18/19. The records indicated CNA A and CNA B performed a return demonstration and indicated a pass. * Inservice training records for Gait Belt Transfer Proficiency were reviewed and indicated return demonstration was required for a pass or fail score. 31 CNAs were retrained and demonstrated competency on 09/18/19-09/23/19. * Interview and observation of a resident who received transfer assist daily indicated staff always used the gait belt for transfer assist. * The administrator indicated monitoring was in place and charge nurses monitored and educated staff, including counseling, re-education, and training as needed.

Based on interview and record review, the facility failed to provide adequate supervision and assistance to prevent accidents for 1 of 8 residents reviewed for accidents. (Resident #1) The facility did not provide required assistance of two staff during a transfer of Resident #1 from her wheelchair to her bed. Resident #1 sustained a fracture to her right femur when she fell during the transfer. This failure could place 104 residents who required assistance with transfers at risk of neglect or injury. Findings included: Physician orders [REDACTED].#1, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. Orders indicated the resident was hospitalized out of town on 08/22/17. The Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 had a Brief Interview of Mental Status (BIMS) of 12, indicating moderate cognitive impairment, she required 2+person physical assist for transfers, and utilized a wheelchair for mobility. The Care Plan dated 08/05/17 indicated Resident #1 required 2 person extensive assistance with transfers. The ADL information provided for CNAs, reviewed on 09/25/17 at 10:00 a.m. indicated Resident #1 required 2 staff for transfers. An incident report dated 08/22/17 indicated Resident #1 fell during a transfer. The fall was witnessed by CNA A. The resident's knee hit the floor when CNA A attempted to lower her into her bed, when Resident #1 slid down. CNA A notified the nurse that during an attempt to transfer Resident #1 from the wheel chair to bed, the resident was lowered to the floor on both knees, complained of pain to the right knee upon assessment, complained of pain when touched, and was administered Tramadol 50 milligrams for pain. The physician was notified, and ordered an x-ray which revealed an acute new fracture of the right distal femur. Orders were received on 08/23/17 to send Resident #1 to the hospital. In an interview on 09/25/17 at 12:08 p.m., CNA A said on 8/22/17, she was doing a pivot transfer with Resident #1, when the resident became weak and was eased to the floor. CNA A said she did not use a gait belt, and was transferring Resident #1 using a bear hug. She said she had taken care of Resident #1 before, and prior to this incident, she transferred the resident alone with no problems. She said on 8/22/17, she could not find anyone to help her transfer Resident #1 at the time. She said after Resident #1 was eased to the floor, she got another aide to help put Resident #1 in bed, and notified the charge nurse. She said they could check the resident's ADL sheet or check with the charge nurse to determine a resident's transfer status. During an interview on 09/25/17 at 12:18 p.m., CNA B said on 8/22/17, she was notified by CNA A that Resident #1 was sitting on the floor. She assisted CNA A with transferring Resident #1 back to bed. She said she and CNA A transferred the resident from the floor to her bed with an aide on each side of the resident. During an interview on 09/25/17 at 12:00 p.m., LVN B said on 8/22/17, CNA A informed her that Resident #1 was complaining of right knee pain. LVN B said she assessed the resident and consulted the physician who ordered an x-ray, which revealed the fracture. She said she completed an incident report. An incident report dated 08/22/17 completed by LVN B indicated Resident #1 was lowered to the floor by CNA A, although the resident's care plan, MDS, and ADL information provided to the CNAs indicated she was to be assisted to be by 2 staff. The resident was assessed, with complaints of pain to the right knee, the physician was consulted, and responsible party was notified. Hospital records dated 08/24/17 indicated Resident #1 had surgical correction of her fractured right femur. During an interview on 09/25/17, the ADON said the aides have the written resident ADL records to know what type of transfer to use. The facility's undated falls policy indicated it is the policy to evaluate residents for their fall risk and develop interventions for prevention. The procedure indicated the interdisciplinary team should determine if a resident is at risk for falls and develop interventions based on the evaluation. Following a fall, the resident should not be moved until the licensed nurse has evaluated the resident's condition. The CMS Form 672 dated 09/25/17 indicated 104 residents required assistance during transfers.

Based on observation, interview and record review, the facility failed to ensure that adequate supervision and assistance were provided to residents to prevent accidents for 1 of 6 residents reviewed for accidents. (Resident #1) Resident #1 fell on [DATE] while alone/unassisted in the shower. She remained on the shower floor for an unknown amount of time, with the hot water running, and sustained first and second degree burns on 10 percent of her body. This failure could place 40 residents who required staff assistance and supervision at risk for injury. Findings included: The September 2013 physician's orders [REDACTED]. Some of the physician ordered medications were Coumadin (blood thinner); Norco (pain relief) routinely 2 times a day, Lidoderm patch every 12 hours routinely, Digoxin (heart medication) and HCTZ (diuretic). The MDS dated [DATE] indicated Resident #1 could make needs known, had slow speech, needed supervision and set up with mobility, transfers, eating and personal care. She was cognitively intact. A care plan dated 06/12/13 indicated Resident #1 required one staff assistance with some ADLS with approaches to work with the resident on scheduling showers and ADLs to resident's preference. A September 2013 MAR indicated Resident #1 received medications on 09/27/13 at 6:30a.m., 7:00 a.m., and 8:00 a.m. The aide flow sheet dated September 2013 indicated Resident #1's shower schedule was on the day shift on Mondays, Wednesdays and Fridays and indicated supervision. The fall risk assessment was dated 09/23/13 and the resident was low risk. The last history and physical dated 09/18/13 was the annual exam and indicated Resident #1's complaint was edema, under skin assessment indicated tendency to bruise, paleness, intact, warm and dry, consciousness was alert and awake with forgetfulness, edema was 1 plus, and required assistance with ADLS, turning, positioning, and transfers. Observation on 10/01/13 at 12:10 p.m. of Resident #1's room revealed a private room with a private bathroom, a walk-in shower and a built-in pull down shower seat. There was a call light in the room and bathroom, both in working order. The incident report was dated 09/27/13 and indicated Resident #1 was found lying on the shower floor in the shower on 09/27/13 at 12:45 p.m. due to a fall. She was assessed, but not moved due to complaints of neck pain until EMS arrived. The maintenance log indicated the maintenance supervisor took the water temperature and recorded on 09/27/13 at 1:30 p.m. Room 315, (Resident #1's room), had a water temperature of 109 degrees. The provider report dated 09/28/13 indicated the state was notified on 09/28/13 of the incident regarding burns. The administrator's written statement indicated she did not know of Resident #1 sustaining burns until a family member called her. The administrator contacted the maintenance supervisor regarding water temperatures. The provider report indicated on 09/28/13 around 10:00 a.m., the maintenance supervisor's written statement indicated he began to check water temperatures around 10:30 a.m. at the sinks. Resident #1's sink temperature was 118 degrees. On 09/29/13 around 12:45 p.m., he again took water temperatures and found Resident #1's sink temp, was 118 degrees. He adjusted the water heaters and the water temperatures ranged from 99-103 degrees including room 315. He did not call the plumber on Sunday but did on 9/30/13 regarding the hot water heaters not operating correctly. The investigation follow-up indicated recommendations to assist Resident#1 with all showers and for staff to check water temperatures daily. Hospital records dated 09/27/13 indicated Resident #1 arrived at 1:25 p.m. She was alert, oriented, and complaining of back pain with posterior cervical tenderness to touch. Her back had visible diffuse first degree burns over her back that extended down toward the upper lumbar area and scattered vesicular eruptions across the back consistent with some second degree burns. The majority of the vesicles were intact but several were ruptured and oozing. The assessment indicated first and second degree thermal burns of the back. Orders dated 09/30/2013 indicated Resident #1 was transferred to another hospital out of town and placed on the burn unit. The hospital records of the burn unit dated 09/30/13 indicated Resident #1 had "1st degree and 2nd degree burns-10% on posterior back from posterior scalp sparing the neck then on shoulders extending to just below mid back, some blistering with clear fluid, scar in midline of back. Patient recalls the episode and denies loss of consciousness. She claims she slipped and was too weak to pick herself up. She called for help, was not sure how long she was on the floor, and waited for help to arrive. " During an interview on 10/01/13 at 12:20 p.m., CNA A who usually worked with Resident #1, but was not assigned to the resident on 09/27/13, said the resident usually gave herself a shower on Mondays, Wednesdays and Fridays around 10:30 a.m.. She said she would provide the towels and set up for Resident #1 to shower, make the bed and supervise while the resident showered. She said she was called by the nurse on 09/27/13 around 12:45 p.m. to assist when Resident #1 was found in the shower. She said Resident #1 was lying on her back, the hot water was running and the resident's chest and arms were red in color. She said the mirror was misted. She said Resident #1 was complaining of neck pain. During an interview on 10/01/13 at 2:40 p.m., the charge nurse responsible for Resident #1 said Resident #1 was a private person and did not like anyone in the bathroom while she showered. She said on that day, 09/27/13, there were 5 aides on duty. She said 2 of the aides left by noon and there were 3 aides with re-assigned schedules. She said when assignments change, the aides are informed of their new assignments and it is written on the assignment sheet. The nurse said she was notified by another resident's family member Resident #1 was on the floor in the shower. She said Resident #1 was lying on her back in the shower with the hot water running. She cut the water off, assessed the resident and due to complaints of neck pain did not move her. She said the water was turned all the way to hot and had been running on the resident. She said Resident #1 stated she did not fall but slipped and was not able to get up. An aide assignment sheet dated 09/27/13 that CNA C was initially assigned to Resident #1. CNA C left at 12:00 p.m. Resident #1 was then reassigned to CNA D. During an interview on 10/01/13 at 3:30 p.m., CNA C said she left at noon on 09/27/13 and the last time she checked on Resident #1 was around breakfast at 9:00 a.m. when she picked up her tray. CNA D's written statement indicated when she passed ice at 10:00 a.m. on 09/27/13, she saw Resident #1 going into the restroom. During an interview on 10/01/13 at 4:30 p.m., CNA D said she last saw Resident #1 on 09/27/13 around 10:00 a.m. when she passed ice to the residents. CNA D said she did not remember Resident #1 saying she was going to shower. CNA D said she was not familiar with Resident #1 or her routines. During an interview on 10/01/13 at 12:40, CNA B said on 09/27/13, she placed Resident #1's lunch tray in her room around 12 noon on 09/27/13 because the resident usually ate in her room. She said she did not see or hear the resident. She denied hearing water running or saying anything while she was in the resident's room. CNA B said she did not check the bathroom. During an interview on 10/01/13 at 1:35 p.m., the friend (non-resident) who found Resident #1 said when she arrived on 09/27/13, Resident #1's door was closed. She said she saw the CNA bring Resident #1's lunch tray around noon to the room. She said she waited until about 12:30 p.m. and went to check on Resident #1. She said the lunch tray was untouched and the bathroom door was closed. She said she knocked on the bathroom door and heard Resident #1 calling for help. She said when she opened the door, Resident #1 was alert, lying on the shower floor asking for help. The shower was on with the water running on the resident. She said she immediately called for the nurse and reported to the DON. During an interview on 10/01/13 at 3:20 p.m., the ADON and MDS nurse said Resident #1's MDS and care plan was coded for supervision and set up help of one person regarding showers and ADL care. The MDS nurse said according to her MDS and care plan, someone should have been with Resident #1. The ADON said the aides have their resident assignments written each shift and the care plans to follow. She said the charge nurses are responsible for aide assignments and the aides are responsible for caring for each resident according to their ADL care plan. She said residents are assigned bath and shower days which are written on the resident's ADL care plan. During an interview on 10/01/13 at 10:20 a.m., the administrator said the water temperatures were taken weekly. She said she was not informed of any burns until Resident #1's family member called her on Saturday, 09/28/13. She said she was told of the fall on Friday, 09/27/13. The administrator said after Resident #1's incident, staff were instructed to check water temperatures daily and it was staff's responsibility to monitor residents. During an interview on 10/01/13 at 10:30 a.m., the maintenance supervisor said he works alone and checks water temperatures every Friday. He said he checked the water temperatures on Saturday after the administrator called him and again on Sunday. He said the mixing valves were fluctuating between 99 degrees to 118 degrees and he had to make adjustments and call a plumbing company who came on 9/30/13. During an interview on 10/01/13 at 1:00 p.m., the plumbing company supervisor said there was no way to tell when a mixing valve was not functioning properly except to take water temperatures. He said the facility was built in 2005 and water temperatures fluctuate due to how much water was being used and the time water temperatures were taken. The facility's census report dated 10/03/13 indicated 40 residents resided on Hall 300. According to The American Burn Association-Scald Injury Prevention Educator's Guide, "The continuing risk of domestic hot water scalds to the elderly." 2000: 26: 347-350 by Ahmed M. Stone and J Evans. "Older adults like young children have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or mediations so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to young adults. Older adults may also have conditions that make them more prone to falls in the bathtub or shower. A time and temperature relationship to severe burns indicated water at 120 degrees could cause third degree buns after 5 minutes."