Every finding on record at Georgetown Nursing and Transitional Care

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for medication administration. MA A failed to administer Resident #1's Hydrocortisone on time on 8/04/2026.MA B failed to administer Resident #1's Levothyroxine on time on 8/04/2026.These failures placed Resident #1 at risk of late medications, decreased absorption, and side effects.Findings included:A record review of Resident #1's face sheet dated 8/04/2026 reflected an [AGE] year-old female admitted on [DATE] with diagnoses including displaced subtrochanteric fracture (fractured leg), adjustment disorder with depressed mood, hypothyroidism (underactive thyroid), muscle wasting (muscle loss), and need for assistance with personal care.A record review of Resident #1's MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated no cognitive impairment.A record review of Resident #1's care plan last revised on 7/21/2026 reflected that she had ADL self-care performance deficit. Interventions included to praise all efforts at self-care.A record review of Resident #1's physician orders reflected an order dated 7/20/2026 for Hydrocortisone Oral Tablet 20 mg to be administered at 8:00 AM.A record review of Resident #1's physician orders reflected an order dated 7/20/2026 for Levothyroxine Sodium Oral Tablet 100 mcg to be administered at 5:00 AM.A record review of Resident #1's Administration History Report dated 8/04/2026 reflected that Hydrocortisone Oral Tablet 20 mg was scheduled for 8:00 AM on 8/04/2026 and MA A administered it at 9:27 AM.A record review of Resident #1's Administration History Report dated 8/04/2026 reflected that Levothyroxine Sodium Oral Tablet 100 Mcg was scheduled for 5:00 AM on 8/04/2026 and MA B administered it at 8:37 AM.During an interview on 8/04/2026 at 9:00 AM, MA C stated that usually medications were given an hour before or after, but there's a lot that are going to be late because of the amount of patients we have.During an observation and interview on 8/04/2026 at 9:54 AM, Resident #1 was observed in her room in the 300 hall. Resident #1 stated that the nurse told her she was running late that morning. Resident #1 said that she panicked when she received her medications late because she had Addison's disease (hormone disorder) and she needs steroids in her body. Resident #1 stated that she took thyroid medicine in the middle of the night but on that day (8/04/2026), she received it before breakfast.During an interview on 8/04/2026 at 10:08 AM, MA A said that she was scheduled as CNA that day (8/04/2026), but she passed medications on 300 hall because she noticed that the medications were late.During an interview on 8/04/2026 at 10:27 AM, MA A stated that she noticed that MA C was running late and Resident #1 was asking for her medications.During an interview on 8/04/2026 at 11:16 AM, the NP said that she had been seeing Resident #1 since July of 2026. The NP said that Resident #1 took hydrocortisone for Addison's Disease. The NP said that she would not speculate as to what her symptoms would be if she received the medication outside of the scheduled time, but that timing mattered for dips and peaks in cortisol. The NP said that it was important for levothyroxine to be administered on time-30 minutes to an hour before or after eating-because it was not absorbed as optimally without an empty stomach.During an interview on 8/04/2026 at 12:35 PM, the DON stated that for non-liberalized medications (medications with a specific administration time) , she expected them to be given within an hour of the order. The DON stated that levothyroxine was a supplement for thyroid gland and yes that levothyroxine needed to be administered 30 minutes to an hour before or after a meal. The DON said that she would need to check with the provider to find out what hydrocortisone was prescribed for. The DON said that staff were trained on administering medications through their schooling, team meetings, and they come to me or the ADON. The DON stated that the nurse leadership team was responsible for monitoring to ensure that medications were administered on time. The DON stated that the nurse leadership team monitored by reviewing the medication administration history report. The DON said that she spoke with MA B, and he said that he did not want to wake up Resident #1. The DON stated that if levothyroxine were administered late, it could cause decreased absorption and she was not sure what could happen if hydrocortisone was given late.During an interview on 8/04/2026 at 1:08 PM, the Administrator stated that his expectation was that medications were passed in a timely manner-an hour before or after they were due. The Administrator stated that staff were trained on medication administration through in-services. The Administrator stated that the ADONs and the DON were responsible for monitoring to ensure that medications were administered on time but that they were not auditing timing daily. The Administrator stated that giving levothyroxine late could limit absorption and that having steroids in the system on a continual basis was a thing.A record review of the facility's policy titled Medication Administration dated 10/24/2022 reflected the following: Policy:Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food safety for one of one kitchen (identifier) reviewed for food safety requirements.The facility failed to ensure that all expired items were removed from storage.The facility failed to ensure all items were properly labeled and dated.The facility failed to store dented cans separately from other canned items.These failures could place residents at risk of foodborne illness.Findings included:During an observation of the kitchen on 6/22/2026 from 9:23 A.M. - 9:36 A.M. revealed the following:At 9:23 A.M., the reach-in fridge contained a gallon of milk with an expiration date of 6/21/2026.At 9:27 A.M., the dry storage room contained a bottle of dessert syrup with a best-by date of 3/14/2026.At 9:34 A.M., the dry storage room contained a dented can of pineapple with an unidentifiable date.At 9:36 A.M., the dry storage room contained an updated bulk container of wild rice. During an interview on 6/2/2026 at 9:29 A.M., the Dietary Manager stated dented cans were kept in his office.During an interview on 6/23/2026 at 12:00 PM, CK A stated, We have to leave the damaged cans in the office to be returned. CK A stated the dented pineapple can needed to be placed in the Dietary Manager's office. CK A stated that she checked the cans on Tuesdays and she just missed it. CK A stated there was no date on the wild rice and it should have been dated. CK A stated the facility adhered to printed best-by dates, and that the dessert sauce was expired. CK A stated she was responsible for making sure everything was labeled and dated. CK A stated that on her days off, no one checked the storage areas.During an interview on 6/24/2026 at 10:54 A.M., the Dietary Manager stated that items were labeled and dated when they were delivered and that everything should have a label and a date. The Dietary Manager stated that CK A was the only one who put away the groceries, and she's very thorough. The Dietary Manager stated that CK A and he monitored the dry room storage. The Dietary Manager stated that they monitored food storage by going into the kitchen every day and looking. The Dietary Manager stated the dietary staff were already trained when he started 10 months ago, but for any new staff, he would have them shadow another employee for 4-7 days. When asked how residents could be affected if food storage policies were not followed, the Dietary Manager stated, my biggest fear is that ta resident could get sick.During an interview on 6/24/2026 at 2:37 PM, the Administrator stated that all food items needed to be labeled, dated, and discarded when they expired. The Administrator stated dented cans were stored in the Dietary Manager's office, and the policy was that they needed to be returned to the vendor. The Administrator stated that the kitchen was monitored by himself, the Dietary Manager, and dietary staff. When asked how residents could be affected if food were not properly stored, the Administrator stated they could consume expired food and have a tummy ache.A record review of the facility's policy titled, Food Storage, dated 6/01/2019, reflected the following: Policy: To ensure that all food served by the facility is of good quality and safe forconsumption, all food will be stored according to the state, federal and US Food Codes andHACCP guidelines.Procedure:.d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated.A record review of chapter 228 of the TAC on 6/25/2026 reflected the following: .(b) The department adopts by reference the U.S. Food and Drug Administration (FDA) Food Code 2017 (Food Code) and the Supplement to the 2017 Food Code.A record review of the FDA's 2022 Food Code reflected the following: 3-302.12 Food Storage Containers, Identified with Common Name of Food.Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD 3-202.15 Package Integrity.FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for two of two dumpsters (identifiers) reviewed for refuse.The facility failed to ensure that dumpsters were covered and that surrounding areas were free from debris.This failure could place residents at risk of exposure to pests. Findings included:During an observation on 6/22/2206 at 11:00 A.M., the facility was observed to have two dumpsters. The dumpster on the right had both side doors open. The ground near the dumpster on the left had a dark residue near the base of the dumpster and the following items were noted on the ground: a plastic straw, a plastic lid, a condiment packet, plastic waste, and paper waste.During an observation on 6/23/2026 at 12:12 PM revealed that the plastic and paper trash from the day prior (6/22/2026) were gone, but the condiment packet was still there. The dumpster on the left had one side door open. The dumpster on the right had one side door open and a bag of trash overflowing from the opened side door.During an interview on 6/23/2026 at 12:00 PM, CK A stated that the dumpster should be clean and covered. CK A stated that dishwashers were responsible for keeping the dumpster clean and covered. CK A stated, everyone uses the dumpster. CK A then stated that nursing staff used the dumpster but not cooks.During an interview on 6/23/2026 at 12:16 PM, DW B said that he checked the dumpsters every morning around 9:00 A.M. and swept the dumpster area occasionally. DW B stated that he also checked the dumpster around 1:00 PM. DW B said that any trash near the dumpster at that time (12:00 PM on 6/23/2026) must have happened after 9:00 A.M. DW B said that the evening dishwasher checked the dumpster at 4:00 PM and at 8:00 PM daily.During an interview on 6/24/2026 at 10:54 A.M., when asked what the policy was on maintaining the dumpster, the Dietary Manager stated, the struggle is keeping the tops and sides closed and sweeping around it. The Dietary Manager said that there was a lot of nursing trash around the dumpster that morning (6/24/2026) but he cleaned it up. The Dietary Manager said that every time the dishwashers [NAME] out trash, they needed to make sure all sides were closed. The Dietary Manager said that the dumpsters were monitored four times a day and if dishwashers saw trash on the ground, they would clean it up. The Dietary Manager stated that there had been no issues with pests. When asked what a potential negative outcome was if the dumpsters were not maintained, the Dietary Manager stated, fighting off rodents. The Dietary Manager stated that trash on the ground was a rodent magnet but that he had not seen any rodents.During an interview on 6/24/2026 at 2:37 PM, the Administrator stated that dumpster lids should be closed when not putting trash in them for pest control purposes. When asked what a potential negative outcome was if dumpsters were not clean and covered, the Administrator stated it increased the risk for pests.A record review of the facility's policy titled, Garbage Receptacles, dated 6/01/2019, reflected the following: Policy: The facility will maintain garbage receptacles in a clean and sanitary manner to minimize the risk of food hazards.Outdoor receptacles:.It shall be constructed to have tight fitting lids, doors or covers and stored in a manner that is inaccessible to insect and rodents with doors/lids kept closed and no waste outside of the receptacle.A record review of chapter 228 of the TAC reflected the following: (b) The department adopts by reference the U.S. Food and Drug Administration (FDA) Food Code 2017 (Food Code) and the Supplement to the 2017 Food Code.A record review of the FDA's 2022 Food Code reflected the following: Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT

Based on observations, interviews, and record review, the facility failed to ensure residents who were unable to carry out Activities of Daily Living receive the necessary services to maintain grooming and personal hygiene for 4 of 12 residents (Resident #19, Resident #22, Resident #28 and Resident #6) reviewed for Activities of Daily Living. The facility failed to ensure Resident #19 and Resident #28's facial hair was shaved from 04/28/2025 and 04/29/2025. The facility failed to ensure Resident #6 and Resident #22 were provided their showers 3 times a week as scheduled. This failure could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem. Findings included: On 04/28/25 at 11:13 AM an observation was conducted of Resident #19 Resident #19 was observed to have approximately quarter inch length facial hair. On 04/28/2025 at 11:13AM an interview was conducted with Resident #19. Resident #19 reported not being offered to have her facial hair shaved. Resident #19 reported that she wishes the staff would provide her with tweezers and a mirror so she could fix her facial hair. Record review of Resident #19's face sheet indicated Resident #19 is an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #19 has diagnoses of Compression fracture of fourth lumbar vertebra (a break in the bones on the spine), subsequent encounter for fracture with routine healing (follow up after injury in the process of healing), and hypo-osmolality (low concentration of sodium and electrolytes), hyponatremia and muscle weakness (low blood sodium that causes muscles to weaken). Record review of care plan dated 04/21/2025 indicated that Resident #19 requires setup assistance for ADLs as of 04/21/2025. This care plan indicated that as of 04/21/2025 Resident #19 requires set up and clean up assist with her personal hygiene and oral care. Record review of MDS sheet dated 04/08/2025 indicated that Resident #19 required set up and clean up assistance for hygiene. According to the MDS, set up and clean up assistance is defined as Helper set up or cleans up; resident completes the activity. Helper assists only prior to or following the activity. Resident #19's MDS dated [DATE] reflected a BIMS score of 11 which indicates moderate cognitive impairment. On 04/28/25 at 01:52 PM an interview was conducted with Resident #22. Resident #22 stated he does not get his showers regularly. He said he is only getting two showers a week. He said he had asked for his showers and the staff told him that there was no one working that could give him a shower. Record Review of Resident #22's face sheet indicated Resident #22 is an [AGE] year-old male admitted to the facility initially on 11/02/2022 with a re-admission on 04/04/2025. Resident #22 has a diagnosis of fracture of unspecified part of neck (broken bone in the neck), hypertensive heart disease without heart failure (heart complications caused by high blood pressure) and paroxysmal atrial fibrillation (irregular heart beat). Record review of care plan dated 04/22/2025 indicates that Resident #22 is at increased risk for potential ADL self-care performance deficit related to history of impaired mobility, falls prior to admission and requires assistance with ADLs. According to this care plan, Resident #22 requires extensive x1 staff assist with bathing and showering as necessary. Record Review of MDS sheet dated 04/10/2025 indicated that Resident #22 required substantial/maximum assist for showering/bathing. According to this MDS, substantial/maximum assist is defined as Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Resident #22 has a BIMs of 15 which indicates no cognitive impairment. Record Review of Resident #22 shower log revealed that his shower days were Tuesday, Thursday and Saturday. He was admitted on [DATE] and did not get a shower until 04/09/2025. He did not get another shower until 4/12/2025. He then had a shower on 04/15/2025 and did not get another shower until 04/24/2025. Record review of Resident #22's progress notes revealed that the resident did not refuse any showers. On 04/29/2025 at 11:45AM an observation was made of Resident #28. Resident #28 was observed to have quarter of an inch length facial hair. Record review of Resident #28's face sheet indicated that Resident #28 is a [AGE] year-old female who was admitted into the facility on [DATE] with a re-admission on 04/07/2025. Resident #28 has a diagnosis of laceration without foreign body, hypokalemia and chronic diastolic heart failure. Record review of care plan dated 04/25/2025 indicated Resident #28 depends on staff to help with ADLs as of 04/25/2025. This care plan indicated Resident #28 was dependent and required x1 staff assist with personal hygiene and oral care. Record review of MDS sheet dated 03/31/2025 indicated that Resident #28 was dependent and required help for personal hygiene needs. According to MDS, dependent is defined as staff to provide total support for Resident #28 in order to complete ADLs. Resident #28 has a BIMS of 4 which indicated severe cognitive impairment. On 04/29/25 at 03:32 PM an interview was conducted with Resident #6 Resident #6 stated that she does not get her showers regularly. She said that she only gets one shower a week. She said she had asked for her showers, but they still did not give them to her. Record review of Resident #6' face sheet indicated that Resident #6 is an [AGE] year-old woman who was admitted to the facility on [DATE]. Resident #6 has a diagnosis of depressive episodes (depression that lasts two weeks), hypertension (high blood pressure), and a history of falling. Resident #6 has a BIMS of 6 which indicates severe cognitive impairment. Record review of care plan dated 03/06/2020 indicated that Resident #6 is at risk of ADL self-care performance deficit relating to impaired mobility and unsteady gait. This care plan indicated that Resident #6 requires supervision and 1 person assist for bathing and showering per schedule as necessary. Record review of MDS dated [DATE] indicated that Resident #6 required substantial/maximum assist for showering/bathing. According to this MDS, substantial/maximum assist is defined as Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Record Review of Resident #6's shower log revealed shower days are Tuesday Thursday and Saturday. Resident had a shower on 04/03/25 and did not get another shower until 04/08/2025. After the resident got a shower on 04/08/2025 the resident did not get another shower until 04/15/2025. The resident did not get another shower until 04/22/2025. The resident got a shower on 04/24/2025 and did not get another shower until 04/29/2025. Record review of Resident #6's progress notes revealed that the resident had not refused any showers. This document revealed the following: 04/01/2025- Resident received a shower. 04/03/2025- Resident received a shower. 04/05/2025- Resident did not receive a shower. 04/08/2025- Resident received a shower. 04/10/2025- Resident did not receive a shower. 04/12/2025- Resident did not receive a shower. 04/15/2025- Resident received a shower. 04/17/2025- Resident did not receive a shower. 04/20/2025- Resident did not receive a shower. 04/22/2025- Resident received a shower. 04/24/2025- Resident received a shower. 04/26/2025- Resident did not receive a shower. 04/29/2025- Resident received a shower. On 04/30/2025 at 10:49AM an interview was conducted with MA A who reported they have received trainings on ADL care. MA A reported that in the ADL training, it covered transfers, charting and level of care for residents. MA A stated the training was provided on their online learning database last month. MA A reported the policy for showers is to offer showers on resident's designated shower days. This policy, according to MA A, reflects residents being scheduled for showers 3 times a week. MA A reported that if a resident refuses a shower, it should be documented. MA A reported the policy for grooming residents is to provide shaving care during showers for both men and women. MA A reported that it is the responsibility of the assigned CNA to provide showers and grooming. MA A reported it is important to ensure ADL care is provided because it helps prevent skin breakdown. MA A reported the potential negative affect this could have on residents is the potential for residents to feel awful. MA A reported that there should be no reason a resident is not provided a shower other than refusing. MA A reported it is the responsibility of the Charge Nurse to ensure that ADL care is being monitored. MA A reported that ADL care is monitored by filling out documentation and reporting to the nurse if there is a refusal. On 04/30/2025 at 11:02AM an interview was conducted with CNA B who reported they have received trainings on ADL care. CNA B reported that the trainings covered hygiene, peri care and resident rights. CNA B reported that the trainings are provided on their online learning database. CNA B reported that the policy for providing showers is to follow the schedules on the hall for showers, which are provided 3 times a week. CNA B stated if a resident refuses a shower, they have a document to fill out. CNA B stated that the policy for grooming/shaving residents is they should provide it when they offer care every day. CNA B stated that they will offer to shave residents during their shower days. CNA B stated that CNAs are in charge of completing showers and shaving residents. CNA B stated it is important to provide ADL care because it could cause an infection. CNA B stated that a negative impact this could cause a resident is that they could feel terrible. CNA B stated is the responsibility of the DON to ensure that ADLs are being monitored. CNA B stated this is monitored by completing a sheet that they should turn in everyday as well as notifying the nurse if a resident refuses care. On 04/30/2025 at 11:30AM an interview was conducted with CNA C who confirmed they have received trainings on ADLs. CNA C stated that ADL training covers what care should be provided to the residents as well as how to provide the care. CNA C stated that they received this training a couple of months ago on their online learning database. CNA C stated that the policy for showers is that residents should be showered 3 times a week and it should be documented. CNA C stated that the policy for grooming/shaving residents is to provide this care during shower days for men, and once a week for women. CNA C stated that the CNAs are responsible for providing showers and ADL care to residents. CNA C reported that it is important to provide ADL care to maintain the resident's hygiene. CNA C stated that a negative impact this could cause a resident is the resident could feel uncomfortable. CNA C stated that is it the Charge Nurse's responsibility to ensure that ADLs are being monitored. CNA C stated that this is monitored by watching the staff complete these tasks. CNA C stated that if a resident refuses a shower, that could be why a resident did not receive one despite it being on their scheduled shower day. On 04/30/2025 at 12:00PM an interview was conducted with LVN D who reported receiving trainings on ADL care. LVN D stated that in this training it covered the needs of ADLs. LVN D stated that this training was completed recently. LVN D stated that the policy for showers is that all residents have scheduled days for showers consisting of 3 days. LVN D stated that the policy for grooming and shaving is to provide this while residents are still in the shower room. LVN D stated this is also provided when the residents request it. LVN D stated that it is the responsibility of the shower aides to ensure that showers and grooming are provided to residents. LVN D reported that it is important to provide ADL care to meet the needs of the residents. LVN D stated that a negative impact this could cause residents is for them to feel unhappy. LVN D stated that it is the responsibility of the nurses to ensure monitoring of ADL care. LVN D stated ADL care is monitored by CNAs notifying the nurse if a resident refuses a shower or ADL care, and the nurse will report it to the family. LVN D stated a reason a resident was not provided a shower despite them not refusing a shower on their scheduled shower day, could be because the resident is out of the facility. On 04/30/2025 at 03:52PM an interview was conducted with the DON who reported being trained on ADL care. DON stated that the facility provides trainings to the staff. DON stated that this training was provided in an in-service throughout the calendar year. DON stated that the policy for showers is residents are scheduled 3 showers per week and have the ability to ask for more or less. DON stated the policy for grooming/shaving residents is that the shower aide should be providing this ADL on shower days. DON stated that it is the responsibility of the shower aides to ensure showers are provided. DON stated it is important to provide ADL care because it provides the resident an opportunity to be clean. DON stated that a negative impact this could have on a resident is being unhappy. DON stated it is the responsibility of the nurses and DON to ensure monitoring of ADL care. DON stated that monitoring of ADLs consists of completing shower sheets during shower days and notifying the nurse. IF the resident refuses a shower more than 3 times on their designated shower days, then the facility will notify the family. DON stated that residents may not be provided showers on their scheduled days if the residents refuse but it should be documented. On 04/30/2025 at 6:15PM an interview was conducted with the ADM who reported that ADL trainings are provided to staff by the nursing department. The ADM stated that the trainings consist of technique, frequency, and support for hygiene. The ADM stated that these trainings are provided during new hire, skills fairs and throughout the year especially if there is a change in resident condition. The ADM stated the expectation for showers is that they are provided to residents. The ADM stated that hygiene is important, and the responsibility of the staff is to help provide this for them if needed. The ADM stated the expectation for grooming and shaving residents is that it should be offered to residents. The ADM stated that it is the CNA and shower aides' responsibility to ensure that showers and grooming is offered and provided to residents. The ADM stated it is important to provide ADL care for residents because it is the resident's rights. The ADM stated that this could affect the resident by not feeling happy, clean or proud of how they look. The ADM stated that women with facial hair may feel bothered that this is not taken care of. The ADM stated that the nurses are responsible for monitoring and ensuring ADL care is provided, as well as managers. The ADM stated that ADLs are monitored by documentation and shower sheets. The ADM stated that the reason a resident may not receive a shower despite not refusing could be lack of communication between shifts, scheduling and potentially time management could affect it. Record review of an undated document labeled Personal Care - Activities of Daily Living provided by the facility indicated the following: 1. The facility will make every reasonable effort to ensure that each resident receives the appropriate personal care assistance necessary to support their health and well being, and to maintain their personal dignity. Personal care will consist of bathing, toileting hygiene, dressing, and grooming, including hair, nail and oral care, and hand and face washing. Residents will be encouraged to participate in activities of daily living which they are able. 2. Residents will be scheduled to bathe at a minimum of three times per week unless otherwise requested by the resident. 3. The bathing attempts and resident refusals will be documented on the ADL record and the Director of Nursing or designee will be notified. 4. Hair will be washed with showers, or per resident preference with assistance as needed from staff members, or at the facility hair salon, or a salon of the resident's choice. Hair will be combed daily in the morning, and as necessary throughout the day. 49410

51115 Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to dispose of open stored perishable food products and damaged food. 2. The facility failed to properly label and date food products in the dry storage pantry, refrigerator, and freezer. 3. The facility failed to ensure Dishwasher H and General Manager wore beard restraints properly while performing duties throughout the kitchen. These failures could place residents who were served from the kitchen at risk for consuming contaminated food and developing foodborne illnesses. Findings include: In an observation on [DATE] at 8:40 AM of the kitchen, it was found that there was food not dated in the dry food area, refrigerator, and freezer. The following food products were found not labeled or dated in the dry food storage: brown gravy mix, chocolate syrup, Worcestershire sauce, barbeque sauce, and tortillas. The following food products were found not labeled or dated in the refrigerator: a carton of milk, lemonade and tea, broth, loaves of bread, bread sticks, Boston cream pie, and butterscotch pudding. The following food products were found not labeled and dated in the freezer: frozen cookie dough, and frozen chopped potatoes. The following food products were found open: apple cider vinegar with no lid located in the dry food storage and frozen chicken breast located in the freezer. There was a broken egg found leaking in the refrigerator. General Manager followed Investigator around and removed the items that were of concern. In an interview on [DATE] at 10:50 AM conducted with [NAME] I, she stated she is trained in labeling and dating. [NAME] I stated she labels and dates all food products. [NAME] I stated all kitchen staff are trained on labeling and dating, and how to properly store food and drinks in the appropriate storing areas. [NAME] I stated she has been trained in food sanitation and foodborne pathogens that can harm residents. [NAME] I stated if she sees broken eggs, she will get rid of them because it can cause salmonella and foodborne pathogen contamination in residents. [NAME] I stated unproperly stored food can make the residents sick. [NAME] I stated it's the kitchen staff's responsibility to get rid of the unlabeled and undated food because the kitchen staff won't know if the food is good or not to serve residents. In an interview on [DATE] at 11:18 AM conducted with Kitchen Manager, she stated she has been trained in labeling and dating. Kitchen Manager stated labeling and dating are done once the facility receives food and the kitchen staff place dates on all food products. Kitchen Manager stated everything is to be labeled and dated depending on the product of food such as if food or drinks have manufacture date's and is expiring. The Kitchen Manager stated kitchen staff place dates on food products when they are opened, and the kitchen staff get rid of the food that is not labeled or dated . Kitchen Manager stated staff label the food and the date it should be used by and what it's for based on the menu. Kitchen Manager stated some food products have longer hold times and will be labeled that day with the hold time of when it should be used. Kitchen Manager stated that kitchen staff will throw away food that does not have a date as it can pose a risk of consumption for the resident. Kitchen Manager stated, kitchen staff providing improperly stored food could ruin the residents' experience or potentially make residents sick. The Kitchen Manager, Dietician, and General Manager are in charge of checking food in the dry food storage, refrigerator, and freezer. The Kitchen Manager, Dietician, and General Manager do walk throughs of the food supply, which is done daily, and Dietician conducts its monthly walk throughs at random. Kitchen Manager stated an open bag of chicken in the freezer is a cross contamination issue and would need to go . Kitchen Manager stated a broken egg can be an issue in the refrigerator for cross contamination and may cause food borne pathogens in residents. In an interview on [DATE] at 11:20 AM conducted with General Manager, he stated he has been trained in labeling and dating. General Manager stated labeling and dating are done once the facility receives food and the kitchen staff place dates on all food products. General Manager stated everything is to be labeled and dated depending on the product of food such as if food or drinks have manufacture date's and is expiring. The Kitchen Manager stated kitchen staff place dates on food products when they are opened, and the kitchen staff get rid of the food that is not labeled or dated. General Manager stated staff label the food and the date it should be used by and what it's for based on the menu. General Manager stated some food products have longer hold times and will be labeled that day with the hold time of when it should be used. General Manager stated that the food products he saw that were pulled out when Investigator discovered them, should have been labeled and dated and General Manager advised the staff as well as removed them. General Manager stated that kitchen staff will throw away food that does not have a date as it can pose a risk of consumption for the resident. General Manager stated, kitchen staff providing improperly stored food could ruin the residents' experience or potentially make residents sick. The Kitchen Manager, Dietician, and General Manager are in charge of checking food in the dry food storage, refrigerator, and freezer. The Kitchen Manager, Dietician, and General Manager do walk throughs of the food supply, which is done daily, and Dietician conducts its monthly walk throughs at random. General Manager stated an open bag of chicken in the freezer is a cross contamination issue and the exposed chicken would need to go . General Manager stated a broken egg can be an issue in the refrigerator for cross contamination and may cause food borne pathogens in residents. In an interview on [DATE] at 11:25 AM conducted with Dietician, she stated the following: She has been trained in labeling and dating. Dietician stated labeling and dating are done once the facility receives food including the kitchen staff place dates on all food products. Dietician stated everything is to be labeled and dated for food products. It was stated that the food products the General Manager saw and pulled out when Investigator discovered them, should have been labeled and dated in which General Manager advised it to the staff as well as removed them. Dietician stated that kitchen staff should throw away food that don't have a date as it can pose a risk of consumption for the resident. Dietician stated kitchen staff providing either expired or not properly stored food could ruin the residents experience or potentially make residents sick. The Kitchen Manager, Dietician, and General Manager are in charge of checking food in the dry food storage, refrigerator, and freezer. The Kitchen Manager, Dietician, and General Manager do walk throughs of the food supply, which is done daily, and Dietician conducts its monthly at random. Dietician stated an open bag of chicken in the freezer is a cross contamination issue. Dietician stated a broken egg can be an issue in the refrigerator for cross contamination and may cause food borne pathogens to residents. Dietician stated kitchen staff are to have proper education to prevent potential sickness or harm to the residents. In an observations on [DATE] at 10:19 AM of Dishwasher H, it revealed him wearing a ballcap hat with hair length to his mid-neckline not tucked into the hat nor wearing a hair restraint to keep the hair restrained. Observation revealed Dishwasher H was wearing a beard restraint to cover and restrain his beard, but his beard restraint was pulled down and his mustache was fully exposed while washing and drying dishes. In an interview on [DATE] at 10:20 AM with Dishwasher H, he stated he's been trained on wearing hair and beard restraints, and it's important to follow wearing proper hair restraints for resident safety and so hair won't get in the resident's food or kitchen ware. Dishwasher H stated if a hair or facial hair restraint is not worn properly, it can affect the resident's quality of life and pose risk to the residents. Dishwasher H stated he doesn't know what the policy says about either wearing a hat or hair restraint while being in the kitchen. Dishwasher H stated the policy for wearing beard restraints is to cover the entire facial hair. Dishwasher H stated he admits that his mustache part of his beard wasn't covered and stated it's supposed to cover the mustache too, but he moved it down because the beard restraint got wet and felt swampy. Dishwasher H stated the facility provided him with training and all kitchen staff are trained in hair and beard restraints, and labeling and dating. In an observation on [DATE] at 10:21 AM revealed that General Manager was wearing a beard restraint to cover and restrain his beard, but his beard restraint was pulled down and his mustache was fully exposed while observed coming out of the kitchen refrigerator and walking through the main kitchen preparation area into the dry food storage. General Manager's mustache was observed to be exposed and observation at 10:30 AM revealed he covered his mustache. In an interview on [DATE] at 10:31 AM conducted with General Manager, General Manager stated the policy for labeling and dating per his knowledge is if kitchen staff open food, the kitchen staff need to put a date on it and if kitchen staff receive food shipments, then a date needs to be put on it. General Manager stated if food is being prepped for the day or night, kitchen staff won't require a label or date since it's being used that day, unless it is reused for another day, then kitchen staff have to label and date the food or drinks for proper storage. General Manager stated the policy for hair and beard restraints per his knowledge is anyone who is in the kitchen area is to wear hair and facial hair or beard restraints. General Manager stated everyone that comes in the kitchen area is required to always wear restraints while remaining in the kitchen. General Manager stated kitchen staffs' hair has to be pulled back out of the way and stuffed into hair restraints or a hat. General Manager stated he would need to see if Dishwasher H has longer hair that needs to be tucked in the hat or hair restraint. General Manager admitted he sometimes forgets to cover his mustache when wearing a beard restraint. In an interview on [DATE] at 3:25 PM conducted with Director of Nursing, she stated she would have concerns for kitchen staff not wearing hair or beard restraints as all staff who enter the kitchen are to utilize them. Director of Nursing stated it's her expectation that kitchen staff and all staff in the kitchen need to wear beard and hair restraints. Director of Nursing stated she is trained on hair restraints and beard restraints and all staff are to wear them. Director of Nursing stated if kitchen staff prepare food or are washing and cleaning dishes, the staff are supposed to wear hair restraints. Director of Nursing stated if facial hair or hair is not properly covered while in the kitchen, it would depend on the length of the staff's hair in terms of the potential health issues to residents. Director of Nursing stated it can be an infection control issue and she would not want a resident to eat off dishes or the prepared food by any kitchen staff that doesn't wear a hair or facial hair restraint properly. Director of Nursing stated if vulnerable residents are exposed to anything prepared by the kitchen staff that aren't wearing beard restraints it is a potential infection control issue. Director of Nursing stated it's the kitchen staff who are in charge of all food products being labeled and dated as well as the quality for health consumption issues if residents are eating food that is not labeled or dated. Director of Nursing stated if the unlabeled or not dated food products are getting out to the dining room during resident meal service, it can potentially affect the vulnerable population the facility serves. Director of Nursing stated if the food products are not properly stored, or labeled and dated, it can get a resident sick and affect their health. Director of Nursing stated it's her expectation for residents to receive quality food products. In an interview on [DATE] at 6:30 PM with Administrator, she stated she has been trained in proper hair and beard restraint and is aware of the policy. Administrator stated not all staff are trained in hair and beard restraints, it's mainly the kitchen staff who undergo the training and other staff are aware of the need to wear hair restraints when entering the kitchen area. Administrator stated the kitchen staff should have the proper training to use hair and beard restraints and they are to practice what they learned when in the kitchen. Administrator stated the policy for hair restraint and beard restraints is for anyone who is in the kitchen area to wear their hair up in a restraint or hat. Administrator stated the policy for facial hair was it should be covered with a beard restraint in order for it to be effective. Administrator stated it can be a risk to the residents if the facial hair or any hair is not properly restrained and if it was her dishes being cleaned and food being prepped for her to eat, she would prefer for the kitchen staff to have all hair restraints properly worn in order for her to eat the food. Administrator stated it can potentially be an infection control issue if a resident consumes food prepared with hair in it. Administrator stated all food products such as, carton of milk, lemonade and tea, broth, loaves of bread, bread sticks, brown gravy mix, chocolate syrup, Worcestershire sauce, barbeque sauce, apple cider vinegar with no lid, tortillas, Boston cream pie, butterscotch pudding, cookie dough, chopped potatoes, chicken breast, and a broken egg that were found is not quality healthy food to provide to residents. Administrator stated labeling and dating food products is important to know if it can be consumed or not. Administrator stated it's the policy and her expectation for kitchen staff to be labeling and dating food products. Administrator stated if the food products are not labeled and dated correctly, it can lead to residents consuming the contaminated food and it's a concern for foodborne pathogens or illnesses to residents. Record review of the facility's Kitchen Labeling and Dating policy (with no revision or policy date) stated: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Most, but not all, products contain an expiration date. The words sell-by, best-by, enjoy-by or use-by should precede the date. The sell-by date is the last date that food can be sold or consumed; do not sell products in retail areas or place on patient trays/resident plates past the date on the product. Foods past the use by, sell-by, best-by, or enjoy by date should be discarded. Cover, label and date unused portions and open packages. Products are good through the close of business on the date noted on the label. Date and rotate items; first in, first out. Discard food past the use-by or expiration date. Wrap food tightly to prevent cross contamination. Food prepared in-house, and then stored frozen should be kept no longer than 3 months. Commercially produced foods may be held frozen until the manufacturer's expiration date, or for 3 months if no expiration date on the package. Once the packaging around the food has been opened, food must be used within 3 months. Record review of the facility's Hair Restraints policy (with no revision or policy date) stated: Consumers are particularly sensitive to food contaminated by hair. Hair can be both a direct and indirect vehicle of contamination. Food employees may contaminate their hands when they touch their hair. A hair restraint keeps dislodged hair from ending up in the food and may deter employees from touching their hair. Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, which are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.

50872 51115 Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Volunteer P) of 3 volunteer members and 4 of 8 residents (Resident # 8, #15, #33, and #57) reviewed for infection control. The facility failed to ensure Volunteer P conducted hand hygiene during resident dining services. 1. The facility failed to ensure 2 of 3 staff (MA E and MA F) disinfected the blood pressure cuff between resident use for 3 of 4 residents (Resident # 8, #33, and #57) reviewed during medication pass. 2. The facility failed to ensure 1 of 2 staff (CNA K) followed proper infection control procedures by folding the disposable wipes and reusing the wipe and not performing proper hand hygiene at the appropriate times during peri care for 1 of 1 resident (Resident # 15) observed during peri care. These failures could place residents at risk for transmission of disease and infection. Findings include: In an observation on 04/28/2025 at 12:30 PM during resident dining room services, there was a volunteer member (Volunteer P) observed going around filling up residents' drinks and not sanitizing their hands. Volunteer member was placing cups on top of their head to balance them while walking to the residents to hand to them without hand sanitization in between residents. 1. Record review of Resident #8's admission record, dated 04/30/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #8 had diagnoses which included: chronic kidney disease (a disease in which kidneys are damaged and can't filter blood properly), unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), hypertension (high blood pressure) and hypothyroidism (a condition where the thyroid gland doesn't produce enough thyroid hormone leading to a slowdown in metabolism). Record review of Resident #8's quarterly MDS, dated [DATE], reflected a BIMS score 15, which indicated no cognitive impairment. Record review of Resident #8's care plan, dated 02/20/2025, reflected Need: [Resident #8] has a dx of hypertension. Approaches included: give antihypertensive (medication used to lower blood pressure) medications as ordered. 2. Record review of Resident #15's admission record, dated 04/30/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #15 had diagnoses which included: aphasia (difficulty using or comprehending language), pain in right shoulder, need for assistance of personal care, lack of coordination, atrial fibrillation (irregular heartbeat), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), rheumatoid arthritis (a chronic disorder where the body's immune system attacks itself and can cause inflammation of the joints and other body systems), unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), neuropathy (damage or disease that affects the nerves causing pain and impaired sensation) and contracture of unspecified joint (the shortening of the muscles, tendons, skin and nearby soft tissue that prevents normal movement). Record review of Resident #15's comprehensive MDS, dated [DATE], reflected a BIMS score was not completed. Section C reflected short-term and long-term memory problems. Record review of Resident #15's care plan, dated 07/31/2020 and last revised on 04/28/2025, reflected Need: [Resident #15] has a hx of incontinence and requires assistance with toileting. Approaches included: Clean peri-area with each incontinence episode. 3. Record review of Resident #33's admission record, dated 04/30/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #33 had diagnoses which included: hypertension (high blood pressure), hyperlipidemia (high cholesterol), and hypothyroidism (a condition where the thyroid gland doesn't produce enough thyroid hormone leading to a slowdown in metabolism). Record review of Resident #33's admission MDS, dated [DATE], reflected a BIMS score of 12, which indicated moderate cognitive impairment. Record review of Resident #33's order summary, dated 04/30/2025, reflected amlodipine besylate oral tablet 5mg give 1 tablet by mouth one time a day for hypertension hold for SBP <110. Record review of Resident #33's care plan, dated 03/28/2025 and revised on 04/28/2025, reflected Need: [Resident #33] has dx of hypertension. Approaches included: evaluate blood pressure. 4. Record review of Resident #57 admission record, dated 04/30/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #57 had diagnoses which included: lymphedema (tissue swelling caused by fluid buildup in the lymphatic system), unspecified atrial fibrillation (irregular heartbeat), chronic pain syndrome (pain that lasts for greater than 3-6 months), hypertension (high blood pressure), and chronic diastolic heart failure (a condition when the heart is unable to adequately pump blood). Record review of Resident #57's quarterly MDS, dated [DATE], reflected a BIMS score of 15, which indicated no cognitive impairment. Record review of Resident #57's order summary, dated 04/30/2025, reflected: 1) Metoprolol tartrate tablet 25mg give 1 tablet by mouth two times a day for afib hold for SBP less than 110 and/or HR less than 60. 2) Torsemide oral tablet 40mg give 1.5 tablet by mouth one time a day for CHF. 3) Enhanced barrier precautions involve gown and glove use during high-contact resident care activities. EBP are required for resident for the following reason: wounds. Examples of high contact resident care activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs every shift. Record review of Resident #57's care plan, dated 07/26/2024 and last revised on 03/18/2025, reflected Needs: [Resident #57] requires enhanced barrier precautions due to: wound. Approaches included: Incorporate periodic monitoring and assessment of adherence to recommended infection prevention practices, such as hand hygiene and PPE use, to determine the need for additional training and education. In an observation on 04/29/2025 at 07:32 AM of MA E administering medications to Resident #57 MA E gathered the blood pressure cuff from the drawer of the medication cart and proceeded to check Resident #57's blood pressure without disinfecting the blood pressure cuff. MA E then placed the blood pressure cuff on top of the medication cart without disinfecting it after checking Resident #57's blood pressure. In an observation on 04/29/2025 at 07:54 AM of MA F administering medications to Resident # 8 MA F gathered the blood pressure cuff from the drawer of the medication cart and proceeded to check Resident #8's blood pressure without disinfecting the blood pressure cuff. MA F then placed the blood pressure cuff back in the drawer of the medication cart without disinfecting if after checking Resident #8's blood pressure. In an observation on 04/29/2025 at 08:08 AM of MA F administering medications to Resident #33 MA F gathered the blood pressure cuff from the drawer of the medication cart and proceeded to check Resident #33's blood pressure without disinfecting the blood pressure cuff. MA F then placed the blood pressure cuff back in the drawer of the medication cart without disinfecting if after checking Resident 33's blood pressure. In an observation on 04/30/2025 at 01:26 PM of CNA L performing peri care on Resident #15 with assistance from CNA K, CNA L and CNA K knocked on the door and entered the room. CNA L and CNA K washed their hands then donned (put on) gown and gloves and pulled the curtain closed to provide privacy for Resident #15. CNA L introduced self and explained procedure. CNA L pulled the covers down and unlatched Resident #15's brief and pushed the front part of the brief between Resident #15's legs. CNA L grabbed a disposable wipe from the package and wiped Resident #15's left groin, then threw the wipe in the trash. CNA L obtained a new wipe from the package and wiped Resident #15's vaginal area from front to back and threw the wipe in the trash. CNA L obtained a new wipe from the package and wiped Resident #15's right groin and threw the wipe in the trash. CNA K assisted resident to turn on right side. CNA L obtained a new wipe from container and wiped Resident #15's buttocks, she then folded the wipe over and used the same wipe to wipe Resident #15's buttocks again. The dirty brief was removed by CNA L from behind the resident and placed in the trash. A new brief was placed under Resident #15 (without hand hygiene or gloves changed) by CNA L. CNA L then doffed (removed) dirty gloves and donned new gloves (without performing hand hygiene). Resident #15 was positioned on her back by CNA K. CNA K and CNA L pulled the front of the brief up between Resident #15's legs and secured with tabs. Resident was then positioned for comfort on her left side. Trash was gathered by CNA L and placed by the door to the room. CNA K and CNA L doffed gown and gloves and washed their hands. In an interview on 04/29/2025 at 08:39 AM, MA E stated the policy for sanitizing medical equipment that is shared between residents was to sanitize the equipment between residents. MA E stated he didn't sanitize the cuff before or after measuring the blood pressure on Resident #57 because he forgot to. MA E stated it was his responsibility to sanitize the blood pressure cuff he used to check the blood pressure of the residents. He stated not sanitizing the blood pressure cuff before and/or after use could transmit disease and infection between the residents. In an interview on 04/29/2025 at 11:18 AM conducted with Kitchen Manager, she stated she has been trained in hand hygiene, and there are signs posted and all staff are to follow them. Hand hygiene goes over washing hands with hot water, scrubbing wrist and arms for 20 seconds, washing hands and sanitizing when changing gloves or touching other equipment as well as products. Kitchen Manager stated all staff are to follow hand hygiene to prevent cross contamination. Kitchen Manager stated hand hygiene is to be followed in the kitchen and dining room by staff members. Kitchen Manager stated all staff are trained in hand hygiene and when it comes to residents or volunteers it is the Nursing staff responsibility to check on hand hygiene to prevent cross contamination. Kitchen Manager stated volunteers or staff going table to table touching resident's drinks to refill them or touch things can pose a risk to residents. Kitchen Manager stated it's a risk because it can be a cross contamination and infection control issue. Kitchen Manager stated if staff and volunteers don't perform hand hygiene, it can affect the resident's quality of life by getting them or other individuals sick. In an interview on 04/29/2025 at 11:20 AM conducted with General Manager, he stated he has been trained in hand hygiene, and there are signs posted and all staff are to follow them. General Manager stated hand hygiene goes over washing hands with hot water, scrubbing wrist and arms for 20 seconds, washing hands and sanitizing when changing gloves or touching other equipment as well as products. General Manager stated all staff are to follow hand hygiene to prevent cross contamination. General Manager stated hand hygiene is to be followed in the kitchen and dining room by staff members. General Manager stated all staff are trained in hand hygiene and when it comes to residents or volunteers it is the Nursing staff responsibility to check on hand hygiene to prevent cross contamination. General Manager stated volunteers or staff going table to table touching resident's drinks to refill them or touch things can pose a risk to residents. General Manager stated it's a risk because it can be a cross contamination and infection control issue. General Manager stated if staff and volunteers don't perform hand hygiene, it can affect the resident's quality of life by getting them or other individuals sick. In an interview on 04/29/2025 at 11:25 AM conducted with Dietician, she stated she has been trained in hand hygiene, and there are signs posted and all staff are to follow them. Hand hygiene goes over washing hands with hot water, scrubbing wrist and arms for 20 seconds, washing hands and sanitizing when changing gloves or touching other equipment as well as products. Dietician stated all staff are to follow hand hygiene to prevent cross contamination. Dietician stated hand hygiene is to be followed in the kitchen and dining room by staff members. Dietician stated all staff are trained in hand hygiene and when it comes to residents or volunteers it is the Nursing staff responsibility to check on hand hygiene to prevent cross contamination. Dietician stated volunteers or staff going table to table touching resident's drinks to refill them or touch things can pose a risk to residents. Dietician stated it's a risk because it can be a cross contamination and infection control issue. Dietician stated if staff and volunteers don't perform hand hygiene, it can affect the resident's quality of life by getting them or other individuals sick. In an interview on 04/29/2025 at 11:54 AM conducted with Licensed Vocational Nurse E, she stated she's been trained in hand hygiene and sanitation; it went over making sure hands are washed under fingernails and completely scrubbed, and this includes if removing gloves as it can be a cross contamination issue to the residents and during dining services. Licensed Vocational Nurse E stated all staff and volunteers are to utilize hand sanitizer pumps. Licensed Vocational Nurse E stated all staff are to follow hand hygiene and Nursing staff in the dining room are in charge of making sure it's followed. Licensed Vocational Nurse E stated staff or volunteers not conducting appropriate hand hygiene and sanitation can cause potential for illness, it can pass on bacteria, spread sickness and germs, cross contamination, and it can affect residents who are vulnerable. Licensed Vocational Nurse E stated volunteers or staff going table to table touching resident's drinks to refill them or touching other things in the dining room can pose a risk to residents. Licensed Vocational Nurse E stated all staff are trained on hand hygiene and volunteers go through the same training as staff. Licensed Vocational Nurse E stated volunteers should be following hand hygiene the same as staff for resident safety and to limit infection control issues. Licensed Vocational Nurse E stated the Nurse assigned to the kitchen that day such as herself today, is in charge of making sure everyone in dining is following hand hygiene and proper sanitation. Licensed Vocational Nurse E stated in her professional opinion, it is an issue if someone is not following hand hygiene and sanitation during dining services for vulnerable residents. In an interview attempt on 04/29/2025 at 12:19 PM, Volunteer P from dining services observed not conducting hand sanitization on 04/28/2025 was not volunteering today nor was there another volunteer located for questions on dining hand hygiene and sanitation. In an interview on 04/29/2025 at 12:28 PM conducted with Certified Nurse Aide F, she stated she's been employed at the facility for 3 years. Certified Nurse Aide F stated she's been trained in hand hygiene, and staff are to sanitize their hands in between residents. Certified Nurse Aide F stated facility staff remind all staff about hand hygiene and sanitization every day. Certified Nurse Aide F stated there are monthly in services as well as annual trainings for hand hygiene. Certified Nurse Aide F stated staff are to wash hands thoroughly in the washroom areas or utilize the hand sanitizer pumps throughout the facility if not able to perform hand washing at the moment. Certified Nurse Aide F stated there are enough hand sanitizing pumps throughout the facility and all staff have access to them in the dining room area and there are not any barriers from using them. Certified Nurse Aide F stated all staff are to wash hands as much as possible or to use the hand pump stations for sanitization before providing resident dining care. Certified Nurse Aide F stated hand sanitization is to be followed by all staff including volunteers as well as residents. Certified Nurse Aide F stated it's a risk if staff or volunteers aren't following hand hygiene because it can spread Covid, germs, and infections. Certified Nurse Aide F stated the Nursing staff, Director of Nursing, and Administrator are in charge of monitoring hand hygiene and sanitization. Certified Nurse Aide F can't recall any staff or volunteers not following hand hygiene. Certified Nurse Aide F stated all staff have been trained and should follow it to prevent infection spreading throughout the facility. In an interview on 04/29/2025 at 12:30 PM conducted with Certified Nurse Aide G, she stated she's been trained in hand hygiene, and staff are to sanitize their hands in between residents. Certified Nurse Aide G state facility staff remind all staff about hand hygiene and sanitization every day. Certified Nurse Aide G stated there are monthly in services as well as annual trainings for hand hygiene. Certified Nurse Aide G stated staff are to wash hands thoroughly in the washroom areas or utilize the hand sanitizer pumps throughout the facility if not able to perform hand washing at the moment. Certified Nurse Aide G stated there are enough hand sanitizing pumps throughout the facility and all staff have access to them in the dining room area and there are not any barriers from using them. Certified Nurse Aide G stated all staff are to wash hands as much as possible or to use the hand pump stations for sanitization before providing resident dining care. Certified Nurse Aide G stated hand sanitization is to be followed by all staff including volunteers as well as residents. Certified Nurse Aide G stated it's a risk if staff or volunteers aren't following hand hygiene because it can spread Covid, germs, infections, and it can 100 percent affect the quality of life for residents. Certified Nurse Aide G stated the Nursing staff, Director of Nursing, and Administrator are in charge of monitoring hand hygiene and sanitization. Certified Nurse Aide G stated the facility staff conduct biweekly meetings and go over hand hygiene education with all residents. Certified Nurse Aide G stated the hand hygiene training the facility provided to all staff is sufficient for the resident's safety and their quality of life. Certified Nurse Aide G can't recall any staff or volunteers not following hand hygiene. Certified Nurse Aide G stated all staff have been trained and should follow it to prevent infection spreading throughout the facility. In an interview on 04/29/2025 at 4:30 PM conducted with Administrator, she stated all volunteers receive the same training as staff except it's not as intense; the training goes over hand hygiene and sanitization. She will see if it is possible to provide the volunteers' contact information since they weren't at the facility today. In an interview on 04/30/2025 at 10:20 AM with Dishwasher H, he stated he's been trained in hand hygiene and sanitation, and it went over washing hands thoroughly and as well as in between glove changes. Dishwasher H stated dining Nursing and other staff should be hand sanitizing or washing hands in between residents and this goes for volunteers, residents, or guests to limit anything being spread that can cause illness. Dishwasher H stated touching other resident's cups and refilling them without proper hand hygiene can pose harm to the resident such as make them sick and affect their health. In an interview on 04/30/2025 at 11:47 AM, MA F stated she had been trained on infection control. She stated the policy for shared medical equipment was to sanitize the equipment before and after use. She stated she was responsible for sanitizing the blood pressure cuff before and after using it on a resident. She stated that she did sanitize the blood pressure cuff prior to checking the blood pressure for Resident #8 but forgot to sanitize it after checking the blood pressure for Resident #8. She stated she forgot to sanitize the blood pressure cuff before and after checking the blood pressure for Resident #33. MA F stated not sanitizing the blood pressure cuff could spread germs and infections, like COVID, to other residents. In an interview attempt on 04/30/2025 at 12:18 PM, Volunteer P from dining services that wasn't hand sanitizing on 04/28/2025 was not volunteering today nor was there another volunteer located for questions on dining hand hygiene and sanitation. Volunteer phone number was not provided by facility. In an interview on 04/30/2025 at 12:37 PM, RN G stated he had been trained on infection control. He stated the policy for shared medical devices was to sanitize all medical devices between use with different residents. He stated the staff that was checking vital signs was responsible for sanitizing the equipment used. RN G stated not sanitizing the equipment between uses could cause transmission of bacteria or infection from one resident to another and they could get sick. In an interview on 04/30/2025 at 01:49 PM, CNA L stated she had been trained on infection control. She stated the policy for shared medical equipment was the staff using the equipment was responsible for sanitizing the equipment before and after use on a resident. She stated not doing so could expose residents to germs and they could get sick. CNA L stated the policy for peri care was to use the disposable wipes one time and throw them in the trash. She stated she did fold the disposable wipe and wiped again while performing peri care on Resident #15. CNA L stated gloves should be changed and hand hygiene performed after cleaning the resident and before placing a new brief. She stated she forgot to change her gloves and use hand sanitizer after cleaning Resident #15 and before placing a new brief down. CNA L stated they are checked two times a year by a checkoff performed by the IP to ensure peri care was being performed correctly. She stated not following infection control procedures during peri care could put the resident at an increased risk of infections, like UTI s. In an interview on 04/30/2025 at 01:55 PM, CNA K stated she had been trained on infection control. She stated the policy for shared blood pressure cuffs was to clean them after use. She stated that the staff member using the blood pressure cuff was responsible for cleaning it. CNA K stated cleaning the blood pressure cuff prevented the transmission of germs between residents. CNA K stated the policy for peri care included using the disposable wipes once and throwing them in the trash and to change gloves after cleaning the resident and before putting down a new brief. She stated during the observation of peri care for Resident #15 the disposable wipes were folded over and used again. CNA K stated gloves were changed after the clean brief was placed and hand hygiene was not performed at that time. She stated she didn't know that hand hygiene, including using hand sanitizer, was required when changing gloves during peri care. CNA K stated not following policy could cause transmission of germs and infection to the resident. In an interview on 04/30/2025 at 03:10 PM, LVN D stated she had been trained on infection control. She stated the policy for shared medical equipment was to wipe it down with sanitizing wipes before and after use by the person who used the equipment. LVN D stated not wiping the equipment down could cause a transmission of infection to the resident. LVN D stated that during peri care the policy is to use the disposable wipe once and throw it away. She stated gloves were supposed to be changed and hand hygiene performed when gloves were visibly soiled and after cleaning the resident and prior to placing a clean brief. She stated not performing hand hygiene appropriately so could mean the cleaning was not effective because dirty gloves touched a clean surface. In an interview on 04/30/2025 at 3:25 PM conducted with Director of Nursing, she stated all aides, Nursing staff, Kitchen staff, and all staff are in charge of monitoring hand sanitization due to it being an infection control issue. Director of Nursing stated she has been trained in hand hygiene and sanitization, and the facility conducts monthly trainings in hand hygiene. Director of Nursing stated there are hand sanitation pumps throughout the facility as well as the dining area has access to hand pump sanitizing stations. Director of Nursing stated all staff are trained in hand sanitization including volunteers undergo the training. Director of Nursing stated the volunteers aren't assigned to residents and they don't encourage them to assist residents with dining services. Director of Nursing stated it's a concern if a volunteer or any staff member is refilling drinks and walking resident to resident without any hand sanitizing occurring. Director of Nursing stated it's a concern if a volunteer is going to residents with a cup of drink on their head to deliver it to residents since there is no sanitization occurring. Director of Nursing stated she hasn't witnessed this prior until admitting witnessing on Monday, 04/28/2025 there was a previous staff member that worked at this facility that is a volunteer now that was doing these things, and she advised Volunteer P not to do that and this is the first time it happened during dining services. Director of Nursing stated it can be harmful to residents since she didn't see the volunteer perform hand washing or sanitation as it can be cross contamination and pose issues affecting the resident's quality of life. Director of Nursing stated it's not acceptable and it's her expectation for volunteers not to do that and hand sanitize. In an interview on 04/30/2025 at 03:30 PM, the DON stated it was her expectation that staff sanitize all shared medical equipment after every use. She stated it was the responsibility of the staff member that is using the equipment to sanitize it. The DON stated if the equipment is not sanitized between residents, then it could cause cross contamination and infection. She stated she visually monitored this daily when she was walking around the facility. She stated it was her expectation for staff to use the disposable wipes one time during peri care and throw them away. The DON stated by folding the wipe and reusing it, infection could occur. She stated that staff was expected to change gloves and perform hand hygiene after cleaning the resident and disposing of the old brief during peri care, but before touching the new, clean brief. The DON stated that not changing gloves and performing hand hygiene at the correct times during peri care, the resident could get an infection. She stated staff perform annual checkoffs to ensure proficiency of the task and spot checks, as needed, are done by herself and the IP. In an interview attempt on 04/30/2025 at 5:09 PM conducted with a confidential resident at different dining table while waiting for dining services, resident was confirmed nonverbal and didn't respond to questions about a staff or volunteer not hand sanitizing. In an interview attempt on 04/30/2025 at 5:11 PM conducted with confidential resident at different dining table while waiting for dining services, resident didn't understand questions when attempted to ask about staff or volunteers not hand sanitizing. Resident mumbled and didn't state anything on topic. The resident looked at the surveyor and smiled without stating anything. In an interview attempt on 04/30/2025 at 5:12 PM conducted with confidential resident at a different dining table, resident was confirmed nonverbal and didn't look at the surveyor or respond during attempt to ask question about the volunteer member from 04/28/2025. In an interview attempt on 04/30/2025 at 5:13 PM conducted with additional confidential resident at different dining table in the dining room area, resident slowly moved around in their wheelchair and didn't respond to Investigator when asked questions. In an interview on 04/30/2025 at 05:40 PM, MA I stated she had received training on infection control. She stated it was policy to clean all shared medical equipment before going into the resident's room with it. She stated it was the responsibility of the staff member using the equipment to sanitize it. MA I stated that failure to sanitize the equipment, like blood pressure cuffs, could cause cross contamination of germs and infection. MA I stated when performing peri care on a resident, the expectation is to use the disposable wipe once and toss it in the trash. She stated that if a wipe was folded and used again that the bacteria from one part of the wipe might transfer to another part of the wipe due to the moisture associated with the wipe. She stated the bacteria might seep through. MA I stated it was policy to change gloves and perform hand hygiene before placing the clean brief under the resident during peri care. She stated not doing so could result in increased risk of infection for the resident. In an interview on 04/30/2025 at 05:48 PM, RN J stated she had received training on infection control. She stated that it was policy to clean/wipe all shared medical equipment between each resident. RN J stated not sanitizing the equipment between residents could lead to spread of infection and disease. RN J stated during peri care the wipes should only be used once and thrown away. She stated using the wipes and folding them to reuse them could increase the risk of infection for the resident. RN J stated that gloves should be changed, and hands sanitized after cleaning the resident, during peri care, and before placing the new, clean brief on the resident. She stated not changing gloves and performing hand hygiene at the appropriate time could lead to an infection in the resident. In an interview on 04/30/2025 at 06:10 PM, the ADM stated she had received training on infection control. She stated that it was her expectation for staff to clean all shared medical equipment between usage and at the end of their shift. The ADM stated not doing so could potentially cause an increased risk of infection. She stated there wasn't a formalized monitoring process for this, but the IP was responsible for focusing on needed areas of education for the staff. The ADM stated she wasn't sure what the policy was related to peri care, but stated in general staff should change gloves and sanitize/wash hands, after touching something that was dirty and before touching something that was clean. She stated not changing gloves at the appropriate times could lead to an infection. The ADM stated competency skills checks were performed annually by the staff and as needed. She stated the IP was responsible for monitoring the checkoffs. In an interview on 04/30/2025 at 6:30 PM with Administrator, she stated she has been trained in hand hygiene and sanitization and it went over the duration of hand washing and proper hand sanitizing as well as when to do it. Administrator stated hand hygiene should be done before providing services with a resident and in between residents. Administrator stated all staff undergo hand hygiene training and those practices should be utilized when they are conducting services with all residents. Administrator stated volunteers review the hand hygiene and infection control procedures when trained. The Administrator oversees all staff and it's her responsibility to monitor volunteers for hand hygiene. It's the responsibility of facility staff as a whole to make sure to follow appropriate hand hygiene. Administrator stated the policy for hand hygiene and sanitization is to follow the [TRUNCATED]

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 of 8 (Resident #15, #25, and #39) residents reviewed for accommodations. The facility failed to ensure call lights were within reach while in resident rooms for Resident #15 and Resident #39. The facility failed to ensure dining room tables were appropriate height for wheelchairs for Resident #25. These failures could place residents at risk of injury, for not receiving timely care, or a decreased quality of life. Findings included: 1. Record review of Resident #15's admission record, dated 04/30/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #15 had diagnoses which included: aphasia (difficulty using or comprehending language), pain in right shoulder, need for assistance of personal care, lack of coordination, atrial fibrillation (irregular heartbeat), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), rheumatoid arthritis (a chronic disorder where the body's immune system attacks itself and can cause inflammation of the joints and other body systems), unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), neuropathy (damage or disease that affects the nerves causing pain and impaired sensation) and contracture of unspecified joint (the shortening of the muscles, tendons, skin and nearby soft tissue that prevents normal movement). Record review of Resident #15's comprehensive MDS, dated [DATE], reflected a BIMS score was not completed. Section C reflected short-term and long-term memory problems. Record review of Resident #15's care plan, dated 07/31/2020 and last revised on 04/28/2025, reflected Need: [Resident #15] is at increased risk for potential falls r/t impaired mobility, and poor balance/coordination. Requires assistance with ADLs. Approaches included: Be sure [Resident #15]'s call light is within reach and encourage the resident to use it for assistance as needed. Observation of Resident #15's call light on 04/28/2025 at 09:34 AM revealed her call light was not within Resident #15's reach. Her call light was draped across a stuffed teddy bears legs sitting on top of her recliner while she was sleeping in bed. She could not have reached the call light if she needed it. 2. Record review of Resident #25's admission record, dated 04/30/2025, reflected an [AGE] year-old female who was originally admitted to the facility on [DATE] with the most recent admission on 09/06/2024. Resident #25 had diagnoses which included: unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), and hx of right femur fracture with surgical repair (a break in the right upper leg bone requiring surgery). Record review of Resident #25's significant change MDS, dated [DATE], reflected a BIMS score of 03, which indicated severe cognitive impairment. Record review of Resident #25's order summary, dated 04/30/2025, reflected no orders for specialty reclining wheelchair. Record review of Resident #25's care plan, dated 9/10/2024 and last revised on 04/07/2025, reflected no care plan related to specialty reclining wheelchair. Observation of Resident #25 on 04/28/2025 at 12:16 PM revealed resident sitting up in a specialty reclining wheelchair in the main dining room. Resident #25's wheelchair was in a reclined position and resident was eating her lunch off of an over the bed table. Resident #25 was seated alone facing all the other resident's tables. All other residents were sitting at tables with 2+ other residents. Attempted to interview resident but received no verbal response. 3. Record review of Resident #39's admission record, dated 04/30/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #39 had diagnoses included: cerebral palsy (a group of disorders that affect movement and muscle tone or posture), spasmodic torticollis (the muscles of the neck contract uncontrollably), and pain in left shoulder. Record review of Resident #39's comprehensive MDS, dated [DATE], reflected a BIMS score of 05, which indicated severe cognitive impairment. Record review of Resident #39's care plan, dated 01/06/2020 and last revised 04/08/2025, reflected Need: [Resident #39] is at increased risk for potential falls r/t impaired mobility . Approaches included: be sure [Resident #39]'s call light is within reach and encourage [Resident #39] to use it for assistance as needed. Observation of Resident #39's call light on 04/28/2025 at 12:48 PM revealed her call light laying in the middle of her bed out of her reach. Resident #39 was sitting up in her specialty wheelchair on the right side of her bed. The call light was behind and to the left of the wheelchair. Resident #39 could not have reached the call light if she needed it. Resident #39's FM was standing at the doorway looking for staff to assist the resident. During an interview on 04/28/2025 with a family member, he stated he was standing in the doorway to try to find staff to assist Resident #39. He stated the call light was often out of reach for Resident #39. He stated he was not able to comment further on the care for Resident #39. Observation of Resident #39's call light on 04/30/2025 at 08:38 AM revealed her call light wrapped around the positioning rail and hanging down below the level of the bedframe. Resident #39 was lying in bed watching tv and could not have reached her call light if she needed it. Attempted to interview resident but received no verbal response. During an interview on 04/30/2025 at 12:37 PM with RN G, he stated he had been trained on resident rights and the policy was for call lights to be within reach of the resident when in their room. RN G stated that all staff were responsible for ensuring call lights were placed within reach of the residents. He stated having call lights out of the resident's reach could be detrimental because the resident could have a medical emergency or fall, and they would not be able to notify staff. During an interview on 04/30/2025 at 01:49 PM with CNA L, she stated she had been trained on resident rights. She stated that the call light was to be placed in the resident's reach, like clipped to them or placed in their hand, anytime residents were in their room or bathroom. She stated CNAs were responsible for doing this and the floor nurse will spot check as they performed their rounds. She stated not having the call light within reach of the resident could put the resident in danger because if the resident needed help the staff wouldn't know. CNA L stated Resident #25 sat alone in the dining room with an over the bed table because her specialty wheelchair was too big to fit under the regular dining room tables. CNA L stated the tables were too short and narrow. She stated that Resident #25 used the wheelchair to assist with positioning and comfort. She stated she didn't think it would affect Resident #25 by sitting alone in the dining room. During an interview on 04/30/2025 at 01:55 PM with CNA K, she stated she had been trained on resident rights. She stated the CNAs and nurses were responsible for ensuring call lights were within the resident's reach all the time. CNA K stated if the call light was not within the resident's reach, then they could possibly fall and hurt themselves. CNA K stated Resident #25 uses a specialty reclining wheelchair to help with positioning due to the contractures in her legs. She stated that Resident #25 sat alone in the dining room so that she could use the over the bed table. CNA K stated Resident #25 used the over the bed table because her chair was too high. She stated that the resident didn't seem to be affected by sitting alone at the over the bed table. During an interview on 04/30/2025 at 02:45 PM with the DOR, she stated she had been trained on resident rights. She stated the policy for call lights was to ensure the resident had their call light in their hand or on their person prior to leaving them in their room. The DOR stated the resident needed to be able to push the call light if they needed something or they could fall because they may need something and they can't get to it, or the resident may need to go to the bathroom. She stated it was the responsibility of any staff member who went into the resident's room to ensure the call light was within reach. During an interview on 04/30/2025 at 03:30 PM with the DON, she stated she had been trained on resident rights. She stated that the policy for call lights was to place call lights close by or within reach of the resident when the resident is in their room. The DON stated it was the responsibility of the staff member providing care to the resident, to put the call light within reach. She stated if the call light was not placed where the resident could reach it, then the resident wouldn't be able to call for assistance if needed. The DON stated she monitored this by spot checking any door she walked past. She stated she also expected for all staff to monitor as they are doing their rounds. The DON stated call lights were everyone's responsibility to ensure they were within reach of the resident. The DON stated Resident #25 used a specialty wheelchair for positioning because the resident couldn't sit up safely in a regular manual wheelchair. She stated Resident #25 sits alone with the over the bed table in the dining room because her chair is a little higher than the tables in the dining room. The DON stated she didn't think it would affect Resident #25 by sitting alone because Resident #25 liked to sit by herself. During an interview on 04/30/2025 at 05:40 PM with MA I, she stated call light policy was to place the call light within reach of the resident when leaving the resident in their room. She stated it was everyone's responsibility to ensure the call light was in reach. MA I stated if the call light wasn't in reach, then they would not be able to call for assistance if needed and they might try to do something independently and fall. She stated she wasn't sure who monitored this. During an interview on 04/30/2025 at 05:48 PM with RN J, she stated the policy on call lights was to make sure they were always within reach. RN J stated it was the responsibility of all staff members to ensure the call lights were within reach of the residents. She stated she monitored this when she went into the resident's room, and she always double checked the call light placement. RN J stated if the call light was not within reach of the resident, then they can't get the help they may need. During an interview on 04/30/2025 at 06:10 PM with the ADM, she stated she had been trained on resident rights. The ADM stated the policy for call light placement was the resident was to have their call light where the resident could utilize the call light when in their room. She stated it was the responsibility of all the staff who entered the resident's room to ensure the call light was within reach. The ADM stated if the call light was not within reach, then it could affect their ability to call for assistance when needed. She stated there was not a monitoring schedule for call lights but that everyone was responsible for call light placement and if there were concerns or grievances raised then frequent monitoring would be started. The ADM stated Resident #25 used the specialty reclining wheelchair for positioning and comfort. She stated she was unsure why Resident #25 was sitting alone in the dining room with an over the bed table, but it might have been because the chair didn't fit under the dining room tables. Record review of grievances revealed no complaints or concerns related to call lights for 01/01/2025-04/30/2025. Record review of the facility's, undated, policy titled Call Lights reflected: Procedure: Basic Responsibility Licensed Nurse and Nursing Assistant, all Facility Staff Purpose To respond promptly to resident' call for assistance . Procedure 1. All facility personnel must be aware of call lights at all times . 8. When providing care to residents be sure to position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light . 11. Be sure all call lights are placed on the bed at all times or within reach of the resident. Record review of the facility's, undated, policy titled Resident Rights reflected: Purpose: To ensure that resident rights are respected and protected. To inform residents of their rights and provide an environment in which they can be exercised. Procedure: Residents do not leave their individual personalities or basic human rights behind when they move to a long-term care facility. Following is a list of resident rights recognized by management and employees as well as local, state and federal laws and regulations. The resident has the right: . To receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. 50872

49410 Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 10 residents (Resident #36, Resident #58, and Resident #67) reviewed for rights. The facility failed to ensure LVN A and CNA B knocked on Resident #36, Resident #58, and Resident #67's doors when going into the residents' rooms. These failures could place residents at risk of feeling like their privacy was being invaded or the facility was not their home. Findings included: Review of Resident #36's Face Sheet dated 04/29/2025 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #36's diagnoses included chronic pain, constipation, depression, insomnia (difficulty sleeping), repeated falls, hypertension (high blood pressure), muscle weakness, multiple sclerosis (disease that causes breakdown of the protective covering of the nerves), dysphagia oropharyngeal phase (inability to empty from the throat to the esophagus), lack of coordination, need for assistance with personal care, hyperthyroidism (excessive production of thyroid hormones), benign prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate), and anxiety (feeling of uneasiness or worry). Record review of Resident #36's Quarterly MDS assessment dated [DATE] revealed Resident #36 had a BIMS score of 02 indicating severe cognitive impairment. Review of Resident #58's Face Sheet dated 04/29/2025 revealed he was an [AGE] year-old male who was admitted to the facility on [DATE] . Resident #58's diagnoses included Parkinson's disease (a progressive disorder that affects the nervous system), dysarthria, and anarthria (severe speech sound disorder), other speech disturbances, anxiety (feeling of uneasiness or worry), hyperlipidemia (high cholesterol), insomnia (difficulty sleeping), muscle wasting, unsteadiness on feet, abnormalities of gait and mobility, history of falling, abnormal posture, and need for assistance with personal care. Record review of Resident #58's Quarterly MDS assessment dated [DATE] revealed Resident #58 had a BIMS score of 15 indicating intact cognitive response. Review of Resident #67's Face Sheet dated 04/29/2025 revealed she was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #67's diagnoses included end stage renal disease (kidney failure), type 2 diabetes mellitus with hyperglycemia (high blood sugar), heart disease, hypertensive heart disease with heart failure (damage to heart and heart failure due to chronic high blood pressure), heart failure, gastroesophageal reflux disease without esophagitis (reflux), muscle wasting, need for assistance with personal care, unsteadiness on feet, muscle weakness, dysphagia oropharyngeal phase (inability to empty from the throat to the esophagus), and cognitive communication deficit (problems with communication), Record review of Resident #67's Quarterly MDS assessment dated [DATE] revealed Resident #67 had a BIMS score of 11 indicating moderate cognitive impairment. Observation of 200 hall meal tray pass on 04/28/2025 at 11:34 a.m., revealed that LVN A did not knock on Resident #67's door before entering the room. Observation of hall 200 meal tray pass on 04/28/2025 at 11:43 am revealed CNA B did not knock on Resident #36 and Resident #58's door before entering the room. In an attempted interview with Resident #36 on 04/28/2025 at 12:06 p.m., he said that he did not want to talk to the surveyor. An interview with Resident #58 on 04/30/2025 at 11:07 a.m., revealed that staff do not knock on his door all the time. He said staff do not knock at least a couple of times a day; that he would like for them to knock before entering all the time. He said knocking was the appropriate thing to do. He said at times he did get upset when staff do not knock especially when he is getting dressed. He said he had not asked the staff to knock. An interview with Resident #67's on 04/30/2025 at 11:10 a.m., revealed that staff knock at times. He said that staff usually did not knock if his door was open. He said he would like for staff to knock all the time especially if the door was closed. He said it did upset him when staff did not knock because he would be changing his underwear and staff would just walk in. He said he never asked the staff to knock because it was not anything the staff had not seen before. During an interview with LVN A on 04/30/2025 at 10:57 a.m., she said she had been trained on resident rights. She said the policy for knocking was that staff were supposed to always knock before entering, introduce themselves and explain to the resident what they were going to do. She said that all staff were required to knock before entering the resident's room. She said that there was no time that the staff should not knock before entering. She said if staff did not knock, the resident may feel like staff do not respect them. She said that all staff monitored to ensure staff were knocking on the residents' doors. She said that staff monitored by observations. She said she was not aware that she was not knocking on the resident's room. During an interview with CNA B on 04/30/2025 at 11:28 a.m., she said that she had been trained on resident rights. She said the policy for knocking was that staff were supposed to always knock before entering and wait for the resident to respond. She said that all staff were required to knock before entering the resident's room. She said she would expect someone to knock on her door. She said that there was no time that the staff should not knock before entering. She said if staff did not knock, the resident may feel uncomfortable. She said that the charge nurse monitored to ensure staff were knocking on the residents' doors. She said that the charge nurse monitored by observations. She said she did not remember knocking on the residents' doors. An interview with the DON on 04/30/2025 at 11:30 a.m., revealed she and staff had been trained on resident rights. She said the policy was that staff were to knock on the door and if the resident could speak the resident will tell the staff to come in. She said that staff were to knock except if it was an emergency. She said it was important for staff to knock because the resident might feel like staff are just going into their room without permission and get upset. She said that all management was responsible for monitoring to ensure staff were knocking. She said that management monitored it by doing observations. She said that the staff should have been knocking on the doors and she was not sure why they did not knock. An interview with the ADM on 04/30/2025 at 5:11 p.m., revealed that she and staff had been trained on resident rights. She said the policy was to knock on the door to uphold the resident's rights. She said that staff should knock, pause and introduce themselves before they go into the resident's room. She said that the staff needed to knock if the resident had their door closed or almost closed. She also said that if the resident's door was open, it was ok for the staff to walk into the room without knocking if they introduced themselves. She said that the resident may feel less safe in their space and like it was not their home if staff did not knock. She said that the managers were to monitor to ensure that staff were knocking on the Residents' doors. She said the managers monitored knocking by observation. She said she did not know why staff were not knocking on residents' doors before entering. Record review of Resident Rights Policy not dated revealed when providing resident care always provide privacy by knocking and announcing yourself. To ensure that resident rights are respected and protected. Residents do not leave their individual personalities or basic human rights behind when they move to a long-term care facility. To personal privacy.

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 8 residents (Resident # 15) reviewed for range of motion. The facility failed to ensure treatment and interventions for Resident #15's contractures of the right hand. This failure could place the resident at risk for not receiving the care and services to prevent worsening contractures that can cause pain and a decreased quality of life. Findings included: Record review of Resident #15's admission record, dated 04/30/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #15 had diagnoses which included: aphasia (difficulty using or comprehending language), pain in right shoulder, need for assistance of personal care, lack of coordination, atrial fibrillation (irregular heartbeat), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), rheumatoid arthritis (a chronic disorder where the body's immune system attacks itself and can cause inflammation of the joints and other body systems), unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), neuropathy (damage or disease that affects the nerves causing pain and impaired sensation) and contracture of unspecified joint (the shortening of the muscles, tendons, skin and nearby soft tissue that prevents normal movement). Record review of Resident #15's comprehensive MDS, dated [DATE], reflected a BIMS score was not completed. Section C-Cognitive Patterns reflected short-term and long-term memory problems. Section GG-Functional Abilities reflected functional limitations in range of motion to one side for upper extremity. Record review of Resident #15's multidisciplinary care conference, dated 03/28/2025, reflected No current therapy or restorative programs at this time. Record review of Resident #15's order summary, dated 04/30/2025, reflected acetaminophen-codeine tablet 300-30mg give 1 tablet by mouth four times a day for pain, rheumatoid arthritis not to exceed 3000mg/24h from all resources. No orders reflected for range of motion exercises. Record review of Resident #15's care plan, dated 07/31/2020 and last revised on 04/28/2025, reflected Need: [Resident #15] is at increased risk for potential falls r/t impaired mobility, and poor balance/coordination. Requires assistance with ADLs. Approaches included: encourage [Resident #15] to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as: AROM/PROM exercises, chair aerobics. Record review of Resident #15's nurses' progress notes for 01/01/2025-04/30/2025, reflected no noted related to ROM exercises or any interventions for the contracture to Resident #15's right hand. During an observation on 04/28/2025 at 09:34 AM, Resident #15 was lying in bed sleeping with right hand laying on top of the blanket. Resident #15's hand was observed to be contracted with no interventions in place. During an observation on 04/29/2025 at 12:00 PM, Resident #15 was sitting up in bed eating independently with left hand. Observation of right hand with contracture revealed no interventions in place. An interview was attempted with Resident #15, but no verbal response was received. During an observation on 04/30/2025 at 01:26 PM, Resident #15 was receiving pericare. No interventions to right hand that had a contracture were observed before, during, or after peri care. During an observation on 04/30/2025 at 06:23 PM, Resident #15 was sleeping in bed. Her right hand was laying on top of the blanket and no interventions observed to right hand. During an interview on 04/30/2025 at 01:49 PM, CNA L stated she had worked at the facility for about 3 1/2 years. She stated the process if a resident starts developing a contracture is to notify the nurse who reports it to therapy for an evaluation. She stated they were to follow the instructions from therapy. CNA L stated Resident # 15 had contractures to her right hand. She stated she didn't think Resident #15 was receiving any therapy for her contracture. CNA L stated she placed a rolled towel in Resident #15's right hand when she provided care to the resident. She stated Resident #15's contractures had remained the same since she first started working with Resident #15. CNA L stated if a resident had contractures and wasn't receiving any interventions then the resident could become more contracted causing pain and difficulty with providing ADLs. During an interview on 04/30/2025 at 01:55 PM, CNA K stated she had worked at the facility for [AGE] years. She stated the process for newly identified contractures was to put a rolled towel in the affected hand and notify the nurse. CNA K stated Resident #15 had a contracture to her right hand. She stated she thought Resident #15 was receiving restorative rehabilitation services. CNA K stated she placed a rolled towel in Resident #15's right hand when she provided care to her. CNA K stated she didn't know how it might affect a resident if they were not receiving ROM exercises. During an interview on 04/30/2025 at 02:45 PM, the DOR stated the expectation for a resident who had contractures was for nursing to refer the resident for a therapy evaluation. She stated that therapy would do a screening to determine needed services and acquire the necessary funding. The DOR stated therapy would then provide services to maintain and/or increase ROM and obtain the necessary devices. The DOR stated she was not familiar with Resident #15 and after a brief record review revealed Resident #15 was not on therapy services. The DOR stated if a resident had contractures and wasn't receiving services it could be really bad. She stated the contracture could cause skin breakdown, pain, and or difficulty with ADLs. During an interview on 04/30/2025 at 3:30 PM, the DON stated if a resident had started developing contractures or was admitted with a contracture, then her expectation was to recognize the change in condition, the nurse was expected to get an order for a therapy evaluation and initiate ROM exercises. The DON stated the nurse was responsible for obtaining the order to initiate services for the resident. She stated she was aware that Resident #15 had a contracture to the left arm. The DON stated Resident #15 was receiving therapy and wasn't making any improvements in ROM so Resident #15's FM refused the aggressive therapy. She stated that happened a while ago but wasn't sure exactly when. The DON stated she didn't know if there was anything in place to prevent Resident #15's contracture from worsening. She stated if a resident didn't receive restorative or therapy for a contracture then it could get worse. During an interview on 04/30/2025 at 06:10 PM with the ADM, she stated she expected staff to report new contractures to the nurse, and the nurse would then report it to the nurse manager who would possibly obtain a therapy referral. The ADM stated that therapy would then make a choice if splints or devices were needed. She stated she couldn't recall if Resident #15 was on therapy services. She stated that she knew Resident#15 has been on occupational therapy and speech therapy within the last year and a half but didn't know the status of therapy at the time. The ADM stated she didn't know the plan to prevent Resident #15's contracture from worsening, but she didn't think there was a device or splint associated. She stated the nursing staff should have been positioning the resident to prevent further decreased ROM. The ADM stated the goal was to prevent the contracture from occurring but that wasn't always possible. She stated if the resident didn't receive the appropriate services, then the contracture could get worse, cause pain, or affect the resident's ability to do things for themselves. Record review of the facility's, undated, policy titled Range of Motion Exercises reflected: Basic Responsibility Licensed Nurse and Nursing Assistant, Restorative Aide, Physical Therapy, Occupational Therapy Purpose To maintain or improve joint flexibility, prevent stiffness, reduce risk for injury and maintain and or improve functional mobility . 50872

Based on observation, interview, and record review the facility failed to ensure drugs were labeled in accordance with currently accepted professional principles, store all drugs in locked compartments, and provide separately locked, permanently affixed compartments for storage of controlled drugs for 3 of 6 (100-hall medication care, 100-hall wound care cart and 100-hall nurses' cart) medication carts reviewed for drug storage and labeling. 1. The facility failed to ensure all medications that required a prescription we labeled with a resident name for 2 of 6 medications carts (100-hall wound care cart and 100-hall nurses' cart). 2. The facility failed to ensure the 100-hall wound care cart was locked when unattended by the IP nurse, who also was the facility's wound care nurse. 3. The facility failed to ensure controlled medications were secured by 2 locks in the 100-hall medication cart for Resident #15, Resident #17, Resident #18 and Resident #57. These failures could place residents at risk of harm due to unauthorized access and potential ingestion of medications not intended for use orally. These failures could also place the residents at risk of not receiving the appropriate medications, missed dosages, or drug diversions. Findings included: 1. Record review of Resident #15's admission record, dated 04/30/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #15 had diagnoses which included: aphasia (difficulty using or comprehending language), pain in right shoulder, need for assistance of personal care, lack of coordination, atrial fibrillation (irregular heartbeat), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), rheumatoid arthritis (a chronic disorder where the body's immune system attacks itself and can cause inflammation of the joints and other body systems), unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), neuropathy (damage or disease that affects the nerves causing pain and impaired sensation) and contracture of unspecified joint (the shortening of the muscles, tendons, skin and nearby soft tissue that prevents normal movement). Record review of Resident #15's comprehensive MDS, dated [DATE], reflected a BIMS score was not completed. Section C reflected short-term and long-term memory problems. Record review of Resident #15's order summary, dated 04/30/2025, reflected acetaminophen-codeine tablet 300-30mg give 1 tablet by mouth four times a day for pain, rheumatoid arthritis not to exceed 3000mg/24h from all resources. Record review of Resident #15's care plan, dated 07/31/2020 and last revised on 04/28/2025, reflected Need: [Resident #15 is on pain medication therapy, r/t hx of rheumatoid arthritis and neuropathy. Approaches included: administer analgesic medications as ordered by physician. Monitor/document side effects and effectiveness q-shift. 2. Record review of Resident #17's admission record, dated 04/30/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #17 had diagnoses which included: chronic pain, diverticulitis of intestine (an inflammation of one or more balloon-like sacs in the large intestine), restless leg syndrome (a condition that causes a very strong urge to move the legs and can be painful), carpal tunnel and osteoarthritis (a joint disease that causes breakdown of cartilage and bone). Record review of Resident #17's comprehensive MDS, dated [DATE], reflected a BIMS score of 12, which indicated moderate cognitive impairment. Record review of Resident #17's order summary, dated 04/30/2025, reflected tramadol hcl tablet 50mg give 1 tablet by mouth three times a day for osteoarthritis. Record review of Resident #17's care plan, dated 07/13/2020 and last revised on 04/15/2025, reflected Need: [Resident #17] is at risk for pain/discomfort r/t hx of chronic pain, osteoarthritis, RLS, and carpal tunnel. She has routine and prn pain medication available. Approaches included: administer analgesia (pain medication), Tramadol/APAP/Lidocaine as per orders. Give 1/2 hour before treatments or care. 3. Record review of Resident #18's admission record, dated 04/30/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #18 had diagnoses which included: unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement) and neuropathy (damage or disease that affects the nerves causing pain and impaired sensation). Record review of Resident #18's quarterly MDS, dated [DATE], reflected a BIMS score of 04, which indicated severe cognitive impairment. Record review of Resident #18's order summary, dated 04/30/2025, reflected tramadol hcl tablet 50mg give 1 tablet by mouth three times a day for pain. Record review of Resident #18's care plan, dated 02/24/2025, reflected Need: [Resident #18] has increased risk for (acute/chronic) pain r/t neuropathy. Approaches included: administer medications as per orders. 4. Record review of Resident #57 admission record, dated 04/30/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #57 had diagnoses which included: lymphedema (tissue swelling caused by fluid buildup in the lymphatic system), unspecified atrial fibrillation (irregular heartbeat), chronic pain syndrome (pain that lasts for greater than 3-6 months), hypertension (high blood pressure), and chronic diastolic heart failure (a condition when the heart is unable to adequately pump blood). Record review of Resident #57's quarterly MDS, dated [DATE], reflected a BIMS score of 15, which indicated no cognitive impairment. Record review of Resident #57's order summary, dated 04/30/2025, reflected: 1) Metoprolol tartrate tablet 25mg give 1 tablet by mouth two times a day for afib hold for SBP less than 110 and/or HR less than 60. 2) Torsemide oral tablet 40mg give 1.5 tablet by mouth one time a day for CHF. 3) Tramadol hcl oral tablet 50mg give 1 tablet by mouth four times a day for chronic pain. Record review of Resident #57's care plan, dated 03/15/2025, reflected Needs: [Resident #57] is on pain medication therapy r/t chronic pain syndrome. Approaches included: Administer analgesic medications as ordered by physician. Monitor/document side effects and effectiveness q-shift. During an interview and observation of wound care set up, at the 100-hall wound care cart, on 04/30/2025 at 09:32 AM, the IP used a tube of mupirocin 2%, with Rx only written on the corner of the box, in the setup of materials needed for wound care. The IP stated the medication was obtained through a third-party source without a prescription therefore she thought it was an over-the-counter medication that didn't require a prescription. She stated all medication that required a prescription are required to have a label on it indicating which resident the medication belonged to. During an observation and interview on 04/30/2025 at 11:02 AM, the 100-hall wound care cart was left unlocked and unattended outside of room [ROOM NUMBER]. The IP came out of room [ROOM NUMBER] and directly to the 100-hall wound care cart to lock it. She stated it was her responsibility to secure that cart and that all carts that contained any medication were supposed to be locked when not supervised. The IP stated that if a cart with medication was left unsecured that a resident could get into the cart and take something they are not meant to. During an observation on 04/30/2025 at 11:08 AM, the 100-hall medication cart had 4 different envelopes with controlled substances secured in the top drawer with only the lock for the medication cart securing it. The envelopes contained: 1. Apap/codeine tab 300mg-30mg 1 tablet labeled for Resident #15 2. Tramadol hcl tab 50mg 1 tablet labeled for Resident #17 3. Tramadol hcl tab 50mg 1 tablet labeled for Resident #18 4. Tramadol hcl tab 50mg 1 tablet labeled for Resident #57. During an observation on 04/30/2025 at 11:34 AM, of the 100-hall nurse cart revealed a tube of mupirocin 2% ointment with a small portion of a resident label that was illegible on it. No resident name was able to be identified on the ointment. During an interview on 04/30/2025 at 11:11 AM, MA E stated the policy for storing controlled medication in the medication cart was to put the medication in the lock box drawer, so that the medication was secured behind 2 locks. He stated he was responsible for securing the medication behind 2 locks. MA E stated if the medication was not secured with 2 locks, then the medication could get taken by someone it wasn't intended for easier or a resident could miss a dose. During an interview on 04/30/2025 at 11:37 AM, LVN M stated all medications that required a prescription to obtain, needed to have a label indicating the resident it was prescribed for. She stated that if a label fell off or was damaged in any way then it needed to be relabeled by the pharmacy or a designated sticker needed to be completed and applied. LVN M stated it was the responsibility of the medication aide or the nurse in charge of the cart to ensure all medications were labeled appropriately. She stated if the medication wasn't labeled then the medication could be used for the wrong resident. During an interview on 04/30/2025 at 11:47 AM, MA F stated all carts that contained medications were to be locked when unattended. She stated all medications that were controlled were supposed to be stored in the lock box on the cart so that they are secured with 2 locks. MA F stated failure to secure the medications appropriately could lead to a resident taking medication that was not prescribed or intended for them. She stated that the person who accepted responsibility for the cart at the beginning of their shift was responsible for securing all medication in the correct spot of the cart throughout their shift. During a phone interview on 04/30/2025 at 01:35 PM, the consultant pharmacist stated mupirocin 2% ointment required a valid prescription from a physician to obtain. She stated that medication should have been labeled with a resident name from the pharmacy. The consultant pharmacist stated the nurse who received and administered the medication was responsible for ensuring that the medication was adequately labeled with the resident name. She stated a resident with an order for the medication may not receive their dose of medication if it isn't labeled properly. During an interview on 04/30/2025 at 03:10 PM, LVN D stated all medications were supposed to be secured behind a lock on the medication cart when unattended. She stated all controlled medication were required to be placed in the separate lock box and secured behind 2 locks when unattended. LVN D stated the person accepting responsibility for the cart at the beginning of the shift (i.e. MA, LVN, RN) was responsible for ensuring all medications were secured in their cart throughout their shift. She stated if the cart was left unlocked or controlled medications were left in the top drawer and not secured with 2 locks then someone may be able to take and ingest medication that was not intended for them. LVN D stated the DON did spot checks while walking around the facility on a daily basis. LVN D stated that anything with the words Rx only required a label with the resident's name that indicated who it was prescribed for. She stated that if a label were to fall off or get damaged then the nurse needed to alert the pharmacy to obtain a new label. LVN D stated if a medication was missing a label, then the wrong medication might be given. During an interview on 04/30/2025 at 03:30 PM, the DON stated that it was her expectation to have all medications locked when left unattended. She stated the medication aide or nurse who assumed responsibility of the cart at the beginning of their shift was responsible for ensuring it remained locked. The DON stated she did visual spot checks daily while walking through the facility. She stated if a cart that contained medication was left unlocked then a resident could get into the medication and get something that was not for them. The DON stated the policy for storing controlled medication in the medication cart was to secure it behind a second lock in the lock box drawer. She stated the person responsible for the cart was responsible for securing the medication in the locked drawer. She stated not securing the controlled medication behind a second lock wouldn't affect the residents in any way because the medications were secured by the first lock. The DON stated the policy for medications with Rx only written on them, required a label which indicated what resident the medication was prescribed for. She stated if the label fell off or was damaged then she expected staff to discard the medication. She stated the staff that is responsible for the medication cart was responsible for ensuring all medications were labeled appropriately with a resident's name. She stated if a medication wasn't labeled properly then it leaves the possibility for the medication to be administered to someone it wasn't prescribed for. During an interview on 04/30/2025 at 05:40 PM, MA I stated the policy when leaving a cart with medications was to lock it before walking away. She stated the staff member with the key to the medication cart was responsible for ensuring the medications were secured. MA I stated the DON monitored this by visually inspecting as she walked around the facility on a daily basis. She stated if a medication cart was left unlocked and unsupervised then a resident might go into the cart and grab some medication that isn't meant for them. MA I stated that all controlled medication was expected to be secured in the locked box on the medication cart. MA I stated if the controlled medication was stored in the top drawer and the cart was accidentally left unsecured, then a resident might have access to the medication and suffer from side effect from taking a controlled medication, like poisoning, or a drug diversion if the medication goes unaccounted for. She stated that all medications that require a prescription to obtain needed a label from the pharmacy which indicated what resident the medication was prescribed to. MA I stated, if a medication was found without a label, then she was expected to take it to the nurse. She stated the staff member with keys to the cart was responsible for ensuring all medications were labeled appropriately with a resident's name. During an interview on 04/30/2025 at 05:48 PM, RN J stated the policy for securing carts with medication was to lock the cart any time it is unattended. She stated the staff with the keys to the cart was responsible for ensuring it was locked when unattended. RN J stated that nursing administration was constantly doing visual spot checks when they were walking through the facility. She stated that if a cart with medications was left unlocked, then a resident who was curious may have access to open the drawer with medications and help their self to whatever medication is inside the cart. She stated that medication could get lost or even stolen. RN J stated the policy for securing controlled medications in the medication cart was to secure the controlled medication in the lock box drawer. She stated the staff member with the keys to the cart was responsible for ensuring the controlled medications were kept in the lock box that required 2 locks to access. RN J stated if controlled medication was kept in the top drawer and the cart was inadvertently left unlocked then a resident's medication may be stolen which would cause a drug diversion. RN J stated that all medications that had Rx only printed on it, required a prescription from the provider and a label from the pharmacy with the resident's name the medication was prescribe for on it. She stated that the staff member with the keys to the cart was responsible for ensuring all medication was labeled appropriately and this was monitored by each on coming shift at shift change. RN J stated if a medication was found that didn't have a label or had a damaged label then the medication would need to be discarded. During an interview on 04/30/2025 at 06:10 PM, the ADM stated that it was her expectation that any cart that contained medication was locked when not being used. She stated that the person passing medications from the cart was responsible for ensuring the cart was locked. The ADM stated that all staff monitors to ensure the carts are locked as they walk by because it is the responsibility of all staff members to ensure compliance. She stated that leaving a medication cart unlocked could affect the resident because their HIPAA information could be seen by someone it wasn't intended for, the medication could be taken or even a drug diversion could occur. The ADM stated that all controlled medications should be secured with a double lock at all times. She stated that on the medication carts, the controlled medication should have been secured in the lock box drawer. She stated the staff member passing medications from the cart was responsible for ensuring the controlled medications are stored properly. The ADM stated this was monitored through the narcotic (controlled) drug count at the beginning and end of each shift. She stated that because of the nature of the controlled medication, the extra level of security was needed for the controlled medication for the resident's safety. The ADM stated that all medications that required a prescription to obtain should have been labeled by the pharmacy with the resident's name, the name of the medication, and the directions for administration. She stated if the label fell off or was damaged then she expected the staff to contact the pharmacy that dispensed the medication. She stated that labelling the medication with the resident's name was a very important process. The ADM stated the staff that was responsible for administering the medication was also responsible for ensuring the medication was labeled correctly. She stated that once a month the nursing administrators were responsible for conducting medication cart audits to ensure compliance. Record review of the facility's, undated, policy titled Storage of Medication reflected: Purpose: Ensure that medications are stored in a safe, secure, and orderly manner. Procedure: . 2. Drug containers that have soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels are returned to the pharmacy for proper labeling before storing . 5. Compartments containing medications are locked when not in use. Trays or carts used to transport such items are not left unattended. (Compartments include, but are not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) . 8. All controlled drugs are stored under double-lock and key. 50872

49410 Based on observation, interview, and record review, the facility failed to ensure residents were free from any physical restraints imposed for purposes of convenience and not required to treat the resident's medical symptoms for 1 (Residents #9 ) of 5 residents reviewed for restraints. The facility failed to ensure that bedrails were not used on the side of Residents #9 bed as Resident #9 requested assistance getting out of bed when the rails were up. This failure could result in residents having physical restraints used that limited their movement without being evaluated for the medical need. Findings include: Record review of Resident #9's face sheet dated 04/30/2025 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (progressive disease that destroys memory and other important mental function), hypertensive heart disease with heart failure (damage to heart and heart failure due to chronic high blood pressure), dementia (memory, thinking, difficulty), hypothyroidism (excessive production of thyroid hormones), need for assistance with personal care, vitamin deficiency, weakness, repeated falls, hyperlipidemia (high cholesterol), heart failure, and dysphagia oropharyngeal phase (inability to empty from the throat to the esophagus). Record review of Resident #9's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 03 indicating severe cognitive impairment. The MDS also indicated Resident #9 was independent for bed mobility and required maximal assist for transfers. Record Review of Resident #9's Orders dated 4/30/2025 revealed that there were no orders for the 1/2 bed rails. Record Review of Resident #9's Side Rail assessment dated [DATE] revealed the resident had an alteration in safety awareness due to cognitive impairment; the resident did not roll out of bed; the resident did not exhibit physical signs that could put them at risk for using side rails; the resident was on medications that could increase risk of injury (blood thinners/steriods/diabetic meds); the resident did not need side rails as a boundary marker; the resident did need side rails to assist with positioning; the resident was referred to the interdisciplinary team and was provided recommendations for a positioning rail for assistance getting in and out of bed and assistance with bed mobility; consent was given by the resident/legal representative regarding risk/benefit of side rails. Record Review of Resident #9's Care Plan dated 02/19/2025 revealed that Resident #9 would benefit from positioning side rails and consent will be obtained from Resident #9's representative. Resident #9 had an actual fall related to poor balance and unsteady gait. Approaches included neuro-checks per facility protocol. Side rails up for safety and bed in low position and fall mat in place. Observation of Resident #9 on 04/29/2025 at 08:13 a.m., revealed that Resident #9's bed had a bed rail that was positioned in the middle of her bed. There was also a bedside table up against the resident's bed. Resident #9's bed was pushed up against the wall on the other side of the bed. Resident #9 had scooted to the end of her bed trying to get off the bed but was not able to due to the bedrail. The knob to lower the bed was at the bottom rail where the resident could not reach to lower. An interview with Resident #9 on 04/29/2025 at 08:14 a.m. revealed she wanted to get up and get dressed. She said that she needed help because she could not get up. When asked more about the bedrail she said she needed to change her clothes. She also asked the surveyors for help getting out of bed. During an interview with CNA B on 04/30/2025 at 11:36 a.m., she said that she had been trained on resident rights. She said that the facility had a no restraints policy. She said all staff were responsible for ensuring that no restraint was used on any residents. She said that the 1/2 bed rails were used on Resident #9 to keep the resident from falling. She said that she was not sure when the staff started to use them. She said the rationale was for protecting the resident from rolling off the bed. She also said some residents preferred to have the bed rails. She said she was not sure what interventions were used before the facility started using the bed rails. She said the risk of the bed rails was that the resident could get hurt trying to get out of the bed. She also said the bed rails could be considered a restraint. She said that the staff remove the bed rails when they get the residents up or when providing care. She said that the staff use the bed rails on Resident #9 every time staff put the residents to bed. She also said that staff check on the residents every two hours and that the residents do not get upset when the bed rails are on. She said that she did not know if the staff needed to have a doctor order for the bed rails. She also said that there were four residents that the facility used the bed rails on. During an interview with LVN A on 04/30/2025 at 10:57 a.m., she said that she had been trained on resident rights. She said that the facility had a no restraints policy. She said all staff were responsible for ensuring that no restraint was used on any residents. She said that the 1/2 bed rails were used on Resident #9 bed so they could reposition them selves. She said that she was not sure when the staff started to use them. She said she did not know the rationale of using the bed rails unless it was when the resident was asleep when they put them on . She said interventions for falls were beds in low position, fall mats in place and frequent rounding. She said the risk of the bed rails was that the resident could climb over them to get out of the bed and hurt themselves. She said that she was not sure how often staff used the bed rails on Resident #9. She also said that staff check on the residents every two hours and that the residents do not get upset when the bed rails are on. She said the bed rails could be a restraint. She said that staff needed to have a doctor order for the bed rails to be used. She said she did not know why the bed rails were being used. During an interview with the DON on 04/30/2025 at 3:24 p.m., she said she and staff had been trained on resident rights. She said that the bed rails for Resident #9 were used for positioning and that the facility did not use restraints. She said she did not know when the bed rails started being used. She said a restraint was when four rails were up, and that the facility did not use bed rails as a restraint. She said the risk of the bed rail was high and that the resident could fall. She also stated the bed rail was not keeping the residents in the bed because they were not being used as a restraint. She said interventions for falls used before the bed rails were that staff would check on the residents and use floor mats and beds in low position. She said that staff help the resident get up and down from the bed when the bed rails are on. She said all staff know that the bed rails were not to be used to prevent falls or restraints, which was something the facility did not even entertain. She said that she was not sure if the doctor was notified of the bed rails. She also said she did not think the facility needed an order since the facility did not use the bed rails as a restraint. She said that if the facility used the bed rails as a restraint, then the facility would need a doctor's order. She also said that the position of Resident #9's beds and the bed rails on in the middle of the bed did not prevent the residents from getting out of the bed. She said she did not know how Resident #9 would have gotten out of the bed, but the bed rail was not used as a restraint. During an interview with the ADM on 04/30/2025 at 5:24 p.m., she said she and staff were trained on resident rights. She said that the bed rails were used for positioning. She said if the rail was on it would be considered a restraint. She also said with positioning it could depend on the person and it might be harder for them to get to the bed rail if it was by their head. She also said that she did consider the bed rail to be a restraint if the bed was up against the wall on one side, and the bedside table blocked the top of the bed. She said that the bed rail can get in the way of providing care to the residents. She said she was not sure when the bed rails started to be used on Resident #9. She said there were several things that could factor in such as for residents that had physical limits it would help the residents get up. She said bed rails any type of length could impact the residents from getting in and out of bed. She said the residents could also get tangled up in the bed rails. She said that bed rails were not on the list for interventions for falls because of the risk. She said the facility did not use restraints. Record review of the Restraints Policy not dated revealed the facility is a restraint free facility. Also included as restraints as facility practices that meet the definition of a restraints such as using side rails to keep a resident from voluntarily getting out of bed. 50872

Based on interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 (Resident #1) of 6 residents reviewed for falls. The facility failed to put assessments and/or neuro checks in place for Resident #1 after she was sent to the ER after a fall on 03/12/25 at approximately 6:00 a.m. and returned to the facility on [DATE] at approximately 10:23 a.m. with diagnoses of an orbital floor fracture, lip or mouth laceration (cut through the skin), hematoma (collection of blood trapped outside of a blood vessel (bruise or a contusion)) to the left side of her head, and a maxillary sinus (midface) fracture. An IJ was identified on 03/14/2025. The IJ template was provided to the facility on [DATE] at 9:20 p.m. While the IJ was removed on 03/15/25, the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm because of the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving necessary medical care, a change in condition, harm, and hospitalization . Findings include: Review of Resident #1's Admission Record, dated 03/14/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses including dementia, hypertensive chronic kidney disease (occurs when chronic high blood pressure damages the kidneys leading to a decline in function), epilepsy (a chronic brain disorder characterized by recurrent seizures), cognitive communication deficit, other speech disturbances, generalized muscle weakness, need for assistance with personal care, other abnormalities of gait and mobility, other chronic pain, muscle wasting and atrophy, stroke, unspecified osteoarthritis (a common joint disease that causes pain, stiffness, and loss of function), and age-related physical debility. Review of Resident #1's Annual MDS, dated [DATE], reflected she had a BIMS score of 6, which indicated she had severe cognitive impairment and had 2 falls with no injury during her admission at the facility. Review of Resident #1's Care Plan, initiated 07/14/20, reflected she had a history of actual falls and had a witnessed fall resulting in a laceration to her lip and swelling to her left cheek on 03/12/25. Staff were required to check range of motion for the next 72 hours, monitor/document/report as needed and for the next 72 hours to the MD for signs and symptoms of pain, bruises, change in mental status, new onset confusion, sleepiness, inability to maintain posture, and agitation, and conduct neurological checks for the next 72 hours. Review of Resident #1's Progress Notes reflected: -A note created by LVN A on 03/12/25 at 9:05 a.m. that reflected Resident #1 had a witnessed fall, had swelling and bleeding from the left side of her cheek and face, was sent to the hospital ER for evaluation, and had moderate to severe cognitive impairments. LVN A was required to conduct an initial assessment, followed by every 15 minutes four times, every two hours post-incident (x4), and every shift for the next 72 hours. There were no notes in the neurological check note text box. -A note created by LVN A on 03/12/25 at 9:03 a.m. that reflected, Resident was getting out of bed ready by CNA to get in the wheelchair and resident was on the side of the bed when resident swung at CNA, the CNA turned her back to resident and when CNA turned back resident had fell to the floor hitting her face. Head to toe assessment completed at this time, noticed puddle of blood on the floor by resident left cheek, cleansed area best as could and had resident apply towel to site to stop bleeding. EMS called at time of accident to send resident out as left cheek was swelling and continuing to bleed. EMS arrived and transferred resident to Hospital ER for evaluation. RP notified of situation. -A note created by LVN A on 03/12/25 at 10:34 a.m. that reflected, Resident returned to facility at this time from hospital by EMS stretcher. Cleaned up resident at this time and applied clean clothes on, resting comfortable in bed, stitches on lip intact, denies any pain at this time. -A note created by RN D on 03/12/25 at 4:05 p.m. that reflected Resident #1 had a witnessed fall, had a lacerated lip, stitches, swollen left side of her face, and bloody drainage by mouth, remained in bed on 03/12/25, had severe cognitive impairment, had stable vital signs and complaint of pain in her face, and staff were required to continue to monitor post-ER visit. RN D was required to conduct an initial assessment, followed by every 15 minutes four times, every two hours post-incident (x4), and every shift for the next 72 hours. -A note created by the VPO on 03/12/25 at 6:21 p.m. that reflected, Additional information when officer was in room. DON witnessed in front of officer introducing that someone was here to visit. Resident was lying in bed with head slightly turned to the right. Resident with noted bruising and swelling to left side of face with sutures present to lip. Left eye swollen. DON asked resident if she was in pain and responded no twice when asked. Resident remains under observation for fall. -A note created by RN D on 03/12/25 at 9:34 p.m. that reflected, Resident was given tramadol 50 mg po at 1450 for mild pain. Resident was able to swallow with some difficulty. She drank water from the cup, but some spilled out of her mouth with bloody drainage. Resident's mouth continued to ooze blood with some drying on a towel that was placed under her chin. The CNA reported removing clots from her mouth at one point. At dinner, she was spoon-fed but did not eat much. Her meds were crushed and put in pudding, which she swallow and drank a small amount of Boost with a spoon, being fed by the CMA. She continued to sleep all evening. She was evaluated by the DON due to continued bleeding, who then spoke with NP and received further orders. After dinner, her oral bleeding seemed to stop. The towel remained clean under her chin. HS blood sugar was 168 and due to her history of hypoglycemia at night and her not eating, her HS Basaglar was held at the nurse's discretion. I gave her the rest of the Boost container by her PEG , along with the new order of 1000mg of acetaminophen. Amoxicillin started per orders this pm. Resident resting, vital signs stable, stitches intact. -A note created by LVN F on 03/13/25 at 12:05 a.m. that reflected, 11:00 p.m. Resident sleeping. Called her name, no response to staff. 98.2-78-16-88/52 manual-74% on room air. O2 started at 2 liters per minute by nasal cannula. 2nd Nurse in to evaluate blood pressure. Unable to get manual blood pressure. Staff talking loudly to resident, she turned her head toward staff. Asked if she is hurting, moved her head side to side-No. Did not open her eyes. 11:14 p.m. On-Call NP notified. Orders received to transfer to hospital. 911 Activated. 11:20 p.m. EMS on site. 11:40 p.m. Resident transferred to Hospital by EMS. DON notified. 11:43 p.m. Nurse to Nurse report called to Hospital ER, spoke with two nurses. 11:50 p.m. RP notified of change in condition & transfer to Hospital. Review of Resident #1's Hospital Records, dated 03/12/25 at 8:38 a.m., reflected she was seen for an orbital floor fracture, lip laceration, and maxillary sinus fracture. Resident #1's face CT reflected an acute comminuted fracture of the anterior left maxillary sinus and orbital floor which involves the orbital canal, associated hematoma in the left inferior extraconal space without significant mass effect on the intracranial structures, large left facial contusion-hematoma, and a remote nasal bone fracture. Review of Resident #1's Weekly Skin Observation Assessment, dated 03/12/25 at 7:03 p.m. by unknown, reflected her left side of face was swollen and remained reddened after 30 minutes of pressure reduction, a hematoma under her left eye, a bruise on the left side of her face, a cut and on the left side of her lip from the fall. Review of Resident #1's Assessments, dated 03/14/24, reflected Resident #1 had one assessment completed on 03/12/25, which was a weekly skin observation. There were no other assessments completed on 03/12/25. Review of Resident #1's Orders and Order Summary Report, dated 03/14/25, reflected there was no hold order on her Clonidine 1 tablet of 0.1 MG of Clonidine (treats high blood pressure) every eight hours for her hypertension post-fall on 03/12/25. There was a hold on her Clopidogrel Bisulfate (an antiplatelet (blood thinner used to prevent stroke, heart attack and other heart problems)) 1 tablet of 75 MG at bedtime for peripheral vascular disease may crush and give by G-tube. Review of Resident #1's MAR/TAR for March 2024 reflected she was given by mouth 1 tablet of 0.1 MG of Clonidine (treats high blood pressure) unless her systolic blood pressure was less than 110 on the following dates and times: -128/64 on 03/12/25 at 1:00 a.m. -115/65 on 03/12/25 at 9:00 a.m. -136/64 on 03/12/25 at 5:00 p.m. Resident #1 was also given by mouth 1 75 MG of Clopidogrel Bisulfate on the following dates and times: -03/11/25 at 8:00 p.m. -Staff documented they held the medication from 03/12/25 through 03/16/25. Review of Resident #1's O2 Saturation Summary, dated 03/14/25, reflected she was assessed for the following O2 saturation values on 03/12/25: -03/12/25 at 12:21 a.m. 96% -03/12/25 at 3:06 p.m. 92% -03/12/25 at 6:14 p.m. 96% There were no other O2 saturation values taken from Resident #1. Review of Resident #1's Blood Pressure Summary, dated 03/14/25, reflected she was assessed for the following blood pressure values on 03/12/25: -03/12/25 at 12:21 a.m. 128/64 mmHg -03/12/25 at 8:17 a.m. 115/65 mmHg -03/12/25 at 3:03 p.m. 136/64 mmHg -03/12/25 at 5:32 p.m. 136/64 mmHg -03/12/25 at 6:15 p.m. 117/65 mmHg -03/12/25 at 7:28 p.m. 117/65 mmHg There were no other blood pressure values taken from Resident #1. Review of Resident #1's Pain Level Summary, dated 03/14/25, reflected she was assessed for the following pain values on 03/12/25: -03/12/25 at 6:20 a.m. 3/10 -03/12/25 at 7:03 a.m. 0/10 -03/12/25 at 8:56 a.m. 0/10 -03/12/25 at 10:30 a.m. 2/10 -03/12/25 at 2:50 p.m. 3/10 03/12/25 at 5:34 p.m. 1/10 There were no other pain values taken from Resident #1. Review of a photograph taken on 03/12/25 at 11:44 a.m. reflected Resident #1 was lying in bed with a towel wrapped around her neck that had red stains on it. Resident #1 had red stains on her right hand. Resident #1's left eye was swollen shut, left cheekbone was swollen and dark pink, left side of her upper and lower lip had sutures and was swollen. Review of the facility's Incident Report, from 03/01/25 through 03/13/25, reflected Resident #1 had a witnessed fall on 03/12/25 at 6:20 a.m. Review of the facility's Discharge Report, from 03/01/25 through 03/13/25, reflected Resident #1 was sent to the hospital on 03/12/25 at 11:40 p.m. During an interview on 03/14/25 at 10:38 a.m., the Infection Preventionist stated she would initiate neurological assessments if a resident had a fall. The Infection Preventionist stated she would also check a resident's vital signs, blood pressure, and pupils after a fall. The Infection Preventionist stated she would frequently check a resident's neurological status and blood pressure after a fall. The Infection Preventionist did not elaborate on what she meant by frequent checks on a resident's neurological status nor explained the importance of conducting neurological assessments on a resident after a fall. During an interview on 03/14/25 at 11:14 a.m., LVN A stated nurses were responsible for assessing residents after a fall. LVN A stated nurses assessed resident's vital signs, blood pressure, neurological status, and performed a head-to-toe assessment after a fall. During an interview on 03/14/25 at 11:34 a.m., LVN A stated on 03/12/25 at 6:30 a.m., CNA C notified her that Resident #1 fell . LVN A explained that CNA C told her that she was trying to apply deodorant to Resident #1, Resident #1 tried to reach for her arm, she twisted to her side, and Resident #1 fell forward from her bed onto her fall mat. LVN A stated she entered Resident #1's room and observed Resident #1 lying on her left side on the fall mat, was bleeding from her mouth and nose, and her left cheekbone started swelling. LVN A stated she asked Resident #1 if she was in pain and Resident #1 told her no. LVN A stated she conducted a head to toe assessment on Resident #1 and observed no other injuries. LVN A stated she applied pressure to Resident #1's nose and notified EMS. LVN A stated she did not take Resident #1's vitals because EMS arrived and took over on the situation. LVN A stated Resident #1 returned from the hospital on 03/12/25 around 10:20 a.m. and she took Resident #1's vitals. LVN A stated she observed Resident #1 had stitches to her lip and a swollen cheekbone. LVN A stated she received the discharge orders, notified the NP that Resident #1 returned from the hospital, and the NP reviewed the discharge orders. LVN A stated she did not initiate neurological assessments on Resident #1 because she forgot. LVN A stated nurses were supposed to initiate neurological assessments on residents whenever there was a fall or if it was unknown whether or not a resident hit their head. LVN A stated she knew the importance of initiating assessments on residents post-fall and said, Residents' blood pressure could drop, a head injury could happen, and a hematoma could develop . During an interview on 03/14/25 at 12:23 p.m., the NP stated on 03/12/25 close to 8:00 a.m., LVN A notified her that Resident #1 had a fall. The NP stated LVN A told her that while a CNA was performing morning care on Resident #1, Resident #1 swung her arm at the CNA, the CNA ducked, Resident #1 fell forward, LVN A observed a pool of blood, and LVN A notified EMS. The NP stated LVN A also notified her that Resident #1 returned to the facility from the hospital on 03/12/25 before lunch (11:00 a.m.-11:30 a.m.). The NP stated she observed Resident #1 before lunch on 03/12/25, reviewed Resident #1's ER records, found Resident #1 was x-rayed while at the hospital and the ER did not give any post-visit recommendations, and told LVN A to monitor Resident #1. The NP explained monitoring was defined as conducting neurological assessments and taking vital signs on a resident. The NP stated the facility was required to perform neurological assessments and take vital signs from a resident after a fall, which was the standard nurse practice. The NP stated she expected the facility nurses to assess Resident #1 every shift. The NP stated she also expected neurological and pain assessments to be performed and vitals to be taken from Resident #1, which was the standard nurse practice. The NP stated she knew the importance of initiating assessments on residents post-fall and said, To check for deterioration. To make sure the resident did not have any decline from the bleeding. Neurological decline. Swallowing decline. That may present itself post-injury. Especially someone on antiplatelet (medications that prevent platelets from clumping together and forming blood clots), which could increase the risk of bleeding due to the injury. [Resident #1] was on an antiplatelet, Clonidine (used to treat high blood pressure), which was held. Blood pressure could drop too. The NP stated she was unaware the facility nurses did not perform neurological assessments on Resident #1 and did not know why the facility nurses did not perform neurological assessments on Resident #1. The NP stated if a resident fell and hit their hit, then neurological assessment checks were appropriate. The NP stated if a resident fell and hit their head and went to the ER, then protocol did not pick back up upon return from higher level of care. The NP stated LVN A and the afternoon and night shift nurses should have completed assessments upon Resident #1's return so there would have been at least eight hour checks completed on Resident #1 for the next 72 hours after the fall. The NP stated the on-call NP notified her that Resident #1 was sent back to the hospital on 03/12/25 during the night shift, could not remember why, and believed the reason was due to Resident #1 having low O2. During an interview on 03/14/25 at 1:00 p.m., Resident #1's FAM stated on 03/12/24, LVN A called and notified them that Resident #1 had a minor fall. Resident #1's FAM stated LVN A told them that Resident #1 tried to swing her arm at a CNA while the CNA was getting her dressed and up for the day, the CNA stepped back, Resident #1 fell forward, and was sent to the hospital. Resident #1's FAM stated on 03/12/25 around 10:30 a.m., the facility notified them that Resident #1 returned from the hospital and received stiches. Resident #1's FAM stated they visited Resident #1 at the facility on 03/12/25, who told them that the CNA pissed her off, did not explain how the CNA pissed her off, and made her fall. Resident #1's FAM stated the police were notified and told them that CNA C and LVN A were in the room when Resident #1 fell and Resident #1's head hit the hardwood floor and body hit the fall mat when she fell . Resident #1's FAM stated on 03/12/25 around 11:54 p.m., the facility called and notified them that Resident #1's blood pressure bottomed out and Resident #1 was sent to the hospital. Resident #1's FAM stated they visited Resident #1 at the hospital on 03/12/25 and the hospital staff told them that Resident #1 was x-rayed and had a fracture and blood pulling from her left eye. Resident #1's FAM stated on 03/13/25, the hospital staff told them that Resident #1 had a fractured nose and needed surgery. During an interview on 03/14/25 at 2:11 p.m., LVN B stated on 03/12/25 at 6:30 a.m., LVN A asked her to come and assess Resident #1. LVN B stated she entered Resident #1's room and observed Resident #1 lying on her left side on the fall mat, her head between her bed and nightstand and her right cheekbone was swollen and blood dripping from her nose and notified EMS. LVN B stated she did not perform a head to toe assessment and did not take Resident #1's vitals because she finished her shift and left the faciity on [DATE] around 7:30 a.m. LVN B stated she did not know if LVN A took Resident #1's vitals and did an assessment on Resident #1. LVN B stated she returned to the facility on [DATE] around 9:45 p.m. and did not check on Resident #1 at the start of her shift because she had to administer medications to other residents. LVN B stated she later entered Resident #1's room and noticed Resident #1 had low blood pressure. LVN B stated she took Resident #1's temperature, pulse, respiration, blood pressure that read of 88/43, and O2 saturation that read 74%, put Resident #1 on O2, and notified EMS. LVN B stated Resident #1's blood pressure dropped more when EMS arrived and said, It was 50/something else. LVN B stated RN D, who worked the previous shift before she started her shift, did not notify her of needing to perform any neurological assessments or other assessments on Resident #1. LVN B stated nurses performed neurological assessment checks and other assessments on residents. LVN B stated performing neurological assessments and other assessments on residents was the standard with an incident report. LVN B explained a nurse must assess a resident and take a full set of vitals and complete neurological assessments every shift anytime there was a fall and witnessed fall in which the resident hit their head. LVN B stated neurological assessments and other assessments were documented in residents' electronic health records. LVN B stated neurological assessments were performed on a resident every 15 minutes four times, every two hours two times, and then every shift for the next 72 hours. The DON and ADON oversaw to ensure neurological assessments and other assessments were initiated and the frequency of assessments performed was completed. LVN B stated she was trained and in-serviced on conducting neurological assessments annually and whenever there was an incident. LVN B stated she knew the importance of initiating assessments on residents post-fall and said, To get a baseline to see if there was any change in status. There could be permanent damage. LVN B stated neurological assessments and other assessments still have to be performed on a resident even if the resident returned from the hospital and said, You do not know. Still got to watch them for 72 hours at the very least. LVN B stated she was unaware that neurological assessment checks and other assessments were not initiated on Resident #1. An attempt to call RN D was made on 03/14/25 at 2:30 p.m. A voicemail and call back number were left. RN D did not return the call before exit on 03/15/25. During an interview on 03/14/25 at 3:24 p.m., CNA C stated Resident #1 had past falls at the facility. CNA C stated on the morning of 03/12/25, she was applying deodorant on Resident #1, turned around to reach for the deodorant, she felt something on her back, she turned around, observed Resident #1 lying on her left side on the floor, bleeding from her mouth and nose and screaming, she freaked out, ran, and notified LVN A. CNA C stated she did not see Resident #1 fall because her back was turned. CNA C stated Resident #1's body was on the fall mat and head was not on the fall mat at the time of her fall. CNA C stated LVN A entered Resident #1's room, took Resident #1's vitals, assisted resident #1 up, and notified EMS. CNA C stated Resident #1 returned from the hospital on 03/12/25 around 11:30 a.m. CNA C stated Resident #1 was still bleeding from her face and she tried to dry and place pressure on her face to stop the bleeding until the end of her shift on 03/12/25 at 2:00 p.m. CNA C stated she observed the nurses take Resident #1's vitals and blood pressure three times during her shift. CNA C stated she did not observe the nurses perform neurological assessments and other assessments on Resident #1. During an interview on 03/14/25 at 3:54 p.m., Resident #1's RP stated on 03/12/25 around 7:00 a.m., LVN A called and notified them that Resident #1 had a fall and it was not too bad. Resident #1's RP stated LVN A told them that Resident #1 was standing, a CNA was helping her transfer, Resident #1 swung her arm at the CNA, the CNA stepped back, Resident #1 lost her balance, fell , hit the floor, was fine, head hit the floor, was sent to the hospital to be checked out and LVN A believed it was not that serious. Resident #1's RP stated on 03/12/25 around 10:30 a.m., she called the facility and the Receptionist told them that Resident #1 returned to the facility from the hospital on 03/12/25 at 10:15 a.m. Resident #1's RP stated LVN A called and notified them that Resident #1 had swelling, stiches on her lip, received morphine, and was resting. Resident #1's RP stated they visited Resident #1 at the facility on 03/12/25 and Resident #1 told them that the CNA pissed her off and dropped her on her face. Resident #1's RP stated they did not observe the nurse take any vitals or perform any neurological assessments or other assessments on Resident #1. Resident #1's RP stated an unknown name staff member told them that the CNA tried to transfer Resident #1 on her own without assistance, Resident #1 fell , and the facility was trying to cover up the incident. Resident #1's RP stated the DON told them that Resident #1 was standing, fell , and then changed her statement and told them that Resident #1 was sitting at the side of her bed, the CNA turned her back to get deodorant, Resident #1 reached for the CNA, lost her balance, and fell . Resident #1's RP stated the facility did not tell them that Resident #1 sustained facial fractures from her fall. Resident #1's RP stated a nurse called and notified her that Resident #1's blood pressure dropped low and was sent to the hospital. Resident #1's RP stated they visited Resident #1 at the hospital and hospital staff told them that Resident #1 was x-rayed during her initial hospital visit and was found to have sustained a left orbital fracture and [NAME] fracture from the fall. During an interview on 03/14/25 at 3:22 p.m., the MD stated he did not know if Resident #1 had a history of falls because he started working at the facility one week ago. The MD stated the NP called and notified him that Resident #1 had a fall after she returned from the hospital on 03/12/25. The MD stated the NP told him that Resident #1 was sitting at the edge of the bed, reached out to the CNA, the CNA moved out the way, and Resident #1 fell to the ground. The MD stated he did not provide guidance or instruction to the facility staff other than to follow-up with Resident #1. The MD stated nurses performed neurological assessments and other assessments on residents. The MD stated it takes 6-24 hours before neurological changes start to appear and then leveled off the following two days. The MD stated neurological assessments did not always have to be initiated if a CT evaluation was performed. The MD stated a resident going to the hospital would stop later neurological changes a little but due to the CT scan performed, but residents still needed to be monitored for a change in condition. The MD stated facility staff were required to keep an eye on Resident #1 and he did not have any documentation of the facility staff doing such. The MD stated he did not request facility staff to conduct neurological assessments at the time of Resident #1's fall. The MD stated it would have been reasonable for facility staff to conduct neurological assessments and other assessments in case there was further injury. The MD stated he knew the importance of initiating assessments on residents post-fall and said, In case if there was delayed neurological changes and they could have altered mental status if not performed. The MD stated Resident #1's Clonidine was held upon her return from the hospital on 03/12/25 and said, Because if there's trauma, there's a risk of a small bleed and we want to limit that. During an interview on 03/14/25 at 4:47 p.m., CNA C stated Resident #1's wheelchair was in the restroom and she did not attempt to transfer Resident #1 on her own. During an interview on 03/14/25 at 5:01 p.m., CNA G stated she was not working when Resident #1 fell on [DATE]. CNA G stated she was instructed by the nurses to keep checking on Resident #1, make sure Resident #1's mouth was clean, and to notify the nurse if she was in pain. CNA G stated she did not observe the nurses perform neurological assessments or other assessments on Resident #1. During an interview on 03/14/25 at 5:15 p.m., the DON stated Resident #1 had a history of falls before admission and fell at the facility in the past. The DON stated on 03/12/25 around 6:20 a.m., LVN A called and notified her that Resident #1 fell , was bleeding, she called EMS, and Resident #1 was sent to the hospital. The DON stated LVN A told her that CNA C was getting Resident #1 ready for breakfast, Resident #1 was sitting at the edge of the bed, CNA C turned around to grab Resident #1's deodorant, Resident #1 tried to grab CNA C, fell and her body hit the fall mat and the left side of her face hit the ground, CNA C notified LVN A, LVN A entered Resident #1's room, observed Resident #1 was bleeding from her mouth, called EMS and applied an ice pack to Resident #1's face. The DON stated staff did not notify her that Resident #1 was bleeding from her nose after the fall and she was unsure if Resident #1's fall was witnessed or unwitnessed. The DON stated she did not ask LVN A if she performed any assessments on Resident #1 before EMS arrived. The DON stated LVN A performed a head to toe assessment on Resident #1 in the incident report. The DON stated LVN A notified her on 03/12/25 at 9:00 a.m.-9:30 a.m. that Resident #1 was returning from the hospital. The DON stated Resident #1 returned to the facility from the hospital on 03/12/25 around 10:00 a.m. The DON stated she reviewed Resident #1's discharge orders and found Resident #1 had a CT evaluation completed at the hospital that found Resident #1 sustained an orbital fracture and maximal fracture from the fall. The DON stated she was unsure when the NP and MD were notified and believed they were notified when Resident #1 returned to the facility from the hospital. The DON stated the NP and MD told staff to keep monitoring Resident #1. The DON explained monitoring was defined as checking vitals, observing for a change in condition, constantly entering Resident #1's room, and tending to Resident #1's pain. The DON stated the nurses performed neurological assessments and other assessments on Resident #1 and did not document the assessments completed. The DON stated the nurses documented the assessments on residents' electronic health records and physical sheets. The DON stated she was responsible for overseeing and ensuring neurological assessments and other assessments were initiated and completed to ensure they were initiated and performed according to the frequencies. The DON stated she believed she in-serviced staff on completing assessments sometime in 2025. The DON stated nurses must initiate neurological assessments and other assessments whenever a resident had an unwitnessed or witnessed fall in which they hit their head and are taking blood thinning medication every 15 minutes four times, every two hours four times, and every shift for the next 72 hours. The DON stated it took approximately some hours before a neurological change or a change in condition to appear. The DON stated Resident #1 took Plavix (blood thinning medication) before her fall on 03/12/25. The DON stated she knew the importance of initiating assessments on residents post-fall and said, In case the resident had an internal injury. Resident could have a critical condition if not monitored. The DON stated a hospital transfer did not stop residents from having neurological changes or change in condition because some changes stop immediately and some take longer to stop. The DON stated on 03/12/25 around 11:40 p.m., LVN F called and notified her that Resident #1 was sent back to the hospital due to low blood pressure of 88/something. The DON stated the nurses checked and documented Resident #1's blood pressure on a physical sheet and they did not input the entries into Resident #1's electronic health records. The surveyor asked the DON for the physical sheets reflecting the nurses blood pressure checks on Resident #1. The DON stated she could not provide the physical sheets reflecting the nurses blood pressure checks on Resident #1 to the surveyor and did not provide a reason when the surveyor asked. The DON stated Resident #1 was unable to explain how she fell . She did not constitute Resident #1's incident as neglect because CNA was in the room when Resident #1 fell and she did not consider it neglect even if CNA turned her back, Resident #1 reached out, and Resident #1 fell . During an interview on 03/14/25 at 6:25 p.m., the ADM stated on 03/12/25 around 9:00 a.m., the DON notified her that Resident #1 had a fall and was sent to the hospital. The ADM stated the DON told her that CNA C was in the room with Resident #1 when Resident #1 fell and hit her head and Resident #1 returned to the facility from the hospital with a laceration and sutures. The ADM stated CNA C told her that on 03/12/25 around 6:00 a.m.-6:30 a.m., she was getting Resident #1 ready, Resident #1 was sitting on the bed, she was applying deodorant on Resident #1, Resident #1 tried to swing her arm at her, she turned to get something, Resident #1 was lying on the fall mat, and she went and notified LVN A. The ADM stated CNA C did not tell her whether or not Resident #1 was completely on the fall mat. The ADM stated LVN A told her that CNA C was assisting Resident #1 for the day notified her that Resident #1 was on the ground, she entered Resident #1's room and observed blood by Resident #1's mouth,

Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #2) of 6 residents reviewed for oxygen use and storage. The facility failed to ensure Resident #2's nebulizer mask in her room was stored away when it was not in use on 03/14/25. This deficient practice could place residents at risk of infection. Findings include: Review of Resident #2's Admission Record, dated 03/14/25, reflected an [AGE] year old female who was readmitted to the facility on [DATE]. Resident #2 had diagnoses including Parkinson's disease with dyskinesia (a movement disorder characterized by involuntary, repetitive, and often jerky movements), chronic obstructive pulmonary disease (a group of lung diseases that cause long-term breathing problems), pneumonitis (an inflammation of the lung tissue) due to inhalation of food and vomit, acute respiratory failure with hypoxia (a condition where the lungs struggle to deliver enough oxygen to the blood), and shortness of breath. Review of Resident #2's Annual MDS, dated [DATE], reflected she had a BIMS score of 14, which indicated she was cognitively intact. Review of Resident #2's Care Plan, dated 01/01/25, reflected she had a diagnosis of aspiration pneumonia and COPD. LPNs and RNs were required to monitor, document, and report for any signs and symptoms of acute respiratory insufficiency and respiratory infection. Review of Resident #2's Order Summary Report, dated 03/14/25, reflected Resident #2 had the following active orders: -Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally every 4 hours as needed for SOB/wheezing ordered and started 12/19/24 -Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally three times a day ordered 12/19/24 and started 12/20/24 -Check O2 sat daily every day shift ordered 05/09/24 and started 05/10/24 -Flutter valve after nebulizer treatments to help clear mucus three times a day ordered and started 01/27/25 Review of Resident #2's MAR Schedule for March 2025 reflected LVN A signed administering the following to Resident #2: -Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally on 03/14/25 at 8:00 a.m. -Check O2 sats during day shift on 03/14/25 -Flutter valve after nebulizer treatments to help clear mucus on 03/14/25 at 9:00 a.m. Review of Resident #2's O2 Sats Summary, dated 03/14/25, reflected LVN A took Resident #1's O2 Sat levels on 03/14/25 at 8:18 a.m. and 8:19 a.m. An observation of Resident #2's room on 03/14/25 at 10:33 a.m. found Resident #2 was not in her room. Resident #2's nebulizer mask, dated 03/10/25, was on her dresser next to her bed and not in use. There were several thick, brown spots that had the consistency of vomit in the nebulizer mask around the opening of the nebulizer's medication cup. During an interview on 03/14/25 at 10:38 a.m., the Infection Preventionist stated nurses were responsible for changing residents' nebulizer masks weekly and cleaning and bagging nebulizer masks whenever they were not in use. The Infection Preventionist stated nurses were expected to check oxygen equipment to ensure it was properly stored away every 2 hours. The Infection Preventionist stated she knew it was important to store away nebulizer masks when not in use and said, Because infection control. Residents could develop an infection if the nebulizer masks were not bagged whenever they were not in use. During an interview on 03/14/25 at 11:14 a.m., LVN A stated she was the only nurse assigned to work Resident #2's hallway on 03/14/25. LVN A stated nurses were responsible for storing oxygen equipment away when it was not being used, storing nebulizer masks in bags whenever they were not in use, and changing out oxygen equipment weekly. LVN A stated she was in-serviced on oxygen use and storage by the DON and ADON within the last two weeks. LVN A stated she learned to store nebulizers in a bag whenever they were not in use. LVN A stated she checked on residents' oxygen equipment to ensure it was stored away when not in use throughout her shift and during her rounds, which were every 2-4 hours. LVN A stated she most recently checked on Resident #2 in the morning around 8:30-9:00 a.m. LVN A stated she did not know Resident #2's nebulizer mask was not bagged and believed she forgot to bag it after Resident #2 used it the morning of 03/14/25. LVN A stated she knew it was important to store oxygen equipment away when not in use and said, Because infection control and making sure oxygen equipment was being changed. Nebulizers could grow bacteria and it could cause an infection in the lungs. During an interview on 03/14/25 at 2:11 p.m., LVN B stated nurses were responsible for rinsing, air drying, and bagging residents' nebulizers if they were not in use. LVN B also stated nurses were responsible for changing out residents' nebulizers weekly. LVN B stated she checked on residents' oxygen equipment during O2 sat checks and every 2 hours. LVN B stated she knew it was important to store oxygen equipment away when not in use and said, To not have contamination and cause infection from tubing. Residents could get an infection. During an interview on 03/14/25 at 5:12 p.m., the DON stated nurses were responsible for ensuring residents' oxygen use and storage. The DON stated nurses were responsible for changing oxygen tubing weekly. The DON stated nurses dated and stored residents' nebulizers and nasal cannula in bags when not in use. The DON stated she oversaw to ensure oxygen equipment was stored away when not in use. The DON stated she knew it was important to store oxygen equipment away when not in use and said, Because it could cause an explosion if the smoking policy was not complied with. Infection control. If not complied with, it could cause something to the resident. During an interview on 03/14/25 at 6:25 p.m., the ADM stated nurses were responsible for storing oxygen equipment away. The ADM stated she expected the CNAs to notify the nurses if oxygen equipment was not stored away when not in use. The ADM stated the DON oversaw the nurses to ensure oxygen equipment was stored properly when not in use. The ADM stated she knew it was important to store oxygen equipment away properly when not in use and said, So equipment did not get lost and kept for infection control reasons too. Infection control risk could happen to the resident. Review of the facility's In-Services, from 03/01/25 through 03/16/25, reflected staff were not re-educated on oxygen use and storage policy and procedures. Review of the facility's Oxygen Therapy Administration policy, undated, reflected: Purpose: To provide resident with additional concentration of oxygen to facilitate adequate tissue oxygenation .Procedure (to be performed by a licensed nurse) .9. Check cannula placement and humidifier level frequently .Storage of oxygen tubing when not in use: when oxygen is not in use by the resident, the cannula with tubing is to be stored in a plastic bag and attached to the tank or concentrator. E-cylinder tanks are stored in e-cylinder stand.

Based on observation, interviews and record reviews, the facility failed to ensure the residents had the right to be free from involuntary seclusion and any physical restraint not required to treat the resident's medical symptoms for one (Resident #1) of three residents reviewed for involuntary seclusion. The facility failed to ensure Resident #1 was free from involuntary seclusion on 02/03/25 when CNA A pushed Resident #1, who was sitting in a wheelchair, into her room, closed the door, and held the door closed with two hands while Resident #1 was heard yelling let me out. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 02/03/25 and ended on 02/27/25. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for seclusion and psychosocial harm. Findings included: Review of Resident #1's face sheet printed on 03/03/25, reflected a [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on 02/12/25. Her diagnoses included dementia, Alzheimer's disease, anxiety disorder, unspecified glaucoma, and muscle wasting and atrophy. Review of Resident #1's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 7 which indicated severe cognitive impairment. Section B (Hearing, Speech, and Vision) reflected moderately impaired vision and sometimes understands others. Section GG (Functional Abilities) reflected she required substantial to maximal assistance for transfers and standing but she was able to propel her wheelchair independently. Review of Resident #1's comprehensive care plan revised 12/03/24 reflected in part: Need - Resident requires assistance for maintaining involvement in social/cognitive/leisure activities due to cognitive impairment and disease process (dementia). Goal - Resident will maintain involvement in cognitive stimulation, social activities as desired through review date. Approaches - loud music/noises bother resident and can cause her to react negatively . Need - Resident is at increased risk for potential ADL self-care performance deficit r/t confusion, dementia, fatigue, limited mobility . Goal Resident will have decreased risk of decline . Approaches - Transfer: Resident requires maximum assistance . Need - Resident has impaired cognitive function/dementia and Alzheimer's . Goal - Resident will maintain current level of decision-making ability . Approaches - COMMUNICATION: Use Resident's preferred name. Identify yourself at each interaction. Face Resident when speaking and make eye contact. Reduce distractions . The resident understands consistent, simple directive sentences. Provide the resident with necessary cues - stop and return if agitated. Review of the facility (PIR) provider investigation report dated 02/10/25, reflected CNA A, an agency CNA, was providing care to Resident #1 on the evening of 02/03/25. The report further reflected, Concerns were identified in the course of viewing camera footage related to the agency employee on suspension. Subsequently this agency CNA is prohibited from working at this community in the future. The PIR did not reflect the involuntary seclusion. Review of a statement from Resident #1 dated 02/04/25, signed by the DON, reflected in part, A teenager came into my room she had a mask on I asked her to remove her mask, she did not introduce herself as she was supposed to, she refused to remove her mask so I did not want her to take care of me . each time I turned the call light she will come in .then she laid me down . she keep coming in turn off the call light. The two girls came and helped me. Review of a note dated 02/05/25, signed by the SW, reflected in part, Met with Resident #1 to offer support .When asked if she feels safe, Resident #1 responded, I won't feel safe until I know the right people are taking care of me. The note also reflected Resident #1 talked about that staff person coming in several times and turning off the call light that she had put on, and that she eventually had moved herself to the doorway to ask for help. Review of a document dated 02/07/25, signed by the VP of Operations, reflected during an interview, CNA D stated he witnessed CNA A holding a door but did not think anything of it at the time. He stated he did hear the aide loudly telling the resident her name over and over. Review of a statement dated 02/04/25, signed by CNA A reflected in part, .Once I entered room (number) the resident was in her wheelchair and asked me to put her in the bed .she asked me my name which I repeated three times and she still called my name wrong but that wasn't the issue .I did not return to her room until 4:35 .She looked at me and ask my name again once again I told her and she told me to get out of her room .At 7:00 PM I ask her if she was ready for bed she ask me my name and said get out . Review of a Security Camera Review Timeline, prepared by the ADM, of two video clips recorded on 02/03/25 reflected in part: 8:00:26pm - (Resident #1) is sitting at her door ringing a bell with call light with another staff member non visible stating room service. Another employee (CNA D) is seen down the hallways toward nursing station. 8:00:33 - (Company name) employee (CNA A) comes to the room and ask the resident Yes, ma'am, how can I help you? (CNA A) asked the resident twice, How may I help you. (CNA A) is seen directly in front of the resident and states to the resident, Is that what you resort to? 8:00:35 (CNA A) then says again, How may I help you? (CNA A) repeats these 2 additional times, How may I help you?. The resident responds, and says I can't see what your name is. (CNA A) is asking in the normal tone of voice at this time and is standing in front of the resident at her doorway. Employee (CNA D) is witnessed walking past the room at this time with (CNA A) asking the resident How may I help you? 8:00:56 - resident remains sitting in her doorway and (CNA A) is standing in front of her. (CNA A) responds I am not the reason you fell because I haven't been here except for tonight. 8:01:09 - The resident continues to ring the bell. (CNA A) starts to push the resident backwards into the room, stating I am going to put you to bed. (CNA A) communicates in a low tone of voice. The resident at this point begins to yell and says what is your name and (CNA A) responds ma'am, ma'am, ma'am. 8:01:13 - (CNA A) is holding the arms of the wheelchair and states to the resident you shouldn't even act like this. 8:01:15 - (Resident#1) states Tell me your name. (CNA A) responds, I told you, (CNA A). 8:01:16 - (CNA A) leans into the left ear of the resident and states loudly (CNA A), (CNA A), (CNA A) (9 times) while she is holding the arms of the wheelchair. 8:01:26 - The resident responds, (name)? (CNA A) responds yes at this time. 8:02:54 - (CNA A) stands back up and states, Now do you feel better? 8:02:56 - Resident states, you came here .and does not finish her sentence. (CNA A) states to the resident you are disturbing other residents with that bell. 8:03:04 - (CNA D) is seen walking back into camera view up the hallway stating,name. 8:03:09 - (CNA A) instructs the resident to roll back, we are going to shut the door because you cannot disturb the other residents. 8:03:21 - (Resident #1) states measure pain . (CNA A) states where do you come up with this stuff? (Resident #1) states you in the dark of night. 8:03:26 - (CNA A) leans forward, and states ok grabbing the resident chair and rolls her back toward the inside of the room. (Resident #1) yells out at this time. 8:03:33 - (CNA A) stands back up shaking her head and says, Are you? (Resident #1) responded that hurts . 8:03:41 - (CNA A) is clapping her hands together stating to the resident I had nothing to do, (Resident #1) states, just to be heard. 8:03:44 - (CNA A) backs out and shuts the door at this time. The resident is ringing the bell behind the closed door of her room. (CNA A) leaves the area at this time. Video clip 2 8:04:36 PM - (CNA A) standing outside resident (Resident #1) room holding door closed, resident's call light is on 8:04:47 PM - (CNA A) puts resident's hand bell on the hallway railing 8:05:09 PM - (CNA A) adds second hand to door knob, continues holding door closed; sounds of someone trying to open door can be heard 8:05:56 PM - Resident can be heard saying let me out, (CNA A) continues holding door closed from outside 8:06:18 PM - (CNA A) opens door, resident sitting right behind door, door hits resident's wheelchair Resident says I want to go to bed, (CNA A) responds that I want to put you to bed but you're not acting right with all the yelling and screaming. 8:06:27 PM - (CNA A) walks away from resident's door, call light still on 8:06:35 PM - Resident opens door all the way and moves to doorway 8:06:36 PM - end of clip [sic] During an interview on 03/03/25 at 10:01 AM, the ADM stated after watching the video of CNA A with Resident #1, she had concerns about how CNA A talked to Resident #1 and the tone used. She stated CNA A should not have isolated the resident in the room. She stated she did not want CNA A to return. She stated she reported the allegations of abuse to the staffing agency that placed CNA A at the facility. The ADM stated she did not know what the Resident #1 meant when she stated, That hurts. During a telephone interview on 03/03/25 at 10:38 AM, Resident #1's FM stated the resident did not see or hear well and she always asked for the name of anyone in the room. The FM stated the resident told her the staff would not say her name, so the resident continued to put on her call light waiting for someone different to come in the room. She stated the same person came in the room and turned off the call light every time. She stated the resident was very fearful about staying at the facility as she did not feel safe. She stated Resident #1 moved to another facility. During an interview on 03/03/25 at 2:23 PM, RN B stated she worked with Resident #1 on the evening of 02/03/25. She stated she was in and out of rooms on Resident #1's hallway and did not see anything unusual or out of the ordinary that evening. She stated during her interactions with Resident #1, the resident was concerned about her fall from earlier on the day shift. RN B stated she received ANE training during orientation to the facility a couple months ago and again just after the alleged abuse with Resident #1. She stated the training after the alleged abuse included type of abuse such as physical, verbal, mental, and seclusion, when to report and who to report to. The training included dealing with challenging behaviors and Resident Rights. She stated any suspected abuse was immediately reported to the ADM who was the Abuse Coordinator. She stated the notification must be a phone call not a text message. During an observation and interview on 03/03/25 at 2:40 PM, the ADM stated she was not able to send the surveillance videos but showed the videos on her laptop. The ADM started the first video clip, time-stamped just after 8:00 PM, which revealed a resident seated in a wheelchair in the doorway of her room. The resident rang a handheld bell. The ADM identified the resident as Resident #1. The call light indicator above the doorway was illuminated which indicated the call light was on. A few seconds later, a person approached Resident #1. The ADM identified the person as CNA A. CNA A wore a blue face mask. CNA A asked twice, How may I help you? Resident #1 intermittently rang the handheld bell. Standing in front of Resident #1, CNA A stated, Is this what you resort to? Resident #1 stated, I can't see, what is your name? CNA A asked, How can I help you? CNA A stated, I'm not the reason you fell . Resident #1 continued to ring the bell. CNA A bent over and pushed the resident in the wheelchair back towards the room and said she would put her to bed. Resident #1 began asking loudly, What is your name? While she held the wheelchair in place, CNA A stated, You shouldn't act like this. Resident #1 pleaded, with desperation in her voice, Tell me your name. CNA A stated, I told you, (name). CNA A leaned over close to Resident #1's head and yelled, (name), (name), (name) . She yelled her name multiple times while still holding the wheelchair in place. The resident looked confused and asked, (similar name)? CNA A stood up and asked the resident, Now do you feel better? CNA A told Resident #1 she was disturbing the other residents with the bell. CNA A told Resident #1 to roll back, We are going to shut the door because you cannot disturb the other residents. CNA A grabbed the wheelchair arms and rolled it back into the room. Resident yelled out. CNA A backed up into the hall and shut the room door. Resident #1 continued to ring the handheld bell inside the room. CNA A left the area. The video clip lasted about three minutes. The second video clip started when CNA A was observed standing outside of Resident #1's room. The door was still closed. CNA A was holding the door handle with one hand. She had Resident #1's bell and placed it on the handrail. CNA A put a second hand on the door handle and held the door closed. Noises of attempts to open the door were heard. Resident #1, sounding distressed yelled, Let me out. CNA A opened the door and the door hit Resident #1's wheelchair. Resident #1 stated she wanted to go to bed. CNA A stated, I want to put you to bed but you aren't acting right with all that yelling and screaming. CNA A walked away from the resident. The call light was still on. Resident #1 moved her wheelchair back into the doorway. The video ended. The ADM stated the tone of voice used by CNA A concerned her. The ADM stated the first time she watched the video, she did not realize CNA A held the room door closed. She stated CNA A should not have closed the door to Resident #1's room, nor held it closed. She stated she did not want CNA A back in the facility. During an interview on 03/03/25 at 3:44 PM with the SW, she stated she had visited with Resident #1 a few times after the alleged incident. She stated the resident did not feel safe. The SW was unable to clarify whether the resident did not feel safe because of the fall or because of something else. She stated the resident was very hard of hearing and almost blind, she had a hard time identifying people. The SW stated Resident #1 was able to move herself around once seated in the wheelchair. The SW stated she had received training after the allegation of abuse of Resident #1 on resident rights, dealing with cognitive impairment and difficult behaviors, and reporting abuse and neglect allegations. During an interview on 03/03/25 at 3:59 PM, the DON stated she had assessed Resident #1 on 02/04/25 and did not have any physical findings. The DON stated the resident told her the staff member would not say her name, so she wanted someone else to take care of her. She stated it was not okay to close a resident's door if they want it open. She stated it was not acceptable to hold a room door closed to prevent the resident from leaving the room. She stated the facility provided frequent training on abuse and neglect. She stated the agency CNA would not be allowed back in the facility. During a telephone interview on 03/03/25 at 4:11 PM, the GM from the staffing agency who placed CNA A in the facility, stated she was made aware, by the facility, of the allegation of abuse against CNA A. She stated the hero, what they call CNAs, was suspended while the facility investigated. During an interview on 03/03/25 at 4:26 PM CNA C stated she worked on the evening of 02/03/25 and assisted Resident #1 from the bed to the wheelchair early in the shift. She stated Resident #1 was never a problem for me. She stated she did not see anything that night unusual on Resident #1's hall. She stated she had been trained on ANE . She stated if you see it or suspect it report it immediately. Report to the supervisor, the charge nurse, and the ADM. She stated the ADM was the abuse coordinator. During an interview on 03/03/25 at 4:26 PM CNA C stated she worked on the evening of 02/03/25 and assisted Resident #1 from the bed to the wheelchair early in the shift. She stated Resident #1 was never a problem for me. She stated she did not see or hear anything that night unusual on Resident #1's hall, but she spent most of her time on the adjacent hall where she was assigned. She stated she had been trained on ANE and resident rights a couple days after 02/03/25. She stated if you see it or suspect it report it immediately. Report to the supervisor, the charge nurse, and the ADM. She stated the ADM was the abuse coordinator. During a telephone interview on 03/05/25 at 3:05 PM, CNA A confirmed that she worked with Resident #1 on the evening of 02/03/25. When asked to describe the events of the evening she stated, Resident #1 wanted to go to sleep. Something happened earlier and she kept asking if I was going to drop her. She let me put her in bed and she napped. Around 4:15 or 4:30 PM Resident #1 put the call light on and she acted like she didn't know me. She stated she wanted the other lady. After dinner I asked if she was ready to go to bed, she told me she didn't want me to put her to bed. She stated she went back to the room around 9:30 PM to ask again and when I walked into the room, she kicked me. The light was on, and I was holding the door closed until I could get someone else to come help me put her in bed. I was told there was no clear evidence that I did anything wrong. CNA A stated she was aware the facility had cameras in the building, Yes, the camera was right there. CNA A stated she had told the GM from the staffing agency that she had been kicked but did not tell anyone else. CNA A stated she was not 100% sure if she had told the Resident #1 that she was disturbing other residents, so she was going to close her door. CNA A stated she had closed Resident #1's door between 7:30 PM to 8:30 PM but was not sure of the specific time. CNA A stated she held the door closed because Resident #1 was yanking on it trying to get out, I did not want her to hurt her arm. She stated she cracked the door open, and they talked through the opening then, opened the door all the way. CNA A stated she had been trained on ANE . She stated abuse could be neglect, verbal, or physical. Review of the undated Resident Rights policy, reflected in part, .To be treated with respect and dignity. To be free from any physical or chemical restraint imposed for convenience or discipline and not required to treat the resident's medical condition. To be free from abuse, neglect, misappropriation of resident property, and exploitation including corporal punishment, involuntary seclusion . Review of the undated Prevention and Reporting of Suspected Resident Abuse and Neglect policy, reflected in part, This facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect. This facility has implemented the following processes in an effort to provide residents and staff a comfortable and safe environment .Protection: suspend suspected employee(s) pending outcome of the investigation .definitions 1. Verbal Abuse - Oral, written or gestured language that includes disparaging and derogatory terms to the residents or their families or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability .5. Involuntary Seclusion - Separation of a resident from other resident or from his/her room against the resident's will . The facility implemented the following interventions : Review of Resident #1's medical record progress notes dated 02/04/25, reflected Resident #1 was assessed by the SW and nursing. A head-to-toe assessment dated [DATE], completed by the DON, reflected no injuries identified. The comprehensive care plan, initiated 12/03/24, was reviewed and revised on 02/11/25. Review of the facility's undated Investigation Summary reflected on 02/04/25, CNA A was interviewed by the ADM and DON. CNA A provided a written statement and was notified she was not allowed to work at the facility pending the investigation. Review of the facility's undated Investigation Summary reflected on 02/04/25, CNA A's staffing agency was notified of the allegations of abuse and indicated as Do Not Return. Review of the facility's undated Investigation Summary reflected on 2/4/25, 2/5/25, and 2/7/25 the facility communicated with Resident #1's responsible party about the allegation and investigation. The facility assured her the alleged perpetrator would not work at the facility. Review of the facility's undated Investigation Summary reflected staff working the evening and night of 02/03/25 were interviewed between 02/04/25 and 02/07/25. The staff interviewed included RN B, CNA C, CNA D, CNA E, and MA F with no further adverse findings. Review of the facility's undated Investigation Summary reflected the local Police Department was contacted regarding the allegation. Review of the facility's undated Investigation Summary reflected the security camera footage of the exterior of Resident #1's room was reviewed on 02/03/25. Other concerns were identified, and CNA A was indicated as Do Not Return. The abuse allegation information was sent to the agency for their follow up. Review of the Resident Interview Questions for Abuse Allegation (Safe Surveys) dated from 02/04/25 through 02/27/25 conducted by the SW revealed no concerns of abuse identified and the residents felt safe in the facility. Review of an in-service dated 02/04/24, reflected administration and therapy staff were in-serviced on Caring for Cognitively Impaired with Challenging Behaviors. Bullet points attached. Review of an in-service dated 02/04/24, reflected all staff were in-serviced on Caring for Cognitively Impaired with Challenging Behaviors. Bullet points attached. Review of an in-service dated 02/04/24, reflected all staff were in-serviced on Abuse Prevention and Reporting - All allegations must be reported immediately to the ADM. Policy attached. Review of an in-service dated 02/04/24, reflected administration and therapy staff were in-serviced on abuse Prevention and Reporting - All allegations must be reported immediately to the ADM. Policy attached. Review of an in-service dated 02/05/25, reflected dietary staff were in-serviced on Prevention and Reporting of Abuse and Neglect. Report any suspected abuse and neglect immediately to ADM. Policy attached. Review of in-services dated 02/05/25, reflected RN B was in-serviced on Conditions to report to administration, Abuse and neglect prevention and reporting, dealing with challenging behaviors. Policies and PowerPoint attached. Review of an in-service dated 02/07/25, reflected housekeeping staff were in-serviced on Prevention and Reporting of Abuse and Neglect. Report any suspected abuse and neglect immediately to ADM. Policy attached. Review of an in-service dated 02/07/25, reflected administration and therapy staff were in-serviced on Resident Rights. Please see list of Resident Rights, including the right to a dignified existence, self-determination, and communication . to be treated with respect and dignity, and to be free from abuse and neglect. Policy attached. Review of an in-service dated 02/07/25, reflected the receptionists were in-serviced on Resident Rights. Please see list of Resident Rights, including the right to a dignified existence, self-determination, and communication . to be treated with respect and dignity, and to be free from abuse and neglect. Policy attached. Review of an in-service dated 02/07/25, reflected all staff were in-serviced on Resident Rights. Please see list of Resident Rights, including the right to a dignified existence, self-determination, and communication . to be treated with respect and dignity, and to be free from abuse and neglect. Policy attached. Review of an in-service dated 02/07/25, reflected dietary staff were in-serviced on Resident Rights. Please see list of Resident Rights, including the right to a dignified existence, self-determination, and communication . to be treated with respect and dignity, and to be free from abuse and neglect. Policy attached.

Based on observation, interviews, and record reviews, the facility failed to protect the residents' right to be free from abuse for one (Resident #1) of three residents reviewed for abuse. The facility failed to ensure Resident #1 was free from verbal abuse on 02/03/25 when CNA A told the resident, You shouldn't even act like this, I want to put you to bed but you're not acting right with all the yelling and screaming and yelled repeatedly at the resident. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 02/03/25 and ended on 02/07/25 . The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for abuse and psychosocial harm. Findings included: Review of Resident #1's face sheet printed on 03/03/25, reflected a [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on 02/12/25. Her diagnoses included dementia, Alzheimer's disease, anxiety disorder, unspecified glaucoma, and muscle wasting and atrophy. Review of Resident #1's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 7 which indicated severe cognitive impairment. Section B (Hearing, Speech, and Vision) reflected moderately impaired vision and sometimes understands others. Section GG (Functional Abilities) reflected she required substantial to maximal assistance for transfers and standing but she was able to propel her wheelchair independently. Review of Resident #1's comprehensive care plan revised 12/03/24 reflected in part: Need - Resident requires assistance for maintaining involvement in social/cognitive/leisure activities due to cognitive impairment and disease process (dementia). Goal - Resident will maintain involvement in cognitive stimulation, social activities as desired through review date. Approaches - loud music/noises bother resident and can cause her to react negatively . Need - Resident is at increased risk for potential ADL self-care performance deficit r/t confusion, dementia, fatigue, limited mobility . Goal Resident will have decreased risk of decline . Approaches - Transfer: Resident requires maximum assistance . Need - Resident has impaired cognitive function/dementia and Alzheimer's . Goal - Resident will maintain current level of decision-making ability . Approaches - COMMUNICATION: Use Resident's preferred name. Identify yourself at each interaction. Face Resident when speaking and make eye contact. Reduce distractions . The resident understands consistent, simple directive sentences. Provide the resident with necessary cues - stop and return if agitated. Review of the facility (PIR) provider investigation report dated 02/10/25, reflected CNA A, an agency CNA, was providing care to Resident #1 on the evening of 02/03/25. The report further reflected, Concerns were identified in the course of viewing camera footage related to the agency employee on suspension. Based on surveillance, the agency CNA's actions and verbal communication were indicative of verbal abuse. Subsequently this agency CNA is prohibited from working at this community in the future. Review of a statement from Resident #1 dated 02/04/25, signed by the DON, reflected in part, A teenager came into my room she had a mask on I asked her to remove her mask, she did not introduce herself as she was supposed to, she refused to remove her mask so I did not want her to take care of me . each time I turned the call light she will come in .then she laid me down . she keep coming in turn off the call light. The two girls came and helped me. Review of a note dated 02/05/25, signed by the SW, reflected in part, Met with Resident #1 to offer support .When asked if she feels safe, Resident #1 responded, I won't feel safe until I know the right people are taking care of me. The note also reflected Resident #1 talked about that staff person coming in several times and turning off the call light that she had put on, and that she eventually had moved herself to the doorway to ask for help. Review of a document dated 02/07/25, signed by the VP of Operations, reflected during an interview, CNA D stated he heard CNA A loudly telling the resident her name over and over. Review of a statement dated 02/04/25, signed by CNA A reflected in part, .Once I entered room (number) the resident was in her wheelchair and asked me to put her in the bed .she asked me my name which I repeated three times and she still called my name wrong but that wasn't the issue .I did not return to her room until 4:35 .She looked at me and ask my name again once again I told her and she told me to get out of her room .At 7:00 PM I ask her if she was ready for bed she ask me my name and said get out . Review of a Security Camera Review Timeline, prepared by the ADM, of two video clips recorded on 02/03/25 reflected in part: 8:00:26pm - (Resident #1) is sitting at her door ringing a bell with call light with another staff member non visible stating room service. Another employee (CNA D) is seen down the hallways toward nursing station. 8:00:33 - (Company name) employee (CNA A) comes to the room and ask the resident Yes, ma'am, how can I help you? (CNA A) asked the resident twice, How may I help you. (CNA A) is seen directly in front of the resident and states to the resident, Is that what you resort to? 8:00:35 (CNA A) then says again, How may I help you? (CNA A) repeats these 2 additional times, How may I help you?. The resident responds, and says I can't see what your name is. (CNA A) is asking in the normal tone of voice at this time and is standing in front of the resident at her doorway. Employee (CNA D) is witnessed walking past the room at this time with (CNA A) asking the resident How may I help you? 8:00:56 - resident remains sitting in her doorway and (CNA A) is standing in front of her. (CNA A) responds I am not the reason you fell because I haven't been here except for tonight. 8:01:09 - The resident continues to ring the bell. (CNA A) starts to push the resident backwards into the room, stating I am going to put you to bed. (CNA A) communicates in a low tone of voice. The resident at this point begins to yell and says what is your name and (CNA A) responds ma'am, ma'am, ma'am. 8:01:13 - (CNA A) is holding the arms of the wheelchair and states to the resident you shouldn't even act like this. 8:01:15 - (Resident #1) states Tell me your name. (CNA A) responds, I told you, (CNA A). 8:01:16 - (CNA A) leans into the left ear of the resident and states loudly (CNA A), (CNA A), (CNA A) (9 times) while she is holding the arms of the wheelchair. 8:01:26 - The resident responds, (name)? (CNA A) responds yes at this time. 8:02:54 - (CNA A) stands back up and states, Now do you feel better? 8:02:56 - Resident states, you came here .and does not finish her sentence. (CNA A) states to the resident you are disturbing other residents with that bell. 8:03:04 - (CNA D) is seen walking back into camera view up the hallway stating Name 8:03:09 - (CNA A) instructs the resident to roll back, we are going to shut the door because you cannot disturb the other residents. 8:03:21 - (Resident #1) states measure pain . (CNA A) states where do you come up with this stuff? (Resident #1) states you in the dark of night. 8:03:26 - (CNA A) leans forward, and states ok grabbing the resident chair and rolls her back toward the inside of the room. (Resident #1) yells out at this time. 8:03:33 - (CNA A) stands back up shaking her head and says, Are you? (Resident #1) responded that hurts . 8:03:41 - (CNA A) is clapping her hands together stating to the resident I had nothing to do, (Resident #1) states, just to be heard. 8:03:44 - (CNA A) backs out and shuts the door at this time. The resident is ringing the bell behind the closed door of her room. (CNA A) leaves the area at this time. Video clip 2 8:04:36 PM - (CNA A) standing outside resident (Resident #1) room holding door closed, resident's call light is on 8:04:47 PM - (CNA A) puts resident's hand bell on the hallway railing 8:05:09 PM - (CNA A) adds second hand to door knob, continues holding door closed; sounds of someone trying to open door can be heard 8:05:56 PM - Resident can be heard saying let me out, (CNA A) continues holding door closed from outside 8:06:18 PM - (CNA A) opens door, resident sitting right behind door, door hits resident's wheelchair Resident says I want to go to bed, (CNA A) responds that I want to put you to bed but you're not acting right with all the yelling and screaming. 8:06:27 PM - (CNA A) walks away from resident's door, call light still on 8:06:35 PM - Resident opens door all the way and moves to doorway 8:06:36 PM - end of clip [sic] During an interview on 03/03/25 at 10:01 AM, the ADM stated after watching the video of CNA A with Resident #1, she had concerns about how CNA A talked to Resident #1 and the tone used. She stated she did not want CNA A to return. She stated she reported the allegations of abuse to the staffing agency that placed CNA A at the facility. The ADM stated she did not know what the Resident #1 meant when she stated, That hurts. During a telephone interview on 03/03/25 at 10:38 AM, Resident #1's FM stated the resident did not see or hear well and she always asked for the name of anyone in the room. The FM stated the resident told her the staff would not say her name, so the resident continued to put on her call light waiting for someone different to come in the room. She stated the same person came in the room and turned off the call light every time. She stated the resident was very fearful about staying at the facility as she did not feel safe. She stated Resident #1 moved to another facility. During an interview on 03/03/25 at 2:23 PM, RN B stated she worked with Resident #1 on the evening of 02/03/25. She stated she was in and out of rooms on Resident #1's hallway and did not see anything unusual or out of the ordinary that evening. She stated during her interactions with Resident #1, the resident was concerned about her fall from earlier on the day shift. RN B stated she received ANE training during orientation to the facility a couple months ago and again just after the alleged abuse with Resident #1. She stated the training after the alleged abuse included type of abuse such as physical, verbal, mental, and seclusion, when to report and who to report to. The training included dealing with challenging behaviors and Resident Rights. She stated any suspected abuse was immediately reported to the ADM who was the Abuse Coordinator. She stated the notification must be a phone call not a text message. During an observation and interview on 03/03/25 at 2:40 PM, the ADM stated she was not able to send the surveillance videos but showed the videos on her laptop. The ADM started the first video clip, time-stamped just after 8:00 PM, which revealed a resident seated in a wheelchair in the doorway of her room. The resident rang a handheld bell. The ADM identified the resident as Resident #1. The call light indicator above the doorway was illuminated which indicated the call light was on. A few seconds later, a person approached Resident #1. The ADM identified the person as CNA A. CNA A wore a blue face mask. CNA A asked twice, How may I help you? Resident #1 intermittently rang the handheld bell. Standing in front of Resident #1, CNA A stated, Is this what you resort to? Resident #1 stated, I can't see, what is your name? CNA A asked, How can I help you? CNA A stated, I'm not the reason you fell . Resident #1 continued to ring the bell. CNA A bent over and pushed the resident in the wheelchair back towards the room and said she would put her to bed. Resident #1 began asking loudly, What is your name? While she held the wheelchair in place, CNA A stated, You shouldn't act like this. Resident #1 pleaded, with desperation in her voice, Tell me your name. CNA A stated, I told you, (name). CNA A leaned over close to Resident #1's head and yelled, (name), (name), (name) . She yelled her name multiple times while still holding the wheelchair in place. The resident looked confused and asked, (similar name)? CNA A stood up and asked the resident, Now do you feel better? CNA A told Resident #1 she was disturbing the other residents with the bell. CNA A told Resident #1 to roll back, We are going to shut the door because you cannot disturb the other residents. CNA A grabbed the wheelchair arms and rolled it back into the room. Resident yelled out. CNA A backed up into the hall and shut the room door. Resident #1 continued to ring the handheld bell inside the room. CNA A left the area. The video clip lasted about three minutes. The second video clip started when CNA A was observed standing outside of Resident #1's room. The door was still closed. CNA A was holding the door handle with one hand. She had Resident #1's bell and placed it on the handrail. CNA A put a second hand on the door handle and held the door closed. Noises of attempts to open the door were heard. Resident #1, sounding distressed, yelled, Let me out. CNA A opened the door and the door hit Resident #1's wheelchair. Resident #1 stated she wanted to go to bed. CNA A stated, I want to put you to bed but you aren't acting right with all that yelling and screaming. CNA A walked away from the resident. The call light was still on. Resident #1 moved her wheelchair back into the doorway. The video ended. The ADM stated the tone of voice used by CNA A concerned her. She stated she did not want CNA A back in the facility. During an interview on 03/03/25 at 3:44 PM with the SW, she stated she had visited with Resident #1 a few times after the alleged incident. She stated the resident did not feel safe. The SW was unable to clarify whether the resident did not feel safe because of the fall or because of something else. She stated the resident was very hard of hearing and almost blind, she had a hard time identifying people. The SW stated Resident #1 was able to move herself around once seated in the wheelchair. The SW stated she had received training after the allegation of abuse of Resident #1 on resident rights, dealing with cognitive impairment and difficult behaviors, and reporting abuse and neglect allegations. During an interview on 03/03/25 at 3:59 PM, the DON stated she had assessed Resident #1 on 02/04/25 and did not have any physical findings. The DON stated the resident told her the staff member would not say her name, so she wanted someone else to take care of her. The DON stated it was not acceptable to yell at a resident. She stated the facility provided frequent training on abuse and neglect. She stated the agency CNA would not be allowed back in the facility. During a telephone interview on 03/03/25 at 4:11 PM, the GM from the staffing agency who placed CNA A in the facility, stated she was made aware, by the facility, of the allegation of abuse against CNA A. She stated the hero, what they call CNAs, was suspended while the facility investigated. During an interview on 03/03/25 at 4:26 PM CNA C stated she worked on the evening of 02/03/25 and assisted Resident #1 from the bed to the wheelchair early in the shift. She stated Resident #1 was never a problem for me. She stated she did not see or hear anything that night unusual on Resident #1's hall, but she spent most of her time on the adjacent hall where she was assigned. She stated she had been trained on ANE and resident rights a couple days after 02/03/25. She stated if you see it or suspect it report it immediately. Report to the supervisor, the charge nurse, and the ADM. She stated the ADM was the abuse coordinator. During an interview on 03/03/25 at 4:45 PM, the ADM stated she had a conversation on 02/04/25 with CNA A about the allegations. The ADM stated CNA A told her she repeated her name three times to the resident and the CNA denied mistreating the resident and most of what she said sounded reasonable. The ADM stated it was after the conversation with CNA A that she watched the video footage from the evening of 02/03/25 that she saw a different version. The ADM stated, Based on our interactions I was not expecting to see what I saw on the video. Part of her statements were consistent with the video, but she did not tell the whole story. During a telephone interview on 03/05/25 at 3:05 PM, CNA A confirmed that she worked with Resident #1 on the evening of 02/03/25. When asked to describe the events of the evening she stated, Resident #1 wanted to go to sleep. Something happened earlier and she kept asking if I was going to drop her. She let me put her in bed and she napped. Around 4:15 or 4:30 PM Resident #1 put the call light on and she acted like she didn't know me. She stated she wanted the other lady. After dinner I asked if she was ready to go to bed, she told me she didn't want me to put her to bed. She stated she went back to the room around 9:30 PM to ask again and when I walked into the room, she kicked me. The light was on, and I was holding the door closed until I could get someone else to come help me put her in bed. I was told there was no clear evidence that I did anything wrong. CNA A stated she was aware the facility had cameras in the building, Yes, the camera was right there. CNA A stated she had told the GM from the staffing agency that she had been kicked but did not tell anyone else. CNA A denied that she raised her voice at the resident, Never. I told her my name was (name), (name), (name). I talked to her just like we are talking right now. She stated she was not 100% sure if she had told the Resident #1 that she was disturbing other residents so she was going to close her door or that the resident should not be acting like that. CNA A stated she had been trained on ANE. She stated abuse could be neglect, verbal, or physical. Review of the undated Resident Rights policy, reflected in part, .To be treated with respect and dignity. To be free from any physical or chemical restraint imposed for convenience or discipline and not required to treat the resident's medical condition. To be free from abuse, neglect, misappropriation of resident property, and exploitation including corporal punishment, involuntary seclusion . Review of the undated Prevention and Reporting of Suspected Resident Abuse and Neglect policy, reflected in part, This facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect. This facility has implemented the following processes in an effort to provide residents and staff a comfortable and safe environment .Protection: suspend suspected employee(s) pending outcome of the investigation .definitions 1. Verbal Abuse - Oral, written or gestured language that includes disparaging and derogatory terms to the residents or their families or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability .5. Involuntary Seclusion - Separation of a resident from other resident or from his/her room against the resident's will . The facility implemented the following interventions: Review of Resident #1's medical record progress notes dated 02/04/25, reflected Resident #1 was assessed by the SW and nursing. A head-to-toe assessment dated [DATE], completed by the DON, reflected no injuries identified. The comprehensive care plan, initiated 12/03/24, was reviewed and revised on 02/11/25. Review of the facility's undated Investigation Summary reflected on 02/04/25, CNA A was interviewed by the ADM and DON. CNA A provided a written statement and was notified she was not allowed to work at the facility pending the investigation. Review of the facility's undated Investigation Summary reflected on 02/04/25, CNA A's staffing agency was notified of the allegations of abuse and indicated as Do Not Return. Review of the facility's undated Investigation Summary reflected on 2/4/25, 2/5/25, and 2/7/25 the facility communicated with Resident #1's responsible party about the allegation and investigation. The facility assured her the alleged perpetrator would not work at the facility. Review of the facility's undated Investigation Summary reflected staff working the evening and night of 02/03/25 were interviewed between 02/04/25 and 02/07/25. The staff interviewed included RN B, CNA C, CNA D, CNA E, and MA F with no further adverse findings. Review of the facility's undated Investigation Summary reflected the local Police Department was contacted regarding the allegation . Review of the facility's undated Investigation Summary reflected the security camera footage of the exterior of Resident #1's room was reviewed on 02/03/25. Other concerns were identified, and CNA A was indicated as Do Not Return. The abuse allegation information was sent to the agency for their follow up. Review of the Resident Interview Questions for Abuse Allegation (Safe Surveys) dated from 02/04/25 through 02/27/25 conducted by the SW revealed no concerns of abuse identified and the residents felt safe in the facility. Review of an in-service dated 02/04/24, reflected administration and therapy staff were in-serviced on Caring for Cognitively Impaired with Challenging Behaviors. Bullet points attached. Review of an in-service dated 02/04/24, reflected all staff were in-serviced on Caring for Cognitively Impaired with Challenging Behaviors. Bullet points attached. Review of an in-service dated 02/04/24, reflected all staff were in-serviced on Abuse Prevention and Reporting - All allegations must be reported immediately to the ADM. Policy attached. Review of an in-service dated 02/04/24, reflected administration and therapy staff were in-serviced on abuse Prevention and Reporting - All allegations must be reported immediately to the ADM. Policy attached. Review of an in-service dated 02/05/25, reflected dietary staff were in-serviced on Prevention and Reporting of Abuse and Neglect. Report any suspected abuse and neglect immediately to ADM. Policy attached. Review of in-services dated 02/05/25, reflected RN B was in-serviced on Conditions to report to administration, Abuse and neglect prevention and reporting, dealing with challenging behaviors. Policies and PowerPoint attached. Review of an in-service dated 02/07/25, reflected housekeeping staff were in-serviced on Prevention and Reporting of Abuse and Neglect. Report any suspected abuse and neglect immediately to ADM. Policy attached. Review of an in-service dated 02/07/25, reflected administration and therapy staff were in-serviced on Resident Rights. Please see list of Resident Rights, including the right to a dignified existence, self-determination, and communication . to be treated with respect and dignity, and to be free from abuse and neglect. Policy attached. Review of an in-service dated 02/07/25, reflected the receptionists were in-serviced on Resident Rights. Please see list of Resident Rights, including the right to a dignified existence, self-determination, and communication . to be treated with respect and dignity, and to be free from abuse and neglect. Policy attached. Review of an in-service dated 02/07/25, reflected all staff were in-serviced on Resident Rights. Please see list of Resident Rights, including the right to a dignified existence, self-determination, and communication . to be treated with respect and dignity, and to be free from abuse and neglect. Policy attached. Review of an in-service dated 02/07/25, reflected dietary staff were in-serviced on Resident Rights. Please see list of Resident Rights, including the right to a dignified existence, self-determination, and communication . to be treated with respect and dignity, and to be free from abuse and neglect. Policy attached.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safely for 1 of 1 kitchen reviewed for food storage and sanitation. 1. The facility failed to ensure food and beverages in refrigerator unit #2 and 3 and the walk-in freezer, were covered, labeled, and dated. This failure could place residents at risk of foodborne illness. Findings included: Observation of the kitchen 02/27/24 08:45 am during initial tour revealed , refrigerator # 2 had a rack of covered drinks not labeled with a use by date, refrigerator # 3 with a 7 shelf rack with brown squares in white container with no cover or labeled, ,3rd shelf with clear bowl containers of green and brown substance not covered and dated or identified 4th, 5, and 6th racks with clear small container with green, purple, white and red pieces in them. The walk in freezer with rack with light brown oblong objects uncovered, not dated, or identified. A tray of red oblong shaped objects with light brown covering. On the bottom shelf was an open bag of red substance undated and not identified. Interview with the DM on 2/27/24 at 08:50 am, he stated that he was responsible for the kitchen and was aware that the food was not covered, and they had run out of saran wrap and they were working on getting some. He stated that he was unaware that each item had to be individually covered. He thought the rack could be covered and a date applied to the rack, not each item. He stated he didn't think about the food getting contaminated. The DM stated that they had a policy in English but there was no copy in Spanish and that he has several staff that English was not their first language and since he also in a Spanish speaker he goes over the policies with them during orientation Interview with the DON at 2/29/24 at 12:00 pm, she stated her expectation was that the kitchen follows CMS and State of Texas guidelines for food storage and covering. She stated not following those guidelines could result in potential illness. Interview with the ADM at 2/29/24 at 1:30 pm, she stated her expectation was that the kitchen staff follow food safety guidelines when preparing meals for the residents. She stated that not following guidelines for food handling could lead to an outbreak of food borne illness. Review of the Policy entitled Food and supply storage, revised 1/24 revealed: Cover, label and date unused portions and open packages. Complete all sections on a [NAME] orange label or use the Medvantage/Freshdate labeling system. Products are good through the close of business on the date noted on the label.

Based on observation, interview, and record review the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 5 of 16 residents (Resident #4, Resident #7, Resident #8, Resident #14, and Resident #35), reviewed for care plans. -The facility failed to ensure Resident #4's care plan accurately reflected her antidepressant medication. -The facility failed to ensure Resident #7's care plan reflected her code status. -The facility failed to ensure Resident #8's care plan accurately reflected his antidepressant medication. -The facility failed to ensure Resident #14's care plan accurately reflected the current g-tube status. -The facility failed to ensure Resident #35's care plan accurately reflected the current diet, cognitive status, and pressure ulcer status. These failures could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Review of Resident #4's face sheet printed 02/29/24 revealed a [AGE] year-old female, admitted to the facility 10/22/19. Her diagnoses included paraplegia, complete (when the damage to the spinal cord is severe enough to completely cut off all connections between the brain and areas below the level of injury), major depressive disorder, recurrent severe without psychotic features (an episode of depression in which symptoms are marked and distressing, typically loss of self-esteem and ideas of worthlessness or guilt), post-traumatic stress disorder, chronic (a common and often disabling anxiety disorder). Review of Resident #4's quarterly MDS dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 13 indicating intact cognition. Section N (Medications) reflected the resident was taking antipsychotic, antianxiety and antidepressant medications. Record review of Resident #4 current physician's orders revealed Duloxetine HCL Oral Capsule delayed release particles 30 mg daily written 08/30/23 and Duloxetine HCL oral capsule delayed release particles 60 mg daily written 07/12/23. Review of Resident #4's discontinued medications reflected an order for Sertraline written 10/27/21 had been discontinued. Review of Resident #4's care plan, initiated on 02/12/20 and revised 09/09/20, reflected the resident used the antidepressant medication Sertraline related to a history of depression and anxiety. The goal of decreased signs and symptoms of depression was revised on 01/11/24. Approaches included, Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of Sertraline initiated 02/12/20 and revised on 09/09/20. Review of Resident #7's face sheet printed 02/29/24 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included unspecified dementia, major depressive disorder, bipolar disorder (a mental illness that causes extreme mood swings), schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), and repeated falls. Review of Resident #7's annual MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 12 indication moderately impaired cognition. Section E (Behavior) reflected no hallucinations, delusions, or behavioral symptoms. Section N (Medications) reflected she received antipsychotic and antidepressant medications. Review of Resident #7's physician order dated 12/03/19 reflected, FULL CODE. Review of Resident #7's comprehensive care plan initiated 12/27/19 and last revised on 01/19/24, reflected no entry regarding the code status. Review of Resident #8's face sheet printed 02/29/24 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease with late onset, dysphagia (difficulty swallowing, diabetes insipidus (an uncommon problem that causes the fluids in the body to become out of balance), major depressive disorder, and anxiety disorder (intense and excessive worry and fear). Review of Resident #8's annual MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 1 indicating severely impaired cognition. Section N (Medications) reflected the resident was not taking an antidepressant medication. Review of Resident #8's active physician orders printed 02/28/24, reflected no orders for antidepressant medications. Review of Resident #8's discontinued physician orders reflected an order for Sertraline (an antidepressant medication) that was discontinued 07/14/22. Review of Resident #8's comprehensive care plan revised on 12/02/20 reflected, Need Resident #8 uses antidepressant medication, Sertraline, related to history of depression. The Goal of showing decreased signs and symptoms of depression was revised on 01/19/24. Approaches included administer antidepressant medications as ordered by physician and educate the resident/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms of Sertraline. Review of Resident #14's face sheet printed 02/29/24, reflected an [AGE] year-old female admitted to the facility 07/15/20. Her diagnoses included unspecified dementia, dysphagia (difficulty swallowing), major depressive disorder, Bell's palsy (A condition that causes temporary weakness or paralysis of the muscles in the face), and hemiplegia and hemiparesis following a cerebral infarction (paralysis that affects one side of the body after a stroke). Review of Resident #14's quarterly MDS assessment dated [DATE] Section C (Cognitive Patterns) reflected resident was unable to participate in the BIMS assessment but had both long- and short-term memory impairment. Section K (Swallowing/Nutritional Status) reflected the resident did not have a feeding tube but had a mechanically altered diet. Review of Resident #14's Discharge summary from the acute care hospital, dated 10/17/23, reflected in part, 81F h/o RA, .multiple strokes, dysphagia s/p PEG placement, removal in 2022, and subsequent persistent gastrocutaneous fistula (a hole or tract connecting the stomach and the skin) so was take to OR for fistula closure. Review of Resident #14's comprehensive care plan, revised 01/29/24 reflected in part, Need Resident #14 has a G-tube related to history of refusing to eat . Goal Resident #14 will have decreased risk for potential side effects or complications related to G-tube placement .Approaches Head of bed elevated 45 degrees, check for tube placement and gastric contents/residual volume per facility protocol and record. Hold medications if greater than 100cc aspirate .Discuss with resident/family/caregivers any concerns about tube feeding . Review of Resident #35's face sheet printed 02/29/24, reflected a [AGE] year-old male admitted to the facility 07/01/20. His diagnoses included Alzheimer's disease, type 2 diabetes (a condition that affects the way the body processes blood sugar), cognitive communication deficit (difficulty communicating after a stroke), dysphagia (difficulty swallowing), and cerebral infarction, (stroke). Review of Resident #35's quarterly MDS assessment dated [DATE] Section B (Hearing, Speech, and Vision) reflected his speech was unclear, he sometimes makes himself understood, and he sometimes understood others. Section C (Cognitive Patterns) reflected a BIMS score of 1 indicating severely impaired cognition. Section K (Swallowing/Nutritional Status) reflected a mechanically altered diet. Section M (Skin Conditions) reflected the resident had two pressure ulcers. Review of Resident #35's physician order dated 03/08/23 reflected, Regular diet pureed texture, nectar consistency liquids. Review of Resident #35's physician orders dated 08/01/23 reflected wound care orders for both the coccyx and right ischial tuberosity that reflected, cleanse with normal saline, pat dry. Apply moisture barrier cream to area cover with hydrocolloid dressing three times a week and PRN. Review of Resident #35's comprehensive care plan revised 01/19/24 reflected in part, Resident #35 has impaired cognitive function with approaches including ask yes/no questions. The care plan also reflected, Resident #35 has a diagnosis of diabetes with approaches including educate regarding medications and importance of compliance. Have resident verbally state understanding. The care plan reflected a potential for impairment to skin integrity, revised 12/13/23 .Stage 2 to coccyx/right ischial tuberosity healed 12/12/23 . Review of Resident #35's weekly skin assessment completed 02/22/24 reflected stage II pressure ulcers on the right ischial tuberosity and coccyx. During an observation and interview on 02/28/24 at 8:42 AM, LVN A performed wound care on Resident #14's abdominal stoma. There was no g-tube present. LVN A stated the tube had been removed a while back, but it often leaked so the resident had a procedure a few months ago to close up the wound on the inside. An observation on 02/29/24 at 8:07 AM revealed Resident #14 in bed, with the head of the bed elevated, drinking from a cup with a straw. During an interview on 02/29/24 at 11:36 AM, the CPC stated he was responsible for completing the MDS assessments for the long-term care residents. He stated as the care plan coordinator, he was responsible for inputting the nursing care plans. He stated each department, such as social services, activities, or dietary, was responsible for inputting their section of the care plan. He stated the wound care nurse was responsible for updating care plans regarding wounds. He stated if a resident no longer had a g-tube, he would expect that would have been removed from the care plan. He stated the care plans were revised after an MDS assessment was completed. He stated he had a program on his computer that alerted him when updates were due. He stated the updates and alerts were based on the assessment reference date. He stated if a resident was no longer taking a medication, he would expect the medication would have been removed from the care plan. He stated he compared the MDS with the care plan to see if anything needed to be updated. He stated he did not attend care plan meetings but learned of changes to medications and diets, falls and behaviors in the morning meetings. He stated he used information from the morning meeting to update care plans. He stated as the care plan coordinator, he was technically responsible for ensuring the MDS assessments and care plans were accurate. He stated, If the care plan isn't right, they aren't getting the care they need. During an interview on 02/29/24 at 12:19 PM, the DON stated, she expected the MDS assessments and care plans to be accurate as she was the one who signed off on them. She stated she looked through the meds and section GG. She stated she was familiar with the residents, and they talked about changes in the morning meetings. She stated if a resident had a diagnosis of CVA, it should have been reflected on the MDS. She stated having an inaccurate MDS or care plan would not cause an adverse outcome for a resident. She stated the physician orders contained the information needed and that was found on the medication administration records, the treatment records, and the FYI box in the medical records. She stated the care plan was a reference. She stated staff performed report at shift change and any changes were passed on at that time. When asked about psychotropic medications on care plans, she stated the care plan should focus more on the behaviors than the medication. She stated the FYI box was updated when there was a change. She stated the care plan and the MDS should match. During an interview on 02/29/24 at 1:05 PM, the ADM stated care plans should be accurate. She stated each department was responsible for adding and updating as appropriate. She stated overall, the MDS/Care plan coordinators were responsible for the MDS and care plans and for accuracy. She stated she and the DON were responsible to oversee the process. She stated if the resident was up for a care plan meeting, that was where the MDS and care plan were reviewed. She stated the policy and procedure should say that the MDS and care plans were kept up to date. She stated she did not think the resident would experience any negative impact because of inaccurate care plans because they were getting the care they needed. She stated the staff completed shift to shift report and passed on pertinent information during that time. Review of the undated facility policy titled Comprehensive Care Plans reflected the following: 1. The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 2. The comprehensive care plan will describe the following: the services that are to be furnished to attain the resident's highest practicable, physical, mental, and psychosocial well-being. Any services that would otherwise be required but are not provided due to a resident exercising the right to refuse treatment and services . 3. The comprehensive care plan will be a. developed within seven days after completion of the comprehensive assessment unless the comprehensive care plan will be used as the baseline care plan which requires completion within 48 hours of admission to the facility. b. Prepared by an interdisciplinary team IDT that includes but is not limited to: i. Attending physician. ii. Assigned nurse with responsibility for the resident. iii. Food and nutrition services staff member. iv. Activity Director staff member. v. The resident and their representative, where practicable and/or requested, and documentation in the medical record, explaining why their participation isn't practicable for the development of the residence care plan. vi. Other appropriate staff, or disciplines, as determined by need or requested by the resident. c. Reviewed and revised (including discharge plans) by the interdisciplinary team after each assessment . 47795

Based on interview and record review, the facility failed to ensure residents were informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, he or she prefers for 2 (Resident #4 and Resident #7) of 5 residents reviewed for informed consent for treatment options. The facility failed to: 1. obtain a signed informed consent for the use of Duloxentine (an anti-depressive) for Resident #4. 2. obtain a signed informed consent for the use of Aripiprazole (an antipsychotic medication) for Resident #7. This failure could affect all residents by placing them at risk of receiving psychotropic medications without informed consent which could cause decrease quality of life and increase the risk of injury and violate the rights of residents to make informed decisions related to care. Findings included: Review of Resident #4's face sheet 2/29/24 at 10:30 am undated revealed a [AGE] year old female, admitted to the facility 10/22/2019 with diagnoses that include Paraplegia, complete ( when the damage to the spinal cord is severe enough to completely cut off all connections between the brain and areas below the level of injury), major depressive disorder, recurrent severe without psychotic features( an episode of depression in which symptoms are marked and distressing, typically loss of self-esteem and ideas of worthlessness or guilt) , post-traumatic stress disorder, chronic ( a common and often chronic and disabling anxiety disorder). Review of Resident #4's quarterly MDS 2/29/24 at 10:45 am dated 12/5/2023 revealed a BIMS score of 13 of 15 which indicated cognitively intact. Quarterly MDS also reflected the resident was on an anti-depressant and there was an indication. Review of Resident #4's Care plan 2/29/24 at 11:00 revised on 1/11/2024 indicates that resident is on an anti-depressive sertraline not Duloxetine. Review of Resident #4's physicians orders 2/29/24 at 11:15 am dated 7/12/2023 revealed an order for Duloxetine HCL capsule delayed release particles 60 mg give 1 capsule by mouth one time a day for depression and 8/30/2023 Duloxetine HCL capsule delayed release particles 30 mg give I capsule by mouth one time a day for depression. Review of Resident # 4's Medication administration record 2/29/24 at 11:50 am dated 2/29/24 for the month of February shows the resident is receiving Duloxetine HCL Capsule delayed release Particles 60 mg and 30 mg daily. Review of Resident # 4's consents for psychotropic medications on 2/29/24 at 10:30 am revealed no written consent for the Duloxetine in the Electronic record. Interview with DON on 2/29/24 at 12:30 stated that she was unable to locate consent for Duloxetine in the paper chart or in medical records. Review of Resident #7's face sheet printed 02/29/24 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included unspecified dementia(A group of thinking and social symptoms that interferes with daily function of unknown cause) , major depressive disorder( A mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with you daily life) , bipolar disorder ( a disorder associated with episode of mood swings ranging from depressive lows to manic highs), schizoaffective disorder ( a disorder that affects a person's ability to think, feel and behave clearly with and additional mood disorder), and repeated falls ( older adults who fall more than once per year) . Review of Resident #7's annual MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 12 indication moderately impaired cognition. Section E (Behavior) reflected no hallucinations, delusions, or behavioral symptoms. Section N (Medications) reflected she received antipsychotic and antidepressant medications. Review of Resident # 7's care plan revised on 2/14/2024 revealed Resident # 7 uses psychotropic medications, Ability, related to Bipolar disease and Resident # 7 uses antidepressant medication, Sertraline ,related to history of depression Review of Resident #7's physician order dated 09/27/23 reflected, Aripiprazole Tablet 5mg give 1 tablet by mouth one time a day for bipolar disorder. Review or Resident #7's discontinued orders reflected orders for Aripiprazole 2mg by mouth in the morning initiated on 08/09/22 and discontinued on 08/30/23. The discontinued orders also reflected Aripiprazole 5mg one time a day initiated 08/31/23 and discontinued 09/27/23. Review of Resident #7's consents for psychotropic medications revealed no written consent for the Aripiprazole. Review of Resident # 7's psychiatric progress note written 08/17/22 reflected in part, .a switch to Abilify was recommended out of an abundance of caution. Initial dose of Abilify (Aripiprazole) was given on 08/11/22 per e-MAR. Writer spoke with patient's [family member] about POC and received consent. Interview on 2/29/24 at 12:30 pm the DON stated that her expectation was that a new anti-psychotic or anti-depressive is not started until the consent was signed. She stated that the potential harm maybe the resident was not aware of the reason for the medications and the side effects. She also stated she was unable to locate Resident# 7's consent for Aripiprazole either in the paper chart or in the medical records office. She stated she is unsure how the consent got missed and the charge nurse on the floor is responsible to obtain consent prior to the first dose, which they administer. The DON stated that consents are monitored monthly by nursing leadership ( don or assistant director of nurses) and the pharmacy consultant. Interview on 2/29/24 at 1:00 pm the ADM stated her expectation was all residents had the right to know the treatment they were receiving and that consents for anti-psychotic and anti-depressive medication be obtained prior to starting treatment. She stated that she did not see the harm, but agreed it was a resident rights issue. Record Review of Policy Resident Rights undated revealed to be informed of, and participate in, his or her treatment, including the right to: . De informed, in advance, by the physician of the risks and benefits of proposed care, of the treatment and alternatives and the right to choose the alternative option they prefer.'

Based on interview and record review the facility failed to develop a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's mental and psychosocial needs that were identified in the comprehensive assessment for five of 25 residents (Residents #99, #101, #46, #76, and #37) reviewed for care planning of activities, in that Residents #99, #101, #46, #76, and #37 had no care planning for activity preferences and interests. This failure placed residents at risk of not achieving or maintaining their highest practicable psychosocial well-being. Findings included: Review of the undated face sheet for Resident #99 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of toxic encephalopathy (a neurologic disorder caused by exposure to neurotoxic organic solvents), acute kidney failure, hypothyroidism (a condition in which your thyroid gland doesn't produce enough of certain crucial hormones), extradural and subdural abscess (serious intracranial infections), obstructive and reflux uropathy (a condition in which the flow of urine is blocked), neuromuscular dysfunction of bladder (urinary bladder problems due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination), neurogenic bowel (loss of normal bowel function), Down syndrome, paraplegia (paralysis of all or part of your trunk, legs, and pelvic organs), obstructive sleep apnea (the most common sleep-related breathing disorder), altered mental status, constipation, rash, muscle weakness, spinal stenosis (the space inside the backbone is too small), muscle wasting and atrophy, abnormalities of gait and mobility, dysphagia (A condition with difficulty in swallowing food or liquid), and symbolic dysfunctions (impaired ability in numerical concepts). Review of the admission MDS for Resident #99 dated 10/31/22 reflected a BIMS score of 11, indicating a moderate cognitive impairment. Review of Section F Preferences for Customary Routine and Activities reflected the following answers: Somewhat important to you to have books, newspapers, and magazines to read. Somewhat important to you to listen to music you like. Not very important to you to be around animals such as pets. Somewhat important to you to keep up with the news. Somewhat important to you to do things with groups of people. Somewhat important to you to do your favorite activities. Somewhat important to you to go outside to get fresh air when the weather is good. Very important to you to participate in religious services or practices. Review of the care plan for Resident #99 dated 11/08/22 reflected no care planning for activities or activity preferences. During an interview on 12/08/22 at 10:11 a.m., Resident #99 stated she liked to color and do crossword puzzles and she liked bingo. She stated she liked to be invited to group activities. Review of the undated face sheet for Resident #101 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of displaced intertrochanteric fracture of right femur (a specific type of hip fracture), fracture of the lower end of right radius (lower arm fracture), acute posthemorrhagic anemia (condition in which a person quickly loses a large volume of circulating blood cells), acute kidney failure, hypoosmolality and hyponatremia (diluted blood and low blood sodium content), major depressive disorder, obstructive and reflux neuropathy (a condition in which the flow of urine is blocked), hypertensive heart disease (heart problems that occur because of high blood pressure), gastroenteritis and colitis (infectious disease that affects the intestines), atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), ulcerative colitis (an inflammatory bowel disease that causes inflammation and sores in your digestive tract), muscle wasting and atrophy, abnormalities of gait and mobility, need for assistance with personal care, muscle weakness, and lack of coordination. Review of the admission MDS for Resident #101 dated 11/23/22 reflected a BIMS score of 12, indicating a moderate cognitive impairment. Review of Section F Preferences for Customary Routine and Activities reflected the following answers: Somewhat important to you to have books, newspapers, and magazines to read. Somewhat important to you to listen to music you like. Somewhat important to you to be around animals such as pets. Somewhat important to you to keep up with the news. Somewhat important to you to do things with groups of people. Somewhat important to you to do your favorite activities. Somewhat important to you to go outside to get fresh air when the weather is good. Very important to you to participate in religious services or practices. Review of the care plan for Resident #101 dated 12/06/22 reflected no care planning for activities or activity preferences. During an interview on 12/07/22 at 1:35 p.m., Resident #101 stated she liked to read and to go outside, but she was trying to focus on healing. She stated she would be interested in participating in activities in the facility when she was feeling better. Review of the undated face sheet for Resident #46 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of displaced trimalleolar fracture of right lower leg (ankle fracture), cellulitis of right lower limb (skin infection on the leg), long-standing persistent atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), congestive heart failure (a progressive heart disease that affects pumping action of the heart muscles), hypertensive heart disease (heart problems that occur because of high blood pressure), vitamin D deficiency, overactive bladder, major depressive disorder, hyperlipidemia (high cholesterol), hypertension (high blood pressure), osteoarthritis (the protective cartilage that cushions the ends of the bones wears down over time), benign prostatic, hyperplasia (A condition in which the flow of urine is blocked due to the enlargement of prostate gland), dysphagia (A condition with difficulty in swallowing food or liquid), muscle wasting and atrophy, abnormalities of gait and mobility, need for assistance with personal care, and muscle weakness. Review of the admission MDS for Resident #46 dated 10/26/22 reflected a BIMS score of 13, indicating mild cognitive impairment. Review of Section F Preferences for Customary Routine and Activities reflected the following answers: Somewhat important to you to have books, newspapers, and magazines to read. Somewhat important to you to listen to music you like. Not very important to you to be around animals such as pets. Very important to you to keep up with the news. Somewhat important to you to do things with groups of people. Somewhat important to you to do your favorite activities. Somewhat important to you to go outside to get fresh air when the weather is good. Very important to you to participate in religious services or practices. Review of the care plan for Resident #46 dated 11/08/22 reflected no care planning for activities or activity preferences. During an interview on 12/08/22 at 11:21 a.m., Resident #46 stated he enjoyed activities at the facility and often participated in bingo and exercise. He stated he felt there could be more activities for men. He stated he was not sure if anyone had talked to him about what activities he would like, but he did not have complaints. Review of the undated face sheet for Resident #76 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of melena (black colored stool), permanent atrial fibrillation (uneven heart rate), atherosclerotic heart disease (hardening and narrowing of your arteries), gastrointestinal hemorrhage (bleeding in the digestive tracts), stage four chronic kidney disease, congestive heart failure (a progressive heart disease that affects pumping action of the heart muscles), acute posthemorrhagic anemia (a condition in which a person quickly loses a large volume of circulating blood cells), hypothyroidism (a condition in which your thyroid gland doesn't produce enough of certain crucial hormones), gastroesophageal reflux disease (a condition affecting the food pipe), muscle weakness, muscle wasting and atrophy, abnormalities of gait and mobility, need for assistance with personal care, dysphagia (A condition with difficulty in swallowing food or liquid), and cognitive communication deficit (deficits resulting in difficulty with thinking and how someone uses language). Review of the admission MDS for Resident #76 dated 11/24/22 reflected a BIMS score of 13, indicating mild cognitive impairment. Review of Section F Preferences for Customary Routine and Activities reflected the following answers: Somewhat important to you to have books, newspapers, and magazines to read. Somewhat important to you to listen to music you like. Not very important to you to be around animals such as pets. Very important to you to keep up with the news. Somewhat important to you to do things with groups of people. Somewhat important to you to do your favorite activities. Somewhat important to you to go outside to get fresh air when the weather is good. Very important to you to participate in religious services or practices. Review of the care plan for Resident #76 dated 12/08/22 reflected no care planning for activities or activity preferences. During an interview on 12/07/22 at 8:40 a.m., Resident #76 stated he had not been interested in group activities but did not think anyone had asked him what activities he might want. Review of the undated face sheet for Resident #37 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction (related conditions that cause weakness on one side of the body after a stroke), lobar pneumonia (a form of pneumonia that affects a large and continuous area of the lobe of a lung), pericardial effusion (condition with the accumulation of too much fluid in the sac surrounding the heart), dysphasia (a partial or complete impairment of the ability to communicate resulting from brain injury), paroxysmal atrial fibrillation (a rapid, erratic heart rate begins suddenly and then stops on its own within 7 days), hypertensive heart disease (disease of the heart caused by high blood pressure), candida stomatitis (yeast infection of the mouth), constipation, hyperlipidemia (high cholesterol), muscle weakness, adjustment disorder, major depressive disorder, muscle wasting and atrophy, abnormalities of gait and mobility, need for assistance with personal care, cognitive communication deficit (deficits resulting in difficulty with thinking and how someone uses language), aphasia (a comprehension and communication disorder resulting from damage or injury to the specific area in the brain), hypertension (high blood pressure), and atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart). Review of the admission MDS for Resident #37 dated 11/14/22 reflected a BIMS score of 13, indicating mild cognitive impairment. Review of Section F Preferences for Customary Routine and Activities reflected the following answers: Somewhat important to you to have books, newspapers, and magazines to read. Somewhat important to you to listen to music you like. Not very important to you to be around animals such as pets. Not very important to you to keep up with the news. Not very important to you to do things with groups of people. Somewhat important to you to do your favorite activities. Somewhat important to you to go outside to get fresh air when the weather is good. Very important to you to participate in religious services or practices. Review of the care plan for Resident #37 dated 11/21/22 reflected no care planning for activities or activity preferences. During an interview on 12/07/22 at 8:59 a.m., Resident #37 stated she had been involved in some exercises but had not participated in anything else. She stated she did not know if she would want to be involved in anything else, because she is focusing on her recovery. During an interview on 12/09/22 at 1:36 p.m., the AD stated she was responsible for completing the activity portion of the MDS assessment, and she gathered that information by interviewing residents when they first admitted to the facility. She stated she entered her initial assessment straight into the activities section of the MDS. She stated the MDS did not capture much about what they enjoyed doing, and the questions were very basic, so she asked them additional questions about religion and past activities, where are they planned to discharge to, and what their goals were. She stated all those items went into the care plan, and she did not use the MDS exclusively to form her care plan goals. She stated she was responsible for creating those care plan items herself and added the goal and interventions were based on all the sources of information she received from residents upon admission. She stated she did not have a specific time she created the care plan and was not aware of any rules regarding care plan timeframes. When asked about Resident #76, she stated she had not created a care plan for him. She stated he liked aerobics classes, drum fitness, and music activities. She stated he had also mentioned recently he liked bingo. She stated she did not know if she had completed a care plan item for Resident #46, but she knew he had his computer and had come to some of the church services and exercise classes. She stated she could not recall who Residents #99, 101, and 37 were by name, as it was harder for her to remember the newly admitted short term residents. After checking her records, she stated Resident #101 liked reading but was upset she could not see, and they had talked about audiobooks. She stated Resident #101 loved big band music and was proud of being from California. She stated Resident #37 loved music and attended the fitness classes. She stated Resident #99 also participated in drum fitness, chair aerobics, cranium crunches, was very close to all the therapists and would attend any activity if they invited her. She stated she should have completed the care plans if the residents had been in the facility for a few weeks. She stated she could not recall whether she had received training about when and how to complete care plans. During an interview on 12/09/22 at 2:59 p.m. the DON stated activities care plans were important, and all the managers used them to learn more about residents. She stated she had only been in the position for a little over a month, and she had not transitioned into overseeing compliance with care plans, so she did not know if there was already a system in place to ensure it was completed, but that would be a question for the chief compliance officer. She stated she thought it was the MDS nurse's responsibility to ensure they were done in a timely manner. She stated she could not think of anything harmful to the resident that would come out of a care plan item for activities not being done, but the staff did rely on them to know resident preferences. During an interview on 12/09/22 at 3:10 p.m., the MDSN stated the AD was responsible for creating the activities care plan items. She stated there should have been care plans on activities for residents who had been in the building more than three weeks. She stated she frequently checked care plans, but there was not a formal process in place to ensure that everything that should be care planned was there. She stated nurses, aides, and anyone in the IDT used the care plans. She stated a potential negative outcome of not having activities care planned was that resident preferences might not be recognized, especially their hobbies and things they like to do or, perhaps more importantly, did not like. She stated she did not think she had received any training about care plans, but any new guidance or direction came from the CCO. During an interview on 12/09/22 at 3:26 p.m., the CCO stated the person/people responsible for creating care plans was multidisciplinary. She stated, for example, the MDSN entered code status, allergies, and medications; the dietitian entered nutrition care plans; and activities would come in and do their part. She stated once the plan was completed, they personalized it further during the care plan meeting. She stated there was not one person responsible for ensuring it was done. She stated she would expect activities be in the care plan. She stated the AD was responsible for that portion of the care plan. During an interview on 12/09/22 at 4:03 p.m., the ADM stated she knew activities should be in the care plans for long term residents, but for shorter term residents, it depended on the situation. She stated if a resident had been in the building for more than ten days, there should have been a care plan for activities. She stated she was not aware of a formal process to ensure compliance. She stated she did not think the residents would experience any negative impact as a result of not having activities care plans, because they were still getting the activities. Review of undated facility policy titled Comprehensive Care Plans reflected the following: The facility will develop and implement a comprehensive person centered care plan for each resident, consistent with the resident rights that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 1. The comprehensive care plan will describe the following: the services that are to be furnished to attain the resident's highest practicable, physical, mental, and psychosocial well-being. 2. Any services that would otherwise be required but are not provided due to a resident exercising the right to refuse treatment and services. -The comprehensive care plan will be developed within seven days after completion of the comprehensive assessment unless the comprehensive care plan will be used as the baseline care plan which requires completion within 48 hours of admission to the facility. -Prepared by an interdisciplinary team IDT that includes but is not limited to: 1. Attending physician. 2. Assigned nurse with responsibility for the resident. 3. Food and nutrition services staff member. 4. Activity Director staff member. 5. The resident and their representative, where practicable and/or requested, and documentation in the medical record, explaining why their participation isn't practicable for the development of the residence care plan. 6. Other appropriate staff, or disciplines, as determined by need or requested by the resident.

Based on observations, interviews, and record review, the facility failed to follow the therapeutic diet as ordered by the physician and documented on their care plan for three of five residents (Resident #10, Resident #11, and Resident #12) reviewed for therapeutic diets. The facility failed to: A. The facility failed to follow Resident #10's physician's orders [REDACTED]. B. Resident #11 received a regular portion size (six ounces) of peach cobbler dessert rather than the consistent carb portion (two ounces) of dessert. C. Resident #12 received a regular portion size (six ounces) of peach cobbler dessert rather than the consistent carb portion (two ounces) of dessert. This failure could place these residents at risk for complications and decreased quality of life if they consumed food that was contraindicated or in larger quantities than ordered. Findings Include: A) Review of Resident #10's electronic Face Sheet, accessed on 10/14/20, revealed he was [AGE] years old. He was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's quarterly Minimum Data Set, dated dated [DATE], revealed he had a Brief Interview for Mental Status score of 13, which indicated his cognitive function was moderately impaired. Documentation also revealed he only required setup help with eating and received a mechanically altered diet. Review of Resident #10's care plan, last reviewed on 09/03/20, revealed the following: Need: (Resident #10) is at risk for potential nutritional problem r/t hx of dysphagia, choking/coughing while eating and poor po intake and significant WT loss. Hx of family providing outside food not consistent with appropriate diet despite re-education and he is at risk for aspiration. He has a history of choking episodes on 1/9/20 and 1/26/20. Receives a mechanically altered diet.supervision for all meals Approaches: Provide, serve diet as ordered. Monitor intake and record every meal. Need: (Resident #10) has a swallowing problem r/t hx of Dysphagia. Hx of choking episodes. Receiving a mechanically altered diet.Approaches .Diet to be followed as prescribed . Need: Nutritional Status-(Resident #10) needs a mechanically altered diet No chips, raw fruits/vegetables, rolls, Can have grilled cheese per SLP . Need: (Resident #10) is at increased risk for potential ADL self-care performance deficit r/t (related to)impaired mobility, weakness Eating: The resident requires supervision/set up help to eat . Review of Resident #10's electronic physician's orders [REDACTED]. Regular diet Mechanical soft texture, regular/Thin consistency, no chips, raw fruits/veggies or rolls; may have grilled cheese. Review of Resident #10's Basic MBSS (Modified [MEDICATION NAME] Swallow Study) performed on 1/16/2020, revealed the following findings: . Physician Evaluation and Management Report .Chief Complaint: Feeding difficulties, Suspect silent aspiration .Conclusion: Patient is at high risk for an aspiration pneumonia due to the following predictors: advanced age, assisted oral alimentation, dysphagia, multiple medical diagnoses, patient is also at risk for a choking episode. Diet recommendations . PO Diet: Solids: Mechanical soft, small bites, slow rate, encourage chewing; avoid breads/dry solids, grilled cheese ok, with small bites and slow rate According to Drugs.com, accessed on 10/15/20: A modified [MEDICATION NAME] swallow (MBS) is an x-ray procedure used to examine problems with swallowing. Liquid [MEDICATION NAME] is a white, chalky solution that helps healthcare providers see the pictures more clearly. [MEDICATION NAME] is mixed with liquids and foods to show how they are swallowed. This helps healthcare providers decide what liquids or foods are safe for you to eat. MBS may also detect if food or liquids go into your airways. https://www.drugs.com/cg/modified-[MEDICATION NAME]-swallow-[MEDICATION NAME].html Observation on 10/09/20 at 11:35 AM of Resident #10 in the facility dining room revealed he was already seated eating his lunch. While speaking to Resident #10 it was noted he had a paper diet card on the table in front of his tray. The diet card had no rolls written on it. Resident #10 had a roll on his plate. At 11:41 am Resident #10 was observed to try to take a bite out of the roll but was unsuccessful and tossed the roll back on his plate. Observation on 10/13/20 at 11:37 AM of Resident #10 in the facility dining room revealed he was seated eating his lunch. Observation of his meal tray items were mechanical soft ground turkey with gravy, mashed potatoes, cooked zucchini, oatmeal with brown sugar and a dinner roll. A paper diet card on his tray revealed the following: No rolls or chips . During an interview on 10/13/20 at 11:44 AM, Resident #10 said he is served a roll with lunch and dinner frequently and that sometimes he will eat them and sometimes he will not, it just depends on what he is eating and if he is full or not. He said he hasn't choked on anything in a good while. In an interview on 10/13/20 at 11:51 AM, LVN A confirmed she had checked Resident #10's meal tray prior to him being served lunch. She said she did not recall any items that were on the tray that should not have been. When asked about the No rolls or chips note on his meal ticket, LVN A replied the kitchen told her it was okay because it is soft. LVN A said she was not sure as to the reason why there was a Note: No rolls or chips on Resident #10's meal ticket but knew he had to be monitored while he was eating to ensure he did not aspirate. In an interview on 10/13/20 at 12:10 PM the Dietician said Notes signify there is something specific from an order or from speech therapy pertaining to the resident's diet. She said if it was just a preference it would be listed in the dislikes or likes column below in the meal ticket. She said she was not familiar with his diet and orders and would have to clarify why the note said no rolls or chips. In an interview on 10/13/20 at 5:30 PM, the DON said she was not familiar with Resident #10's diet. The DON at this time reviewed Resident #10's chart and confirmed he was on a mechanical soft diet and he was not supposed to receive dinner rolls and chips. The DON said the nurses should check the meal ticket against the meal tray prior to serving to ensure the correct menu options are being served, especially remarks that are in the notes. The DON said the roll should not have been offered to Resident #10. B) Review of Resident #11's electronic Face Sheet, accessed on 10/14/20, revealed she was [AGE] years old. She was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's quarterly Minimum Data Set, dated dated [DATE], revealed she had a Brief Interview for Mental Status score of 13, which indicated his cognitive function was moderately impaired. Documentation also revealed she only required setup help with eating and received a therapeutic diet. Review of Resident #11's care plan, last reviewed on 09/09/20, revealed the following: Need: (Resident #11) is currently on a carb-controlled diet, regular texture. Significant weight gain of 20% in 180 days .Approaches: Provide meals and snacks according to (Resident#11's) current diet order. Review of Resident #11's electronic physician's orders [REDACTED]. Consistent Carbohydrate diet Regular texture, Regular/Thin Consistency. Observation on 10/13/20 at 1:00 PM, revealed Resident #11 was served her meal tray in her room. She received a full cup of peach cobbler on her meal tray. Her paper meal ticket read Consistent Carb diet. Observation on 10/13/20 at 1:30 PM, revealed Resident #11 to have consumed 100% of her dessert. Record review on 10/13/20 at 12:30 PM of the Lunch, Tuesday Week 4 sheet for portion sizes for the lunch meal served on 10/13/20 revealed the following: CCHO (Consistent Carbohydrate) Blackberry Cobbler ¼ cup (spoodle-2 oz) . In an interview on 10/13/20 at 1:05 PM, the Dietary Chef said the blackberry cobbler was substituted for peach cobbler due to the blackberry cobbler being on back order. The dietary manager said the consistent carb portion for the peach cobbler was the same portion size as the blackberry cobbler on the spread sheet. C) Review of Resident #12's electronic Face Sheet, accessed on 10/14/20, revealed he was [AGE] years old. He was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., and [MEDICAL CONDITION]. Review of Resident #12's quarterly Minimum Data Set, dated dated [DATE], revealed his cognitive function was moderately impaired - decisions poor; cues/supervision required. Documentation also revealed he required one person to assist him with eating and he received a therapeutic diet. Review of Resident #12's care plan, last reviewed on 09/01/20, revealed the following: Need: Nutritional Status-(Resident #12) needs a therapeutic diet. Non compliant per nursing. Obesity BMI. Elevated HgbA1c 9.8 .Goal: Compliance to therapeutic diet .Approaches: Provide Consistent CHO (carbohydrate), Regular Texture/Consistency as ordered by MD. Review of Resident #12's electronic physician's orders [REDACTED]. Consistent Carbohydrate diet Regular texture, Regular/Thin Consistency. Record review of Resident #12's most recent laboratory result of his Hemoglobin A1C, revealed a result of: HGBA1C% 9.8 H (high) Ref Range 4.5-5.7, EAG (estimated average glucose) 235 mg/dl (milligrams per deciliter). According to cdc.gov, accessed on 10/15/20, The A1C test-also known as the hemoglobin A1C or HbA1c test-is a simple blood test that measures your average blood sugar levels over the past 3 months. It's one of the commonly used tests to diagnose prediabetes and diabetes, and is also the main test to help you and your health care team manage your diabetes https://www.cdc.gov/diabetes/managing/managing-blood-sugar/a1c.html. Observation on 10/13/20 at 12:33 revealed Resident #12 was served his meal tray and was served a full cup of peach cobbler. The paper meal ticket said Consistent Carb diet. Observation on 10/13/20 at 1:28 PM, revealed Resident #12 had consumed 100% of his dessert. In an interview on 10/13/20 at 12:10 PM, the Dietician said the facility served a liberal diet experience for the residents and all residents can eat from the same menu, however a resident that had an order for [REDACTED]. She said the spread sheet was in the kitchen and staff would reference when serving meals. The dietary staff also would conduct a Showtime meeting prior to serving each meal and go over any special portion sizes or information relevant to the meal being served. In an interview on 10/13/20 at 12:57 PM, Dietary Aide A said Consistent Carb diets usually do not get bread. Dietary Aide A said the staff did conduct a Showtime meeting this morning but did not go over portion sizes of the consistent carb diets. In an interview on 10/13/20 at 1:03 PM, LVN B said she had checked trays during the second round of lunch and she looked for texture, if the food items were appropriate and if it was the correct meal choice the resident had requested. She said the Consistent Carb was a diet for the diabetic residents. She said typically meant no bread. In an interview on 10/13/20 at 1:05 PM, the Dietary Chef said she was over the kitchen staff currently due to the dietary manager being out on leave. She said during the time meals are served, she oversees the plating of the food and observes the portions being served. She said she makes sure it is the right diet, texture and portion size. She said the consistent carb sometimes will have a different portion size and there is a sheet called a spread and it will identify what portion size the consistent carb diet should receive. She said the plastic cups the peach cobbler were served in were about 5-6-ounce cups and the consistent carb diets should have received a little under half of a cup of peach cobbler in them. She agreed Resident #11 and Resident #12 were served a full cup of peach cobbler at lunch and they should have just received a little less than half of a cup. In an interview on 10/13/20 at 1:30 PM, the Kitchen Manager said she did conduct a Showtime meeting today. She said the team talked about what the menu was for the day. She said the regular diets receive a full-size portion and the consistent carb, which usually were diabetic residents, received smaller portions of dessert depending on what was being served. She said today it should have been about half of what a regular diet would have received. In an interview on 10/13/20 at 4:45 PM, the Dietician said the correct portion size for the peach cobbler should have been 2 ounces, which would have been about one quarter of the plastic cup that was used. She verified the plastic cup used at lunch held six ounces. She was shown a picture from Resident #11's lunch tray and agreed it was greater than a quarter of a cup. She said depending on the overall intake the resident had would depend on the effects the larger dessert portion would have on a resident. In an interview on 10/13/20 at 5:30 PM, the DON said the consistent carb diet is for diabetic residents. She said her expectation would be that dietary and nursing should monitor and ensure residents are receiving the correct diets and portion sizes. She said if diabetic residents continually receive food items that have excessive carbohydrates, it could cause their blood sugars to be elevated, which could cause them to require additional medications to control the residents blood sugar. The DON said checking meal trays should be within their Realm and the nurses should be paying attention to breads and large desserts for a resident on a consistent carb diet. She said if nurses saw a full cup of dessert, it should have been questioned to dietary. In an interview on 10/13/20 at 6:45 PM, the Administrator said the facility offered a very liberal dining plan for their residents but did confirm there was a consistent carb diet offered to specific residents. Review of the facility's policy, Therapeutic Diets undated, revealed: 1. The resident's attending physician must prescribe a therapeutic diet.4. A tray identification system is established to ensure that each resident receives his or her diet as ordered .6. Mechanically altered diets will be considered therapeutic diets.

Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision to prevent accidents for two of four residents (Resident #68 and Resident #55) reviewed for accidents, hazards, and supervision. RA A failed to ensure Resident #68's AFO (ankle foot orthosis) was properly placed prior to ambulation. Resident #68 sustained a fractured ankle. This failure could place resident at risk for falls and injuries. Findings include: Review of Resident #68's facesheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #68's most recent MDS, 14- day, dated 9/26/2019 reflected in section G titled functional status, reflected resident required extensive assist of one staff member for locomotion on the unit. Review of section G0300 titled Balance reflected during transitions and walking the resident was not stable unless with staff assistance when walking and turning around. Review of Resident #68's care plan dated 9/22/2019, prior to the fall on 9/28/2019, did not reflect a care plan for the AFO device. Review of Resident #68's Incident and Accident report dated 9/28/2019 reflected staff alerted the nurse that Resident #68 was on the floor in the hallway. Upon initial assessment the resident was in a sitting position. Observation of the AFO, to the right lower extremity, revealed the Velcro straps were loose. Report reflected there was swelling noted to Resident #68's right ankle. The on-call Nurse Practitioner ordered a STAT ankle x-ray 2-view. Resident #68 was sitting in recliner with her foot elevated after incident. Review of the report reflected RA A stated she was walking the resident and her foot became tangled. Review of ankle x-ray dated 9/28/2019 reflected a fracture involving the distal tibia and fibula with no displacement. Conclusion revelated an acute ankle fracture. In an interview on 10/14/2019 at 9:55 a.m. Resident #68 stated one day she was walking when someone else was following her with a wheelchair and somehow, they got tangled up and she had a fall to the ground. In an interview on 10/15/2019 at 12:00 p.m., RA A stated on the day Resident #68 had the fall she was doing well she had walked to the other end of the hallway and was going to take another lap. RA A stated as the resident was turning she (RA A) was turning the wheelchair and then it appeared that Resident #68's legs twisted and then she went down to the floor. RA A stated when Resident #68 was on the ground another CNA went to go get the nurse and she looked at her limb because it looked weird and she lifted the resident's pant leg and the AFO was loose. RA A stated Resident #68's AFO went down the front of her leg and curved around the back and the strap was not secured correctly. The AFO was supposed to run down the back of her leg and the straps should have been secured. RA A stated Resident #68 was doing stretches prior and she did not notice the AFO was loose. RA A stated she asked the resident who placed the AFO on her and the resident stated that she put it on by herself, and the aides were not placing it on her. RA A stated she did not ensure the AFO was properly placed prior to Resident #68 ambulating. In an interview on 10/16/2019 at 10:51 a.m., DON stated she spoke with RA A and she had explained they did ROM exercises prior to ambulation and did not notice the AFO was not placed appropriately. DON stated staff should have checked to ensure the resident's AFO devise was appropriately secured. DON stated Resident #68's AFO should have been in her care plan at the time. However, it will not be in the care plan due to resident had a cast placed on that ankle. Review of the facility's policy titled Fall Management, dated 3/29/2019, reflected the facility would identify each patient/resident who was at risk for falls and would plan care and implement interventions to manage falls. Review of procedures reflected the facility would provide assistive devices based on individual residents need to facilitate mobility and prevent falls.

Based on observation, interview, and record review the facility failed to ensure residents were free from neglect for one (1) of seven (7) residents reviewed for neglect. (Resident #2) The facility failed to transfer Resident #2 as care planned with a two (2) person Hoyer lift transfer to prevent neglect. CNA [NAME] did not utilize a Hoyer as directed in resident's care plan while transferring Resident #2. Actual harm was determined to exist 4/01/2018 until 04/03/2018. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the investigation. This failure contributed to Resident #2 having a left distal femur in the metaphysical region who required a Hoyer lift during transfers at risk of discomfort, pain, injury, and neglect. Findings included: Review of Resident #2's Face Sheet reflected a [AGE] year old female admitted on [DATE] with diagnoses' including; [MEDICAL CONDITION], Pneumonitis due to inhalation of food and vomit, Pain, Impacted cerumen, Stage 2 pressure ulcer of sacral region. Generalized [MEDICAL CONDITION], cognitive communication deficit, muscle wasting and atrophy. [MEDICAL CONDITION], mild cognitive impairment and abnormalities of gait and mobility. Review of Resident #2's Significant change Minimum Data Set ((MDS) dated [DATE] reflected a Brief Interview of Mental Status (BIMS) score of three (3) indicating severe cognitive impairment. MDS reflects that Resident #2 was Hospice, was total dependence and a two person physical assist for transfers. MDS reflected falls was not scored. Review of Resident #2's care plan dated 03/28/2017 reflected resident was at risk for falls due to being a two person assist Hoyer lift transfer. Record review of the investigation report dated 04/02/2018 reflected Resident #2 started to complain of pain on 4/01/18, told a nurse that went to do an assessment. The DON was notified and a portable x-ray obtained that reflected an acute [MEDICAL CONDITION] femur though not clearly defined and recommend repeat x-rays. Initial interviews with nursing staff, Resident #2 and family could not explain the source to the injury. The event was reported to the administrator and then the administrator self-reported the serious injury of unknown origin to state agency on 4/01/18. The investigation report also reflected Resident #2 stated on 4/02/18 that CNA [NAME] transferred me without the Hoyer lift. It was then determined the resident sustained [REDACTED]. CNA [NAME] did not return to work after 04/01/2018 and therefore employment was terminated. In-services education done for Abuse, Neglect, Reporting and proper transfers. The Administrator then self-reported the serious injury to state agency again on 04/02/2018. Record review of Incident/Accident worksheet dated 04/02/2018 reflected the type of incident/accident was a fracture to the left Distal Femur. Physician and Family were notified at 5:30 PM. Record further reflected the resident started to complain of leg pain on the evening of 04/01/2018. X-ray report on 4/02/18 at 8:38am could not confirm fracture, suggested to repeat x-ray on the same day for more views. X-Ray report on 04/02/2018 reports distal [MEDICAL CONDITION] Femur. Investigation initiated self-report. Record review of the x-ray report dated 4/2/18 at 4:33pm reflected Finding: There is a [MEDICAL CONDITION] femur. Soft tissue swelling is seen. There is normal alignment. No erosions are demonstrated. Impression: [MEDICAL CONDITION] Femur, acute. In an interview on 04/12/2018 at 11:00 AM, DON stated on 04/01/2018 he was asked to call in a prescription for Tylenol #3 for Resident #2. He stated LVN B reported Resident #2 had started to complain about her leg hurting her. The nurse practitioner ordered Tylenol #3 and x-rays to Resident #2 leg. After phoning in the prescription at the request of LVN B he then spoke with (CNA [NAME] and CNA F) on the 300 hall caring for Resident #2. The DON stated CNA [NAME] and CNA F reported Resident #2 was fine all morning (04/01/2018). They did not report any unusual events or circumstances. On 04/01/2018 the Hospice nurse conducted initial interviews with Resident #2, nursing staff, and family that could not explain the source of the injury at that point. On 04/01/2018 the facility self- reported the injury of unknown source to the state agency. The DON further stated the next day on 04/02/2018 Resident #2 said CNA [NAME] transferred me without the Hoyer Lift. Resident #2 then stated she denied any fear or mistreatment by staff and also stated CNA [NAME] didn't do anything on purpose to hurt her. The DON stated he did believe Resident #2 in her statement of being transferred with the use of the Hoyer on 04/01/2018. When the DON re-questioned CNA F on 04/02/2018, CNA F stated she did helped CNA [NAME] get Resident #2 from the chair to the bed. CNA F further stated she did not help her CNA [NAME] transfer Resident #2 from the bed to the chair when the alleged incident occurred. The Administrator stated CNA F reported she was getting Resident #2's roommate up and witnessed CNA [NAME] go over to Resident #2 and performed a one person transfer however she did not report it when she was first asked of her on 04/01/2018. The DON then stated he attempted to contact CNA [NAME] to ask her to come in for questioning. CNA [NAME] was to come to the facility on [DATE] but did not come into the facility. He then stated CNA [NAME] has not been in the facility since 04/01/18. The DON continued to say that CNA [NAME] contacted him on 4/9/2018 at 2:52 p.m. and acknowledges a one person transfer was performed on Resident #2 prior to dinner on 4/1/18 and then a Hoyer transfer was performed after dinner on 4/1/18. CNA [NAME] further stated that she saw Resident #2 transferred by another staff person in the past and she did not look up resident's plan of care for transfers and was not aware of her being a Hoyer lift. CNA [NAME] expressed sincere remorse and said she didn't do anything to intentionally hurt Resident #2. She then stated she should have said something right away but I didn't know her leg was broken. The DON stated this injury is a stress/torsion related fracture. It most likely occurred when the CNA [NAME] was assisting the resident pivot transfer. He further stated that CNA [NAME] acknowledge the plan of care is available on Matrix Kiosk (computer system). Observation of Resident #2 on 4/12/18 at 11:30 am revealed resident was in bed resting and looked comfortable. Further observation revealed left leg was elevated in bed. Further observation revealed no additional issues observed. In an Interview on 4/12/18 at 11:31 am, when asked do staff members use Hoyer lifts during the transfer, Resident #2 stated no do not. When ask are you in any pain, Resident #2 pointed to her leg and said yes. When ask can you stated what occurred during the transfer early this month, Resident #2 could not recall the incident and had no further comments. In an interview at 04/12/2018 1:15 PM CNA G stated she worked the 300 hall and has worked on this hall for two years. Resident #2 is a two person Hoyer at all times. CNA G then stated that she stresses two person Hoyer to all of CNA's. She knows to look at the care plan on the kiosk to find out how to transfer a person. She further stated the resident profile in the kiosk will tell you if someone is a Hoyer, two person assist, a one person assist or a limited and the care plan approaches for each resident. CNA G stated all CNA's are trained for 3 days before they are allowed to work on the floor (with residents). CNA G also stated they (CNA's) had a Hoyer (Hands-on) in-service yesterday. There were no concerns with responses to the abuse and neglect protocol questions. Additionally, CNA G was aware of the facility policy to transfer all residents who cannot bear weight with a Hoyer lift. In an interview at 04/12/2018 1:30 PM CNA H stated Resident #2 is a two person Hoyer at all times at least since she started in November. Resident #2's fracture leg did not happen on her shift. CNA H stated she knows to look at the care plan on the kiosk to find out how to transfer a person. CNA H stated if they have doubts regarding a resident then they should go to the Kiosk. There were no concerns with responses to the abuse and neglect protocol questions. Additionally, CNA H was aware of the facility policy to transfer all residents who cannot bear weight with a Hoyer lift. In an interview 04/12/2018 at 3:40 PM, Nurse Practitioner stated she did not feel that the transfer was the only thing that caused the fracture for Resident #2. She also stated doing a pivot transfer can cause this type of injury. Resident #2 although not now but was taking steroids for a long time that can cause thinning of the bones. She further stated Resident #2 has [MEDICAL CONDITION] and [MEDICAL CONDITION] that causes thinning of bones. She expected the staff to follow the care plan. The Hoyer residents need to be transferred with a Hoyer. Additionally, Nurse Practitioner was aware of the facility policy to transfer all residents who cannot bear weight with a Hoyer lift. Record Review of the facility's policy and procedure titled Nursing Policies and Procedures revised date 07/1/2016, reflected the following including: Policy: A) The facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. B) Person-centered care means the facility focuses on the resident as the center of control, and supports each resident in making his or her own choices. Person-centered care includes making an effort to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident with regard to daily routines and preferred activities, and having an understanding of the resident's life before coming to reside in the nursing home. C) The facility will provide the resident and their legal representative with a summary of the baseline care plan that includes but is not limited to: the initial goals of the resident, a summary of the resident's medications and dietary instructions, any services and treatments to be administered by the facility and personnel acting on behalf of the facility any updated information based on the details of the comprehensive care plan, as necessary. The services provided or arranged by the facility, as outlined by the comprehensive care plan, will meet professional standards of quality. Record Review of the facility's Abuse Prohibition dated revision (MONTH) (YEAR) reflected the following including: 1. The facility's Leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment and misappropriation of a patient's/resident's property Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. It was determined these failures above caused actual harm past non-compliance to Resident #2 from 04/01/2018 until 4/03/18. The facility took the following actions to correct the non-compliance on 4/03/18. 1. On 04/03/2018 all nursing staff were in-serviced on abuse and neglect policies and procedures. 2. On 04/03/2018 all nursing staff were in-serviced on proper resident Hoyer transfers. 3. On 04/03/2018 all nursing staff received Hoyer lift/ transfer (Standards of practice) training. 4. CNA [NAME] did not return to work at the facility and employment then terminated. 5. CNA F was in-serviced on Abuse, Neglect, Reporting and proper transfers. Record Review of staff education/orientation standards of practice dated 04/03/2018 (In-Service for a minimum of twelve staff members) reflected a competency check list for Lifting /Moving the patient that reflected: 1-Lifting/Moving the Patient: 2-Pump the lift handle or press the UP ('1) button to raise the patient above the bed. The patient should be elevated high enough to clear the bed with their weight fully supported by the lift. When the patient is lifted from the bed (with the patient's head supported by the sling and/or an assistant), he/she will be raised to a sitting position. 3-Using the steering handle, move the lift away from the bed. 4-When moving the patient lift away from the bed, turn the patient so that he/she faces assistant operating the patient lift. 5-Press the down button (electric) or open the control valve (manual/hydraulic) lowering patient so that his feet rest on the base of the lift, straddling the mast. Close the control valve. 6-ull the patient lift away from the bed and then push it from behind with both hands firmly on the steering handle. Transferring to a Wheelchair: 1-When the sling is a few inches off the surface of the bed and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the swivel bar. If any attachments are NOT properly in place, lower the patient back onto the stationary surface and correct this problem. 2-Adjustments for safety and comfort should be made before moving the patient. The patient's arms should be inside the straps. Move the wheelchair into position. 3-Engage the rear wheel locks of the wheelchair to prevent movement of the chair. 4-Use the straps or handles on the side and the back of the sling to guide the patient's hips as far back as possible into the seat for proper positioning 5-Position the patient over the seat with their back against the back of the chair. 6-Begin to lower the patient either by opening the control valve or by pressing the DOWN (NJ') button. With one assistant behind the chair and the other operating the patient lift, the assistant behind the chair will pull back on the grab handle (on select models) or sides of the sling to seat the patient well into the back of the chair. This will maintain a good center of balance and prevent the chair from tipping forward. 7-Use the straps or handles on the side and the back of the sling to guide the patient's hips as far back as possible into the seat for proper positioning. Remove sling only if a divided leg sling was used. In an interview on 04/12/2018 at 4:05 PM when asked what was his expectations of CNA's knowing how to transfer residents DON said I expected them to know their residents before helping them, to check the care plans on the Kiosk (computer system) and follow procedures. His expectation are that staff inform him, look at the matrix kiosk for transferring residents, report abuse/neglect and report accident/ incidents. There were no concerns with responses to the abuse and neglect protocol questions. Additionally, DON was aware of the facility policy to transfer all residents who cannot bear weight with a Hoyer lift by using the Kiosk system and reading the care plan for each resident. In an interview on 04/12/2018 at 4:15 PM LVN A stated all the CNA's are to look at the Kiosk and look to see what type of transfers are to be done on the care plan. I expect them to get me if needed or when they need help. There were no concerns with responses to the abuse and neglect protocol questions. Additionally, LVN A was aware of the facility policy to transfer all residents who cannot bear weight with a Hoyer lift. In an interview on 04/12/2018 at 4:30 PM LVN B stated she reports anything she thinks is not right. She then stated she talks to the residents, watches her staff, and will go to the patient records on the Kiosk to check the care plan to know how to transfer someone. She also stated she will also discuss with therapy. She then stated she expected staff to check the Kiosk and perform transfers to the check list. There were no concerns with responses to the abuse and neglect protocol questions. Additionally, LVN B was aware of the facility policy to transfer all residents who cannot bear weight with a Hoyer lift. In an interview 04/12/2018 at 4:45 PM LVN C stated she expected staff to follow procedures and look at the Kiosk if not familiar with the person. There were no concerns with responses to the abuse and neglect protocol questions. Additionally, LVN C was aware of the facility policy to transfer all residents who cannot bear weight with a Hoyer lift. In an interview on 04/12/2018 at 5:05 PM when asked what his expectations of CNA's knowing how to transfer residents the Administrator said I expect them to follow the care plan and procedures. They should look at the Kiosk to know the resident. There were no concerns with responses to the abuse and neglect protocol questions. Additionally, the Administrator was aware of the facility policy to transfer all residents who cannot bear weight with a Hoyer lift. This investigator interviewed six residents on 04/12/2018 who required assistance with transfers (Resident #1, Resident #2, Resident #3, Resident #5, Resident #6 and number #7). Five residents stated they have never been injured or hurt from a transfer. This investigator interviewed four CNAs, three LVNs, two RNs and the Administrator on 04/12/2018 and all were knowledgeable of abuse/neglect policies/procedures, proper resident transfer techniques and of reviewing residents' care plans prior to performing transfers on residents with whom they are unfamiliar. Additionally, all staff were aware of the facility policy to transfer all residents who cannot bear weight with a Hoyer lift. This investigator observed one staff member (administrator) transferred by a Hoyer lift on 04/12/2018 by two CNA's. The transfer was performed correctly and without injury. The facility provided a list that reflected Resident #2 was identified for being a Hoyer lift transfer.

Based on observation, interview, and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for one (1) of seven (7) residents reviewed for neglect. (Resident #2). The facility failed to transfer Resident #2 as care planned with a two (2) person Hoyer lift transfer to prevent neglect. CNA [NAME] did not utilize a Hoyer as directed in resident's care plan while transferring Resident #2. Actual harm was determined to exist 4/01/2018 until 04/03/2018. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the investigation. This failure contributed to Resident #2 having a left distal femur in the metaphysical region who required a Hoyer lift during transfers at risk of discomfort, pain, injury, and neglect. Findings included: Review of Resident #2's Face Sheet reflected a [AGE] year old female admitted on [DATE] with diagnoses' including; [MEDICAL CONDITION], Pneumonitis due to inhalation of food and vomit, Pain, Impacted cerumen, Stage 2 pressure ulcer of sacral region. Generalized [MEDICAL CONDITION], cognitive communication deficit, muscle wasting and atrophy. [MEDICAL CONDITION], mild cognitive impairment and abnormalities of gait and mobility. Review of Resident #2's Significant change Minimum Data Set ((MDS) dated [DATE] reflected a Brief Interview of Mental Status (BIMS) score of three (3) indicating severe cognitive impairment. MDS reflects that Resident #2 was Hospice, was total dependence and a two person physical assist for transfers. MDS reflected falls was not scored. Review of Resident #2's care plan dated 03/28/2017 reflected resident was at risk for falls due to being a two person assist Hoyer lift transfer. Record review of the investigation report dated 04/02/2018 reflected Resident #2 started to complain of pain on 4/01/18, told a nurse that went to do an assessment. The DON was notified and a portable x-ray obtained that reflected an acute [MEDICAL CONDITION] femur though not clearly defined and recommend repeat x-rays. Initial interviews with nursing staff, Resident #2 and family could not explain the source to the injury. The event was reported to the administrator and then the administrator self-reported the serious injury of unknown origin to state agency on 4/01/18. The investigation report also reflected Resident #2 stated on 4/02/18 that CNA [NAME] transferred me without the Hoyer lift. It was then determined the resident sustained [REDACTED]. CNA [NAME] did not return to work after 04/01/2018 and therefore employment was terminated. In-services education done for Abuse, Neglect, Reporting and proper transfers. The Administrator then self-reported the serious injury to state agency again on 04/02/2018. Record review of Incident/Accident worksheet dated 04/02/2018 reflected the type of incident/accident was a fracture to the left Distal Femur. Physician and Family were notified at 5:30 PM. Record further reflected the resident started to complain of leg pain on the evening of 04/01/2018. X-ray report on 4/02/18 at 8:38am could not confirm fracture, suggested to repeat x-ray on the same day for more views. X-Ray report on 04/02/2018 reports distal [MEDICAL CONDITION] Femur. Investigation initiated self-report. Record review of the x-ray report dated 4/2/18 at 4:33pm reflected Finding: There is a [MEDICAL CONDITION] femur. Soft tissue swelling is seen. There is normal alignment. No erosions are demonstrated. Impression: [MEDICAL CONDITION] Femur, acute. In an interview on 04/12/2018 at 11:00 AM, DON stated on 04/01/2018 he was asked to call in a prescription for Tylenol #3 for Resident #2. He stated LVN B reported Resident #2 had started to complain about her leg hurting her. The nurse practitioner ordered Tylenol #3 and x-rays to Resident #2 leg. After phoning in the prescription at the request of LVN B he then spoke with (CNA [NAME] and CNA F) on the 300 hall caring for Resident #2. The DON stated CNA [NAME] and CNA F reported Resident #2 was fine all morning (04/01/2018). They did not report any unusual events or circumstances. On 04/01/2018 the Hospice nurse conducted initial interviews with Resident #2, nursing staff, and family that could not explain the source of the injury at that point. On 04/01/2018 the facility self- reported the injury of unknown source to the state agency. The DON further stated the next day on 04/02/2018 Resident #2 said CNA [NAME] transferred me without the Hoyer Lift. Resident #2 then stated she denied any fear or mistreatment by staff and also stated CNA [NAME] didn't do anything on purpose to hurt her. The DON stated he did believe Resident #2 in her statement of being transferred with the use of the Hoyer on 04/01/2018. When the DON re-questioned CNA F on 04/02/2018, CNA F stated she did helped CNA [NAME] get Resident #2 from the chair to the bed. CNA F further stated she did not help her CNA [NAME] transfer Resident #2 from the bed to the chair when the alleged incident occurred. The Administrator stated CNA F reported she was getting Resident #2's roommate up and witnessed CNA [NAME] go over to Resident #2 and performed a one person transfer however she did not report it when she was first asked of her on 04/01/2018. The DON then stated he attempted to contact CNA [NAME] to ask her to come in for questioning. CNA [NAME] was to come to the facility on [DATE] but did not come into the facility. He then stated CNA [NAME] has not been in the facility since 04/01/18. The DON continued to say that CNA [NAME] contacted him on 4/9/2018 at 2:52 p.m. and acknowledges a one person transfer was performed on Resident #2 prior to dinner on 4/1/18 and then a Hoyer transfer was performed after dinner on 4/1/18. CNA [NAME] further stated that she saw Resident #2 transferred by another staff person in the past and she did not look up resident's plan of care for transfers and was not aware of her being a Hoyer lift. CNA [NAME] expressed sincere remorse and said she didn't do anything to intentionally hurt Resident #2. She then stated she should have said something right away but I didn't know her leg was broken. The DON stated this injury is a stress/torsion related fracture. It most likely occurred when the CNA [NAME] was assisting the resident pivot transfer. He further stated that CNA [NAME] acknowledge the plan of care is available on Matrix Kiosk (computer system). Observation of Resident #2 on 4/12/18 at 11:30 am revealed resident was in bed resting and looked comfortable. Further observation revealed left leg was elevated in bed. Further observation revealed no additional issues observed. In an Interview on 4/12/18 at 11:31 am, when asked do staff members use Hoyer lifts during the transfer, Resident #2 stated no do not. When ask are you in any pain, Resident #2 pointed to her leg and said yes. When ask can you stated what occurred during the transfer early this month, Resident #2 could not recall the incident and had no further comments. In an interview at 04/12/2018 1:15 PM CNA G stated she worked the 300 hall and has worked on this hall for two years. Resident #2 is a two person Hoyer at all times. CNA G then stated that she stresses two person Hoyer to all of CNA's. She knows to look at the care plan on the kiosk to find out how to transfer a person. She further stated the resident profile in the kiosk will tell you if someone is a Hoyer, two person assist, a one person assist or a limited and the care plan approaches for each resident. CNA G stated all CNA's are trained for 3 days before they are allowed to work on the floor (with residents). CNA G also stated they (CNA's) had a Hoyer (Hands-on) in-service yesterday. There were no concerns with responses to the abuse and neglect protocol questions. Additionally, CNA G was aware of the facility policy to transfer all residents who cannot bear weight with a Hoyer lift. In an interview at 04/12/2018 1:30 PM CNA H stated Resident #2 is a two person Hoyer at all times at least since she started in November. Resident #2's fracture leg did not happen on her shift. CNA H stated she knows to look at the care plan on the kiosk to find out how to transfer a person. CNA H stated if they have doubts regarding a resident then they should go to the Kiosk. There were no concerns with responses to the abuse and neglect protocol questions. Additionally, CNA H was aware of the facility policy to transfer all residents who cannot bear weight with a Hoyer lift. In an interview 04/12/2018 at 3:40 PM, Nurse Practitioner stated she did not feel that the transfer was the only thing that caused the fracture for Resident #2. She also stated doing a pivot transfer can cause this type of injury. Resident #2 although not now but was taking steroids for a long time that can cause thinning of the bones. She further stated Resident #2 has [MEDICAL CONDITION] and [MEDICAL CONDITION] that causes thinning of bones. She expected the staff to follow the care plan. The Hoyer residents need to be transferred with a Hoyer. Additionally, Nurse Practitioner was aware of the facility policy to transfer all residents who cannot bear weight with a Hoyer lift. Record Review of the facility's policy and procedure titled Nursing Policies and Procedures revised date 07/1/2016, reflected the following including: Policy: A) The facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. B) Person-centered care means the facility focuses on the resident as the center of control, and supports each resident in making his or her own choices. Person-centered care includes making an effort to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident with regard to daily routines and preferred activities, and having an understanding of the resident's life before coming to reside in the nursing home. C) The facility will provide the resident and their legal representative with a summary of the baseline care plan that includes but is not limited to: the initial goals of the resident, a summary of the resident's medications and dietary instructions, any services and treatments to be administered by the facility and personnel acting on behalf of the facility any updated information based on the details of the comprehensive care plan, as necessary. The services provided or arranged by the facility, as outlined by the comprehensive care plan, will meet professional standards of quality. It was determined these failures above caused actual harm past non-compliance to Resident #2 from 04/01/2018 until 4/03/18. The facility took the following actions to correct the non-compliance on 4/03/18. 1. On 04/03/2018 all nursing staff were in-serviced on abuse and neglect policies and procedures. 2. On 04/03/2018 all nursing staff were in-serviced on proper resident Hoyer transfers. 3. On 04/03/2018 all nursing staff received Hoyer lift/ transfer (Standards of practice) training. 4. CNA [NAME] did not return to work at the facility and employment then terminated. 5. CNA F was in-serviced on Abuse, Neglect, Reporting and proper transfers. Record Review of staff education/orientation standards of practice dated 04/03/2018 (In-Service for a minimum of twelve staff members) reflected a competency check list for Lifting /Moving the patient that reflected: 1-Lifting/Moving the Patient: 2-Pump the lift handle or press the UP ('1) button to raise the patient above the bed. The patient should be elevated high enough to clear the bed with their weight fully supported by the lift. When the patient is lifted from the bed (with the patient's head supported by the sling and/or an assistant), he/she will be raised to a sitting position. 3-Using the steering handle, move the lift away from the bed. 4-When moving the patient lift away from the bed, turn the patient so that he/she faces assistant operating the patient lift. 5-Press the down button (electric) or open the control valve (manual/hydraulic) lowering patient so that his feet rest on the base of the lift, straddling the mast. Close the control valve. 6-ull the patient lift away from the bed and then push it from behind with both hands firmly on the steering handle. Transferring to a Wheelchair: 1-When the sling is a few inches off the surface of the bed and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the swivel bar. If any attachments are NOT properly in place, lower the patient back onto the stationary surface and correct this problem. 2-Adjustments for safety and comfort should be made before moving the patient. The patient's arms should be inside the straps. Move the wheelchair into position. 3-Engage the rear wheel locks of the wheelchair to prevent movement of the chair. 4-Use the straps or handles on the side and the back of the sling to guide the patient's hips as far back as possible into the seat for proper positioning 5-Position the patient over the seat with their back against the back of the chair. 6-Begin to lower the patient either by opening the control valve or by pressing the DOWN (NJ') button. With one assistant behind the chair and the other operating the patient lift, the assistant behind the chair will pull back on the grab handle (on select models) or sides of the sling to seat the patient well into the back of the chair. This will maintain a good center of balance and prevent the chair from tipping forward. 7-Use the straps or handles on the side and the back of the sling to guide the patient's hips as far back as possible into the seat for proper positioning. Remove sling only if a divided leg sling was used. In an interview on 04/12/2018 at 4:05 PM when asked what was his expectations of CNA's knowing how to transfer residents DON said I expected them to know their residents before helping them, to check the care plans on the Kiosk (computer system) and follow procedures. His expectation are that staff inform him, look at the matrix kiosk for transferring residents, report abuse/neglect and report accident/ incidents. There were no concerns with responses to the abuse and neglect protocol questions. Additionally, DON was aware of the facility policy to transfer all residents who cannot bear weight with a Hoyer lift by using the Kiosk system and reading the care plan for each resident. In an interview on 04/12/2018 at 4:15 PM LVN A stated all the CNA's are to look at the Kiosk and look to see what type of transfers are to be done on the care plan. I expect them to get me if needed or when they need help. There were no concerns with responses to the abuse and neglect protocol questions. Additionally, LVN A was aware of the facility policy to transfer all residents who cannot bear weight with a Hoyer lift. In an interview on 04/12/2018 at 4:30 PM LVN B stated she reports anything she thinks is not right. She then stated she talks to the residents, watches her staff, and will go to the patient records on the Kiosk to check the care plan to know how to transfer someone. She also stated she will also discuss with therapy. She then stated she expected staff to check the Kiosk and perform transfers to the check list. There were no concerns with responses to the abuse and neglect protocol questions. Additionally, LVN B was aware of the facility policy to transfer all residents who cannot bear weight with a Hoyer lift. In an interview 04/12/2018 at 4:45 PM LVN C stated she expected staff to follow procedures and look at the Kiosk if not familiar with the person. There were no concerns with responses to the abuse and neglect protocol questions. Additionally, LVN C was aware of the facility policy to transfer all residents who cannot bear weight with a Hoyer lift. In an interview on 04/12/2018 at 5:05 PM when asked what his expectations of CNA's knowing how to transfer residents the Administrator said I expect them to follow the care plan and procedures. They should look at the Kiosk to know the resident. There were no concerns with responses to the abuse and neglect protocol questions. Additionally, the Administrator was aware of the facility policy to transfer all residents who cannot bear weight with a Hoyer lift. This investigator interviewed six residents on 04/12/2018 who required assistance with transfers (Resident #1, Resident #2, Resident #3, Resident #5, Resident #6 and number #7). Five residents stated they have never been injured or hurt from a transfer. This investigator interviewed four CNAs, three LVNs, two RNs and the Administrator on 04/12/2018 and all were knowledgeable of abuse/neglect policies/procedures, proper resident transfer techniques and of reviewing residents' care plans prior to performing transfers on residents with whom they are unfamiliar. Additionally, all staff were aware of the facility policy to transfer all residents who cannot bear weight with a Hoyer lift. This investigator observed one staff member (administrator) transferred by a Hoyer lift on 04/12/2018 by two CNA's. The transfer was performed correctly and without injury. The facility provided a list that reflected Resident #2 was identified for being a Hoyer lift transfer.

Based on observation, interview, and record review the facility failed to promptly consult with the physician when a resident had a significant change in condition and a decline in health status for two of eleven residents reviewed for changes of condition (Resident #1 and #2). A. Resident #1 was a Full Code. The facility failed to monitor Resident #1 for a continued change of condition on [DATE], as evidenced by altered mental status, abnormal vital signs and abnormal lab work ordered as STAT on [DATE]. The facility failed to recheck, monitor and notify the physician or NP of Resident #1 ' s abnormal vital signs and abnormal STAT lab work obtained on [DATE]. LVN C failed to provide an accurate description of Resident #1 ' s change of condition, including his altered mental status, abnormal vital signs and abnormal STAT lab work, when she called EMS on [DATE] requesting Resident #1 ' s transfer to the hospital. The facility failed to initiate CPR on Resident #1 when he was found to have no pulse and no respirations. Resident #1 expired at the facility on [DATE]. B. The facility failed to notify Resident #2's physician or NP of a fall with injury on [DATE]. Resident #2 did not receive care and treatment until [DATE], when x-rays revealed right hip and upper leg fracture. Resident #2 was sent to the hospital, returned to the facility with an inoperable [MEDICAL CONDITION] on [DATE]. Resident #2 was placed on hospice on [DATE], and expired on [DATE]. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at an actual harm with a scope identified as pattern. This deficient practice contributed to a delay in Resident #1 and Resident #2 receiving needed medical treatment. This failure could place 36 residents identified as full code at risk for not receiving timely life-sustaining measures, and 84 residents who required assistance from staff for transfers at risk for pain and discomfort, injury or death. Findings include: A. Review of the Face Sheet dated [DATE] indicated Resident #1 was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was identified as a Full Code. Review of the Daily Skilled Nurse's Note for the day shift (6:00 a.m. to 2:00 p.m.) on [DATE] at 7:15 a.m. revealed Resident #1 had a temperature of 100.0 degrees. He received Tylenol 650 mg. At 8:00 a.m., Resident #1 was in bed with his eyes closed without any signs or symptoms of distress. At 8:15 a.m., Resident #1 was given oxygen at 3L per nasal cannula due to oxygen saturation of 90%. His oxygen saturation increased to 94% on 3L of oxygen. Additional vital signs for Resident #1 for the day shift revealed blood pressure-,[DATE]; pulse-92; and respirations-22. Nurse's Notes for the evening shift (2:00 p.m. to 10:00 p.m.) on [DATE] at 2:00 p.m. revealed Resident #1 was in bed with his eyes closed. He had an IV flowing. Resident #1 had no distress. He was uneasy to arouse. Resident #1's vital signs for the evening shift were temperature-101.0 degrees F; blood pressure-,[DATE]; pulse-98; and respirations-22. Review of the Nurse's Notes dated [DATE] at 1:30 p.m. revealed CNA reported Resident #1's Foley catheter had zero output. The DON assessed and removed Resident #1's 12F (French, indicating size of catheter) Foley catheter. Nurse's Notes documented the DON replaced Resident #1's Foley catheter with a 16F catheter, which then revealed frothy urine, dark brown in color. The DON obtained orders for STAT labs. A peripheral IV was inserted to Resident #1's right forearm, and he was given one liter of ½ Normal Saline. Nurse's Notes documented the nurse attempted to reach Resident #1's family at 2:00 p.m. with no option to leave a voicemail. Review of the Daily Skilled Nurse's Note dated [DATE], revealed nurse reassessed Resident #1 at 5:45 p.m., and he was still in deep sleep appearing incoherent. Further documentation continued, SN notified DON at 1800 (6:00 p.m.) and SW about code status and his condition. Family notified at 1820 (6:20 p.m.) in regards to patients 'change' in condition. Family requested resident to be sent to (hospital). EMS called. Once in room, resident was not breathing. CPR initiated by EMS. Resident pronounced dead at 1922 (7:22 p.m.). During an interview on [DATE] at 12:00 p.m., NP A stated she saw Resident #1 for his initial visit on [DATE]. NP A reviewed her Progress Note from [DATE], and stated Resident #1 could nod in response to questions and tried to speak, but was not easy to understand. She stated she observed Resident #1's urine in the Foley catheter drainage bag to be clear. NP A stated she found Resident #1 was a DNR in the hospital prior to his admission to the facility, so she wrote an order for [REDACTED].#1 his vital signs were within normal range when she saw him on [DATE]. NP A stated she was not notified of Resident #1's low blood pressure on the evening of [DATE] (blood pressure-,[DATE]), and considered this to be an abnormal blood pressure for Resident #1. NP A stated she expected the vital signs obtained on the evening shift on [DATE] (blood pressure of ,[DATE] and temperature of 101 degrees Fahrenheit) to be questioned. NP A stated she was not notified of any abnormal vital signs for Resident #1 on [DATE] or [DATE]. NP A stated she expected the nurse to be at Resident #1's bedside if he had a change of condition or altered mental status. During an interview on [DATE] at 3:45 p.m., the DON stated some time before shift change on [DATE] (before 2:00 p.m.), she was called to Resident #1's room by CNA S because there was no urine in Resident #1's Foley catheter drainage bag; urine was leaking out around the catheter insertion site. The DON stated Resident #1 was alert and talking at that time. The DON stated she changed Resident #1's Foley catheter because it was leaking and not going into the catheter drainage bag. The DON stated she then notified NP B because she was concerned Resident #1 was not drinking enough fluids and was possibly dehydrated. She stated NP B ordered STAT labs and IV fluids. She stated she gave report to the evening shift oncoming nurse, LVN C, around 2:00 p.m., at Resident #1's bedside, where she told LVN C about Resident #1's Foley catheter change and IV fluids. The DON stated between 2:00 p.m. to 2:15 p.m., Resident #1 was sleeping and did not have any irregular breathing. She stated at some point after she left the facility for the day (after 5:00 p.m.), LVN C left a message for her that Resident #1 did not look well. The DON stated when she returned LVN C's message, LVN C was with the SW questioning Resident #1's code status. The DON stated LVN C reported that Resident #1's hospital records prior to his admission to the facility indicated the family wanted a natural death. The DON stated she instructed LVN C to notify the family and ask them what they wanted to do. The DON stated the family said they wanted Resident #1 to be a full- code and sent to the hospital. She stated then LVN C called [DATE], but when paramedics arrived, Resident #1 had no pulse. The DON stated LVN C said she did not start CPR because up to that point, he was breathing and had a pulse. During an interview on [DATE] at 12:20 p.m., NP B stated she never saw Resident #1 physically; he was usually seen by NP A. NP B stated she shared duties with NP A. NP B stated the DON notified her on [DATE] that she was concerned Resident #1 could be dehydrated due to the dark color of his urine in his Foley catheter drainage bag. NP B stated she ordered STAT labs and ½ Normal Saline fluids to be given to Resident #1 through an IV. NP B stated she was never notified of Resident #1's low blood pressure (,[DATE]) or elevated temperature (101.0 degrees F) on [DATE], taken on the evening shift (2:00 p.m. to 10:00 p.m.). During an additional interview on [DATE] at 4:00 p.m., NP B stated she never received results of the STAT labs she ordered. NP B stated the next time she received an update on Resident #1 was to report that Resident #1 expired. Review of lab work dated [DATE] revealed Resident #1 had lab work obtained on [DATE] at 1:49 p.m. for Complete Metabolic Panel (CMP), Complete Blood Count (CBC) and Urinalysis (UA). The lab results for the CBC were printed on [DATE] at 2:44 p.m. Elevated labs included WBC 14.2 (normal range 4XXX,[DATE].8); RBC 3.91 (normal range 4XXX,[DATE].10); HGB 10.7 (normal range 14XXX,[DATE].0); and HCT 35.1 (normal range 42XXX,[DATE].0). There was no physician signature on the STAT labs. The lab results for the CMP were printed on [DATE] at 2:55 p.m. Elevated labs included BUN-77 (normal range ,[DATE] mg/dL); creatinine-1.97 (normal range 0XXX,[DATE].60 mg/dL); and glucose-214 (normal range ,[DATE] mg/dL). There was no physician signature on the STAT labs. The lab results for the UA was printed on [DATE] at 3:12 p.m. Elevated labs included dark brown urine (normal-yellow); appearance-turbid (normal-clear to hazy); and blood 3+ (normal-negative). There was no physician signature on the STAT labs. During an interview on [DATE] at 5:10 p.m., LVN C stated she came onto her shift on [DATE] at 2:15 p.m. She stated the DON gave her report on Resident #1 at his bedside, stating she started an IV for additional fluids due to him having dark brown urine. LVN C stated Resident #1 was sleeping at that time. She stated sometime between 3:30 p.m. to 4:00 p.m., she observed CNAs in training standing outside Resident #1's door, debating whether or not to obtain his vital signs. LVN C stated she instructed the CNA students to check vital signs on another resident because of Resident #1's IV. LVN C stated at that time, Resident #1 was in a deep sleep. She stated around 5:30 to 5:45 p.m., the MA (MA H) reported she was unable to wake Resident #1 up for his medications. LVN C stated she told MA H not to give Resident #1 any medications because he was pale and in a deep sleep. LVN C stated she was the nurse who performed Resident #1's admission paperwork, and he was initially able to hold a conversation. LVN C stated Resident #1 was asleep during her entire shift (2:00 p.m. to 10:00 p.m.). LVN C stated she had a conversation with CNA L outside Resident #1's room. CNA L stated, I hope he doesn't die. LVN C stated she observed a change in Resident #1 from 2:00 p.m. to 5:45 p.m. but denied calling the doctor or NP. She stated she attempted to reach the DON, and left a message because she was concerned about Resident #1's code status. LVN C stated she then called the ADON and reported to him Resident #1 was a full code. She stated the day nurse (LVN J) told her she attempted to get clarification from the family on Resident #1's code status but was never able to speak to the family. LVN C stated the ADON instructed her to notify the social worker and obtain clarification on Resident #1's code status. LVN C stated she and the social worker (SW G) called the family around 6:00 p.m. to clarify Resident #1's code status. She stated Resident #1's family was unaware of Resident #1's change in condition, and the family said they wanted Resident #1 sent to the hospital. LVN C stated she requested CNA D to get Resident #1 ready to go to the hospital, while she called EMS and printed out the paperwork. LVN C stated after EMS arrived, she heard EMS personnel cursing at facility staff, and she informed EMS personnel Resident #1 was breathing when she last saw him. She stated she then went to the nurses' station to call the family. I didn't have any evidence that he was going to pass. Review of the Witness Statement for LVN C obtained on [DATE] revealed, On [DATE], (LVN C) worked 2p-10p (2:00 p.m. to 10:00 p.m. shift) for (facility). As I enter my shift walking in, I was greeted by DON. When she told me she wanted to show me something on a patient. We enter room (Resident #1's room) on Hall (Resident #1's Hall). (DON) gave me, oncoming nurse, a bedside report on her just finishing an IV on (Resident #1) due to catheter problems and possible dehydration. (Resident #1) was observed resting. Exiting room and counted Narc (narcotic) count with Nurse (LVN J) from 6a-2p (6:00 a.m. to 2:00 p.m.) shift. When I was relieved, she gave me report on (Resident #1), stating patient had a decline. IV was started. Family had been notified all shift to check DNR status per MD orders and no call back. At 3:30 p.m., SN assessed patient. Patient resting and no change, appearing same lethargic, no change in urine color brown. At 4 p.m. (4:00 p.m.), a group of students entered room (Resident #1's room) to complete V/S (vital signs) standing outside doorway with SN (skilled nurse). I explain to students at this time this would not be a good candidate to complete V/S on d/t IV in arm. SN obtain V/S on patient during 1600 (4:00 p.m.) and 1700 (5:00 p.m.) round. V/S stable. IV patent flowing, no change. Patient resting appearing lethargic. At ,[DATE] (5:45 p.m. to 5:50 p.m.), Med Aide enter room to complete V/S for evening meds. Med Aide came to me SN on hall and asked if I think he should receive meds. We enter room doing another assess. Patient RR (respiratory rate) and pulse V/S present, just very lethargic, not responding to name. SN questioning CNA about resident (CNA L), and nurse agrees resident is not the same when we admitted on [DATE]. SN contacted DON to notify of wanting to send patient to ER d/t change in condition from how patient was at admission to now. No answer. SN then notified ADON. No answer from DON and SN wanting to send patient to ER. SN question patient ' s code status to see if patient could be sent out d/t chart stating 'Full Code' but hospital and MD order shown possible DNR. This was at 1805 (6:05 p.m.). ADON told me to 'notify social worker then would know more.' As I dialed # (number) social worker happened to be walking toward nurses' station. I explained to her I wanted to send a patient out to ER d/t change in condition from when I admitted patient. I needed information on code status. As we were speaking, DON call back and I explain everything to her. She said she would contact MD on call to let her know. We were going to send patient out and await on us to notify family. Both SN and social worker notify family in regards to code status and patient's change in condition. SN and social worker explained the two differences letting family know patient status Full Code in facility and DNR at hospital. To see if we could receive or send patient to ER, son wanted to contact brother to figure out what was going on. He stated 'They were here at 11:30 a.m. signing papers with (SW) and their father was fine, going on to say no one notified them until 1815 (6:15 p.m.) of change.' Son contacted brother immediately calling back stating 'it was okay to send patient to hospital.' Going on to say to send patient to (different hospital) and not (previous hospital) d/t DNR. They didn't know it was on file. SN, social worker and another SN present got verbal agreement. SN went back to hall, checking on patient. (Resident #1) was no change, lethargic, RR and pulse present. Unresponsive to name. SN gather aides telling aides to have patient ready. SN was also speaking with [DATE] while leaving patient. On cordless phone gathering paperwork and labs (recent). While ending call ,[DATE] minutes later, EMS and aides were seen entering room. SN could hear EMS cursing at staff. 'What the [***] is wrong with him? Where is the [***] ing nurse?' Both SN and social worker enter room. EMS was stating 'Get the [***] out.' SN ask one EMS worker 'What going on?' He then replied are you the nurse? Is he a Full Code status? SN standing at entrance of door with social worker explained his status, 'Full Code and reason for call' within that time frame CPR was started to be initiated by EMS, who placed resident on ground. Paperwork was exchange between EMS and nurse. SN contacted DON back letting her know what all had taken place. Explaining to her EMS did not want staff in room. The DON advise me to just stay out of room and notify family back of new changes. SW contacted family. Sons both arrived. SW, son and police officer stood outside room. I believe 7 something p.m. EMS came out handing a strip to SN of HR and MD who pronounced patient dead. DON, MD notified. (Funeral home) also notified. All documentation completed. During a clarification interview following review of LVN C's written witness statement on [DATE] at 1:05 p.m., LVN C stated from the time she started her shift on [DATE] (2:00 p.m. to 10:00 p.m.), Resident #1 was lethargic and unresponsive. LVN C stated she did not check Resident #1's vital signs, but checked his respirations and pulse I think. LVN C denied documenting any of Resident #1's vital signs or notifying the physician or NP. LVN C stated sometime during her shift, MA H told her she wanted to check Resident #1's vital signs to give him medications. LVN C stated she told MA H not to give Resident #1 any medications because he would not wake up. LVN C stated she called the DON and left a message. She then called the ADON because she wanted to verify Resident #1's code status before sending him to the ER. LVN C stated she and the SW called Resident #1's family, and the family wanted Resident #1 sent to a different hospital than where he was prior to his admission to the facility because he was a DNR at that hospital. LVN C stated she then called [DATE]. LVN C stated Resident #1's vital signs were stable. When surveyor asked if Resident #1's vital signs taken on the evening shift (temperature-101.0 degrees F; blood pressure-,[DATE]; pulse-98; and respirations-22) were stable compared to his previous vital signs, she stated, I guess not. During an interview on [DATE] at 3:00 p.m., the ADON stated he received a call from LVN C sometime after 5:00 p.m. on [DATE], who said Resident #1 was not looking good, and she was about the send him to the hospital. The ADON stated LVN C inquired about Resident #1's code status. He stated he instructed LVN C if the code status was not in the chart, to contact social services. He denied any further contact with LVN C or Resident #1 on [DATE]. During an interview on [DATE] at 11:15 a.m., MA H stated she went into Resident #1's room sometime between 2:30 p.m. and 3:30 p.m. on [DATE] to check his vital signs. MA H stated she was unable to check Resident #1's vital signs because he was asleep. She stated she called his name, but he did not respond. MA H stated she notified the nurse that Resident #1 was in a deep sleep and would not wake up. She stated she never attempted to give Resident #1 any medications. She stated LVN C instructed her to document on the back of Resident #1's MAR indicated [REDACTED]. MA H stated she did not know why LVN C said she wanted to give Resident #1 medication at 5:30 to 5:45 p.m. MA H stated she only attempted to obtain his vital signs around 3:00 p.m. Review of the admission orders [REDACTED]not alert/oriented. Review of Witness Statement for MA H on [DATE] revealed, I (MA H) first seen (Resident #1) around 2:30 or something to 3p, knocked and entered into his room. Called out couple of times to let (Resident #1) know I (MA H) was there to do B/P (blood pressure) on him. While in room when called out to resident, did touch resident. Never got a response, didn't wake, so left room. The nurse she was in hall. Notified nurse (LVN C) on duty didn't get B/P and resident was asleep seem to be sleeping good. Proceeding on to next room. Next time I seen resident EMS was here doing CPR on him. Couldn't believe the EMS was here. Didn't know anything or what was going on. It was quiet when left hall looked in room. Heard CNAs tell nurse EMTs were talking bad language to them. During an interview on [DATE] at 5:35 p.m., CNA E stated she started her shift on [DATE] at 2:00 p.m. CNA E stated she checked on Resident #1 periodically. She stated around the middle of her shift, she noted Resident #1's mouth open but his chest was moving. She stated her co-worked checked Resident #1's vital signs. CNA E stated around 5:30 p.m., she entered Resident #1's room with CNA D to change him. CNA E stated Resident #1's skin was warm. She stated she placed her hand on his chest and checked his pulse. CNA E stated Resident #1 did not have a pulse. She stated, We left him alone because he was gone. CNA E stated she told CNA D to get the nurse. Review of Witness Statement for CNA E dated [DATE] revealed, I started my shift at 2 p.m. The walk with morning shift had already been completed. I did my rounds right when morning shift had left. I checked on all my residents and made sure everyone was ok. When I got into (Resident #1's) room, I saw his mouth open but his chest was moving so he was breathing. I made sure he was comfortable and left the room to check on the other residents. By the time dinner had hit, we were asked to go in and make sure (Resident #1) was cleaned up because the nurse was sending him out to the hospital. When I walked in the room (Resident #1) had his mouth open still and was warm, but I didn't see him breathing. I put my hand on his chest and didn't feel a heartbeat so I checked his wrist. I still didn't feel anything. My partner (CNA D) went to go get the nurse and by the time my partner walked back down the hall EMS showed up and they snapped asking where's the nurse and why we weren't doing anything. We explained the nurse is on the way. EMS then was asking about his code status but we weren't sure. They then started CPR. They couldn't revive him. They left him in the floor and we were asked to pick him up put him back in bed and clean him up. During a clarification interview following review of CNA E's written witness statement on [DATE] at 1:55 p.m., CNA E stated she entered Resident #1's room with CNA D on [DATE] (between 5:00 p.m. and 6:00 p.m.) to get him ready to go to the hospital. CNA E stated she touched Resident #1's skin and observed it to be warm. She stated Resident #1 was not breathing and did not have a pulse. CNA E stated she told CNA D to get the nurse. CNA E stated when CNA D returned, the EMTs yelled at her stating, There's a potential dead body. CNA E stated she did not start CPR because she was not CPR certified and did not want to get in trouble. CNA E stated LVN C was at the nurses' station when EMS arrived, and it took LVN C a little while to come to Resident #1's room. When asked what she was supposed to do if she found a resident unresponsive, CNA E stated she was supposed to notify the nurse. During an interview on [DATE] at 5:05 p.m., CNA D stated on [DATE] around dinner time, she was serving dinner in the dining room. Her partner (CNA E) told her she needed to help get Resident #1 cleaned up because EMS was coming. CNA D stated when she entered Resident #1's room, she asked CNA E why they were cleaning him up because he was deceased . CNA D stated she was in shock and could not recall what exactly happened. CNA D was unable to state how long she was in Resident #1's room before EMS arrived, but added it was less than five minutes. CNA D stated CNA E touched his face and stated his skin was still warm. CNA D stated they did not press the call light to request assistance. CNA stated she was unable to recall if Resident #1 was breathing or had a pulse because she was in shock. CNA D stated when EMS arrived, they started going off on her. When asked if the nurse was present, CNA D stated, I'm pretty sure she came down because it was serious. Review of Witness Statement for CNA D dated [DATE] revealed, .While in the dining room I was addressed by (CNA E) to come and help her dress a resident because EMS was coming to get him. At that point, I informed the nurse currently in the dining room that I was going to assist her. When we arrived, (CNA E) enter, we had multiple lights on at that moment so I answer some lights to, then when I returned I noticed (Resident #1) mouth was open and his breathing was low. (CNA E) checked to see if he was breathing and he was. I then ran to get the nurse. Mind you I was in the dining room. I was unaware of his condition. All I was asked was to help her clean someone because EMS was coming. As I was exiting the room I was met by EMS. They began to yell at us, complained about his condition. They immediately began to take over and started CPR. I made to retrieve the nurse and informed her about what was going on. She informed us to not return back into the room until they left. During a clarification interview following review of CNA D's written witness statement on [DATE] at 2:10 p.m., CNA D stated she was in Resident #1's room, standing at the door. She stated CNA E entered Resident #1's room and placed her hand on his cheek and stated his skin was still warm. CNA D stated she was in shock and did not get close to the bed. All I knew was I was supposed the clean him up. CNA D stated she turned around and EMS was there. She stated EMS started CPR. CNA D stated LVN C was at the nurses' station on the phone. CNA D was unable to state whether Resident #1 was breathing or had a pulse because she was in shock. When asked specific questions regarding the incident, CNA D stated she was unsure what actually occurred because she was in shock. During an interview on [DATE] at 11:15 a.m., representative from EMS stated they received a call from the nursing facility on [DATE] regarding Resident #1, reporting the resident had a loss of consciousness and blood in his urine. He stated the call was dispatched as a routine transport because Resident #1 was breathing normally. EMS representative stated when they arrived, there were two staff members without identifiers on them (one wearing a red shirt and one wearing a blue shirt) standing at the foot of Resident #1's bed. EMS representative stated they asked if the two staff members could provide any details or information about Resident #1's transfer to the hospital. He stated both staff members looked at EMS staff very confused. EMS representative stated the staff member in the blue shirt said (in regards to Resident #1 ' s EMS transfer to the hospital), Umm, are you sure? I am pretty sure this patient is deceased . EMS representative stated he asked the staff member in the blue shirt if she could find someone who knew anything about Resident #1. EMS representative stated the staff member in the blue shirt said, Umm, are you serious right now? EMS representative stated the staff member in the blue shirt then walked away without further interest in what she just stated. He stated the staff member in the red shirt walked away and did not provide any information on Resident #1. EMS representative stated Resident #1 was apneic and pulseless when they arrived, so they moved him to the floor and performed CPR, without knowing anything in regards to his advance directives. He stated it took about ten minutes before another staff member wearing a navy blue shirt entered Resident #1's room with paperwork, and informed EMS staff Resident #1 was a full code. EMS representative stated this staff member was unaware of any care that occurred recently and said, I don't know. This is not my patient. He stated CPR continued for about 50 minutes before Resident #1 expired. Resident #1's family showed up during CPR. Review of Communications Event Report for dispatch notes dated [DATE] revealed EMS received initial [DATE] call at 6:32 p.m. EMS arrived at facility on [DATE] at 6:35 p.m. Event Notes Addendum documented Resident #1 was incoherent with blood in urine. Resident #1 expired on [DATE] at 7:22 p.m. at the facility. Review of Fire Department Dispatch notes dated [DATE] revealed Resident #1's skin was warm to touch, but he did not have a pulse and was not breathing. Narrative notes revealed, PT (Patient) (Resident #1) incoh (incoherent), blood in urine. Chief Complaint: Sick Person, He is breathing normally. Upon arrival, Medic and Fire crews grab stretcher and equipment and approach Pt's room, based off notes provided through EMD. As crew enters Pt's room, two Facility staff members exit the room at the same time. (Medic) crew asks if this is the correct room for the Pt that we were called for. The facility staff members look confused, and stated 'they don't know' and also stated 'this Pt is deceased .' Staff was unable to provide any information on the approx (approximate) down time of Pt, nor were good historians. Medic and Fire crew approach Pt, lying in his bed, finding Pt apneic, pulseless, and warm to touch. Medic and Fire crews transfer Pt to the floor and initiate CPR per protocol .CPR was in progress for a total time of 44 min (minutes), Pt was in asystole/PEA (Pulseless Electrical Activity) a total of approx. (approximately) 20 min (minutes) when Medic crew contacted Med Control .to confirm pronouncement of death. Med Control gave the ok to cease CPR and all medical efforts. CPR was stopped, rhythm strip printed, and TOD (time of death) at 19:22 (7:22 p.m.) . (There was no evidence the facility or LVN C provided an accurate description of Resident #1 ' s change of condition, including his altered mental status, abnormal vital signs and abnormal STAT lab work.) During an interview on [DATE] at 1:30 p.m. local Police Department Detective stated he reviewed the dispatch [DATE] call for Resident #1 on [DATE]. He stated it was odd that LVN C stated during questions asked by dispatch, It's not like he's dead or anything. B. Review of Resident #2 ' s face sheet revealed she was [AGE] years old, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review of Resident #2 ' s face sheet revealed she was readmitted to the facility on [DATE] with fracture of her right femur (upper leg) and hip. Review of Resident #2 ' s admission MDS dated [DATE], documented she was non-ambulatory, required extensive assistance of two people for transfers, and had limited range of motion to both upper and lower extremities on one side. Resident #2 used a wheelchair for mobility, wheeled by staff. Continued review of Resident #2 ' s admission MDS documented she reported occasional pain that was moderate and did not limit day-to-day activities, or make it hard for her to sleep. Resident #2 had no falls in the facility, no falls in the previous month prior to admitting to the facility, but did have a fall, without fracture, in the last two to six months prior to entering the facility. Resident #2 ' s admission MDS documented she did not have a condition or chronic disease that may result in a life expectancy of less than six months. Review of the facility ' s Incident/Accident Investigation Worksheet dated [DATE] documented Resident #2 was found on the floor in her room in front of her wheel chair at 8:10 p.m. The Worksheet documented no apparent injury. Documentation revealed Resident #2 ' s family was notified, but there was no documentation as to when Resident #2 ' s physician was notified of the fall. Review of the radiology report for Resident #2 dated [DATE], .abnormal angle is present in the lateral femoral neck related to right femoral head. Right thigh soft tissue swelling is present .finds are highly suggestive of right femoral neck fracture. Review of telephone orders for Resident #2 dated [DATE], send to ER for right femoral head and neck fracture in regards to fall last night. Resident #2 was readmitted on [DATE] on palliative care, and admitted to hospice on 2

Based on observation, interview and record review the facility failed to provide care and services in accordance with the comprehensive assessment to ensure two of eleven residents were reviewed for changes of condition (Residents #1 and #2). A. Resident #1 was a Full Code. The facility failed to monitor Resident #1 for a continued change of condition on [DATE], as evidenced by altered mental status, abnormal vital signs and abnormal lab work ordered as STAT on [DATE]. The facility failed to recheck, monitor and notify the physician or NP of Resident #1 ' s abnormal vital signs and abnormal STAT lab work obtained on [DATE]. LVN C failed to provide an accurate description of Resident #1 ' s change of condition, including his altered mental status, abnormal vital signs and abnormal STAT lab work, when she called EMS on [DATE] requesting Resident #1 ' s transfer to the hospital. The facility failed to initiate CPR on Resident #1 when he was found to have no pulse and no respirations. Resident #1 expired at the facility on [DATE]. B. The facility failed to provide a wedge cushion for Resident #2's wheelchair to prevent her from falling. Resident #2 fell from her wheelchair on [DATE], sustained an inoperable [MEDICAL CONDITION]. The facility failed to notify Resident #2's physician or NP of her fall with injury on [DATE]. Resident #2 did not receive care and treatment until [DATE], when x-rays revealed right hip and upper leg fracture. The facility failed to adequately assess for pain when Resident #2 was yelling, screaming and grimacing after the fall on [DATE], through the night shift, 10:00 p.m. to 6:00 a.m. Resident #2 was sent to the hospital, returned to the facility with an inoperable [MEDICAL CONDITION] on [DATE]. Resident #2 was placed on hospice on [DATE], and expired on [DATE]. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at an actual harm with a scope identified as pattern. This deficient practice could place 36 residents identified as full code at risk for not receiving timely life-sustaining measures, and 84 residents who required assistance from staff for transfers at risk for pain and discomfort, injury or death. The Findings Include: A. Review of the Face Sheet dated [DATE] indicated Resident #1 was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was identified as a Full Code. Review of the Admission Data Collection Tool dated [DATE] revealed Resident #1 was admitted to NF on [DATE] at 5:00 p.m. His vital signs on admission were temperature-97.9; pulse-82; respirations-20; and blood pressure ,[DATE]. Review of the undated Interim Plan of Care revealed Resident #1 was at risk for dehydration. Interventions included determining likes and dislikes and monitoring for signs and symptoms of dehydration. Resident #1 received a pureed diet with honey thickened liquids. Interventions included monitoring intake. The Interim Plan of Care was not dated and did not have a signature indicating who completed the document. Review of the Nurse's Notes for [DATE] through [DATE] revealed Resident #1 was alert and oriented and able to verbalize his needs. His vital signs were stable, within acceptable parameters: temperature with range of 97XXX,[DATE].8 degrees F; blood pressure with range of 97-,[DATE]-76; pulse with range of ,[DATE] beats per minute; and respirations with range of ,[DATE] breaths per minute. Resident #1 had a Foley catheter and was being treated for [REDACTED]. Resident #1 received honey-thickened liquids. Review of the Daily Skilled Nurse's Note for the day shift (6:00 a.m. to 2:00 p.m.) on [DATE] at 7:15 a.m. revealed Resident #1 had a temperature of 100.0 degrees. He received Tylenol 650 mg. At 8:00 a.m., Resident #1 was in bed with his eyes closed without any signs or symptoms of distress. At 8:15 a.m., Resident #1 was given oxygen at 3L per nasal cannula due to oxygen saturation of 90%. His oxygen saturation increased to 94% on 3L of oxygen. Additional vital signs for Resident #1 for the day shift revealed blood pressure-,[DATE]; pulse-92; and respirations-22. Nurse's Notes for the evening shift (2:00 p.m. to 10:00 p.m.) on [DATE] at 2:00 p.m. revealed Resident #1 was in bed with his eyes closed. He had an IV flowing. Resident #1 had no distress. He was uneasy to arouse. Resident #1's vital signs for the evening shift were temperature-101.0 degrees F; blood pressure-,[DATE]; pulse-98; and respirations-22. Review of the Nurse's Notes dated [DATE] at 1:30 p.m. revealed CNA reported Resident #1's Foley catheter had zero output. The DON assessed and removed Resident #1's 12F (French, indicating size of catheter) Foley catheter. Nurse's Notes documented the DON replaced Resident #1's Foley catheter with a 16F catheter, which then revealed frothy urine, dark brown in color. The DON obtained orders for STAT (immediate) labs. A peripheral IV was inserted to Resident #1's right forearm, and he was given one liter of ½ Normal Saline. Nurse's Notes documented the nurse attempted to reach Resident #1's family at 2:00 p.m. with no option to leave a voicemail. Review of the Daily Skilled Nurse's Note dated [DATE], revealed the nurse reassessed Resident #1 at 5:45 p.m., and he was still in deep sleep appearing incoherent. Further documentation continued, SN notified DON at 1800 (6:00 p.m.) and SW about code status and his condition. Family notified at 1820 (6:20 p.m.) in regards to patients 'change' in condition. Family requested resident to be sent to (hospital). EMS called. Once in room, resident was not breathing. CPR initiated by EMS. Resident pronounced dead at 1922 (7:22 p.m.). During an interview on [DATE] at 12:00 p.m., NP A stated she saw Resident #1 for his initial visit on [DATE]. NP A reviewed her Progress Note from [DATE], and stated Resident #1 could nod in response to questions and tried to speak, but was not easy to understand. She stated she observed Resident #1's urine in the Foley catheter drainage bag to be clear. NP A stated she found Resident #1 was a DNR in the hospital prior to his admission to the facility, so she wrote an order for [REDACTED].#1 his vital signs were within normal range when she saw him on [DATE]. NP A stated she was not notified of Resident #1's low blood pressure on the evening of [DATE] (blood pressure-,[DATE]), and considered this to be an abnormal blood pressure for Resident #1. NP A stated she expected the vital signs obtained on the evening shift on [DATE] (blood pressure of ,[DATE] and temperature of 101 degrees Fahrenheit) to be questioned. NP A stated she was not notified of any abnormal vital signs for Resident #1 on [DATE] or [DATE]. NP A stated she expected the nurse to be at Resident #1's bedside if he had a change of condition or altered mental status. During an interview on [DATE] at 3:45 p.m., the DON stated some time before shift change on [DATE] (before 2:00 p.m.), she was called to Resident #1's room by CNA S because there was no urine in Resident #1's Foley catheter drainage bag; urine was leaking out around the catheter insertion site. The DON stated Resident #1 was alert and talking at that time. The DON stated she changed Resident #1's Foley catheter because it was leaking and not going into the catheter drainage bag. The DON stated she then notified NP B because she was concerned Resident #1 was not drinking enough fluids and was possibly dehydrated. She stated NP B ordered STAT labs and IV fluids. She stated she gave report to the evening shift oncoming nurse, LVN C, around 2:00 p.m., at Resident #1's bedside, where she told LVN C about Resident #1's Foley catheter change and IV fluids. The DON stated between 2:00 p.m. to 2:15 p.m., Resident #1 was sleeping and did not have any irregular breathing. She stated at some point after she left the facility for the day (after 5:00 p.m.), LVN C left a message for her that Resident #1 did not look well. The DON stated when she returned LVN C's message, LVN C was with the SW questioning Resident #1's code status. The DON stated LVN C reported that Resident #1's hospital records prior to his admission to the facility indicated the family wanted a natural death. The DON stated she instructed LVN C to notify the family and ask them what they wanted to do. The DON stated the family said they wanted Resident #1 to be a full- code and sent to the hospital. She stated then LVN C called [DATE], but when paramedics arrived, Resident #1 had no pulse. The DON stated LVN C said she did not start CPR because up to that point, he was breathing and had a pulse. During an interview on [DATE] at 12:20 p.m., NP B stated she never saw Resident #1 physically; he was usually seen by NP A. NP B stated the DON notified her on [DATE] that she was concerned Resident #1 could be dehydrated due to the dark color of his urine in his Foley catheter drainage bag. NP B stated she ordered STAT labs and ½ Normal Saline fluids to be given to Resident #1 through an IV. NP B stated she was never notified of Resident #1's low blood pressure (,[DATE]) or elevated temperature (101.0 degrees F) on [DATE], taken on the evening shift (2:00 p.m. to 10:00 p.m.). During an additional interview on [DATE] at 4:00 p.m., NP B stated she never received results of the STAT labs she ordered. NP B stated the next time she received an update on Resident #1 was to report that Resident #1 expired. Review of Witness Statement for CNA S dated [DATE] revealed, I (CNA S) had entered (Resident #1's room) to get his weight for Restorative Nursing Program. So, I (CNA S) had checked (Resident #1's) brief and before I doing his weight and I noticed it was saturated and that his catheter was empty. So, I (CNA S) went to notify the nurse but she was busy with another resident. So, then I had another staff member to get the DON to come to check (Resident #1). So, when the DON came in and checked him and notice the same thing I observed, she got all the supplies together to change out his catheter. While in his room while we were changing his catheter, (Resident #1) was alert and moving. Also, (Resident #1) had grasp my hand in shock. After the DON changed out his catheter, (Resident #1) did have output coming out into his catheter bag. I (CNA S) kept going back into his room throughout the shift checking on him and he was sleeping and was responding back to me when I was checking on him. The last time I had seen (Resident #1) was around 2:30 p.m. and (Resident #1) was still resting. I asked him was he okay he said yes. Then I left out of his room. (Resident #1) was in the same state when I had checked on him before lunch time which was around 12:30 p.m. During an interview on [DATE] at 11:02 a.m., LVN J stated Resident #1 was his usual self during the day shift (6:00 a.m. to 2:00 p.m.) on [DATE]. She stated he was alert, but not active. LVN J stated sometime during the morning (around 9:00 a.m. to 10:30 a.m.), she noticed a decrease in Resident #1's output. She stated the CNA reported to the DON because she was with another resident. LVN J stated when she exited the resident's room she was with, the DON was changing Resident #1's Foley catheter. She stated Resident #1 was awake, but not very alert, moaning. She stated the DON changed his Foley catheter, obtained STAT labs and started an IV for fluids. LVN J stated she monitored Resident #1 closely and was pretty much in the room with him every 30 minutes. LVN J stated she attempted to call the family at least three times to update them on Resident #1's status, but was unable to talk to them or leave a message. Review of lab work dated [DATE] revealed Resident #1 had lab work obtained on [DATE] at 1:49 p.m. for Complete Metabolic Panel (CMP), Complete Blood Count (CBC) and Urinalysis (UA). The lab results for the CBC were printed on [DATE] at 2:44 p.m. Elevated labs included WBC 14.2 (normal range 4XXX,[DATE].8); RBC 3.91 (normal range 4XXX,[DATE].10); HGB 10.7 (normal range 14XXX,[DATE].0); and HCT 35.1 (normal range 42XXX,[DATE].0). There was no physician signature on the STAT labs. The lab results for the CMP were printed on [DATE] at 2:55 p.m. Elevated labs included BUN-77 (normal range ,[DATE] mg/dL); creatinine-1.97 (normal range 0XXX,[DATE].60 mg/dL); and glucose-214 (normal range ,[DATE] mg/dL). There was no physician signature on the STAT labs. The lab results for the UA was printed on [DATE] at 3:12 p.m. Elevated labs included dark brown urine (normal-yellow); appearance-turbid (normal-clear to hazy); and blood 3+ (normal-negative). There was no physician signature on the STAT labs. Review of the Treatment Administration Record (TAR) dated [DATE] revealed Resident #1 had a UA and Culture and Sensitivity collected at 1:00 p.m. Resident #1 received ½ Normal Saline via IV at 60 ml per hour for a total of one liter. During an interview on [DATE] at 5:10 p.m., LVN C stated she came onto her shift on [DATE] at 2:15 p.m. She stated the DON gave her report on Resident #1 at his bedside, stating she started an IV for additional fluids due to him having dark brown urine. LVN C stated Resident #1 was sleeping at that time. She stated sometime between 3:30 p.m. to 4:00 p.m., she observed CNAs in training standing outside Resident #1's door, debating whether or not to obtain his vital signs. LVN C stated she instructed the CNA students to check vital signs on another resident because of Resident #1's IV. LVN C stated at that time, Resident #1 was in a deep sleep. She stated around 5:30 to 5:45 p.m., the MA (MA H) reported she was unable to wake Resident #1 up for his medications. LVN C stated she told MA H not to give Resident #1 any medications because he was pale and in a deep sleep. LVN C stated she was the nurse who performed Resident #1's admission paperwork, and he was initially able to hold a conversation. LVN C stated Resident #1 was asleep during her entire shift (2:00 p.m. to 10:00 p.m.). LVN C stated she had a conversation with CNA L outside Resident #1's room. CNA L stated, I hope he doesn't die. LVN C stated she observed a change in Resident #1 from 2:00 p.m. to 5:45 p.m. but denied calling the doctor or NP. She stated she attempted to reach the DON, and left a message because she was concerned about Resident #1's code status. LVN C stated she then called the ADON and reported to him Resident #1 was a full code. She stated the day nurse (LVN J) told her she attempted to get clarification from the family on Resident #1's code status but was never able to speak to the family. LVN C stated the ADON instructed her to notify the social worker and obtain clarification on Resident #1's code status. LVN C stated she and the social worker (SW G) called the family around 6:00 p.m. to clarify Resident #1's code status. She stated Resident #1's family was unaware of Resident #1's change in condition, and the family said they wanted Resident #1 sent to the hospital. LVN C stated she requested CNA D to get Resident #1 ready to go to the hospital, while she called EMS and printed out the paperwork. LVN C stated after EMS arrived, she heard EMS personnel cursing at facility staff, and she informed EMS personnel Resident #1 was breathing when she last saw him. She stated she then went to the nurses' station to call the family. I didn't have any evidence that he was going to pass. Review of the Witness Statement for LVN C obtained on [DATE] revealed, On [DATE], (LVN C) worked 2p-10p (2:00 p.m. to 10:00 p.m. shift) for (facility). As I enter my shift walking in, I was greeted by DON. When she told me she wanted to show me something on a patient. We enter room (Resident #1's room) on Hall (Resident #1's Hall). (DON) gave me, oncoming nurse, a bedside report on her just finishing an IV on (Resident #1) due to catheter problems and possible dehydration. (Resident #1) was observed resting. Exiting room and counted Narc (narcotic) count with Nurse (LVN J) from 6a-2p (6:00 a.m. to 2:00 p.m.) shift. When I was relieved, she gave me report on (Resident #1), stating patient had a decline. IV was started. Family had been notified all shift to check DNR status per MD orders and no call back. At 3:30 p.m., SN assessed patient. Patient resting and no change, appearing same lethargic, no change in urine color brown. At 4 p.m. (4:00 p.m.), a group of students entered room (Resident #1's room) to complete V/S (vital signs) standing outside doorway with SN (skilled nurse). I explain to students at this time this would not be a good candidate to complete V/S on d/t IV in arm. SN obtain V/S on patient during 1600 (4:00 p.m.) and 1700 (5:00 p.m.) round. V/S stable. IV patent flowing, no change. Patient resting appearing lethargic. At ,[DATE] (5:45 p.m. to 5:50 p.m.), Med Aide enter room to complete V/S for evening meds. Med Aide came to me SN on hall and asked if I think he should receive meds. We enter room doing another assess. Patient RR (respiratory rate) and pulse V/S present, just very lethargic, not responding to name. SN questioning CNA about resident (CNA L), and nurse agrees resident is not the same when we admitted on [DATE]. SN contacted DON to notify of wanting to send patient to ER d/t change in condition from how patient was at admission to now. No answer. SN then notified ADON. No answer from DON and SN wanting to send patient to ER. SN question patient ' s code status to see if patient could be sent out d/t chart stating 'Full Code' but hospital and MD order shown possible DNR. This was at 1805 (6:05 p.m.). ADON told me to 'notify social worker then would know more.' As I dialed # (number) social worker happened to be walking toward nurses' station. I explained to her I wanted to send a patient out to ER d/t change in condition from when I admitted patient. I needed information on code status. As we were speaking, DON call back and I explain everything to her. She said she would contact MD on call to let her know. We were going to send patient out and await on us to notify family. Both SN and social worker notify family in regards to code status and patient's change in condition. SN and social worker explained the two differences letting family know patient status Full Code in facility and DNR at hospital. To see if we could receive or send patient to ER, son wanted to contact brother to figure out what was going on. He stated 'They were here at 11:30 a.m. signing papers with (SW) and their father was fine, going on to say no one notified them until 1815 (6:15 p.m.) of change.' Son contacted brother immediately calling back stating 'it was okay to send patient to hospital.' Going on to say to send patient to (different hospital) and not (previous hospital) d/t DNR. They didn't know it was on file. SN, social worker and another SN present got verbal agreement. SN went back to hall, checking on patient. (Resident #1) was no change, lethargic, RR and pulse present. Unresponsive to name. SN gather aides telling aides to have patient ready. SN was also speaking with [DATE] while leaving patient. On cordless phone gathering paperwork and labs (recent). While ending call ,[DATE] minutes later, EMS and aides were seen entering room. SN could hear EMS cursing at staff. 'What the [***] is wrong with him? Where is the [***] ing nurse?' Both SN and social worker enter room. EMS was stating 'Get the [***] out.' SN ask one EMS worker 'What going on?' He then replied are you the nurse? Is he a Full Code status? SN standing at entrance of door with social worker explained his status, 'Full Code and reason for call' within that time frame CPR was started to be initiated by EMS, who placed resident on ground. Paperwork was exchange between EMS and nurse. SN contacted DON back letting her know what all had taken place. Explaining to her EMS did not want staff in room. The DON advise me to just stay out of room and notify family back of new changes. SW contacted family. Sons both arrived. SW, son and police officer stood outside room. I believe 7 something p.m. EMS came out handing a strip to SN of HR and MD who pronounced patient dead. DON, MD notified. (Funeral home) also notified. All documentation completed. During a clarification interview following review of LVN C's written witness statement on [DATE] at 1:05 p.m., LVN C stated from the time she started her shift on [DATE] (2:00 p.m. to 10:00 p.m.), Resident #1 was lethargic and unresponsive. LVN C stated she did not check Resident #1's vital signs, but checked his respirations and pulse I think. LVN C denied documenting any of Resident #1's vital signs or notifying the physician or NP. LVN C stated sometime during her shift, MA H told her she wanted to check Resident #1's vital signs to give him medications. LVN C stated she told MA H not to give Resident #1 any medications because he would not wake up. LVN C stated she called the DON and left a message. She then called the ADON because she wanted to verify Resident #1's code status before sending him to the ER. LVN C stated she and the SW called Resident #1's family, and the family wanted Resident #1 sent to a different hospital than where he was prior to his admission to the facility because he was a DNR at that hospital. LVN C stated she then called [DATE]. LVN C stated Resident #1's vital signs were stable. When surveyor asked if Resident #1's vital signs taken on the evening shift (temperature-101.0 degrees F; blood pressure-,[DATE]; pulse-98; and respirations-22) were stable compared to his previous vital signs, she stated, I guess not. During an interview on [DATE] at 3:00 p.m., the ADON stated he received a call from LVN C sometime after 5:00 p.m. on [DATE], who said Resident #1 was not looking good, and she was about the send him to the hospital. The ADON stated LVN C inquired about Resident #1's code status. He stated he instructed LVN C if the code status was not in the chart, to contact social services. He denied any further contact with LVN C or Resident #1 on [DATE]. During an interview on [DATE] at 3:25 p.m., SW G stated the NP mentioned Resident #1 was a DNR in the hospital, and SW F talked to the family about completing the paperwork for Resident #1 to be a DNR. She stated around 6:00 p.m. on [DATE], LVN C wanted to clarify Resident #1's code status with the family. SW G stated she and LVN C called the family on speaker phone and discussed Resident #1's current status as a full code. She stated one son called the other son, and stated they understood all the circumstances. Both brothers agreed they wanted Resident #1 to be a full code. SW G stated she again asked and explained to Resident #1's sons if the staff walked in and Resident #1 was not breathing, they would have to initiate CPR. Both of Resident #1's sons agreed they wanted Resident #1 to be a full-code and sent to the hospital. Review of the Social Service Progress Notes dated [DATE] at 6:30 p.m. revealed, This SW (SW G) and Charge Nurse (LVN C) spoke with son on speaker phone. Son wants facility to treat patient as a full code. SW educated son about full code versus DNR, and son said he understood. He also requested for patient to be sent out to the hospital. During a telephone interview on [DATE] at 3:25 p.m., Resident #1's two sons (both on speaker phone) stated their father was admitted to the facility following a stroke. One of Resident #1's sons stated he was at the facility earlier in the day on [DATE], and was approached about his father's code status. This son stated he told the facility he would get back with them on this matter. They stated when the staff found their father non-responsive later that day, both sons agreed they told the facility they wanted their father to be treated as a full-code and sent to the hospital. Both sons stated the EMTs found their father without a pulse. They stated they both arrived while CPR was being provided to their father. Both sons agreed their main concern was their father was not getting enough fluids to keep him from becoming dehydrated. During an interview on [DATE] at 11:15 a.m., MA H stated she went into Resident #1's room sometime between 2:30 p.m. and 3:30 p.m. on [DATE] to check his vital signs. MA H stated she was unable to check Resident #1's vital signs because he was asleep. She stated she called his name, but he did not respond. MA H stated she notified the nurse that Resident #1 was in a deep sleep and would not wake up. She stated she never attempted to give Resident #1 any medications. She stated LVN C instructed her to document on the back of Resident #1's MAR indicated [REDACTED]. MA H stated she did not know why LVN C said she wanted to give Resident #1 medication at 5:30 to 5:45 p.m. MA H stated she only attempted to obtain his vital signs around 3:00 p.m. Review of the admission orders [REDACTED]not alert/oriented. Review of Witness Statement for MA H on [DATE] revealed, I (MA H) first seen (Resident #1) around 2:30 or something to 3p, knocked and entered into his room. Called out couple of times to let (Resident #1) know I (MA H) was there to do B/P (blood pressure) on him. While in room when called out to resident, did touch resident. Never got a response, didn't wake, so left room. The nurse she was in hall. Notified nurse (LVN C) on duty didn't get B/P and resident was asleep seem to be sleeping good. Proceeding on to next room. Next time I seen resident EMS was here doing CPR on him. Couldn't believe the EMS was here. Didn't know anything or what was going on. It was quiet when left hall looked in room. Heard CNAs tell nurse EMTs were talking bad language to them. During an interview on [DATE] at 5:35 p.m., CNA E stated she started her shift on [DATE] at 2:00 p.m. CNA E stated she checked on Resident #1 periodically. She stated around the middle of her shift, she noted Resident #1's mouth open but his chest was moving. She stated her co-worked checked Resident #1's vital signs. CNA E stated around 5:30 p.m., she entered Resident #1's room with CNA D to change him. CNA E stated Resident #1's skin was warm. She stated she placed her hand on his chest and checked his pulse. CNA E stated Resident #1 did not have a pulse. She stated, We left him alone because he was gone. CNA E stated she told CNA D to get the nurse. Review of Witness Statement for CNA E dated [DATE] revealed, .By the time dinner had hit, we were asked to go in and make sure (Resident #1) was cleaned up because the nurse was sending him out to the hospital. When I walked in the room (Resident #1) had his mouth open still and was warm, but I didn't see him breathing. I put my hand on his chest and didn't feel a heartbeat so I checked his wrist. I still didn't feel anything. My partner (CNA D) went to go get the nurse and by the time my partner walked back down the hall EMS showed up and they snapped asking where's the nurse and why we weren't doing anything. We explained the nurse is on the way. EMS then was asking about his code status but we weren't sure. They then started CPR. They couldn't revive him. They left him in the floor and we were asked to pick him up put him back in bed and clean him up. During a clarification interview following review of CNA E's written witness statement on [DATE] at 1:55 p.m., CNA E stated she entered Resident #1's room with CNA D on [DATE] (between 5:00 p.m. and 6:00 p.m.) to get him ready to go to the hospital. CNA E stated she touched Resident #1's skin and observed it to be warm. She stated Resident #1 was not breathing and did not have a pulse. CNA E stated she told CNA D to get the nurse. CNA E stated when CNA D returned, the EMTs yelled at her stating, There's a potential dead body. CNA E stated she did not start CPR because she was not CPR certified and did not want to get in trouble. CNA E stated LVN C was at the nurses' station when EMS arrived, and it took LVN C a little while to come to Resident #1's room. When asked what she was supposed to do if she found a resident unresponsive, CNA E stated she was supposed to notify the nurse. During an interview on [DATE] at 5:42 p.m., CNA L stated at the beginning of his shift on [DATE] (2:00 p.m. to 10:00 p.m.), Resident #1 was responsive, but not verbal. He stated Resident #1 nodded in response to his questions. CNA L stated he was in the dining room around 6:00 p.m., when he was notified Resident #1 expired. CNA L stated he knew CNA E was in the room with Resident #1. Review of Witness Statement for CNA L dated [DATE] revealed, 2 p.m. I made first rounds and got report on Hall. He (Resident #1) seemed fine. I talked with him ask if he needed anything. He told me no. Went back just before dinner (5 p.m.) he was asleep and breathing. Walked to the side of the bed looking at his face and chest. He did not respond to me. I left to feed residents in dining room. By the time I had gotten back around 7 p.m. he had passed away and EMT had started working on CPR. I had talked with the nurse if he was a full code or a DNR. Nurse told me she was unsure. Nurse told me the paperwork that came back with him from the hospital he was a DNR and what we had said he was a full code. Nurse told me she would check on his status around 3 p.m. During an interview on [DATE] at 5:05 p.m., CNA D stated on [DATE] around dinner time, she was serving dinner in the dining room. Her partner (CNA E) told her she needed to help get Resident #1 cleaned up because EMS was coming. CNA D stated when she entered Resident #1's room, she asked CNA E why they were cleaning him up because he was deceased . CNA D stated she was in shock and could not recall what exactly happened. CNA D was unable to state how long she was in Resident #1's room before EMS arrived, but added it was less than five minutes. CNA D stated CNA E touched his face and stated his skin was still warm. CNA D stated they did not press the call light to request assistance. CNA stated she was unable to recall if Resident #1 was breathing or had a pulse because she was in shock. CNA D stated when EMS arrived, they started going off on her. When asked if the nurse was present, CNA D stated, I'm pretty sure she came down because it was serious. Review of Witness Statement for CNA D dated [DATE] revealed, .While in the dining room I was addressed by (CNA E) to come and help her dress a resident because EMS was coming to get him. At that point, I informed the nurse currently in the dining room that I was going to assist her. When we arrived, (CNA E) enter, we had multiple lights on at that moment so I answer some lights to, then when I returned I noticed (Resident #1) mouth was open and his breathing was low. (CNA E) checked to see if he was breathing and he was. I then ran to get the nurse. Mind you I was in the dining room. I was unaware of his condition. All I was asked was to help her clean someone because EMS was coming. As I was exiting the room I was met by EMS. They began to yell at us, complained about his condition. They immediately began to take over and started CPR. I made to retrieve the nurse and informed her about what was going on. She informed us to not return back into the room until they left. During a clarification interview following review of CNA D's written witness statement on [DATE] at 2:10 p.m., CNA D stated she was in Resident #1's room, standing at the door. She stated CNA E entered Resident #1's room and placed her hand on his cheek and stated his skin was still warm. CNA D stated she was in shock and did not get close to the bed. All I knew was I was supposed the clean him up. C

Based on observation, interview and record review the facility failed to ensure staff provided services that met professional standards of quality nursing care for one of three residents (Resident #1) reviewed for Advance Directives and CPR. Resident #1 was a Full Code. LVN C failed to monitor Resident #1 for a continued change of condition on [DATE], as evidenced by altered mental status, abnormal vital signs and abnormal lab work ordered as STAT on [DATE]. LVN C failed to recheck, monitor and notify the physician or NP of Resident #1 ' s abnormal vital signs and abnormal STAT lab work obtained on [DATE]. LVN C failed to provide an accurate description of Resident #1 ' s change of condition, including his altered mental status, abnormal vital signs and abnormal STAT lab work, when she called EMS on [DATE] requesting Resident #1 ' s transfer to the hospital. LVN C failed to initiate CPR on Resident #1 when he was found to have no pulse and no respirations. Resident #1 expired at the facility on [DATE]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at an actual harm with a scope identified as pattern. This deficient practice could place 36 residents identified as full code at risk for not receiving services by professionally qualified staff, for not having their choices honored and not receiving timely life-sustaining measures, which could result in death. The Findings Include: Review of Texas Administrative Code, Title 22 Examining Boards, Part 11 Texas Board of Nursing, Chapter 217 Licensure, Peer Assistance and Practice, Rule 217.11 Standards of Nursing Practice reflected the following: The Texas Board of nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury results. (1) Standards Applicable to all nurses. All vocational nurses, registered and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the boards rules and regulations as well as all federal, stated, or local laws, rules or regulations affecting the nurse ' s current area of nursing practice; . (B) Implement measures to promote a safe environment . (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications . (2) Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and: (A) Shall utilize a systematic approach to provide individualized, goal-directed nursing care by . (iv) Implementing appropriate aspects of care within the LVN's scope of practice . (3) Standards Specific to Registered Nurses. The registered nurse shall assist in the determination of healthcare needs of clients and shall: (A) Utilize a systematic approach to provide individualized, goal-directed, nursing care by . (iv) Implementing nursing care . Review of the Face Sheet dated [DATE] indicated Resident #1 was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was identified as a Full Code. Review of Physician order [REDACTED].#1 was full code status. Review of the Admission Data Collection Tool dated [DATE] revealed Resident #1 was admitted to NF on [DATE] at 5:00 p.m. His vital signs on admission were temperature-97.9; pulse-82; respirations-20; and blood pressure ,[DATE]. Review of the undated Interim Plan of Care revealed Resident #1 was at risk for dehydration. Interventions included determining likes and dislikes and monitoring for signs and symptoms of dehydration. Resident #1 received a pureed diet with honey thickened liquids. Interventions included monitoring intake. The Interim Plan of Care was not dated and did not have a signature indicating who completed the document. Review of the Nurse ' s Notes for [DATE] through [DATE] revealed Resident #1 was alert and oriented and able to verbalize his needs. His vital signs were stable, within acceptable parameters: temperature with range of 97XXX,[DATE].8 degrees F; blood pressure with range of 97-,[DATE]-76; pulse with range of ,[DATE] beats per minute; and respirations with range of ,[DATE] breaths per minute. Resident #1 had a Foley catheter and was being treated for [REDACTED]. Resident #1 received honey-thickened liquids. Review of the Physician order [REDACTED]. Review of the Daily Skilled Nurse ' s Note for the day shift on [DATE] at 7:15 a.m. revealed Resident #1 had a temperature of 100.0 degrees. He received Tylenol 650 mg. At 8:00 a.m., Resident #1 was in bed with his eyes closed without any signs or symptoms of distress. At 8:15 a.m., Resident #1 was given oxygen at 3L per nasal cannula due to oxygen saturation of 90%. His oxygen saturation increased to 94% on 3L of oxygen. Additional vital signs for Resident #1 for the day shift revealed blood pressure-,[DATE]; pulse-92; and respirations-22. Nurse ' s Notes for the evening shift on [DATE] at 2:00 p.m. revealed Resident #1 was in bed with his eyes closed. He had an IV flowing. Resident #1 had no distress. He was uneasy to arouse. Resident #1's vital signs for the evening shift were temperature-101.0 degrees F; blood pressure-,[DATE]; pulse-98; and respirations-22. Review of the Nurse ' s Notes dated [DATE] at 1:30 p.m. revealed CNA reported Resident #1 ' s Foley catheter had zero output. The DON assessed and removed Resident #1 ' s 12F (French, indicating size of catheter) Foley catheter. Nurse ' s Notes documented the DON replaced Resident #1 ' s Foley catheter with a 16F catheter, which then revealed frothy urine, dark brown in color. The DON obtained orders for STAT labs. A peripheral IV was inserted to Resident #1 ' s right forearm, and he was given one liter of ½ Normal Saline. Nurse ' s Notes documented the nurse attempted to reach Resident #1 ' s family at 2:00 p.m. with no option to leave a voicemail. Review of the Daily Skilled Nurse ' s Note reflected on [DATE], nurse reassessed at 5:45 p.m. and Resident #1 was still in deep sleep appearing incoherent. Further documentation continued, SN notified DON at 1800 (6:00 p.m.) and SW about code status and his condition. Family notified at 1820 (6:20 p.m.) in regards to patients ' change ' in condition. Family requested resident to be sent to (hospital). EMS called. Once in room, resident was not breathing. CPR initiated by EMS. Resident pronounced dead at 1922 (7:22 p.m.). During an interview on [DATE] at 12:00 p.m., NP A stated she saw Resident #1 for his initial visit on [DATE]. NP A reviewed her Progress Note from [DATE]. She stated Resident #1 previously lived at home and was on [MEDICATION NAME] (blood thinner) for a blood clot. She stated Resident #1 stopped the [MEDICATION NAME] due to cost. He had a stroke and was found on the floor by his son; they were unaware how long he had been in that condition. NP A stated while Resident #1 was in the hospital, he had multi-organ failure and a UTI. She stated when Resident #1 admitted to the facility, he was aphasic and on a pureed diet with nectar thickened liquids. She stated he had severe contractures and a right BKA, with prosthesis. NP A stated Resident #1 could nod in response to questions and tried to speak, but was not easy to understand. She stated on [DATE], she observed Resident #1 ' s urine in the Foley catheter drainage bag to be clear. NP A stated she found Resident #1 was a DNR in the hospital prior to his admission to the facility, so she wrote an order for [REDACTED].#1 had no changes in his vital signs when she saw him on [DATE]. NP A stated she was not notified of Resident #1 ' s low blood pressure on [DATE] of ,[DATE], and considered this to be an abnormal blood pressure for Resident #1. NP A stated she expected the vital signs obtained on the evening shift on [DATE] (blood pressure of ,[DATE] and temperature of 101 degrees Fahrenheit) to be questioned. NP A stated she expected the nurse to be at Resident #1 ' s bedside on [DATE] due to his change of condition and altered mental status. Review of the Progress Note for NP A dated [DATE] revealed, Patient is [AGE] year old male admitted to the facility and services sp (status [REDACTED]. CT scan was negative at presentation and at 12 hours. He had been living at home and was on [MEDICATION NAME] (blood thinner) but had stopped the med re (related) to the cost. He was also dx with UTI and initially tx with for group B with [MEDICATION NAME] (antibiotic) and tapered to Keflex (antibiotic) for total of 7 days and was restarted on [MEDICATION NAME]. He has knee flexion contracture, R (right) BKA with prosthetic. He is admitted on pureed and nectar thick. Will have SW fu (follow-up) with code status as he was DNR in hospital. Goal is to return home if possible with adult son . [DIAGNOSES REDACTED]. During an interview on [DATE] at 3:45 p.m., the DON stated some time before shift change on [DATE] (before 2:00 p.m.), she was called to Resident #1 ' s room by CNA S because there was no urine in Resident #1 ' s Foley catheter drainage bag; urine was leaking out around the catheter insertion site. The DON stated Resident #1 was alert and talking at that time. The DON stated she changed Resident #1 ' s Foley catheter because it was leaking and not going into the catheter drainage bag. The DON stated she then called NP B because she was concerned Resident #1 was not drinking enough fluids and was possibly dehydrated. She stated NP B ordered STAT labs and IV fluids. She stated she gave report to the evening shift oncoming nurse, LVN C, around 2:00 p.m., at Resident #1's bedside, where she told LVN C about Resident #1 ' s Foley catheter change and IV fluids. The DON stated between 2:00 p.m. to 2:15 p.m., Resident #1 was sleeping and did not have any irregular breathing. She stated at some point after she left the facility for the day (after 5:00 p.m.), LVN C left a message for her that Resident #1 did not look well. The DON stated when she returned LVN C's message, LVN C was with the SW. She stated Resident #1 was a DNR during his last hospital admission, but the facility had him listed as a full code. She stated the family had issues and were going back and forth on Resident #1 ' s code status. The DON stated LVN C reported Resident #1 ' s hospital records prior to his admission to the facility indicated the family wanted a natural death. The DON stated she instructed LVN C to notify the family and ask them what they wanted to do. The DON stated the family said they wanted Resident #1 sent to the hospital. She stated then LVN C called [DATE], but when paramedics arrived, Resident #1 had no pulse. The DON stated LVN C said she did not start CPR because up to that point, he was breathing and had a pulse. During an additional interview on [DATE] at 3:33 p.m., the DON stated it was her understanding at the time EMS personnel arrived, Resident #1 had a pulse and was breathing. She stated if a resident was a full code and did not have a pulse, she expected CPR to be started. She stated if a CNA entered a resident ' s room and observed them to not be breathing or have a pulse, she expected them to pull the call light and notify the nurse. The DON stated the facility had an AED and staff was previously trained on use of the AED. She stated there is a scheduled in-service in March for use of the AED. During an interview on [DATE] at 12:20 p.m., NP B stated she never saw Resident #1 physically; he was usually seen by NP A. NP B stated the DON notified her on [DATE] and reported she was concerned about Resident #1 ' s Foley catheter, which the DON just replaced. NP B stated the DON reported she was concerned that Resident #1 was dehydrated due to the dark color of his urine. NP B stated she ordered STAT labs and ½ Normal Saline fluids to be given to Resident #1 through an IV. NP B stated she was not notified of Resident #1 ' s low blood pressure (,[DATE]) or elevated temperature (101.0 degrees F). During an additional interview on [DATE] at 4:00 p.m., NP B stated she never received results of the STAT labs she ordered. She stated the next time she received an update on Resident #1 was to report that Resident #1 expired. Review of Witness Statement for CNA S dated [DATE] revealed, I (CNA S) had entered (Resident #1 ' s room) to get his weight for Restorative Nursing Program. So, I (CNA S) had checked (Resident #1 ' s) brief and before I doing his weight and I noticed it was saturated and that his catheter was empty. So, I (CNA S) went to notify the nurse but she was busy with another resident. So, then I had another staff member to get the DON to come to check (Resident #1). So, when the DON came in and checked him and notice the same thing I observed, she got all the supplies together to change out his catheter. While in his room while we were changing his catheter, (Resident #1) was alert and moving. Also, (Resident #1) had grasp my hand in shock. After the DON changed out his catheter, (Resident #1) did have output coming out into his catheter bag. I (CNA S) kept going back into his room throughout the shift checking on him and he was sleeping and was responding back to me when I was checking on him. The last time I had seen (Resident #1) was around 2:30 p.m. and (Resident #1) was still resting. I asked him was he okay he said yes. Then I left out of his room. (Resident #1) was in the same state when I had checked on him before lunch time which was around 12:30 p.m. During an interview on [DATE] at 11:02 a.m., LVN J stated Resident #1 was his usual self during the day shift (6:00 a.m. to 2:00 p.m.) on [DATE]. She stated he was alert, but not active. LVN J stated sometime during the morning (around 9:00 a.m. to 10:30 a.m.), she noticed a decrease in Resident #1 ' s output. She stated the CNA reported to the DON because she was with another resident. LVN J stated when she exited the resident ' s room she was with, the DON was working on Resident #1's Foley catheter. She stated Resident #1 was awake, but not very alert, moaning. She stated the DON changed his Foley catheter, obtained STAT labs and started an IV for fluids. LVN J stated she monitored Resident #1 closely and was pretty much in the room with him every 30 minutes. LVN J stated she attempted to call the family at least three times to update them on Resident #1 ' s status, but was unable to get a hold of the family or leave a message. Review of lab work dated [DATE] revealed Resident #1 had lab work obtained on [DATE] at 1:49 p.m. for Complete Metabolic Panel (CMP), Complete Blood Count (CBC) and Urinalysis (UA). The lab results for the CBC were printed on [DATE] at 2:44 p.m. Elevated labs included WBC 14.2 (normal range 4XXX,[DATE].8); RBC 3.91 (normal range 4XXX,[DATE].10); HGB 10.7 (normal range 14XXX,[DATE].0); and HCT 35.1 (normal range 42XXX,[DATE].0). There was no physician signature on the STAT labs. The lab results for the CMP were printed on [DATE] at 2:55 p.m. Elevated labs included BUN-77 (normal range ,[DATE] mg/dL); creatinine-1.97 (normal range 0XXX,[DATE].60 mg/dL); and glucose-214 (normal range ,[DATE] mg/dL). There was no physician signature on the STAT labs. The lab results for the UA was printed on [DATE] at 3:12 p.m. Elevated labs included dark brown urine (normal-yellow); appearance-turbid (normal-clear to hazy); and blood 3+ (normal-negative). There was no physician signature on the STAT labs. Review of the Treatment Administration Record (TAR) dated [DATE] revealed Resident #1 had a UA and Culture and Sensitivity collected at 1:00 p.m. Resident #1 received ½ Normal Saline via IV at 60 ml per hour for a total of one liter. During an interview on [DATE] at 5:10 p.m., LVN C stated she came onto her shift on [DATE] at 2:15 p.m. She stated the DON gave her report on Resident #1 at his bedside, stating she started an IV for additional fluids due to him having dark brown urine. LVN C stated Resident #1 was sleeping at that time. She stated sometime between 3:30 p.m. to 4:00 p.m., she observed CNAs in training standing outside Resident #1's door, debating whether or not to obtain his vital signs. LVN C stated she instructed the CNA students to check vital signs on another resident because of Resident #1's IV. LVN C stated at that time, Resident #1 was in a deep sleep. She stated around 5:30 to 5:45 p.m., the MA (MA H) reported she was unable to wake Resident #1 up for his medications. LVN C stated she told MA H not to give Resident #1 any medications because he was pale and in a deep sleep. LVN C stated she was the nurse who performed Resident #1's admission paperwork, and he was initially able to hold a conversation. LVN C stated Resident #1 was asleep during her entire shift (2:00 p.m. to 10:00 p.m.). LVN C stated she had a conversation with CNA L outside Resident #1's room. CNA L stated, I hope he doesn't die. LVN C stated she observed a change in Resident #1 from 2:00 p.m. to 5:45 p.m. but denied calling the doctor or NP. She stated she attempted to reach the DON, and left a message because she was concerned about Resident #1's code status. LVN C stated she then called the ADON and reported to him Resident #1 was a full code. She stated the day nurse (LVN J) told her she attempted to get clarification from the family on Resident #1's code status but was never able to speak to the family. LVN C stated the ADON instructed her to notify the social worker and obtain clarification on Resident #1's code status. LVN C stated she and the social worker (SW G) called the family around 6:00 p.m. to clarify Resident #1's code status. She stated Resident #1's family was unaware of Resident #1's change in condition, and the family said they wanted Resident #1 sent to the hospital. LVN C stated she requested CNA D to get Resident #1 ready to go to the hospital, while she called EMS and printed out the paperwork. LVN C stated after EMS arrived, she heard EMS personnel cursing at facility staff, and she informed EMS personnel Resident #1 was breathing when she last saw him. She stated she then went to the nurses' station to call the family. I didn't have any evidence that he was going to pass. Review of the Witness Statement for LVN C obtained on [DATE] revealed, On [DATE], (LVN C) worked 2p-10p (2:00 p.m. to 10:00 p.m. shift) for (facility). As I enter my shift walking in, I was greeted by DON. When she told me she wanted to show me something on a patient. We enter room (Resident #1 ' s room) on Hall (Resident #1 ' s Hall). (DON) gave me, oncoming nurse, a bedside report on her just finishing an IV on (Resident #1) due to catheter problems and possible dehydration. (Resident #1) was observed resting. Exiting room and counted Narc (narcotic) count with Nurse (LVN J) from 6a-2p (6:00 a.m. to 2:00 p.m.) shift. When I was relieved, she gave me report on (Resident #1), stating patient had a decline. IV was started. Family had been notified all shift to check DNR status per MD orders and no call back. At 3:30 p.m., SN assessed patient. Patient resting and no change, appearing same lethargic, no change in urine color brown. At 4 p.m. (4:00 p.m.), a group of students entered room (Resident #1 ' s room) to complete V/S (vital signs) standing outside doorway with SN (skilled nurse). I explain to students at this time this would not be a good candidate to complete V/S on d/t IV in arm. SN obtain V/S on patient during 1600 (4:00 p.m.) and 1700 (5:00 p.m.) round. V/S stable. IV patent flowing, no change. Patient resting appearing lethargic. At ,[DATE] (5:45 p.m. to 5:50 p.m.), Med Aide enter room to complete V/S for evening meds. Med Aide came to me SN on hall and asked if I think he should receive meds. We enter room doing another assess. Patient RR (respiratory rate) and pulse V/S present, just very lethargic, not responding to name. SN questioning CNA about resident (CNA L), and nurse agrees resident is not the same when we admitted on [DATE]. SN contacted DON to notify of wanting to send patient to ER d/t change in condition from how patient was at admission to now. No answer. SN then notified ADON. No answer from DON and SN wanting to send patient to ER. SN question patient ' s code status to see if patient could be sent out d/t chart stating ' Full Code ' but hospital and MD order shown possible DNR. This was at 1805 (6:05 p.m.). ADON told me to ' notify social worker then would know more. ' As I dialed # (number) social worker happened to be walking toward nurses ' station. I explained to her I wanted to send a patient out to ER d/t change in condition from when I admitted patient. I needed information on code status. As we were speaking, DON call back and I explain everything to her. She said she would contact MD on call to let her know. We were going to send patient out and await on us to notify family. Both SN and social worker notify family in regards to code status and patient ' s change in condition. SN and social worker explained the two differences letting family know patient status Full Code in facility and DNR at hospital. To see if we could receive or send patient to ER, son wanted to contact brother to figure out what was going on. He stated ' They were here at 11:30 a.m. signing papers with (SW) and their father was fine, going on to say no one notified them until 1815 (6:15 p.m.) of change. ' Son contacted brother immediately calling back stating ' it was okay to send patient to hospital. ' Going on to say to send patient to (different hospital) and not (previous hospital) d/t DNR. They didn ' t know it was on file. SN, social worker and another SN present got verbal agreement. SN went back to hall, checking on patient. (Resident #1) was no change, lethargic, RR and pulse present. Unresponsive to name. SN gather aides telling aides to have patient ready. SN was also speaking with [DATE] while leaving patient. On cordless phone gathering paperwork and labs (recent). While ending call ,[DATE] minutes later, EMS and aides were seen entering room. SN could hear EMS cursing at staff. What the [***] is wrong with him? Where is the [***] ing nurse? Both SN and social worker enter room. EMS was stating Get the [***] out. SN ask one EMS worker ' What going on? ' He then replied are you the nurse? Is he a Full Code status? SN standing at entrance of door with social worker explained his status, ' Full Code and reason for call ' within that time frame CPR was started to be initiated by EMS, who placed resident on ground. Paperwork was exchange between EMS and nurse. SN contacted DON back letting her know what all had taken place. Explaining to her EMS did not want staff in room. The DON advise me to just stay out of room and notify family back of new changes. SW contacted family. Sons both arrived. SW, son and police officer stood outside room. I believe 7 something p.m. EMS came out handing a strip to SN of HR and MD who pronounced patient dead. DON, MD notified. (Funeral home) also notified. All documentation completed. During a clarification interview following review of LVN C ' s written witness statement on [DATE] at 1:05 p.m., LVN C stated from the time she started her shift on [DATE] (2:00 p.m. to 10:00 p.m.), Resident #1 was lethargic and unresponsive. LVN C stated she did not check Resident #1 ' s vital signs, but checked his respirations and pulse I think. LVN C denied documenting any of Resident #1 ' s vital signs. LVN C stated sometime during her shift, MA H told her she wanted to check Resident #1 ' s vital signs to give him medications. LVN C stated she told MA H not to give Resident #1 any medications because he would not wake up. LVN C stated she called the DON and left a message. She then called the ADON because she wanted to verify Resident #1 ' s code status before sending him to the ER. LVN C stated she and the SW called Resident #1 ' s family, and the family wanted Resident #1 sent to a different hospital than where he was prior to his admission to the facility because he was a DNR at that hospital. LVN C stated she then called [DATE]. LVN C stated Resident #1's vital signs were stable. When surveyor asked if Resident #1's vital signs taken on the evening shift (temperature-101.0 degrees F; blood pressure-,[DATE]; pulse-98; and respirations-22) were stable compared to his previous vital signs, she stated, I guess not. During an interview on [DATE] at 3:00 p.m., the ADON stated he received a call from LVN C sometime after 5:00 p.m. on [DATE], who said Resident #1 was not looking good, and she was about the send him to the hospital. The ADON stated LVN C inquired about Resident #1 ' s code status. He stated he instructed LVN C if the code status was not in the chart, to contact social services. He denied any further contact with LVN C or Resident #1 on [DATE]. During an interview on [DATE] at 3:25 p.m., SW G stated if a resident was a DNR at the hospital, she talked to the family or resident and explained the need for an out of hospital DNR to be signed. SW G stated a resident was considered a full code until the DNR was signed. She stated the NP mentioned Resident #1 was a DNR in the hospital, and SW F talked to the family about completing the paperwork for Resident #1 to be a DNR. She stated around 6:00 p.m. on [DATE], LVN C wanted to clarify Resident #1 ' s code status with the family. SW G stated she and LVN C called the family on speaker phone and discussed Resident #1 ' s current status as a full code. She stated one son called the other son, and stated they understood all the circumstances. Both brothers agreed they wanted Resident #1 to be a full code. SW G stated she again asked and explained to Resident #1 ' s sons if the staff walked in and Resident #1 was not breathing, they would have to initiate CPR. Both of Resident #1 ' s sons agreed they wanted Resident #1 to be a full-code and sent to the hospital. Review of the Social Service Progress Notes dated [DATE] at 6:30 p.m. revealed, This SW (SW G) and Charge Nurse (LVN C) spoke with son on speaker phone. Son wants facility to treat patient as a full code. SW educated son about full code versus DNR, and son said he understood. He also requested for patient to be sent out to the hospital. During a telephone interview on [DATE] at 3:25 p.m., Resident #1 ' s two sons (both on speaker phone) stated their father was admitted to the facility following a stroke. One of Resident #1 ' s sons stated he was at the facility earlier in the day on [DATE], and was approached about his father ' s code status. This son stated he told the facility he would get back with them on this matter. They stated when the staff found their father non-responsive later that day, both sons agreed they told the facility they wanted their father to be treated as a full-code and sent to the hospital. Both sons stated the EMTs found their father without a pulse. They stated they both arrived while CPR was being provided to their father. During an interview on [DATE] at 11:15 a.m., MA H stated she went into Resident #1's room sometime between 2:30 p.m. and 3:30 p.m. on [DATE] to check his vital signs. MA H stated she was unable to check Resident #1's vital signs because he was asleep. She stated she called his name, but he did not respond. MA H stated she notified the nurse that Resident #1 was in a deep sleep and would not wake up. She stated she never attempted to give Resident #1 any medications. She stated LVN C instructed her to document on the back of Resident #1's MAR indicated [REDACTED]. MA H stated she did not know why LVN C said she wanted to give Resident #1 medication at 5:30 to 5:45 p.m. MA H stated she only attempted to obtain his vital signs around 3:00 p.m. Review of the admission orders [REDACTED] not alert/oriented. Review of Witness Statement for MA H on [DATE] revealed, I (MA H) first seen (Resident #1) around 2:30 or something to 3p, knocked and entered into his room. Called out couple of times to let (Resident #1) know I (MA H) was there to do B/P (blood pressure) on him. While in room when called out to resident, did touch resident. Never got a response, didn ' t wake, so left room. The nurse she was in hall. Notified nurse (LVN C) on duty didn ' t get B/P and resident was asleep seem to be sleeping good. Proceeding on to next room. Next time I seen resident EMS was here doing CPR on him. Couldn ' t believe the EMS was here. Didn ' t know anything or what was going on. It was quiet when left hall looked in room. Heard CNAs tell nurse EMTs were talking bad language to them. During an interview on [DATE] at 5:35 p.m., CNA E stated she started her shift on [DATE] at 2:00 p.m. CNA E stated she checked on Resident #1 periodically. She stated around the middle of her shift, she noted Resident #1's mouth open but his chest was moving. She stated her co-worked checked Resident #1's vital signs. CNA E stated around 5:30 p.m., she entered Resident #1's room with CNA D to change him. CNA E stated Resident #1's skin was warm. She stated she placed her hand on his chest and checked his pulse. CNA E stated Resident #1 did not have a pulse. She stated, We left him alone because he was gone. CNA E stated she told CNA D to get the nurse. Review of Witness Statement for CNA E dated [DATE] revealed, .By the time dinner had hit, we were asked to go in and make sure (Resident #1) was cleaned up because the nurse was sending him out to the hospital. When I walked in the room (Resident #1) had his mouth open still and was warm, but I didn't see him breathing. I put my hand on his chest and didn't feel a heartbeat so I checked his wrist. I still didn't feel anything. My partner (CNA D) went to go get the nurse and by the time my partner walked back down the hall EMS showed up and they snapped asking where's the nurse and why we weren't doing anything. We explained the nurse is on the way. EMS then was asking about his code status but we weren't sure. They then started CPR. They couldn't revive him. They left him in the floor and we were asked to pick him up put him back in bed and clean him up. During a clarification interview following review of CNA E's written witness statement on [DATE] at 1:55 p.m., CNA E stated she entered Resident #1's room with CNA D on [DATE] (between 5:00 p.m. and 6:00 p.m.) to get him ready to go to the hospital. CNA E stated she touched Resident #1's skin and observed it to be warm. She stated Resident #1 was not breathing

Based on observation, interview, and record review, the facility failed to implement policies and procedures that prohibit neglect for one of three residents (Resident #1) reviewed for code status, and two of five residents (Residents #2 and # 4) reviewed for falls. A. Resident #1 was a Full Code. The facility failed to monitor Resident #1 for a continued change of condition on [DATE], as evidenced by altered mental status, abnormal vital signs and abnormal lab work ordered as STAT on [DATE]. The facility failed to recheck, monitor and notify the physician or NP of Resident #1 ' s abnormal vital signs and abnormal STAT lab work obtained on [DATE]. LVN C failed to provide an accurate description of Resident #1 ' s change of condition, including his altered mental status, abnormal vital signs and abnormal STAT lab work, when she called EMS on [DATE] requesting Resident #1 ' s transfer to the hospital. The facility failed to initiate CPR on Resident #1 when he was found to have no pulse and no respirations. Resident #1 expired at the facility on [DATE]. B. The facility failed to provide a wedge cushion for Resident #2's wheelchair to prevent her from falling. Resident #2 fell from her wheelchair on [DATE], sustained an inoperable [MEDICAL CONDITION]. The facility failed to notify Resident #2's physician or NP of her fall with injury on [DATE]. Resident #2 did not receive care and treatment until [DATE], when x-rays revealed right hip and upper leg fracture. The facility failed to adequately assess for pain when Resident #2 was yelling, screaming and grimacing after the fall on [DATE], through the night shift, 10:00 p.m. to 6:00 a.m. Resident #2 was sent to the hospital, returned to the facility with an inoperable [MEDICAL CONDITION] on [DATE]. Resident #2 was placed on hospice on [DATE], and expired on [DATE]. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at an actual harm with a scope identified as pattern. This deficient practice could place 36 residents identified as full code at risk for not having their choices honored and not receiving timely life-sustaining measures, which could result in death. Non-IJ: C. Facility staff member performed an inappropriate transfer of Resident #4, when moving her from the bed to the wheelchair. Resident #4 fell four times before facility staff requested assistance with the transfer. This deficient practice could place 82 residents who require assistance with transfers at risk for falls, resulting in pain or discomfort, injury and death. The Findings Include: A. Review of the Face Sheet dated [DATE] indicated Resident #1 was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was identified as a Full Code. Review of Physician order [REDACTED].#1 was full code status. Review of the Admission Data Collection Tool dated [DATE] revealed Resident #1 was admitted to NF on [DATE] at 5:00 p.m. His vital signs on admission were temperature-97.9; pulse-82; respirations-20; and blood pressure ,[DATE]. Review of the undated Interim Plan of Care revealed Resident #1 was at risk for dehydration. Interventions included determining likes and dislikes and monitoring for signs and symptoms of dehydration. Resident #1 received a pureed diet with honey thickened liquids. Interventions included monitoring intake. The Interim Plan of Care was not dated and did not have a signature indicating who completed the document. Review of the Nurse ' s Notes for [DATE] through [DATE] revealed Resident #1 was alert and oriented and able to verbalize his needs. His vital signs were stable, within acceptable parameters: temperature with range of 97XXX,[DATE].8 degrees F; blood pressure with range of 97-,[DATE]-76; pulse with range of ,[DATE] beats per minute; and respirations with range of ,[DATE] breaths per minute. Resident #1 had a Foley catheter and was being treated for [REDACTED]. Resident #1 received honey-thickened liquids. Review of the Physician order [REDACTED]. Review of the Daily Skilled Nurse ' s Note for the day shift on [DATE] at 7:15 a.m. revealed Resident #1 had a temperature of 100.0 degrees. He received Tylenol 650 mg. At 8:00 a.m., Resident #1 was in bed with his eyes closed without any signs or symptoms of distress. At 8:15 a.m., Resident #1 was given oxygen at 3L per nasal cannula due to oxygen saturation of 90%. His oxygen saturation increased to 94% on 3L of oxygen. Additional vital signs for Resident #1 for the day shift revealed blood pressure-,[DATE]; pulse-92; and respirations-22. Nurse ' s Notes for the evening shift on [DATE] at 2:00 p.m. revealed Resident #1 was in bed with his eyes closed. He had an IV flowing. Resident #1 had no distress. He was uneasy to arouse. Resident #1's vital signs for the evening shift were temperature-101.0 degrees F; blood pressure-,[DATE]; pulse-98; and respirations-22. Review of the Nurse ' s Notes dated [DATE] at 1:30 p.m. revealed CNA reported Resident #1 ' s Foley catheter had zero output. The DON assessed and removed Resident #1 ' s 12F (French, indicating size of catheter) Foley catheter. Nurse ' s Notes documented the DON replaced Resident #1 ' s Foley catheter with a 16F catheter, which then revealed frothy urine, dark brown in color. The DON obtained orders for STAT (immediate) labs. A peripheral IV was inserted to Resident #1 ' s right forearm, and he was given one liter of ½ Normal Saline. Nurse ' s Notes documented the nurse attempted to reach Resident #1 ' s family at 2:00 p.m. with no option to leave a voicemail. Review of the Daily Skilled Nurse ' s Note reflected on [DATE], nurse reassessed at 5:45 p.m. and Resident #1 was still in deep sleep appearing incoherent. Further documentation continued, SN notified DON at 1800 (6:00 p.m.) and SW about code status and his condition. Family notified at 1820 (6:20 p.m.) in regards to patients ' change ' in condition. Family requested resident to be sent to (hospital). EMS called. Once in room, resident was not breathing. CPR initiated by EMS. Resident pronounced dead at 1922 (7:22 p.m.). During an interview on [DATE] at 12:00 p.m., NP A stated she saw Resident #1 for his initial visit on [DATE]. NP A reviewed her Progress Note from [DATE]. She stated Resident #1 previously lived at home and was on [MEDICATION NAME] (blood thinner) for a blood clot. She stated Resident #1 stopped the [MEDICATION NAME] due to cost. He had a stroke and was found on the floor by his son; they were unaware how long he had been in that condition. NP A stated while Resident #1 was in the hospital, he had multi-organ failure and a UTI. She stated when Resident #1 admitted to the facility, he was aphasic and on a pureed diet with nectar thickened liquids. She stated he had severe contractures and a right BKA, with prosthesis. NP A stated Resident #1 could nod in response to questions and tried to speak, but was not easy to understand. She stated on [DATE], she observed Resident #1 ' s urine in the Foley catheter drainage bag to be clear. NP A stated she found Resident #1 was a DNR in the hospital prior to his admission to the facility, so she wrote an order for [REDACTED].#1 had no changes in his vital signs when she saw him on [DATE]. NP A stated she was not notified of Resident #1 ' s low blood pressure on [DATE] of ,[DATE], and considered this to be an abnormal blood pressure for Resident #1. NP A stated she expected the vital signs obtained on the evening shift on [DATE] (blood pressure of ,[DATE] and temperature of 101 degrees Fahrenheit) to be questioned. NP A stated she expected the nurse to be at Resident #1 ' s bedside on [DATE] due to his change of condition and altered mental status. Review of the Progress Note for NP A dated [DATE] revealed, Patient is [AGE] year old male admitted to the facility and services sp (status [REDACTED]. CT scan was negative at presentation and at 12 hours. He had been living at home and was on [MEDICATION NAME] (blood thinner) but had stopped the med re (related) to the cost. He was also dx with UTI and initially tx with for group B with [MEDICATION NAME] (antibiotic) and tapered to Keflex (antibiotic) for total of 7 days and was restarted on [MEDICATION NAME]. He has knee flexion contracture, R (right) BKA with prosthetic. He is admitted on pureed and nectar thick. Will have SW fu (follow-up) with code status as he was DNR in hospital. Goal is to return home if possible with adult son . [DIAGNOSES REDACTED]. During an additional interview on [DATE] at 4:17 p.m., NP A stated upon a resident ' s admission, she reviewed their code status and determined if they were a DNR at the hospital prior to their admission to the facility. If so, she requested SW to follow-up. NP A stated a resident ' s code status was identified by a red or green form in the front of their chart. If the resident was a DNR, they would have the DNR paperwork in a sleeve behind the red DNR form. NP A stated she usually went to the SW if she had a question about a resident ' s code status. Review of Witness Statement for CNA S dated [DATE] revealed, I (CNA S) had entered (Resident #1 ' s room) to get his weight for Restorative Nursing Program. So, I (CNA S) had checked (Resident #1 ' s) brief and before I doing his weight and I noticed it was saturated and that his catheter was empty. So, I (CNA S) went to notify the nurse but she was busy with another resident. So, then I had another staff member to get the DON to come to check (Resident #1). So, when the DON came in and checked him and notice the same thing I observed, she got all the supplies together to change out his catheter. While in his room while we were changing his catheter, (Resident #1) was alert and moving. Also, (Resident #1) had grasp my hand in shock. After the DON changed out his catheter, (Resident #1) did have output coming out into his catheter bag. I (CNA S) kept going back into his room throughout the shift checking on him and he was sleeping and was responding back to me when I was checking on him. The last time I had seen (Resident #1) was around 2:30 p.m. and (Resident #1) was still resting. I asked him was he okay he said yes. Then I left out of his room. (Resident #1) was in the same state when I had checked on him before lunch time which was around 12:30 p.m. During an interview on [DATE] at 11:02 a.m., LVN J stated Resident #1 was his usual self during the day shift (6:00 a.m. to 2:00 p.m.) on [DATE]. She stated he was alert, but not active. LVN J stated sometime during the morning (around 9:00 a.m. to 10:30 a.m.), she noticed a decrease in Resident #1 ' s output. She stated the CNA reported to the DON because she was with another resident. LVN J stated when she exited the resident ' s room she was with, the DON was working on Resident #1's Foley catheter. She stated Resident #1 was awake, but not very alert, moaning. She stated the DON changed his Foley catheter, obtained STAT labs and started an IV for fluids. LVN J stated she monitored Resident #1 closely and was pretty much in the room with him every 30 minutes. LVN J stated she attempted to call the family at least three times to update them on Resident #1 ' s status, but was unable to get a hold of the family or leave a message. During an interview on [DATE] at 3:05 p.m., SW F stated she called Resident #1 ' s family to inquire about his code status, but was unable to recall what date this occurred. She stated she informed the family they could come to the facility before 5:00 p.m., when she got off work, to sign the DNR paperwork. SW F stated Resident #1 ' s family never came to sign the DNR paperwork. Review of the Social Service Progress Notes dated [DATE] revealed SW F spoke with Resident #1 ' s son about an out of hospital DNR. SW F documented Resident #1 ' s family stated he would look into this today before 5:00 p.m. SW F documented Resident #1 was asleep each time she tried to see him. Documentation indicated Resident #1 ' s son would get with his father and talk about a DNR. During an interview on [DATE] at 3:45 p.m., the DON stated some time before shift change on [DATE] (before 2:00 p.m.), she was called to Resident #1 ' s room by CNA S because there was no urine in Resident #1 ' s Foley catheter drainage bag; urine was leaking out around the catheter insertion site. The DON stated Resident #1 was alert and talking at that time. The DON stated she changed Resident #1 ' s Foley catheter because it was leaking and not going into the catheter drainage bag. The DON stated she then called NP B because she was concerned Resident #1 was not drinking enough fluids and was possibly dehydrated. She stated NP B ordered STAT labs and IV fluids. She stated she gave report to the evening shift oncoming nurse, LVN C, around 2:00 p.m., at Resident #1's bedside, where she told LVN C about Resident #1 ' s Foley catheter change and IV fluids. The DON stated between 2:00 p.m. to 2:15 p.m., Resident #1 was sleeping and did not have any irregular breathing. She stated at some point after she left the facility for the day (after 5:00 p.m.), LVN C left a message for her that Resident #1 did not look well. The DON stated when she returned LVN C's message, LVN C was with the SW. She stated Resident #1 was a DNR during his last hospital admission, but the facility had him listed as a full code. She stated the family had issues and were going back and forth on Resident #1 ' s code status. The DON stated LVN C reported Resident #1 ' s hospital records prior to his admission to the facility indicated the family wanted a natural death. The DON stated she instructed LVN C to notify the family and ask them what they wanted to do. The DON stated the family said they wanted Resident #1 sent to the hospital. She stated then LVN C called [DATE], but when paramedics arrived, Resident #1 had no pulse. The DON stated LVN C said she did not start CPR because up to that point, he was breathing and had a pulse. During an additional interview on [DATE] at 3:33 p.m., the DON stated it was her understanding at the time EMS personnel arrived, Resident #1 had a pulse and was breathing. She stated if a resident was a full code and did not have a pulse, she expected CPR to be started. She stated if a CNA entered a resident ' s room and observed them to not be breathing or have a pulse, she expected them to pull the call light and notify the nurse. The DON stated the facility had an AED and staff was previously trained on use of the AED. She stated there is a scheduled in-service in March for use of the AED. During an interview on [DATE] at 12:20 p.m., NP B stated she never saw Resident #1 physically; he was usually seen by NP A. NP B stated the DON notified her on [DATE] and reported she was concerned about Resident #1 ' s Foley catheter, which the DON just replaced. NP B stated the DON reported she was concerned that Resident #1 was dehydrated due to the dark color of his urine. NP B stated she ordered STAT labs and ½ Normal Saline fluids to be given to Resident #1 through an IV. NP B stated she was not notified of Resident #1 ' s low blood pressure (,[DATE]) or elevated temperature (101.0 degrees F). During an additional interview on [DATE] at 4:00 p.m., NP B stated she never received results of the STAT labs she ordered. She stated the next time she received an update on Resident #1 was to report that Resident #1 expired. Review of lab work dated [DATE] revealed Resident #1 had lab work obtained on [DATE] at 1:49 p.m. for Complete Metabolic Panel (CMP), Complete Blood Count (CBC) and Urinalysis (UA). The lab results for the CBC were printed on [DATE] at 2:44 p.m. Elevated labs included WBC 14.2 (normal range 4XXX,[DATE].8); RBC 3.91 (normal range 4XXX,[DATE].10); HGB 10.7 (normal range 14XXX,[DATE].0); and HCT 35.1 (normal range 42XXX,[DATE].0). There was no physician signature on the STAT labs. The lab results for the CMP were printed on [DATE] at 2:55 p.m. Elevated labs included BUN-77 (normal range ,[DATE] mg/dL); creatinine-1.97 (normal range 0XXX,[DATE].60 mg/dL); and glucose-214 (normal range ,[DATE] mg/dL). There was no physician signature on the STAT labs. The lab results for the UA was printed on [DATE] at 3:12 p.m. Elevated labs included dark brown urine (normal-yellow); appearance-turbid (normal-clear to hazy); and blood 3+ (normal-negative). There was no physician signature on the STAT labs. Review of the Treatment Administration Record (TAR) dated [DATE] revealed Resident #1 had a UA and Culture and Sensitivity collected at 1:00 p.m. Resident #1 received ½ Normal Saline via IV at 60 ml per hour for a total of one liter. During an interview on [DATE] at 5:10 p.m., LVN C stated she came onto her shift on [DATE] at 2:15 p.m. She stated the DON gave her report on Resident #1 at his bedside, stating she started an IV for additional fluids due to him having dark brown urine. LVN C stated Resident #1 was sleeping at that time. She stated sometime between 3:30 p.m. to 4:00 p.m., she observed CNAs in training standing outside Resident #1's door, debating whether or not to obtain his vital signs. LVN C stated she instructed the CNA students to check vital signs on another resident because of Resident #1's IV. LVN C stated at that time, Resident #1 was in a deep sleep. She stated around 5:30 to 5:45 p.m., the MA (MA H) reported she was unable to wake Resident #1 up for his medications. LVN C stated she told MA H not to give Resident #1 any medications because he was pale and in a deep sleep. LVN C stated she was the nurse who performed Resident #1's admission paperwork, and he was initially able to hold a conversation. LVN C stated Resident #1 was asleep during her entire shift (2:00 p.m. to 10:00 p.m.). LVN C stated she had a conversation with CNA L outside Resident #1's room. CNA L stated, I hope he doesn't die. LVN C stated she observed a change in Resident #1 from 2:00 p.m. to 5:45 p.m. but denied calling the doctor or NP. She stated she attempted to reach the DON, and left a message because she was concerned about Resident #1's code status. LVN C stated she then called the ADON and reported to him Resident #1 was a full code. She stated the day nurse (LVN J) told her she attempted to get clarification from the family on Resident #1's code status but was never able to speak to the family. LVN C stated the ADON instructed her to notify the social worker and obtain clarification on Resident #1's code status. LVN C stated she and the social worker (SW G) called the family around 6:00 p.m. to clarify Resident #1's code status. She stated Resident #1's family was unaware of Resident #1's change in condition, and the family said they wanted Resident #1 sent to the hospital. LVN C stated she requested CNA D to get Resident #1 ready to go to the hospital, while she called EMS and printed out the paperwork. LVN C stated after EMS arrived, she heard EMS personnel cursing at facility staff, and she informed EMS personnel Resident #1 was breathing when she last saw him. She stated she then went to the nurses' station to call the family. I didn't have any evidence that he was going to pass. Review of the Witness Statement for LVN C obtained on [DATE] revealed, On [DATE], (LVN C) worked 2p-10p (2:00 p.m. to 10:00 p.m. shift) for (facility). As I enter my shift walking in, I was greeted by DON. When she told me she wanted to show me something on a patient. We enter room (Resident #1 ' s room) on Hall (Resident #1 ' s Hall). (DON) gave me, oncoming nurse, a bedside report on her just finishing an IV on (Resident #1) due to catheter problems and possible dehydration. (Resident #1) was observed resting. Exiting room and counted Narc (narcotic) count with Nurse (LVN J) from 6a-2p (6:00 a.m. to 2:00 p.m.) shift. When I was relieved, she gave me report on (Resident #1), stating patient had a decline. IV was started. Family had been notified all shift to check DNR status per MD orders and no call back. At 3:30 p.m., SN assessed patient. Patient resting and no change, appearing same lethargic, no change in urine color brown. At 4 p.m. (4:00 p.m.), a group of students entered room (Resident #1 ' s room) to complete V/S (vital signs) standing outside doorway with SN (skilled nurse). I explain to students at this time this would not be a good candidate to complete V/S on d/t IV in arm. SN obtain V/S on patient during 1600 (4:00 p.m.) and 1700 (5:00 p.m.) round. V/S stable. IV patent flowing, no change. Patient resting appearing lethargic. At ,[DATE] (5:45 p.m. to 5:50 p.m.), Med Aide enter room to complete V/S for evening meds. Med Aide came to me SN on hall and asked if I think he should receive meds. We enter room doing another assess. Patient RR (respiratory rate) and pulse V/S present, just very lethargic, not responding to name. SN questioning CNA about resident (CNA L), and nurse agrees resident is not the same when we admitted on [DATE]. SN contacted DON to notify of wanting to send patient to ER d/t change in condition from how patient was at admission to now. No answer. SN then notified ADON. No answer from DON and SN wanting to send patient to ER. SN question patient ' s code status to see if patient could be sent out d/t chart stating ' Full Code ' but hospital and MD order shown possible DNR. This was at 1805 (6:05 p.m.). ADON told me to ' notify social worker then would know more. ' As I dialed # (number) social worker happened to be walking toward nurses ' station. I explained to her I wanted to send a patient out to ER d/t change in condition from when I admitted patient. I needed information on code status. As we were speaking, DON call back and I explain everything to her. She said she would contact MD on call to let her know. We were going to send patient out and await on us to notify family. Both SN and social worker notify family in regards to code status and patient ' s change in condition. SN and social worker explained the two differences letting family know patient status Full Code in facility and DNR at hospital. To see if we could receive or send patient to ER, son wanted to contact brother to figure out what was going on. He stated ' They were here at 11:30 a.m. signing papers with (SW) and their father was fine, going on to say no one notified them until 1815 (6:15 p.m.) of change. ' Son contacted brother immediately calling back stating ' it was okay to send patient to hospital. ' Going on to say to send patient to (different hospital) and not (previous hospital) d/t DNR. They didn ' t know it was on file. SN, social worker and another SN present got verbal agreement. SN went back to hall, checking on patient. (Resident #1) was no change, lethargic, RR and pulse present. Unresponsive to name. SN gather aides telling aides to have patient ready. SN was also speaking with [DATE] while leaving patient. On cordless phone gathering paperwork and labs (recent). While ending call ,[DATE] minutes later, EMS and aides were seen entering room. SN could hear EMS cursing at staff. What the [***] is wrong with him? Where is the [***] ing nurse? Both SN and social worker enter room. EMS was stating Get the [***] out. SN ask one EMS worker ' What going on? ' He then replied are you the nurse? Is he a Full Code status? SN standing at entrance of door with social worker explained his status, ' Full Code and reason for call ' within that time frame CPR was started to be initiated by EMS, who placed resident on ground. Paperwork was exchange between EMS and nurse. SN contacted DON back letting her know what all had taken place. Explaining to her EMS did not want staff in room. The DON advise me to just stay out of room and notify family back of new changes. SW contacted family. Sons both arrived. SW, son and police officer stood outside room. I believe 7 something p.m. EMS came out handing a strip to SN of HR and MD who pronounced patient dead. DON, MD notified. (Funeral home) also notified. All documentation completed. During a clarification interview following review of LVN C ' s written witness statement on [DATE] at 1:05 p.m., LVN C stated from the time she started her shift on [DATE] (2:00 p.m. to 10:00 p.m.), Resident #1 was lethargic and unresponsive. LVN C stated she did not check Resident #1 ' s vital signs, but checked his respirations and pulse I think. LVN C denied documenting any of Resident #1 ' s vital signs. LVN C stated sometime during her shift, MA H told her she wanted to check Resident #1 ' s vital signs to give him medications. LVN C stated she told MA H not to give Resident #1 any medications because he would not wake up. LVN C stated she called the DON and left a message. She then called the ADON because she wanted to verify Resident #1 ' s code status before sending him to the ER. LVN C stated she and the SW called Resident #1 ' s family, and the family wanted Resident #1 sent to a different hospital than where he was prior to his admission to the facility because he was a DNR at that hospital. LVN C stated she then called [DATE]. LVN C stated Resident #1's vital signs were stable. When surveyor asked if Resident #1's vital signs taken on the evening shift (temperature-101.0 degrees F; blood pressure-,[DATE]; pulse-98; and respirations-22) were stable compared to his previous vital signs, she stated, I guess not. During an interview on [DATE] at 3:00 p.m., the ADON stated he received a call from LVN C sometime after 5:00 p.m. on [DATE], who said Resident #1 was not looking good, and she was about the send him to the hospital. The ADON stated LVN C inquired about Resident #1 ' s code status. He stated he instructed LVN C if the code status was not in the chart, to contact social services. He denied any further contact with LVN C or Resident #1 on [DATE]. During an interview on [DATE] at 3:25 p.m., SW G stated if a resident was a DNR at the hospital, she talked to the family or resident and explained the need for an out of hospital DNR to be signed. SW G stated a resident was considered a full code until the DNR was signed. She stated the NP mentioned Resident #1 was a DNR in the hospital, and SW F talked to the family about completing the paperwork for Resident #1 to be a DNR. She stated around 6:00 p.m. on [DATE], LVN C wanted to clarify Resident #1 ' s code status with the family. SW G stated she and LVN C called the family on speaker phone and discussed Resident #1 ' s current status as a full code. She stated one son called the other son, and stated they understood all the circumstances. Both brothers agreed they wanted Resident #1 to be a full code. SW G stated she again asked and explained to Resident #1 ' s sons if the staff walked in and Resident #1 was not breathing, they would have to initiate CPR. Both of Resident #1 ' s sons agreed they wanted Resident #1 to be a full-code and sent to the hospital. Review of the Social Service Progress Notes dated [DATE] at 6:30 p.m. revealed, This SW (SW G) and Charge Nurse (LVN C) spoke with son on speaker phone. Son wants facility to treat patient as a full code. SW educated son about full code versus DNR, and son said he understood. He also requested for patient to be sent out to the hospital. During a telephone interview on [DATE] at 3:25 p.m., Resident #1 ' s two sons (both on speaker phone) stated their father was admitted to the facility following a stroke. One of Resident #1 ' s sons stated he was at the facility earlier in the day on [DATE], and was approached about his father ' s code status. This son stated he told the facility he would get back with them on this matter. They stated when the staff found their father non-responsive later that day, both sons agreed they told the facility they wanted their father to be treated as a full-code and sent to the hospital. Both sons stated the EMTs found their father without a pulse. They stated they both arrived while CPR was being provided to their father. During an interview on [DATE] at 11:15 a.m., MA H stated she went into Resident #1 ' s room sometime between 2:30 p.m. and 3:30 p.m. on [DATE] to check his vital signs. MA H stated she was unable to check Resident #1 ' s vital signs because he was asleep. She stated she called his name, but he did not respond. MA H stated she notified the nurse that Resident #1 was in a deep sleep and would not wake up. She stated she never attempted to give Resident #1 any medications. MA H stated later that evening, she heard CNA D talking about EMT staff using bad language toward facility staff. She stated LVN C instructed her to document on the back of Resident #1 ' s MAR indicated [REDACTED]. Review of the admission orders [REDACTED] not alert/oriented. Review of Witness Statement for MA H on [DATE] revealed, I (MA H) first seen (Resident #1) around 2:30 or something to 3p, knocked and entered into his room. Called out couple of times to let (Resident #1) know I (MA H) was there to do B/P (blood pressure) on him. While in room when called out to resident, did touch resident. Never got a response, didn ' t wake, so left room. The nurse she was in hall. Notified nurse (LVN C) on duty didn ' t get B/P and resident was asleep seem to be sleeping good. Proceeding on to next room. Next time I seen resident EMS was here doing CPR on him. Couldn ' t believe the EMS was here. Didn ' t know anything or what was going on. It was quiet when left hall looked in room. Heard CNAs tell nurse EMTs were talking bad language to them. During an interview on [DATE] at 5:35 p.m., CNA E stated she started her shift on [DATE] at 2:00 p.m. CNA E stated she checked on Resident #1 periodically. She stated around the middle of her shift, she noted Resident #1 ' s mouth open but his chest was moving. She stated her co-worked checked Resident #1 ' s vital signs. CNA E stated around 5:30 p.m., she entered Resident #1 ' s room with CNA D to change him. CNA E stated Resident #1 ' s skin was warm. She stated she placed her hand on his chest and checked his pulse. CNA E stated Resident #1 did not have a pulse. She stated, We left him alone because he was gone. CNA E stated she told CNA D to get the nurse. Review of Witness Statement for CNA E dated [DATE] revealed, .By the time dinner had hit, we were asked to go in and make sure (Resident #1) was cleaned up because the nurse was sending him out to the hospital. When I walked in the room (Resident #1) had his mouth open still and was warm, but I didn ' t see him breathing. I put my hand on his chest and didn ' t feel a heartbeat so I checked his wrist. I still didn ' t feel anything. My partner (CNA D) went to go get the nurse and by the time my partner walked back down the hall EMS showed up and they snapped asking where ' s the nurse and why we weren ' t doing anything. We explained the nurse is on the way. EMS then was asking about his code status but we weren ' t sure. They then started CPR. They couldn ' t revive him. They left him in the floor and we were asked to pick him up put him back in bed and clean him up. <br

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit neglect for one of three residents (Resident #1) reviewed for code status, and two of five residents (Residents #2 and # 4) reviewed for falls. A. Resident #1 was a Full Code. The facility failed to monitor Resident #1 for a continued change of condition on [DATE], as evidenced by altered mental status, abnormal vital signs and abnormal lab work ordered as STAT on [DATE]. The facility failed to recheck, monitor and notify the physician or NP of Resident #1 ' s abnormal vital signs and abnormal STAT lab work obtained on [DATE]. LVN C failed to provide an accurate description of Resident #1 ' s change of condition, including his altered mental status, abnormal vital signs and abnormal STAT lab work, when she called EMS on [DATE] requesting Resident #1 ' s transfer to the hospital. The facility failed to initiate CPR on Resident #1 when he was found to have no pulse and no respirations. Resident #1 expired at the facility on [DATE]. B. The facility failed to provide a wedge cushion for Resident #2's wheelchair to prevent her from falling. Resident #2 fell from her wheelchair on [DATE], sustained an inoperable [MEDICAL CONDITION]. The facility failed to notify Resident #2's physician or NP of her fall with injury on [DATE]. Resident #2 did not receive care and treatment until [DATE], when x-rays revealed right hip and upper leg fracture. The facility failed to adequately assess for pain when Resident #2 was yelling, screaming and grimacing after the fall on [DATE], through the night shift, 10:00 p.m. to 6:00 a.m. Resident #2 was sent to the hospital, returned to the facility with an inoperable [MEDICAL CONDITION] on [DATE]. Resident #2 was placed on hospice on [DATE], and expired on [DATE]. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at an actual harm with a scope identified as pattern. This deficient practice could place 36 residents identified as full code at risk for not having their choices honored and not receiving timely life-sustaining measures, which could result in death. Non-IJ: C. Facility staff member performed an inappropriate transfer of Resident #4, when moving her from the bed to the wheelchair. Resident #4 fell four times before facility staff requested assistance with the transfer. This deficient practice could place 82 residents who require assistance with transfers at risk for falls, resulting in pain or discomfort, injury and death. The Findings Include: Review of the facility's Abuse Prohibition Policy, (complete) revision date ,[DATE]: 2. The facility's Leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect, or misappropriation of funds and/or property. 3. The facility's Leadership will provide notification to the proper authorities, and, when required, the release of information to those agencies, pursuant to applicable federal and/or state law. Component III: Prevention: 5. Adequate supervision of staff is maintained in order to identify and prevent inappropriate behaviors, such as: A) the use of derogatory/harassing language; B) rough handling; and C) ignoring the patients'/residents/ needs, requests, etc. 6. On-going assessment, care planning, and monitoring of those patients with special needs that may lead to neglect . Component IV: Identification: E: Neglect: Failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish, or mental illness. Review of Emergency-911 policy dated [DATE] read in part, Policy: The staff will call 911 for emergency situations. This policy only applies to residents who have been determined to be a full code. This policy does not apply to residents who have elected DNR status. Procedures: 1. Qualified staff initiates the appropriate emergency procedures, i.e., oxygen, suction, CPR (with or without automatic external defibrillation (AED), as appropriate, etc. in accordance with patient/resident Advance Directives .B. Licensed nurses should inform the attending physician of the resident change of condition. 2. Call 911 when the patient ' s/resident ' s condition is life threatening, unless the patient/resident is coding, and staff has determined that the patient/resident is coding, and staff has determined that the patient/resident is a DNR. 3. Qualified staff attempts to stabilize and monitor the patient/resident until the advance medical team arrives, if appropriate . Review of Do Not Resuscitate policy dated [DATE] read in part, Facility staff will follow the resident ' s Advance Directives in accordance with applicable law and regulation as well as the applicable Facility Policies and Procedures. Each resident ' s medical record will be flagged in a standardized manner to identify the resident ' s code status as DNR or Full Code. Absent any appropriate DNR Order/Identifier, Facility Staff will respond to medical emergencies with CPR measures and a Full Code will be instituted . Review of Resuscitation of Patients/Residents With and Without Automatic External Defibrillation (AED) policy dated [DATE] read in part, Policy: 1. Cardiopulmonary resuscitation (CPR) will be performed in the performed in the presence or absence of an automatic external defibrillator (AED). 2. The AED will be utilized according to manufacturer ' s guidelines. 3. This policy only applies to residents who have been determined to be a full code. This policy does not apply to residents who have elected a do not resuscitate (DNR) status . Review of Physician Communication/Change in Condition policy dated ,[DATE] read in part, Policy: 1. To improve communication between physicians and nursing staff in order to promote optimal patient/resident care. 2. To provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient ' s/resident ' s condition. Procedures: .2. Notify the physician of the change in medical condition .3. If the physician does not respond within an acceptable time frame, the Medical Director and Director of Nursing will be notified .4. The patient ' s/resident ' s family member/legal representative will be notified of any changes in medical condition or treatment pla as indicated by HIPPA directives. 5. Patient ' s/resident ' s family member/legal representative will be notified of any change in condition requiring an emergency transfer to the hospital .7. In the event of a life threatening event-contact 911 immediately .Physician Communication Grid .Altered Mental Status: Treatment Required within 1 hour: Sudden change in mental status-including LOC (loss of consciousness); .Lab Reports: Treatment Required within 1 hour: Any report for which physician requests STAT notification; or PANIC (potentially life-threatening) values not anticipated or already discussed with the physician .BUN: Treatment Required within 1 hour: BUN elevated > (greater than) 50% above usual in someone on diuretics or at high risk for dehydration or > 60 mg/dl, unless values are consistently at this level and MD is aware . Review of Accident/Incident Reporting-Patient/Resident policy dated [DATE] read in part, Policy: The Facility ' s Leadership will follow the established guidelines for the reporting of accidents and incidents. In the event of a state reportable incident, the Facility ' s Leadership will notify the state regulatory agency according to applicable law and regulation. Definitions: An incident is any adverse outcome associated as a direct consequence of treatment or care .An accident is an unexpected, unintended event that can result in bodily injury. Procedures .9. Incidents such as unusual deaths or other serious adverse incidents require reporting to the state in which the facility is located. Some examples of state reportable unusual occurrences or circumstance encompassed by this policy are listed below .A. One that results in the unexpected death of a patient/resident . A. Review of the Face Sheet dated [DATE] indicated Resident #1 was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was identified as a Full Code. Review of Physician order [REDACTED].#1 was full code status. Review of the Admission Data Collection Tool dated [DATE] revealed Resident #1 was admitted to NF on [DATE] at 5:00 p.m. His vital signs on admission were temperature-97.9; pulse-82; respirations-20; and blood pressure ,[DATE]. Review of the undated Interim Plan of Care revealed Resident #1 was at risk for dehydration. Interventions included determining likes and dislikes and monitoring for signs and symptoms of dehydration. Resident #1 received a pureed diet with honey thickened liquids. Interventions included monitoring intake. The Interim Plan of Care was not dated and did not have a signature indicating who completed the document. Review of the Nurse ' s Notes for [DATE] through [DATE] revealed Resident #1 was alert and oriented and able to verbalize his needs. His vital signs were stable, within acceptable parameters: temperature with range of 97XXX,[DATE].8 degrees F; blood pressure with range of 97-,[DATE]-76; pulse with range of ,[DATE] beats per minute; and respirations with range of ,[DATE] breaths per minute. Resident #1 had a Foley catheter and was being treated for [REDACTED]. Resident #1 received honey-thickened liquids. Review of the Physician order [REDACTED]. Review of the Daily Skilled Nurse ' s Note for the day shift on [DATE] at 7:15 a.m. revealed Resident #1 had a temperature of 100.0 degrees. He received Tylenol 650 mg. At 8:00 a.m., Resident #1 was in bed with his eyes closed without any signs or symptoms of distress. At 8:15 a.m., Resident #1 was given oxygen at 3L per nasal cannula due to oxygen saturation of 90%. His oxygen saturation increased to 94% on 3L of oxygen. Additional vital signs for Resident #1 for the day shift revealed blood pressure-,[DATE]; pulse-92; and respirations-22. Nurse ' s Notes for the evening shift on [DATE] at 2:00 p.m. revealed Resident #1 was in bed with his eyes closed. He had an IV flowing. Resident #1 had no distress. He was uneasy to arouse. Resident #1's vital signs for the evening shift were temperature-101.0 degrees F; blood pressure-,[DATE]; pulse-98; and respirations-22. Review of the Nurse ' s Notes dated [DATE] at 1:30 p.m. revealed CNA reported Resident #1 ' s Foley catheter had zero output. The DON assessed and removed Resident #1 ' s 12F (French, indicating size of catheter) Foley catheter. Nurse ' s Notes documented the DON replaced Resident #1 ' s Foley catheter with a 16F catheter, which then revealed frothy urine, dark brown in color. The DON obtained orders for STAT (immediate) labs. A peripheral IV was inserted to Resident #1 ' s right forearm, and he was given one liter of ½ Normal Saline. Nurse ' s Notes documented the nurse attempted to reach Resident #1 ' s family at 2:00 p.m. with no option to leave a voicemail. Review of the Daily Skilled Nurse ' s Note reflected on [DATE], nurse reassessed at 5:45 p.m. and Resident #1 was still in deep sleep appearing incoherent. Further documentation continued, SN notified DON at 1800 (6:00 p.m.) and SW about code status and his condition. Family notified at 1820 (6:20 p.m.) in regards to patients ' change ' in condition. Family requested resident to be sent to (hospital). EMS called. Once in room, resident was not breathing. CPR initiated by EMS. Resident pronounced dead at 1922 (7:22 p.m.). During an interview on [DATE] at 12:00 p.m., NP A stated she saw Resident #1 for his initial visit on [DATE]. NP A reviewed her Progress Note from [DATE]. She stated Resident #1 previously lived at home and was on [MEDICATION NAME] (blood thinner) for a blood clot. She stated Resident #1 stopped the [MEDICATION NAME] due to cost. He had a stroke and was found on the floor by his son; they were unaware how long he had been in that condition. NP A stated while Resident #1 was in the hospital, he had multi-organ failure and a UTI. She stated when Resident #1 admitted to the facility, he was aphasic and on a pureed diet with nectar thickened liquids. She stated he had severe contractures and a right BKA, with prosthesis. NP A stated Resident #1 could nod in response to questions and tried to speak, but was not easy to understand. She stated on [DATE], she observed Resident #1 ' s urine in the Foley catheter drainage bag to be clear. NP A stated she found Resident #1 was a DNR in the hospital prior to his admission to the facility, so she wrote an order for [REDACTED].#1 had no changes in his vital signs when she saw him on [DATE]. NP A stated she was not notified of Resident #1 ' s low blood pressure on [DATE] of ,[DATE], and considered this to be an abnormal blood pressure for Resident #1. NP A stated she expected the vital signs obtained on the evening shift on [DATE] (blood pressure of ,[DATE] and temperature of 101 degrees Fahrenheit) to be questioned. NP A stated she expected the nurse to be at Resident #1 ' s bedside on [DATE] due to his change of condition and altered mental status. Review of the Progress Note for NP A dated [DATE] revealed, Patient is [AGE] year old male admitted to the facility and services sp (status [REDACTED]. CT scan was negative at presentation and at 12 hours. He had been living at home and was on [MEDICATION NAME] (blood thinner) but had stopped the med re (related) to the cost. He was also dx with UTI and initially tx with for group B with [MEDICATION NAME] (antibiotic) and tapered to Keflex (antibiotic) for total of 7 days and was restarted on [MEDICATION NAME]. He has knee flexion contracture, R (right) BKA with prosthetic. He is admitted on pureed and nectar thick. Will have SW fu (follow-up) with code status as he was DNR in hospital. Goal is to return home if possible with adult son . [DIAGNOSES REDACTED]. During an additional interview on [DATE] at 4:17 p.m., NP A stated upon a resident ' s admission, she reviewed their code status and determined if they were a DNR at the hospital prior to their admission to the facility. If so, she requested SW to follow-up. NP A stated a resident ' s code status was identified by a red or green form in the front of their chart. If the resident was a DNR, they would have the DNR paperwork in a sleeve behind the red DNR form. NP A stated she usually went to the SW if she had a question about a resident ' s code status. Review of Witness Statement for CNA S dated [DATE] revealed, I (CNA S) had entered (Resident #1 ' s room) to get his weight for Restorative Nursing Program. So, I (CNA S) had checked (Resident #1 ' s) brief and before I doing his weight and I noticed it was saturated and that his catheter was empty. So, I (CNA S) went to notify the nurse but she was busy with another resident. So, then I had another staff member to get the DON to come to check (Resident #1). So, when the DON came in and checked him and notice the same thing I observed, she got all the supplies together to change out his catheter. While in his room while we were changing his catheter, (Resident #1) was alert and moving. Also, (Resident #1) had grasp my hand in shock. After the DON changed out his catheter, (Resident #1) did have output coming out into his catheter bag. I (CNA S) kept going back into his room throughout the shift checking on him and he was sleeping and was responding back to me when I was checking on him. The last time I had seen (Resident #1) was around 2:30 p.m. and (Resident #1) was still resting. I asked him was he okay he said yes. Then I left out of his room. (Resident #1) was in the same state when I had checked on him before lunch time which was around 12:30 p.m. During an interview on [DATE] at 11:02 a.m., LVN J stated Resident #1 was his usual self during the day shift (6:00 a.m. to 2:00 p.m.) on [DATE]. She stated he was alert, but not active. LVN J stated sometime during the morning (around 9:00 a.m. to 10:30 a.m.), she noticed a decrease in Resident #1 ' s output. She stated the CNA reported to the DON because she was with another resident. LVN J stated when she exited the resident ' s room she was with, the DON was working on Resident #1's Foley catheter. She stated Resident #1 was awake, but not very alert, moaning. She stated the DON changed his Foley catheter, obtained STAT labs and started an IV for fluids. LVN J stated she monitored Resident #1 closely and was pretty much in the room with him every 30 minutes. LVN J stated she attempted to call the family at least three times to update them on Resident #1 ' s status, but was unable to get a hold of the family or leave a message. During an interview on [DATE] at 3:05 p.m., SW F stated she called Resident #1 ' s family to inquire about his code status, but was unable to recall what date this occurred. She stated she informed the family they could come to the facility before 5:00 p.m., when she got off work, to sign the DNR paperwork. SW F stated Resident #1 ' s family never came to sign the DNR paperwork. Review of the Social Service Progress Notes dated [DATE] revealed SW F spoke with Resident #1 ' s son about an out of hospital DNR. SW F documented Resident #1 ' s family stated he would look into this today before 5:00 p.m. SW F documented Resident #1 was asleep each time she tried to see him. Documentation indicated Resident #1 ' s son would get with his father and talk about a DNR. During an interview on [DATE] at 3:45 p.m., the DON stated some time before shift change on [DATE] (before 2:00 p.m.), she was called to Resident #1 ' s room by CNA S because there was no urine in Resident #1 ' s Foley catheter drainage bag; urine was leaking out around the catheter insertion site. The DON stated Resident #1 was alert and talking at that time. The DON stated she changed Resident #1 ' s Foley catheter because it was leaking and not going into the catheter drainage bag. The DON stated she then called NP B because she was concerned Resident #1 was not drinking enough fluids and was possibly dehydrated. She stated NP B ordered STAT labs and IV fluids. She stated she gave report to the evening shift oncoming nurse, LVN C, around 2:00 p.m., at Resident #1's bedside, where she told LVN C about Resident #1 ' s Foley catheter change and IV fluids. The DON stated between 2:00 p.m. to 2:15 p.m., Resident #1 was sleeping and did not have any irregular breathing. She stated at some point after she left the facility for the day (after 5:00 p.m.), LVN C left a message for her that Resident #1 did not look well. The DON stated when she returned LVN C's message, LVN C was with the SW. She stated Resident #1 was a DNR during his last hospital admission, but the facility had him listed as a full code. She stated the family had issues and were going back and forth on Resident #1 ' s code status. The DON stated LVN C reported Resident #1 ' s hospital records prior to his admission to the facility indicated the family wanted a natural death. The DON stated she instructed LVN C to notify the family and ask them what they wanted to do. The DON stated the family said they wanted Resident #1 sent to the hospital. She stated then LVN C called [DATE], but when paramedics arrived, Resident #1 had no pulse. The DON stated LVN C said she did not start CPR because up to that point, he was breathing and had a pulse. During an additional interview on [DATE] at 3:33 p.m., the DON stated it was her understanding at the time EMS personnel arrived, Resident #1 had a pulse and was breathing. She stated if a resident was a full code and did not have a pulse, she expected CPR to be started. She stated if a CNA entered a resident ' s room and observed them to not be breathing or have a pulse, she expected them to pull the call light and notify the nurse. The DON stated the facility had an AED and staff was previously trained on use of the AED. She stated there is a scheduled in-service in March for use of the AED. During an interview on [DATE] at 12:20 p.m., NP B stated she never saw Resident #1 physically; he was usually seen by NP A. NP B stated the DON notified her on [DATE] and reported she was concerned about Resident #1 ' s Foley catheter, which the DON just replaced. NP B stated the DON reported she was concerned that Resident #1 was dehydrated due to the dark color of his urine. NP B stated she ordered STAT labs and ½ Normal Saline fluids to be given to Resident #1 through an IV. NP B stated she was not notified of Resident #1 ' s low blood pressure (,[DATE]) or elevated temperature (101.0 degrees F). During an additional interview on [DATE] at 4:00 p.m., NP B stated she never received results of the STAT labs she ordered. She stated the next time she received an update on Resident #1 was to report that Resident #1 expired. Review of lab work dated [DATE] revealed Resident #1 had lab work obtained on [DATE] at 1:49 p.m. for Complete Metabolic Panel (CMP), Complete Blood Count (CBC) and Urinalysis (UA). The lab results for the CBC were printed on [DATE] at 2:44 p.m. Elevated labs included WBC 14.2 (normal range 4XXX,[DATE].8); RBC 3.91 (normal range 4XXX,[DATE].10); HGB 10.7 (normal range 14XXX,[DATE].0); and HCT 35.1 (normal range 42XXX,[DATE].0). There was no physician signature on the STAT labs. The lab results for the CMP were printed on [DATE] at 2:55 p.m. Elevated labs included BUN-77 (normal range ,[DATE] mg/dL); creatinine-1.97 (normal range 0XXX,[DATE].60 mg/dL); and glucose-214 (normal range ,[DATE] mg/dL). There was no physician signature on the STAT labs. The lab results for the UA was printed on [DATE] at 3:12 p.m. Elevated labs included dark brown urine (normal-yellow); appearance-turbid (normal-clear to hazy); and blood 3+ (normal-negative). There was no physician signature on the STAT labs. Review of the Treatment Administration Record (TAR) dated [DATE] revealed Resident #1 had a UA and Culture and Sensitivity collected at 1:00 p.m. Resident #1 received ½ Normal Saline via IV at 60 ml per hour for a total of one liter. During an interview on [DATE] at 5:10 p.m., LVN C stated she came onto her shift on [DATE] at 2:15 p.m. She stated the DON gave her report on Resident #1 at his bedside, stating she started an IV for additional fluids due to him having dark brown urine. LVN C stated Resident #1 was sleeping at that time. She stated sometime between 3:30 p.m. to 4:00 p.m., she observed CNAs in training standing outside Resident #1's door, debating whether or not to obtain his vital signs. LVN C stated she instructed the CNA students to check vital signs on another resident because of Resident #1's IV. LVN C stated at that time, Resident #1 was in a deep sleep. She stated around 5:30 to 5:45 p.m., the MA (MA H) reported she was unable to wake Resident #1 up for his medications. LVN C stated she told MA H not to give Resident #1 any medications because he was pale and in a deep sleep. LVN C stated she was the nurse who performed Resident #1's admission paperwork, and he was initially able to hold a conversation. LVN C stated Resident #1 was asleep during her entire shift (2:00 p.m. to 10:00 p.m.). LVN C stated she had a conversation with CNA L outside Resident #1's room. CNA L stated, I hope he doesn't die. LVN C stated she observed a change in Resident #1 from 2:00 p.m. to 5:45 p.m. but denied calling the doctor or NP. She stated she attempted to reach the DON, and left a message because she was concerned about Resident #1's code status. LVN C stated she then called the ADON and reported to him Resident #1 was a full code. She stated the day nurse (LVN J) told her she attempted to get clarification from the family on Resident #1's code status but was never able to speak to the family. LVN C stated the ADON instructed her to notify the social worker and obtain clarification on Resident #1's code status. LVN C stated she and the social worker (SW G) called the family around 6:00 p.m. to clarify Resident #1's code status. She stated Resident #1's family was unaware of Resident #1's change in condition, and the family said they wanted Resident #1 sent to the hospital. LVN C stated she requested CNA D to get Resident #1 ready to go to the hospital, while she called EMS and printed out the paperwork. LVN C stated after EMS arrived, she heard EMS personnel cursing at facility staff, and she informed EMS personnel Resident #1 was breathing when she last saw him. She stated she then went to the nurses' station to call the family. I didn't have any evidence that he was going to pass. Review of the Witness Statement for LVN C obtained on [DATE] revealed, On [DATE], (LVN C) worked 2p-10p (2:00 p.m. to 10:00 p.m. shift) for (facility). As I enter my shift walking in, I was greeted by DON. When she told me she wanted to show me something on a patient. We enter room (Resident #1 ' s room) on Hall (Resident #1 ' s Hall). (DON) gave me, oncoming nurse, a bedside report on her just finishing an IV on (Resident #1) due to catheter problems and possible dehydration. (Resident #1) was observed resting. Exiting room and counted Narc (narcotic) count with Nurse (LVN J) from 6a-2p (6:00 a.m. to 2:00 p.m.) shift. When I was relieved, she gave me report on (Resident #1), stating patient had a decline. IV was started. Family had been notified all shift to check DNR status per MD orders and no call back. At 3:30 p.m., SN assessed patient. Patient resting and no change, appearing same lethargic, no change in urine color brown. At 4 p.m. (4:00 p.m.), a group of students entered room (Resident #1 ' s room) to complete V/S (vital signs) standing outside doorway with SN (skilled nurse). I explain to students at this time this would not be a good candidate to complete V/S on d/t IV in arm. SN obtain V/S on patient during 1600 (4:00 p.m.) and 1700 (5:00 p.m.) round. V/S stable. IV patent flowing, no change. Patient resting appearing lethargic. At ,[DATE] (5:45 p.m. to 5:50 p.m.), Med Aide enter room to complete V/S for evening meds. Med Aide came to me SN on hall and asked if I think he should receive meds. We enter room doing another assess. Patient RR (respiratory rate) and pulse V/S present, just very lethargic, not responding to name. SN questioning CNA about resident (CNA L), and nurse agrees resident is not the same when we admitted on [DATE]. SN contacted DON to notify of wanting to send patient to ER d/t change in condition from how patient was at admission to now. No answer. SN then notified ADON. No answer from DON and SN wanting to send patient to ER. SN question patient ' s code status to see if patient could be sent out d/t chart stating ' Full Code ' but hospital and MD order shown possible DNR. This was at 1805 (6:05 p.m.). ADON told me to ' notify social worker then would know more. ' As I dialed # (number) social worker happened to be walking toward nurses ' station. I explained to her I wanted to send a patient out to ER d/t change in condition from when I admitted patient. I needed information on code status. As we were speaking, DON call back and I explain everything to her. She said she would contact MD on call to let her know. We were going to send patient out and await on us to notify family. Both SN and social worker notify family in regards to code status and patient ' s change in condition. SN and social worker explained the two differences letting family know patient status Full Code in facility and DNR at hospital. To see if we could receive or send patient to ER, son wanted to contact brother to figure out what was going on. He stated ' They were here at 11:30 a.m. signing papers with (SW) and their father was fine, going on to say no one notified them until 1815 (6:15 p.m.) of change. ' Son contacted brother immediately calling back stating ' it was okay to send patient to hospital. ' Going on to say to send patient to (different hospital) and not (previous hospital) d/t DNR. They didn ' t know it was on file. SN, social worker and another SN present got verbal agreement. SN went back to hall, checking on patient. (Resident #1) was no change, lethargic, RR and pulse present. Unresponsive to name. SN gather aides telling aides to have patient ready. SN was also speaking with [DATE] while leaving patient. On cordless phone gathering paperwork and labs (recent). While ending call ,[DATE] minutes later, EMS and aides were seen entering room. SN could hear EMS cursing at staff. What the [***] is wrong with him? Where is the [***] ing nurse? Both SN and social worker enter room. EMS was stating Get the [***] out. SN ask one EMS worker ' What going on? ' He then replied are you the nurse? Is he a Full Code status? SN standing at entrance of door with social worker explained his status, ' Full Code and reason for call ' within that time frame CPR was started to be initiated by EMS, who placed resident on ground. Paperwork was exchange between EMS and nurse. SN contacted DON back letting her know what all had taken place. Explaining to her EMS did not want staff in room. The DON advise me to just stay out of room and notify family back of new changes. SW contacted family. Sons both arrived. SW, son and police officer stood outside room. I believe 7 something p.m. EMS came out handing a strip to SN of HR and MD who pronounced patient dead. DON, MD notified. (Funeral home) also notified. All documentation completed. During a clarification interview following review of LVN C ' s written witness statement on [DATE] at 1:05 p.m., LVN C stated from the time she started her shift on [DATE] (2:00 p.m. to 10:00 p.m.), Resident #1 was lethargic and unresponsive. LVN C stated she did not check Resident #1 ' s vital signs, but checked his respirations and pulse I think. LVN C denied documenting any of Resident #1 ' s vital signs. LVN C stated sometime during her shift, MA H told her she wanted to check Resident #1 ' s vital signs to give him medications. LVN C stated she told MA H not to give Resident #1 any medications because he would not wake up. LVN C stated she called the DON and left a message. She then called the ADON because she wanted to verify Resident #1 ' s code status before sending him to the ER. LVN C stated she and the SW called Resident #1 ' s family, and the family wanted Resident #1 sent to a different hospital than where he was prior to his admission to the facility because he was a DNR at that hospital. LVN C stated she then called [DATE]. LVN C stated Resident #1's vital signs were stable. When surveyor asked if Resident #1's vital signs taken on the evening shift (temperature-101.0 degrees F; blood pressure-,[DATE]; pulse-98; and respirations-22) were stable compared to his previous vital signs, she stated, I guess not. During an interview on [DATE] at 3:00 p.m., the ADON stated he received a call from LVN C sometime after 5:00 p.m. on [DATE], who said Resident #1 was not looking good, and she was about the send him to the hospital. The ADON stated LVN C inquired about Resident #1 ' s code status. He stated he instructed LVN C if the code status

Based on interview and record review the facility failed to implement policies for an Advance Directive for one of eleven residents reviewed for Advance Directives (Resident #1). Resident #1 was a Full Code. The facility failed to monitor Resident #1 for a continued change of condition on [DATE], as evidenced by altered mental status, abnormal vital signs and abnormal lab work ordered as STAT on [DATE]. The facility failed to recheck, monitor and notify the physician or NP of Resident #1 ' s abnormal vital signs and abnormal STAT lab work obtained on [DATE]. LVN C failed to provide an accurate description of Resident #1 ' s change of condition, including his altered mental status, abnormal vital signs and abnormal STAT lab work, when she called EMS on [DATE] requesting Resident #1 ' s transfer to the hospital. The facility failed to initiate CPR on Resident #1 when he was found to have no pulse and no respirations. Resident #1 expired at the facility on [DATE]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at an actual harm with a scope identified as pattern. This deficient practice could place 36 residents identified as full code at risk for not having their choices honored and not receiving timely life-sustaining measures, which could result in death. The Findings Include: Review of the Face Sheet dated [DATE] indicated Resident #1 was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was identified as a Full Code. Review of Physician order [REDACTED].#1 was full code status. Review of the Physician order [REDACTED]. Review of the Daily Skilled Nurse's Note for the evening shift (2:00 p.m. to 10:00 p.m.) on [DATE] at 2:00 p.m. revealed Resident #1 was in bed with his eyes closed. He had an IV flowing. Resident #1 had no distress. He was uneasy to arouse. Resident #1's vital signs for the evening shift were temperature-101.0 degrees F; blood pressure-,[DATE]; pulse-98; and respirations-22. Review of the Daily Skilled Nurse's Note dated [DATE], revealed the nurse reassessed Resident #1 at 5:45 p.m., and he was still in deep sleep appearing incoherent. Further documentation continued, SN notified DON at 1800 (6:00 p.m.) and SW about code status and his condition. Family notified at 1820 (6:20 p.m.) in regards to patients 'change' in condition. Family requested resident to be sent to (hospital). EMS called. Once in room, resident was not breathing. CPR initiated by EMS. Resident pronounced dead at 1922 (7:22 p.m.) During an interview on [DATE] at 12:00 p.m., NP A stated she found Resident #1 was a DNR in the hospital prior to his admission to the facility, so she wrote an order for [REDACTED].#1's bedside if he had a change of condition or altered mental status. During an interview on [DATE] at 3:45 p.m., the DON stated she gave report to the evening shift oncoming nurse, LVN C, around 2:00 p.m., at Resident #1's bedside, where she told LVN C about Resident #1's Foley catheter change and IV fluids. The DON stated between 2:00 p.m. to 2:15 p.m., Resident #1 was sleeping and did not have any irregular breathing. She stated at some point after she left the facility for the day (after 5:00 p.m.), LVN C left a message for her that Resident #1 did not look well. The DON stated when she returned LVN C's message, LVN C was with the SW questioning Resident #1's code status. The DON stated LVN C reported that Resident #1's hospital records prior to his admission to the facility indicated the family wanted a natural death. The DON stated she instructed LVN C to notify the family and ask them what they wanted to do. The DON stated the family said they wanted Resident #1 to be a full- code and sent to the hospital. She stated then LVN C called [DATE], but when paramedics arrived, Resident #1 had no pulse. The DON stated LVN C said she did not start CPR because up to that point, he was breathing and had a pulse. During an interview on [DATE] at 4:00 p.m., NP B stated she did not receive any additional information on Resident #1 after 2:00 p.m., until she was notified he expired. During an interview on [DATE] at 3:05 p.m., SW F stated she called Resident #1's family to inquire about his code status, but was unable to recall what date this occurred. She stated she informed the family they could come to the facility before 5:00 p.m., when she got off work, to sign the DNR paperwork. SW F stated Resident #1's family never came to sign the DNR paperwork. Review of the Social Service Progress Notes dated [DATE] revealed SW F spoke with Resident #1's son about an out of hospital DNR. SW F documented Resident #1's family stated he would look into this today before 5:00 p.m. SW F documented Resident #1 was asleep each time she tried to see him. Documentation indicated Resident #1's son would get with his father and talk about a DNR. During an interview on [DATE] at 5:10 p.m., LVN C stated she came onto her shift on [DATE] at 2:15 p.m. She stated the DON gave her report on Resident #1 at his bedside, stating she started an IV for additional fluids due to him having dark brown urine. She stated sometime between 3:30 p.m. to 4:00 p.m., she observed CNAs in training standing outside Resident #1's door, debating whether or not to obtain his vital signs. LVN C stated she instructed the CNA students to check vital signs on another resident because of Resident #1's IV. LVN C stated at that time, Resident #1 was in a deep sleep. She stated around 5:30 to 5:45 p.m., the MA (MA H) reported she was unable to wake Resident #1 up for his medications. LVN C stated she told MA H not to give Resident #1 any medications because he was pale and in a deep sleep. LVN C stated she was the nurse who performed Resident #1's admission paperwork, and he was initially able to hold a conversation. LVN C stated Resident #1 was asleep during her entire shift (2:00 p.m. to 10:00 p.m.). LVN C stated she observed a change in Resident #1 from 2:00 p.m. to 5:45 p.m. but denied calling the doctor or NP. She stated she attempted to reach the DON, and left a message because she was concerned about Resident #1's code status. LVN C stated she then called the ADON and reported to him Resident #1 was a full code. She stated the day nurse (LVN J) told her she attempted to get clarification from the family on Resident #1's code status but was never able to speak to the family. LVN C stated the ADON instructed her to notify the social worker and obtain clarification on Resident #1's code status. LVN C stated she and the social worker (SW G) called the family around 6:00 p.m. to clarify Resident #1's code status. She stated Resident #1's family was unaware of Resident #1's change in condition, and the family said they wanted Resident #1 sent to the hospital. LVN C stated she requested CNA D to get Resident #1 ready to go to the hospital, while she called EMS and printed out the paperwork. LVN C stated after EMS arrived, she heard EMS personnel cursing at facility staff, and she informed EMS personnel Resident #1 was breathing when she last saw him. She stated she then went to the nurses' station to call the family. I didn't have any evidence that he was going to pass. Review of the Witness Statement for LVN C obtained on [DATE] revealed, On [DATE], (LVN C) worked 2p-10p (2:00 p.m. to 10:00 p.m. shift) for (facility). As I enter my shift walking in, I was greeted by DON. When she told me she wanted to show me something on a patient. We enter room (Resident #1 ' s room) on Hall (Resident #1 ' s Hall). (DON) gave me, oncoming nurse, a bedside report on her just finishing an IV on (Resident #1) due to catheter problems and possible dehydration. (Resident #1) was observed resting. Exiting room and counted Narc (narcotic) count with Nurse (LVN J) from 6a-2p (6:00 a.m. to 2:00 p.m.) shift. When I was relieved, she gave me report on (Resident #1), stating patient had a decline. IV was started. Family had been notified all shift to check DNR status per MD orders and no call back. At 3:30 p.m., SN assessed patient. Patient resting and no change, appearing same lethargic, no change in urine color brown. At 4 p.m. (4:00 p.m.), a group of students entered room (Resident #1 ' s room) to complete V/S (vital signs) standing outside doorway with SN (skilled nurse). I explain to students at this time this would not be a good candidate to complete V/S on d/t IV in arm. SN obtain V/S on patient during 1600 (4:00 p.m.) and 1700 (5:00 p.m.) round. V/S stable. IV patent flowing, no change. Patient resting appearing lethargic. At ,[DATE] (5:45 p.m. to 5:50 p.m.), Med Aide enter room to complete V/S for evening meds. Med Aide came to me SN on hall and asked if I think he should receive meds. We enter room doing another assess. Patient RR (respiratory rate) and pulse V/S present, just very lethargic, not responding to name. SN questioning CNA about resident (CNA L), and nurse agrees resident is not the same when we admitted on [DATE]. SN contacted DON to notify of wanting to send patient to ER d/t change in condition from how patient was at admission to now. No answer. SN then notified ADON. No answer from DON and SN wanting to send patient to ER. SN question patient ' s code status to see if patient could be sent out d/t chart stating ' Full Code ' but hospital and MD order shown possible DNR. This was at 1805 (6:05 p.m.). ADON told me to ' notify social worker then would know more. ' As I dialed # (number) social worker happened to be walking toward nurses ' station. I explained to her I wanted to send a patient out to ER d/t change in condition from when I admitted patient. I needed information on code status. As we were speaking, DON call back and I explain everything to her. She said she would contact MD on call to let her know. We were going to send patient out and await on us to notify family. Both SN and social worker notify family in regards to code status and patient ' s change in condition. SN and social worker explained the two differences letting family know patient status Full Code in facility and DNR at hospital. To see if we could receive or send patient to ER, son wanted to contact brother to figure out what was going on. He stated ' They were here at 11:30 a.m. signing papers with (SW) and their father was fine, going on to say no one notified them until 1815 (6:15 p.m.) of change. ' Son contacted brother immediately calling back stating ' it was okay to send patient to hospital. ' Going on to say to send patient to (different hospital) and not (previous hospital) d/t DNR. They didn ' t know it was on file. SN, social worker and another SN present got verbal agreement. SN went back to hall, checking on patient. (Resident #1) was no change, lethargic, RR and pulse present. Unresponsive to name. SN gather aides telling aides to have patient ready. SN was also speaking with [DATE] while leaving patient. On cordless phone gathering paperwork and labs (recent). While ending call ,[DATE] minutes later, EMS and aides were seen entering room. SN could hear EMS cursing at staff. What the [***] is wrong with him? Where is the [***] ing nurse? Both SN and social worker enter room. EMS was stating Get the [***] out. SN ask one EMS worker ' What going on? ' He then replied are you the nurse? Is he a Full Code status? SN standing at entrance of door with social worker explained his status, ' Full Code and reason for call ' within that time frame CPR was started to be initiated by EMS, who placed resident on ground. Paperwork was exchange between EMS and nurse. SN contacted DON back letting her know what all had taken place. Explaining to her EMS did not want staff in room. The DON advise me to just stay out of room and notify family back of new changes. SW contacted family. Sons both arrived. SW, son and police officer stood outside room. I believe 7 something p.m. EMS came out handing a strip to SN of HR and MD who pronounced patient dead. DON, MD notified. (Funeral home) also notified. All documentation completed. During a clarification interview following review of LVN C's written witness statement on [DATE] at 1:05 p.m., LVN C stated from the time she started her shift on [DATE] (2:00 p.m. to 10:00 p.m.), Resident #1 was lethargic and unresponsive. LVN C stated she did not check Resident #1's vital signs, but checked his respirations and pulse I think. LVN C denied documenting any of Resident #1's vital signs or notifying the physician or NP. LVN C stated sometime during her shift, MA H told her she wanted to check Resident #1's vital signs to give him medications. LVN C stated she told MA H not to give Resident #1 any medications because he would not wake up. LVN C stated she called the DON and left a message. She then called the ADON because she wanted to verify Resident #1's code status before sending him to the ER. LVN C stated she and the SW called Resident #1's family, and the family wanted Resident #1 sent to a different hospital than where he was prior to his admission to the facility because he was a DNR at that hospital. LVN C stated she then called [DATE]. LVN C stated Resident #1's vital signs were stable. When surveyor asked if Resident #1's vital signs taken on the evening shift (temperature-101.0 degrees F; blood pressure-,[DATE]; pulse-98; and respirations-22) were stable compared to his previous vital signs, she stated, I guess not. During an interview on [DATE] at 3:00 p.m., the ADON stated he received a call from LVN C sometime after 5:00 p.m. on [DATE], who said Resident #1 was not looking good, and she was about the send him to the hospital. The ADON stated LVN C inquired about Resident #1's code status. He stated he instructed LVN C if the code status was not in the chart, to contact social services. He denied any further contact with LVN C or Resident #1 on [DATE]. During an interview on [DATE] at 3:25 p.m., SW G stated the NP mentioned Resident #1 was a DNR in the hospital, and SW F talked to the family about completing the paperwork for Resident #1 to be a DNR. She stated around 6:00 p.m. on [DATE], LVN C wanted to clarify Resident #1's code status with the family. SW G stated she and LVN C called the family on speaker phone and discussed Resident #1's current status as a full code. She stated one son called the other son, and stated they understood all the circumstances. Both brothers agreed they wanted Resident #1 to be a full code. SW G stated she again asked and explained to Resident #1's sons if the staff walked in and Resident #1 was not breathing, they would have to initiate CPR. Both of Resident #1's sons agreed they wanted Resident #1 to be a full-code and sent to the hospital. Review of the Social Service Progress Notes dated [DATE] at 6:30 p.m. revealed, This SW (SW G) and Charge Nurse (LVN C) spoke with son on speaker phone. Son wants facility to treat patient as a full code. SW educated son about full code versus DNR, and son said he understood. He also requested for patient to be sent out to the hospital. During a telephone interview on [DATE] at 3:25 p.m., Resident #1's two sons (both on speaker phone) stated their father was admitted to the facility following a stroke. One of Resident #1's sons stated he was at the facility earlier in the day on [DATE], and was approached about his father's code status. This son stated he told the facility he would get back with them on this matter. They stated when the staff found their father non-responsive later that day, both sons agreed they told the facility they wanted their father to be treated as a full-code and sent to the hospital. Both sons stated the EMTs found their father without a pulse. They stated they both arrived while CPR was being provided to their father. During an interview on [DATE] at 11:15 a.m., MA H stated she went into Resident #1's room sometime between 2:30 p.m. and 3:30 p.m. on [DATE] to check his vital signs. MA H stated she was unable to check Resident #1's vital signs because he was asleep. She stated she called his name, but he did not respond. MA H stated she notified the nurse that Resident #1 was in a deep sleep and would not wake up. She stated she never attempted to give Resident #1 any medications. She stated LVN C instructed her to document on the back of Resident #1's MAR indicated [REDACTED]. MA H stated she did not know why LVN C said she wanted to give Resident #1 medication at 5:30 to 5:45 p.m. MA H stated she only attempted to obtain his vital signs around 3:00 p.m. Review of Witness Statement for MA H on [DATE] revealed, I (MA H) first seen (Resident #1) around 2:30 or something to 3p, knocked and entered into his room. Called out couple of times to let (Resident #1) know I (MA H) was there to do B/P (blood pressure) on him. While in room when called out to resident, did touch resident. Never got a response, didn ' t wake, so left room. The nurse she was in hall. Notified nurse (LVN C) on duty didn ' t get B/P and resident was asleep seem to be sleeping good. Proceeding on to next room. Next time I seen resident EMS was here doing CPR on him. Couldn ' t believe the EMS was here. Didn ' t know anything or what was going on. It was quiet when left hall looked in room. Heard CNAs tell nurse EMTs were talking bad language to them. During an interview on [DATE] at 5:35 p.m., CNA E stated around 5:30 p.m., she entered Resident #1's room with CNA D to change him. CNA E stated Resident #1's skin was warm. She stated she placed her hand on his chest and checked his pulse. CNA E stated Resident #1 did not have a pulse. She stated, We left him alone because he was gone. CNA E stated she told CNA D to get the nurse. Review of Witness Statement for CNA E dated [DATE] revealed, . By the time dinner had hit, we were asked to go in and make sure (Resident #1) was cleaned up because the nurse was sending him out to the hospital. When I walked in the room (Resident #1) had his mouth open still and was warm, but I didn ' t see him breathing. I put my hand on his chest and didn ' t feel a heartbeat so I checked his wrist. I still didn ' t feel anything. My partner (CNA D) went to go get the nurse and by the time my partner walked back down the hall EMS showed up and they snapped asking where ' s the nurse and why we weren ' t doing anything. We explained the nurse is on the way. EMS then was asking about his code status but we weren ' t sure. They then started CPR. They couldn ' t revive him. They left him in the floor and we were asked to pick him up put him back in bed and clean him up. During a clarification interview following review of CNA E's written witness statement on [DATE] at 1:55 p.m., CNA E stated she entered Resident #1's room with CNA D on [DATE] (between 5:00 p.m. and 6:00 p.m.) to get him ready to go to the hospital. CNA E stated she touched Resident #1's skin and observed it to be warm. She stated Resident #1 was not breathing and did not have a pulse. CNA E stated she told CNA D to get the nurse. CNA E stated when CNA D returned, the EMTs yelled at her stating, There's a potential dead body. CNA E stated she did not start CPR because she was not CPR certified and did not want to get in trouble. CNA E stated LVN C was at the nurses' station when EMS arrived, and it took LVN C a little while to come to Resident #1's room. When asked what she was supposed to do if she found a resident unresponsive, CNA E stated she was supposed to notify the nurse. During an interview on [DATE] at 5:05 p.m., CNA D stated on [DATE] around dinner time, she was serving dinner in the dining room. Her partner (CNA E) told her she needed to help get Resident #1 cleaned up because EMS was coming. CNA D stated when she entered Resident #1's room, she asked CNA E why they were cleaning him up because he was deceased . CNA D stated she was in shock and could not recall what exactly happened. CNA D was unable to state how long she was in Resident #1's room before EMS arrived, but added it was less than five minutes. CNA D stated CNA E touched his face and stated his skin was still warm. CNA D stated they did not press the call light to request assistance. CNA stated she was unable to recall if Resident #1 was breathing or had a pulse because she was in shock. CNA D stated when EMS arrived, they started going off on her. When asked if the nurse was present, CNA D stated, I'm pretty sure she came down because it was serious. Review of Witness Statement for CNA D dated [DATE] revealed, .While in the dining room I was addressed by (CNA E) to come and help her dress a resident because EMS was coming to get him. At that point, I informed the nurse currently in the dining room that I was going to assist her. When we arrived, (CNA E) enter, we had multiple lights on at that moment so I answer some lights to, then when I returned I noticed (Resident #1) mouth was open and his breathing was low. (CNA E) checked to see if he was breathing and he was. I then ran to get the nurse. Mind you I was in the dining room. I was unaware of his condition. All I was asked was to help her clean someone because EMS was coming. As I was exiting the room I was met by EMS. They began to yell at us, complained about his condition. They immediately began to take over and started CPR. I made to retrieve the nurse and informed her about what was going on. She informed us to not return back into the room until they left. During a clarification interview following review of CNA D's written witness statement on [DATE] at 2:10 p.m., CNA D stated she was in Resident #1's room, standing at the door. She stated CNA E entered Resident #1's room and placed her hand on his cheek and stated his skin was still warm. CNA D stated she was in shock and did not get close to the bed. All I knew was I was supposed the clean him up. CNA D stated she turned around and EMS was there. She stated EMS started CPR. CNA D stated LVN C was at the nurses' station on the phone. CNA D was unable to state whether Resident #1 was breathing or had a pulse because she was in shock. When asked specific questions regarding the incident, CNA D stated she was unsure what actually occurred because she was in shock. When asked what she was supposed to do if she found a resident unresponsive, CNA D stated she was supposed to notify the nurse. During an interview on [DATE] at 11:15 a.m., representative from EMS stated they received a call from the nursing facility on [DATE] regarding Resident #1, reporting the resident had a loss of consciousness and blood in his urine. He stated the call was dispatched as a routine transport because Resident #1 was breathing normally. EMS representative stated when they arrived, there were two staff members without identifiers on them (one wearing a red shirt and one wearing a blue shirt) standing at the foot of Resident #1's bed. EMS representative stated they asked if the two staff members could provide any details or information about Resident #1's transfer to the hospital. He stated both staff members looked at EMS staff very confused. EMS representative stated the staff member in the blue shirt said (in regards to Resident #1 ' s EMS transfer to the hospital), Umm, are you sure? I am pretty sure this patient is deceased . EMS representative stated he asked the staff member in the blue shirt if she could find someone who knew anything about Resident #1. EMS representative stated the staff member in the blue shirt said, Umm, are you serious right now? EMS representative stated the staff member in the blue shirt then walked away without further interest in what she just stated. He stated the staff member in the red shirt walked away and did not provide any information on Resident #1. EMS representative stated Resident #1 was apneic and pulseless when they arrived, so they moved him to the floor and performed CPR, without knowing anything in regards to his advance directives. He stated it took about ten minutes before another staff member wearing a navy blue shirt entered Resident #1's room with paperwork, and informed EMS staff Resident #1 was a full code. EMS representative stated this staff member was unaware of any care that occurred recently and said, I don't know. This is not my patient. He stated CPR continued for about 50 minutes before Resident #1 expired. Resident #1's family showed up during CPR. Review of Communications Event Report for dispatch notes dated [DATE] revealed EMS received initial [DATE] call at 6:32 p.m. EMS arrived at facility on [DATE] at 6:35 p.m. Event Notes Addendum documented Resident #1 was incoherent with blood in urine. Resident #1 expired on [DATE] at 7:22 p.m. Review of Fire Department Dispatch notes dated [DATE] revealed Resident #1's skin was warm to touch, but he did not have a pulse and was not breathing. Narrative notes revealed, PT (Patient) (Resident #1) incoh (incoherent), blood in urine. Chief Complaint: Sick Person, He is breathing normally. Upon arrival, Medic and Fire crews grab stretcher and equipment and approach Pt's room, based off notes provided through EMD. As crew enters Pt's room, two Facility staff members exit the room at the same time. (Medic) crew asks if this is the correct room for the Pt that we were called for. The facility staff members look confused, and stated 'they don't know' and also stated 'this Pt is deceased .' Staff was unable to provide any information on the approx (approximate) down time of Pt, nor were good historians. Medic and Fire crew approach Pt, lying in his bed, finding Pt apneic, pulseless, and warm to touch. Medic and Fire crews transfer Pt to the floor and initiate CPR per protocol .CPR was in progress for a total time of 44 min (minutes), Pt was in asystole/PEA (Pulseless Electrical Activity) a total of approx. (approximately) 20 min (minutes) when Medic crew contacted Med Control .to confirm pronouncement of death. Med Control gave the ok to cease CPR and all medical efforts. CPR was stopped, rhythm strip printed, and TOD (time of death) at 19:22 (7:22 p.m.) . (There was no evidence the facility or LVN C provided an accurate description of Resident #1 ' s change of condition, including his altered mental status, abnormal vital signs and abnormal STAT lab work.) During an interview on [DATE] at 1:30 p.m. local Police Department Detective stated he reviewed the dispatch [DATE] call for Resident #1 on [DATE]. He stated it was odd that LVN C stated during questions asked by dispatch, It ' s not like he ' s dead or anything. Review of the Record of Death and Mortitian ' s Receipt revealed Resident #1 expired on [DATE] at 7:22 p.m. Review of Emergency-911 policy dated [DATE] read in part, Policy: The staff will call 911 for emergency situations. This policy only applies to residents who have been determined to be a full code. This policy does not apply to residents who have elected DNR status. Procedures: 1. Qualified staff initiates the appropriate emergency procedures, i.e., oxygen, suction, CPR (with or without automatic external defibrillation (AED), as appropriate, etc. in accordance with patient/resident Advance Directives .B. Licensed nurses should inform the attending physician of the resident change of condition. 2. Call 911 when the patient ' s/resident ' s condition is life threatening, unless the patient/resident is coding, and staff has determined that the patient/resident is coding, and staff has determined that the patient/resident is a DNR. 3. Qualified staff attempts to stabilize and monitor the patient/resident until the advance medical team arrives, if appropriate . Review of Do Not Resuscitate policy dated [DATE] read in part, Facility staff will follow the resident ' s Advance Directives in accordance with applicable law and regulation as well as the applicable Facility Policies and Procedures. Each resident ' s medical record will be flagged in a standardized manner to identify the resident ' s code status as DNR or Full Code. Absent any appropriate DNR Order/Identifier, Facility Staff will respond to medical emergencies with CPR measures and a Full Code will be instituted . Review of Resuscitation of Patients/Residents With and Without Automatic External Defibrillation (AED) policy dated [DATE] read in part, Policy: 1. Cardiopulmonary resuscitation (CPR) will be performed in the performed in the presence or absence of an automatic external defibrillator (AED). 2. The AED will be utilized according to manufacturer ' s guidelines. 3. This policy only applies to residents who have been determined to be a full code. This policy does not apply to residents who have elected a do not resuscitate (DNR) status . The DON and Clinical Services Director were notified on [DATE] at 4:45 p.m. that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the DON and the Clinical Services Director on [DATE] at 8:25 a.m. The final Plan of Removal was accepted by the Survey Team on [DATE] at 12:09 p.m. The facility ' s Plan of Removal is as follows: RESIDENT RIGHTS: Issue Identified: I. Code status of residents was not clearly identified. II. 100 % of medical records will be audited by licensed nurses and social workers for accuracy of code status by 6:00 p.m. on [DATE]. Any code status that does not have an order and is not clear will be readdressed with the responsible party and/or resident and physician. The code status will be confirmed and the order will be present in the chart for Do Not Resuscitate or Full Code. Red/green identifiers will also be validated to be correct and consistent with code status and Care Plans will be updated to reflect current code status by licensed nurses and social worker by 6:00 p.m. on [DATE]. Certified and licensed staff ' s re-education includes the location of code status identifiers: red/green identifiers are located in the front of the resident ' s chart and on the Kiosk (Electronic medical record, computers are on each hall and in the dining room al staff has access to the resident ' s record). III. Licensed Nurses, Certified Nurse Aides and Certified Medication Aides will be re-educated by Director of Nursing/designee regarding code status and actions to be taken in the event of a change in condition of a resident by 6:00 p.m. on [DATE]. No nurse staff will be allowed to work after 6:00 p.m. on [DATE] until they received the required education. This information will be provided in new hire orientation and all new hires will receive this education before allowed to work. All agency staff will receive this education one on one using an Agency Quick Start (Specified Education material grouped together) with signature list of who has had the training and will be located in an agency binder. Any agency staff who has not received the education will not be allowed to prove patient care. The orientation process for all new hire and agency nurses will be monitored by Staff Development Coordinator. This started [DATE] and will be ongoing. IV. Director of nursing/designee will monitor charts of all new admissions and re-admissions within 72 hours of admit to validate code status and that status is identified following policy. The process will begin on [DATE]; will be done daily for the next 30 days, two times a week for 30 days and then randomly thereafter. Any areas of concern wil