Every finding on record at Granbury Care Center

Based on observation, interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 3 of 7 residents (Resident #3, Resident #4, and Resident #6) reviewed for accurate records. 1.The facility failed to have documentation to indicate why Resident #3's medications were not given on 07/15/2026. (Ivermectin and Spinosad), and 07/16/2026 (Spinosad). The facility failed to document when Ivermectin was administered.2.The facility failed to have documentation to indicate why Resident #6's medications were not given on 07/15/2026 (Ivermectin and Spinosad), and on 07/16/2026 (Spinosad).3.The facility failed to have physician's order for Spinosad's administration to Resident #3, Resident #4, and Resident #6 on 07/25/2026.4.The facility failed to have documentation to indicate Spinosad's administration to Resident #3, Resident #4, and Resident #6 on 07/25/2026. These failures could place residents of an accurate depiction of care in the facility.Findings include:Resident #3Record review of Resident #3's electronic face sheet, dated 07/29/2026, reflected a [AGE] year-old female admitted on [DATE] into the secure unit with diagnoses including dementia (a condition where the brain gradually loses its ability to think, remember, and make decisions, affecting daily life), and Alzheimer's disease (most common type of dementia which is a general term for problems with memory, thinking, and reasoning that interfere with daily life).Record review of Resident #3's quarterly MDS assessment, dated 07/01/2026, reflected a BIMS score of 03 indicating severe cognitive impairment.Record review of Resident #3's electronic physician orders, reflected: Ivermectin oral tablet 3mg give 6 tablets by mouth one time a day for rash dated 07/15/2026; Ivermectin oral tablet 3mg give 6 tablets by mouth one time a day for rash dated 07/16/2026; Spinosad external suspension 0.9% apply to entire body topically one time a day for rash dated 07/15/2026; No evidence of a physician's order for Spinosad external suspension 0.9% on 07/25/2026.Record review of Resident #3's July 2026 MAR reflected: Ivermectin was not administered on 07/15/2026 with no explanation why; Ivermectin was not administered on 07/16/2026 with no explanation why; No evidence of what date and time Ivermectin was administered; Spinosad was not administered on 07/15/2026 with explanation unavailable by MA A; Spinosad was not administered on 07/25/2026 with no explanation why.Record review of Resident #3's progress notes, reflected no explanation as to why Ivermectin was not administered on 07/15/2026 and 07/16/2026. Further review reflected no explanation as to why Spinosad was unavailable. No documentation that Spinosad was administered on 07/25/2026.During an observation on 07/29/2026 at 10:10 a.m., Resident #3 had a rash present on her trunk and in the bends of her elbows. She could not answer questions about the rash. She was observed in the secure unit.During a telephone interview on 07/30/2026 at 8:55 a.m., Resident #3's representative stated they had been notified about a week ago that Resident #3 was being treated for a rash with an oral medication and a topical medication. They stated they had picked up Resident #3 a couple of weeks ago and took her out on pass. They stated at that time Resident #3 had a rash on her skin and she told them that the rash was itchy, but the rash did not look bad. They stated they did not have any complaints about how Resident #3 was treated for her rash. They stated it was their understanding that everyone on the secure unit was being treated for the rash at the same time.Resident #4Record review of Resident #4's electronic face sheet, dated 07/29/2026, reflected an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] to the secure unit with diagnoses including dementia (a condition where the brain gradually loses its ability to think, remember, and make decisions, affecting daily life), and dermatitis (inflammation of skin).Record review of Resident #4's quarterly MDS assessment, dated 07/26/2026, reflected a BIMS score of 03 indicating severe cognitive impairment.Record review of Resident #4's electronic physician orders, reviewed on 07/29/2026reflected: No evidence there was a physician's order for Spinosad external suspension 0.9% on 07/25/2026.Record review of Resident #4's July 2026 MAR reflected: Spinosad was not administered on 07/25/2026 with no explanation why.Record review of Resident #4's progress notes, reviewed on 07/29/2026reflected no documentation that Spinosad was administered on 07/25/2026.During an observation on 07/29/2026 at 10:10 a.m., Resident #4 had no rash present on her trunk or extremities. She could not answer questions about the rash. Resident #4 was in the secure unit.During a telephone interview on 07/29/2026 at 10:47 a.m., Resident #4's representative stated they were aware of a rash on Resident #4. They stated they believed the rash had mostly resolved but there may still be some of the rash on Resident #4's foot. They stated the facility told them that Resident #4 had been treated with oral and topical medication and was last treated with topical medication last Saturday. She stated she had no concerns with how the facility treated Resident #4's rash this time because the facility had treated everyone in the secure unit at the same time.Resident #6Record review of Resident #6's electronic face sheet, dated 07/29/2026, reflected a [AGE] year-old female admitted on [DATE] into the secure unit with diagnoses including dementia (a condition where the brain gradually loses its ability to think, remember, and make decisions, affecting daily life), and psoriasis vulgaris (chronic skin disease characterized by itchy, scaly patches that commonly appear on the knees, elbows, trunk, and scalp).Record review of Resident #6's quarterly MDS assessment, dated 07/10/2026, reflected BIMS not conducted because she was rarely / never understood. Record review of Resident #6's electronic physician orders, reviewed on 07/29/2026reflected: Ivermectin oral tablet 3mg give 6 tablets by mouth one time a day for rash dated 07/15/2026; Ivermectin oral tablet 3mg give 6 tablets by mouth one time a day for rash dated 07/20/2026; Spinosad external suspension 0.9% apply to entire body topically one time a day for rash dated 07/15/2026; No evidence of physician's order for Spinosad external suspension 0.9% on 07/25/2026.Record review of Resident #6's July 2026 MAR reflected: Ivermectin was not administered on 07/15/2026 with no explanation why; Ivermectin was administered on 07/20/2026 by MA A; Spinosad was not administered on 07/15/2026 with no explanation why; Spinosad was not administered on 07/16/2026 with explanation why other see nurse notes; Spinosad was not administered on 07/25/2026 with no explanation why.Record review of Resident #6's progress notes, reviewed on 07/29/2026reflected no explanation of why Ivermectin was not administered on 07/15/2026. Further review reflected no explanation of why Spinosad was not administered on 07/15/2026 and 07/16/2026. No documentation that Spinosad was administered on 07/25/2026.During an observation on 07/29/2026 at 12:40 p.m., Resident #6 was walking around in the secure unit. There was no rash observed on Resident #6's exposed skin and she was not itching. Resident #6 could not answer questions about her treatment.During a telephone interview on 07/29/2026 at 2:28 p.m., Resident #6's representative stated they had no concerns with the facility not giving treatment to Resident #6 for her rash. They stated Resident #6 had been seen by a dermatologist for her rash and they felt the treatments were working. They stated they were notified about the treatment being provided to Resident #6 and the other residents on the secure unit.During an interview on 07/30/2026 at 9:45 a.m., the interim DON stated she expected medications to be administered per physician orders. She stated physician orders should be added into the electronic medical record system for nurses and medication aides to document the date and time a medication was administered. She stated all residents in the secure unit received Spinosad on 07/25/2026 and the ADONs were present to make sure the medication was administered. She stated she was unsure why medications were not documented administered when they were administered. She stated it was a stressful time making sure all things were done in order to help prevent further rash spread and she was sure the medications were administered because of the monitoring that was going on by herself, daily discussions with staff member who worked on the secure unit, and the ADONs supervision to make sure the medications were administered. She stated the residents on the secured unit were lined up and the staff went down the list ensuring all residents were administered the Ivermectin and Spinosad about two weeks ago. She stated the Spinosad was administered again on 07/25/2026. She stated she expected there to be a nurses note in the progress notes when the medication was not administered as ordered and a new order obtained from the physician when the medication was administered. She stated not having accurate physician orders, medication administration records, and no progress notes when medications were not administered could cause confusion on what had occurred. She stated inaccurate documentation could interfere with the tracking of the treatment and if it was effective. She stated it may cause medication errors due to staff may administer more doses not knowing if the medication had been administered before. She stated all the Ivermectin arrived at the facility from different pharmacies at different times and the facility waited until all the medication was available before administering it so that all residents would get the medication at the same time. She stated that may have made the MAR inaccurate but there should have been documentation of why the medication was not administered and then documented when the medication was administered. During an interview on 07/30/2026 at 10:22 a.m., MA A stated she gave the Ivermectin to all the residents on the secure unit the same day. She stated it was not available for all the residents when the orders were to administer the medication and that could be why some of the MAR documentation was incomplete. She stated she could not put in orders for the medication to be administered and she remembered asking the nurse several days later to put in the orders so that she could document the medication was administered. She did not state any follow up with the nurse when the medication could not be documented as given. She stated she did not administer the Spinosad because she could not administer topical medication and the nurse was responsible for topical medication administration. She stated she thought all medication was administered on Friday July 17th, 2026 by a nurse that was not in the facility at this time because that was when she remembered giving the Ivermectin. She stated she did not know why that nurse did not put in an order so that she could document the medication was administered then. She stated not having medication administration documented could cause people to not know if the medication was administered.During an interview on 07/30/2026 at 11:40 a.m., the ADMN stated medication documentation should be accurate so that information was known about the residents' care. The ADMN stated the person, nurse or medication aide, who passed the medication was responsible for documenting the medication administration. He stated the DON and ADONs monitored that the documentation was complete and accurate daily. He stated not having the documentation accurate could cause staff not to know about the residents, or if a different kind of medication was provided. He stated it could make the staff know if treatment was effective. During an interview on 07/30/2026 at 12:00 p.m., LVN B stated she was sure Spinosad was administered a week prior to Saturday July 25th, 2026 and she and the other ADON were present on July 25th, 2026, to apply Spinosad to all residents in the secure unit themselves. She stated she knew all residents on the secure unit were given Ivermectin as well by MA A. She stated all residents on the secure unit received the Ivermectin on the same day except Resident #4 who received the day before the other residents because they had to wait for pharmacies to deliver the other resident's medications. She stated if a medication was not given then it should be documented on the MAR as not given and a progress note put into the medical record. She stated if a medication was unavailable, a new order should be obtained and put into the electronic medical record when that medication was available so that the nurse and the medication aide could document that it was given with the date and time of administration. She stated if there was no documentation, then people would not know if it was administered. She stated the electronic system updated and it was frantic at that time which could have led to the failure to document. She stated the DON and the ADONS reviewed the documentation afterward and she was unable to fix the issue due to the system update.Record review of the facility's, undated, policy titled Physician's Orders, reflected Nurse will review the order and if needed contact the prescriber for any clarifications. The nurse will enter the order into [electronic medical record] for the resident and select prescriber written. If the order requires documentation, it will be directed to the proper electronic administration record one the order is completed.Clarify all communications.Ensure all elements of the order are included.Immediately transcribe verbal / telephone orders into the patient's medical record or onto a prescription pad as they are being communicated. Read the order back to the prescriber for verification. Record review of the facility's policy titled Medication Administration Procedures, dated 10/25/2017, reflected After the resident has been identified, administer the medication and immediately chart doses administered on the medication administration record. It is recommended that medication by charted immediately after administration, but if facility policy permits, medication may be charted immediately before administration. Initials are to be used. Check marks are not acceptable.If a dose of regularly scheduled medication is withheld or refused, the nurse is to initial and circle the front of the medication administration record in the space provided for that dosage administration and an explanatory note is to be entered in the nursing notes or in the PRN nurses notes section of the medication administration record. In the presence of individual facility policies concerning refused and held documentation, the facility policy supersedes this policy.The five rights of medication should always be adhered to 1. Right drug 2. Right dose 3. Right resident 4. Right time 5. Right route Record review of the facility's, undated, policy titled Documentation, reflected The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets.Document in the clinical record regarding notification of the physician of abnormal diagnostic test or laboratory results and any new orders or follow-up from the physician.

Based on interviews and record review, the facility failed to complete a comprehensive assessment within 14 days after admission to the facility, for 1 of 7 (Resident #6) residents reviewed for comprehensive assessments.The facility failed to complete Resident #5's comprehensive admission MDS assessment within 14 days after admission.This failure could place residents at risk of not having their care and treatment needs assessed to ensure necessary care and services were provided.Findings included:Record review of Resident #5's electronic face sheet dated 03/30/3036, reflected a [AGE] year-old male admitted on [DATE] with diagnoses including non-pressure chronic ulcer of left heel (left heel chronic wound that was not a pressure ulcer), DM type 2 (a chronic condition characterized by high blood sugar levels due to the body's inability to use insulin effectively), hyperlipidemia (high cholesterol), insomnia (inability to fall or stay asleep during the night), cellulitis of left lower limb (left lower leg skin infection), peripheral vascular disease (decreased blood flow to extremities), acquired absence of right leg below knee (right leg amputation below the knee), and hypothyroidism (low thyroid function).Record review of Resident #5's admission MDS assessment, dated 03/30/2026, reflected no evidence that it was completed and no CAAs were triggered.Record review of Resident #5's admission nurses note, dated 03/13/2026, reflected Resident #5 had a PICC line to his right upper arm, was incontinent to bowel and bladder, his right leg was amputated below the knee, he required two-person assistance with bed mobility and needed a mechanical lift for transfers, he required two-person assistance with toileting, he required one-person assistance with dressing, hygiene, and bathing, he was able to eat and drink with supervision, and he used dentures or both upper and lower to consume his regular diet.Record review of Resident #5's care plan, dated 03/13/2026, reflected Resident #5 had care areas with interventions including EBP, peripheral vascular disease, DM, incontinence, osteomyelitis (bone infection), IV (intravenous) access, ADL self-care deficit, oral / dental health problems, and pressure ulcer care.Record review of facility document titled Resident Matrix, dated 03/27/2026, reflected Resident #5 had pressure ulcer stage 4 and was admitted on [DATE]. There was no evidence that Resident #5 received medication for diabetes, had an infection, or was receiving IV therapy. During an observation and interview on 03/30/2026 at 9:22 a.m., Resident #5 was lying in the bed in his room. There was an IV pole to the left of his bed. He had an IV access site to his right upper arm, and the dressing was clean, dry, and intact. He had a wound vac on his left heel, and the dressing was clean, dry, and intact. He stated he had no concerns with how the facility cared for his IV access or about how they had administered his IV medication for infection. He stated he had an issue with the wound vac on Saturday, but the facility had put another dressing on it and they changed the dressing that morning putting on a new wound vac dressing. During an interview on 03/27/2026 at 3:40 p.m., the DON stated she went to the MDS Coordinator and asked why Resident #5 was not listed on the Matrix as receiving IV therapy. She stated she was told the IV therapy was not listed because the Matrix went off of the MDS assessment that had not triggered him to receive IV therapy. She stated Resident #5 was on IV therapy at that time.During an interview on 03/30/2026 at 2:48 p.m., MDS Coordinator A stated she was responsible for completing Resident #5's admission assessment. She stated it had not been completed because she was behind performing those assessments. She stated not completing the MDS assessment timely could cause residents to not get all care needed because the MDS assessment triggered the CAAs for the care planning process. She stated Resident #5's admission MDS assessment should have been completed on 03/25/2026.During a follow-up interview on 03/30/2026 at 3:30 p.m., the DON stated the MDS Coordinators were responsible for completing comprehensive assessments. She stated the facility had two MDS Coordinators and she expected them to come to her when they were behind on those assessments so she could help complete them. She stated she and the Regional Reimbursement Nurse would sign off on the assessments when the MDS Coordinators had completed them. She stated she did not have a process for monitoring that the comprehensive assessments were completed timely because the ADMN monitored them. She stated her expectation would be for the MDS assessments to be completed per policy. She stated the care plan had been done because the facility used the comprehensive care plan as the baseline care plan and the care areas had already been added onto the care plan. She stated not having the MDS assessment completed could cause a delay in the residents not receiving all of the services needed to care for them. She stated she captured care areas on Resident #5's care plan so she did not feel any delay happened with his care due to the comprehensive assessment not being completed timely.During an interview on 03/30/2026 at 4:32 p.m., the ADMN stated the MDS Coordinator nurses were responsible for completing comprehensive assessments and an RN signed the assessments. She stated the Regional Reimbursement Nurse, and the DON would sign them. The ADMN stated the Regional Reimbursement Nurse would monitor facilities on Fridays if there had been situations that required her to be monitoring the comprehensive MDS assessments and she would now add this facility onto her list to check. The ADMN stated she would now be asking in the morning meeting if those comprehensive assessments had been done and would be looking daily to see that they were. She did not state how she had been monitoring that the assessments were completed prior to that day. She stated the assessments should be completed timely per the RAI manual, and she did not know why Resident #5's admission assessment had not been completed. She stated completing those comprehensive assessments was important for accuracy in providing proper care for the residents. Record review of the facility's undated policy titled Resident Assessment, reflected: A comprehensive assessment will be completed within 14 days of admission.The results of the assessment are used to develop, review, and revise the resident's comprehensive plan of care.Each assessment must be conducted or coordinated by a registered nurse who signs and certifies the completion of the assessment.

Based on interview and record review the facility failed to ensure residents were free of any significant medication error reviewed 5 of 5 (LVN E, LVN I, LVN J, LVN K and ADON A) staff reviewed for Insulin use. The facility failed to ensure LVN E held Resident #102's Lantus 100 Units/ML two (2) times when his blood glucose was under 120 for a two (2)-month review period. The facility failed to ensure LVN I held Resident #102's Lantus 100 Units/ML thirteen (13) times when his blood glucose was under 120 for a two (2)-month review period. The facility failed to ensure LVN J held Resident #102's Lantus 100 Units/ML three (3) times when his blood glucose was under 120 for a two (2)-month review period. The facility failed to ensure LVN K held Resident #102's Lantus 100 Units/ML six (6) times when his blood glucose was under 120 for a two (2)-month review period. The facility failed to ensure ADON A held Resident #102's Lantus 100 Units/ML six (1) times when his blood glucose was under 120 for a two (2)-month review period. These failures could place residents at risk of not receiving care and services to meet their needs. Findings include: Record review of Resident #102's face sheet, dated 02/19/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #102's medical diagnoses included dementia, psychotic disturbance, mood disturbance, and anxiety, mild cognitive impairment, morbid obesity, schizophrenia, essential hypertension, type 2 diabetes, and acute kidney failure. Record review of Resident #102's Annual MDS, dated [DATE], revealed in Section C - Cognitive Patterns-C0500 a BIMS Summary Score 09, which indicated the resident was moderately impaired. Section N-Medications, documented Resident #102 received Insulin. Record review of Resident #102's Comprehensive Care Plan, initiated 09/10/2023 and reviewed/revised 04/22/2025, revealed the following focused areas: Focus: Diabetes Mellitus: insulin dependent Goal: The resident will be free from any s/sx of hyperglycemia (High blood sugars). The resident will have no complications related to diabetes. The resident will be free from any s/sx of hypoglycemia (low blood sugar).Intervention Task: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Record review of Resident #102's physician order, with a start date of 04/05/2024 and a revision date of 08/04/2025, revealed: Lantus SoloStar Subcutaneous Solution Pen-injector 100UNIT/ML (Insulin Glargine), Inject 10 unit subcutaneously one time daily for hyperglycemia Hold if <120. Record review of Resident #102's electronic MAR for the months of January 2026, and February 2026 revealed insulins being administered when blood glucose was <120 revealed: 01/01/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 115 recorded by LVN-K.01/02/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 103 recorded by LVN-I.01/04/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 118 recorded by LVN-I. 01/16/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 117 recorded by LVN-I. 01/17/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 107 recorded by LVN-I. 01/19/2026 Lantus soloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 107 recorded by LVN-K.01/20/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 118 recorded by LVN-K. 01/23/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 102 recorded by LVN-K. 01/24/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 104 recorded by LVN-J. 01/25/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 91 recorded by LVN-J. 01/26/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 84 recorded by LVN-A. 01/30/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 92 recorded by LVN-I. 01/31/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 99 recorded by LVN-I.02/01/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 103 recorded by LVN-I. 02/02/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 118 recorded by LVN-K. 02/03/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 110 recorded by LVN-K. 02/04/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 114 recorded by LVN-I.02/05/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 114 recorded by LVN-I.02/07/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 one time a day with blood glucose of 109 recorded by LVN-E. 02/08/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 one time a day with blood glucose of 102 recorded by ADON-A 02/09/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 one time a day with blood glucose of 93 recorded by LVN-I.02/11/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 one time a day with blood glucose of 107 recorded by LVN-E.02/13/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 one time a day with blood glucose of 101 recorded by LVN-I.02/14/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 one time a day with blood glucose of 101 recorded by LVN-I.02/15/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 one time a day with blood glucose of 111 recorded by LVN-I.02/16/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 one time a day with blood glucose of 99 recorded by LVN-J. During an interview on 02/18/2026 at 3:10 PM, LVN-E stated if there was a check mark on the MAR with letters, it would have meant the medication had been administered to the resident. She stated if there was blood sugar below the parameter of 120, she would hold the insulin and check it again at a later time. LVN-E stated if she had a resident with a sliding scale, she would give/hold the insulin depending on the doctor's order and what the sliding scale was in place. She stated there would not have been any reason for her to give insulin if the blood sugar were outside the parameters. She stated if insulin was given if below the parameters, the side effects of the residents could bottom out (low blood sugar), then they would have to give something to bring the sugars back up. LVN-E stated it was the nurse's responsibility to document in the MAR whether the medication was given or not. She stated she felt the order for Resident #102 used to have an order with no parameters and did not know when it had changed to having parameters. During an interview on 02/18/2026 at 3:38 PM, the DON stated the medication Lantus for Resident #102's order had a parameter to hold if less than (<) 120. She stated if there was a check mark, it meant the medication was given. The DON stated she felt there was an order of no parameter a couple of months ago. She stated if doctors change orders they were discussed in the twenty-four (24) hour report. She stated if you had a blood sugar below the parameters the insulin should be held and if there was an order change or update, the LVN's and RNs should be aware of the change. She stated the nurses are briefed on changes during IDT meetings. The DON stated if you give insulin outside of those parameters, the side effects could be hypoglycemia (low blood sugar) and could have led to hospitalization and/or death. She stated the failure occurred with the nurses not paying attention to updated order changes and the DON for not monitoring the nurses close enough. During an interview on 02/18/2026 at 4:06 PM, MD-L, during a returned phone call, he stated if Resident #102's sugar was under the parameter, the nurses should not be giving his Lantus SoloStar Subcutaneous medication. He stated all nurses administering medications should have followed orders and it was his expectations to do so. Record review of the facility policy Physician Orders, dated 2015 revealed: Purpose:To monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident. Written Orders by the Physician or Nurse Practitioner:1. Nurse will review the order and if needed contact the prescriber for any clarifications2. The nurse will enter the order into PCC for the resident and select prescriber written3. If the order requires documentation, it will be directed to the proper electronic administration record once the order is completed. 4. The receiving nurse will contact any other department or external facilities as required, i.e. dietary department, pharmacy, lab provider, x-ray provider, etc.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed food safety. The facility failed to ensure foods were properly labeled in the kitchen. This failure could place residents at risk for food borne illnesses.Findings include: During an observation on 02/16/2026 between 9:02 AM and 9:24 AM, of the kitchen revealed: 2 boxes of bananas in the walk-in refrigerator appeared brown and/or bruised. The box was not labeled with the received date or use by date.1 - 106 oz can labeled Frutas Tropicals was dented along the top rim1 - 112 oz can labeled Banana Pudding was dented along the top rim1 - 116 oz can labeled Blueberry Topping was dented along the top rim1 - 7 lb 8 oz bottle labeled Chocolate Syrup was opened and not labeled with a received date or use by date1 - 15.8 oz bottle labeled Chocolate Syrup was not labeled with a received date or expiration date1 - 5 lb bag labeled white cake mix was not labeled with a received date or expiration date4 - 7.5 oz cans labeled Tomato Soup with no received or use by date1 - 5 lb bag labeled Cornbread Mix was not labeled with a received date or expiration date1 - 128 oz bottle labeled Liquid Smoke, was opened and not labeled with a received date or expiration date1 - 1 gallon bottle labeled Worcestershire Sauce was not labeled with a received date or expiration date2 - 5 lb bags labeled Pecans with 2 handwritten dates - one bag 10/30/25 and 12/30/25 and 2nd bag 10/15/25 and 12/15/254 - 24 oz bags labeled Lemon Gelatin Mix were not labeled with a received date or expiration date4 - 24 oz bags labeled Peach Gelatin Mix were not labeled with a received date or expiration date1 - 24 oz bag labeled Watermelon Gelatin Mix was not labeled with a received date or expiration date3 - 24 oz bags labeled Grape Gelatin Mix were not labeled with a received date or expiration date1 - 24 oz bag labeled Orange Gelatin Mix was not labeled with a received date or expiration date1 - 24 oz bag labeled Berry Blue Gelatin Mix was not labeled with a received date or expiration date1 - 24 oz bag labeled Banana Gelatin Mix was not labeled with a received date or expiration date1/2 bag labeled Lime Gelatin Mix with a handwritten date of 1/18/26 and use by date of 1/24/261 squeeze bottle containing an orange color liquid with no label and was not labeled with a received date or expiration date During an interview on 02/18/2026 at 8:13 AM, DA-F stated all staff were responsible for putting up grocery deliveries. She stated the staff members putting up the deliveries marked all items/boxes with the date delivered and once opened the item was marked with a use by date. During an interview on 02/18/2026 at 8:13 AM, DA-G stated all food items were marked with received date and use by date when opened. She stated the DM was responsible for monitoring for expiration or use by dates and removal of items out of date. During a follow up interview on 02/19/2026 at 9:25 AM, DA-F stated she received training on labeling and storage when she was hired by the staff member assigned to train her. DA-F stated a possible effect on residents for failing to properly label food items could have been spoiled food that could make someone sick. During an interview on 02/19/2026 at 10:27 AM, the DM stated all kitchen staff were responsible for dating food items when delivered. The DM stated she was responsible for monitoring that food items were properly dated. She explained staff training consisted of reviewing policies with the DM, and a tour of food storage areas with an explanation of the process for receiving food deliveries. She stated her expectations were for all staff to follow the policy and label all food items. The DM stated the effect on residents may be a food item may go bad, or staff would not know how old a food item was. She stated she monitored dates and discarded all food items out of date. Record review of the Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code, accessed 02/19/2026 reflected 3-602.11 Food Labels.(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers.(B) Label information shall include:(1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement .refrigerated foods must be consumed, sold or discarded by the expiration date. Record review of facility's, undated, Policy titled Food Storage and Supplies, revealed Procedure 6. If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as to when it is received, and shelf-stable items will be stored in a 'first in, first out' manner, to be used within one year. 7 .products without a dated shipping label should be dated when they are received by the facility so there is a method to keep track of the age of the product. 9. Perishable and non-perishable foods are classified based on their pH and water content. Any food with a pH of less than 4.2 OR a water activity of less than 88% . is automatically classified as perishable or non-perishable based on the tables in the Texas Food Establishment rules (October 2015 edition, page 19). Food manufacturers must determine whether their products meet the perishable criteria when determining whether they are required to declare expiration dates according to the Food and Drug Administration which regulates their manufacturing processes. If a manufacturer is not required to declare an expiration date, then that means that time is not a criteria in determining whether the product is safe to consume. Non-perishable foods meet the criteria in the Texas Food Establishment rules for classifying foods as non-time and temperature controlled for safety foods (NTCS). NTCS foods do not use time or temperature as a criteria for determining food safety. These non-perishable foods are still dated when received if they do not have an expiration date and once opened, but do not need to be discarded within 7 days after opening. Perishable items that are refrigerated are dated once opened and used within 7 days (if they do not have an expiration date or best by/use by date), but non-perishable items that are refrigerated once opened should be dated when opened but do not need to be discarded until their expiration date or until the quality has deteriorated.

Based on interview and record review the facility failed ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 26 residents (Resident #6) reviewed for accurate records.1. The facility failed to have documentation to indicate why Resident #6's long-acting insulin (insulin glargine) was held when chart codes indicated see nurse notes.2. The facility failed to have parameter for Resident #6's long-acting insulin (insulin glargine) documented in physician orders.These failures could place residents of an accurate depiction of care in the facility.Findings include:Record review of Resident #6's electronic physician orders, dated 09/24/2025, reflected Basaglar KwikPen Subcutaneous Solution Pen - Injector 100 unit/ml (insulin glargine) Inject 14 unit subcutaneously two times a day related to type 2 diabetes mellitus without complications. There was no evidence MD-M had parameters to hold insulin if FSBS was less than 70.Record review of Resident #6's electronic face sheet, dated 02/19/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #6 had a diagnosis which included type 2 diabetes (a chronic condition where the body cannot effectively use insulin or produce enough of it, causing sugar to build up in the blood.) Further review of her electronic face sheet reflected MD-M was her primary physician.Record review of Resident #6's quarterly MDS, dated [DATE], reflected a BIMS score of 05, which indicated severe cognitive impairment. Resident #6 took high-risk drug classes which included hypoglycemic (including insulin). Record review of Resident #6's comprehensive care plan, dated 11/13/2023, reflected Focus: The resident has Diabetes Mellitus.Intervention Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness.Record review of Resident #6's MAR, dated January 2026, reflected: Insulin glargine held on 1/3/2026 a.m. dose with code 9 (= other / see nurses notes) used. Insulin glargine held on 1/8/2026 a.m. dose with code 11 (= BS within normal limits no admin required) used. Insulin glargine held on 1/12/2026 a.m. dose with code 12 (no chart code found) used. Insulin glargine held on 1/17/2026 p.m. dose with code 11 (= BS within normal limits no admin required) used. Insulin glargine held on 1/21/2026 p.m. dose with code 9 (= other / see nurses notes) used. Insulin glargine held on 1/27/2026 a.m. dose with code 9 (= other / see nurses notes) used. Insulin glargine held on 1/31/2026 a.m. dose with code 11 (= BS within normal limits no admin required) used.Record review of Resident #6's MAR, dated February 2026, reflected: Insulin glargine held on 2/1/2026 a.m. dose with code 11 (= BS within normal limits no admin required) used. Insulin glargine held on 2/3/2026 p.m. dose with code 2 (= drug refused) used. Insulin glargine held on 2/13/2026 a.m. dose with code 5 (= hold / see nurses notes) used. Insulin glargine held on 2/14/2026 a.m. dose with code 9 (= other / see nurses notes) used. Insulin glargine held on 2/18/2026 a.m. dose with code 9 (= other / see nurses notes) used.Record review of Resident #6's progress notes reflected no notes about insulin not being administered or the physician being notified of holding insulin glargine on 1/3/2026, 1/8/2026, 1/12/2026, 1/17/2026, 1/21/2026, 1/21/2026, 1/27/2026, 1/31/2026, 2/1/2026, 2/3/2026, 2/13/2026, or 2/14/2026. There was a progress note written by LVN-C, dated 2/18/2026 at 3:42 p.m., which reflected Message sent to [MD-M] informing of holding glargine insulin this a.m. FSBS ran off and placed in his box on next review and asked if we could have a hold order if FSBS under what FSBS. There was another progress note written by LVN-C, dated 2/18/2026 at 5:45 p.m., which reflected [MD-M] replied hold if FSBS under 70. During an interview on 02/18/2026 at 2:59 p.m., LVN-C stated she did not administer insulin glargine that morning. She stated she had put in code 9, which meant other / see nurses notes and thought the system would automatically generate and progress note stating why the medication was held. She stated MD-M usually did not want insulin given if a resident's blood sugar reading was under 70. She stated she usually would reach out to the physician when the medication was held at the end of her shift unless she felt it was an emergency. She stated she also printed out a list of blood sugar readings and placed them in the physician's bin to review when he was in the building next. She stated she would make a note in the progress notes when she notified the physician about insulin levels and would ask for a parameter. She stated she thought she told MD-M about Resident #6's blood sugar readings in the past and MD-M told her to hold the insulin glargine. She stated she could not find documentation in the progress notes about that conversation. She stated it was the responsibility of the nurse who held the medication to notify the physician and they should also make a note in the electronic medical record about the physician notification. She stated it was important to notify the physician about holding medications so the physician would know what was going on with their patient. She stated not documenting communication could lead to her being accused of neglect due to no proof that communication had occurred and the resident could receive the wrong care.During an interview on 02/18/2026 at 3:24 p.m., the DON stated she expected the nurses to follow physician's orders. She stated if a medication was held, she expected the nurse to notify the physician right away. She stated she did not know if the nurse notified the physician since the communication between the nurse and physician should be documented in the electronic medical record if the nurse notified the physician. She stated she did monitor the nurses' documentation but she could not monitor all of the MARs of every resident. She stated moving forward, she believed medication education and documentation education needed to occur due to multiple nurses holding the medication and no progress notes were written. She stated the effect of not giving the medication could be hyperglycemia, heart failure, and death. She stated Resident #6 made improvement since she had been a resident at the facility and did not feel any negative impact occurred. She stated not documenting physician communications and updating orders could lead to other staff not knowing parameters of the medication or if the physician had been notified. During a telephone interview on 02/18/2026 at 4:30 p.m., MD-M stated he expected for nursing staff to hold insulin glargine if the resident had a FSBS less than 70. He stated he did remember being notified of Resident #6's blood sugars in the past and holding of the insulin glargine but could not remember exactly when and how many times because he had a lot of patients. He stated he had no concerns about not being notified by the facility's nurses. He stated he would expect the order in Resident #6's electronic medical record to have the parameter to hold insulin glargine if her FSBS was less than 70 and stated different staff putting in his orders may not have carried over the parameter. He stated he was in the building several times a week and the facility nurses always asked him questions about his patients. He stated if those conversations were not documented, it was probably just a slip up in documentation and not a communication issue.Record review of the facility's, undated, policy titled Physician's Orders, reflected Nurse will review the order and if needed contact the prescriber for any clarifications.Clarify all communications.Ensure all elements of the order are included.Immediately transcribe verbal / telephone orders into the patient's medical record or onto a prescription pad as they are being communicated. Read the order back to the prescriber for verification.Record review of the facility's policy titled Medication Administration Procedures, dated 10/25/2017, reflected If a dose of regularly scheduled medication is withheld or refused, the nurse is to initial and circle the front of the medication administration record in the space provided for that dosage administration and an explanatory note is to be entered in the nursing notes or in the PRN nurses notes section of the medication administration record. In the presence of individual facility policies concerning refused and held documentation, the facility policy supersedes this policy.Record review of the facility's, undated, policy titled Documentation, reflected The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets.Document in the clinical record regarding notification of the physician of abnormal diagnostic test or laboratory results and any new orders or follow-up from the physician.

Based on observation, interview and record review the facility failed to ensure regular inspections were conducted of all bed frames, mattresses, and bed rails, as part of a regular maintenance program to identify areas of possible entrapment for 3 of 4 residents (Resident #7, Resident #22 and Resident #48) reviewed for physical environment.The facility failed to conduct regular inspections of resident side rails, bed frames and mattresses to identify entrapment risks for Resident #7, Resident #22, and Resident #48.This failure could place residents at risk of injury, equipment malfunction, entrapment, or falls.Findings include: Record review of Resident #7's electronic face sheet, dated 02/19/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #7 had diagnoses which included paraplegia (the impairment or total loss of motor and sensory function in the lower half of the body, usually affecting the legs, feet, and sometimes the torso), history of falling, and muscle spasm (a sudden, involuntary, and often painful tightening of a muscle that cannot relax).Record review of Resident #7's quarterly MDS, dated 12/4082025, reflected a BIMS score of 11, which indicated she had moderate cognitive impairment. Resident #7 needed substantial to maximal assistance with bed mobility.Record review of Resident #7's comprehensive care plan, dated 01/07/2025, reflected she was able to hold the rail while getting peri care.Record review of Resident #7's electronic physician orders, dated 04/20/2023, reflected Resident #7 may have bilateral assist rails to the bedside to promote safety with turning, repositioning, transferring and bed mobility.Record review of the facility document Bed Rail Assessment, dated 09/20/2025, for Resident #7 reflected no evidence that regular inspections and maintenance of resident bed frames, mattresses, and bed rails, to identify areas of potential entrapment hazards for Resident #7.During an observation and interview on 02/17/2026 at 9:44 a.m., revealed Resident #7 was lying in bed with bed rails to both sides of the bed and in the up position. Resident #7 stated she used the bed rails when in the bed to help staff turn her.Record review of Resident #22's electronic face sheet, dated 02/19/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #22 had diagnoses which included dementia (a general term for a range of conditions affecting memory, thinking, and social abilities) and Alzheimer's disease (the most common cause of dementia, affecting memory, thinking, and behavior). Record review of Resident #22's quarterly MDS assessment, dated 01/10/2026, reflected a BIMS score of 12, which meant moderate cognitive impairment. Resident #22 used a walker, needed supervision or touching assistance with rolling in bed, going from lying to sitting, going from sitting to standing, and transferring from the bed to the chair. Record review of Resident #22's comprehensive care plan, dated 05/22/2024, reflected the resident had an actual fall on 05/10/2024 and was assessed and provided a hand assist bar for assistance with transfers and maintain independence. Resident #22's care plan noted she needed assistance x 1 for transfers.Record review of Resident #22's electronic physician orders reviewed on 02/19/2026 reflected no order for the use of bed rails.Record review of facility document Bed Rail Assessment, dated 08/21/2025, for Resident #22 reflected no evidence that regular inspections and maintenance of resident bed frames, mattresses, and bed rails, to identify areas of potential entrapment hazards for Resident #22.During an observation and interview on 02/16/2026 at 10:31 a.m., revealed Resident #22's bed had a mobility bar to the right of her bed. Resident #22 was sitting in a chair in her room. The right mobility bar was loose and moved approximately one inch when pushed against. Resident #22 stated she used the bar for getting out of bed. She stated she did not notice that it was loose and did not know if she told anyone about the loose bar. Resident #22 could not provide an explanation to how long the rail had been loose.During an observation and interview on 02/19/2026 at 10:33 a.m., the DON stated she expected all residents who utilized bed rails to have staff member assess the beds to make sure they rails were tight and fit the bed properly. The DON stated she was asked by Maint D just before the survey had started for a list of residents who utilized bed rails and she did not have the chance to get that list to him. She stated, prior to Maint D assessing the bed, there were Champion Rounds where leadership staff were assigned to go into resident's rooms and check equipment to make sure it was in working order. She stated she was unsure who was assigned to Resident #22 and verified the bed rail was loose and needed to be tightened. She told Maint D. which room Resident #22 was in so he could tighten the quarter bed rail.3. Record review of Resident #48's electronic face sheet, dated 02/19/2026, reflected a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #48 had diagnoses which included dementia (a general term for a range of conditions affecting memory, thinking, and social abilities), left femur fracture (broken left hip bone), obesity (increased body mass index greater than being overweight) and pain.Record review of Resident #48's quarterly MDS assessment, dated 11/17/2025, reflected a BIMS score of 15, which meant cognitively intact. Resident #48 used a walker and wheelchair, needed setup assistance for bed mobility and supervision for transfers.Record review of Resident #48's comprehensive care plan, dated 02/02/2026, reflected 1/8 rail to be used on left and right side of the bed. Further review of the care plan reflected staff to perform a bed rail assessment at least every quarter.Record review of Resident #48's electronic physician orders, dated 1/28/2026, reflected Resident #48 may use bed rail/grab assist bar on the bed for bed mobility.Record review of the facility document Bed Rail Assessment, dated 02/13/2026, reflected no evidence that regular inspections and maintenance of resident bed frames, mattresses, and bed rails, to identify areas of potential entrapment hazards for Resident #48.During an observation and interview on 02/17/2026 at 1:19 p.m., revealed Resident #48 was sitting in a wheelchair in his room. There were bed rails on his bed on both sides. Resident #48 stated they helped him move around in his bed.During an interview on 02/19/2026 at 10:35 a.m., Maint D stated he did not have a system in place for assessing the bed rails. He stated he asked for a list of residents who used bed rails but had not performed any assessments on the bed rails. He stated the direct care staff would notify him if the bed rails were loose and he would go and tighten them. He did not have anything in the computer system the facility used to report maintenance issues for Resident #22. He stated he would be notified of items that needed to be maintained during the morning stand-up meetings but he had not been notified of Resident #22's bed rail being loose.During an interview on 02/19/2026 at 10:39 a.m., the ADMN stated she expected the Champion Round representative, SW-B, to notice Resident #22's bed rail was loose and report to the Maint D during morning meeting. Or, for SW-B to enter the loose bed rail in the maintenance tracking computer system. She stated she would monitor the issue that had been corrected by watching the maintenance tracking log system. The ADMN stated the facility did not have a process in making sure the Champion Round representative was checking bed rails when they checked on the residents they were assigned to. She stated she had not been informed of the loose bed rail for Resident #22 and that was why she had not been tracking that the work had been completed. She stated not performing the regular maintenance checks on bed rails could cause harm by the resident falling when using the loose bed rail or entrapment from the rail not being tight.During an interview on 02/19/2026 at 10:50 a.m., SW-B stated she performed Champion Rounds for Resident #22. She stated the Champion Round would be done by her entering the residents' rooms twice a day and making sure items were in working order. She stated she was told to look at the bed to make sure it was in working order but she had not been instructed on how to assess the bed rails. She stated she assumed the therapist or direct care staff were checking the bed rails for tightness during their assessments. She stated she would ask the residents if everything was in working order but did not physically check the bed to see if the bed rails were tight. She stated Resident #22 had not told her there was anything wrong with her bed and that was why she had not reported it to Maint D.Record review of facility's policy titled Bed Rails, dated November, 8 2016, reflected The facility will conduct regular inspection of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment and ensure rails are installed according to manufacturer recommendations. When bed rails and mattresses are used and purchased separately from the bed frame, the facility must ensure that the bed rails, mattress, and bed frame are compatible.

Based on interview and record review the facility failed to ensure the resident had the right to be informed of, and participate in, his or her treatment including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he/ she preferred for 1 of 6 residents (Resident #8) reviewed for antipsychotic consents.The facility failed to ensure Resident #8 or their representative signed consent for antipsychotic medication aripiprazole (an antipsychotic medication used to treat mental health disorders, such as schizophrenia) prior to administering medication after dosage increased and prior to administering new dosage ordered by physician. This failure could affect residents by placing them at risk of not being informed of their health status which would allow them to make informed decisions regarding their care.Findings include: Record review of Resident #8's electronic face sheet, dated 02/19/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #8 had a diagnosis which included bipolar disorder (a chronic mental health condition characterized by intense, extreme shifts in mood, energy, and activity levels).Record review of Resident #8's significant change MDS, dated [DATE], reflected a BIMS score of 15, which meant cognitively intact. Resident #8 was taking high risk antipsychotic medication.Record review of Resident #8's comprehensive care plan, dated 03/13/2024, reflected Resident #8 required anti-psychotic medication with interventions which included educate the resident / family / caregivers about risks, benefits and side effects.Record review of Resident #8's electronic physician orders reflected Resident #8 started taking risperidone 1mg in the AM and 2mg in the PM starting on 01/28/2026. Resident #8's risperidone was changed to 2mg in the AM and PM starting on 2/18/2026. Record review of Resident #8's MAR, dated January 2026, reflected Resident #8 received risperidone 1mg in the AM and 2mg in the PM starting the night of 01/28/2026 - 01/31/2026.Record review of Resident #8's MAR, dated February 2026, reflected Resident #8 received risperidone 1mg in the AM and 2mg in the PM from 02/01/2026 - 02/18/2026 AM. Resident #8 received risperidone 2mg twice a day starting the night of 02/18/2026 - 02/19/2026.Record review of Resident #8's electronic medical chart, accessed on 02/18/2026, reflected no evidence she or her representative consented to risperidone prior to receiving the medication starting on January 28, 2026, using HHSC Form 3713. There was no evidence she or her representative agreed to a dosage increase on February 18, 2026, using HHSC Form 3713.During a telephone interview on 02/19/2026 at 1:09 p.m., Resident #8's representative stated she had been informed about the risperidone changes. She stated Resident #8 had been on the medication in the past and was happy the medication had been ordered. She stated she was informed about the increase in dosage. She stated she had not signed a form stating she was informed about the risks from the medication. She stated she was not able to come up to the facility frequently and stated she would sign the next time she went to the facility. During an interview on 02/19/2026 at 1:07 p.m., ADON-A stated she was responsible for getting the HHSC state form 3713 signed by residents or their representatives prior to the medication being administered. She had a form from 2024 with consent for risperidone and the dosage was 1mg. She stated a new consent should be obtained when there was a dosage change and not getting the consent could cause the representative to not be able to make an informed decision about the medication. She stated she had not been told by the psychiatric physician he was changing Resident #8's medications and that was why she had not gotten the form signed.During an interview on 02/19/2026 at 1:15 p.m., the DON stated consents for antipsychotic medications should have been obtained prior to the medication being administered. She stated ADON-A was responsible for obtaining those consents and she monitored those consents were obtained. She stated the psychiatric physician placed the order in the electronic system without notifying her or the ADON-A of the medication change which led to the failure of obtaining the consent. She stated not obtaining the consent could cause Resident #8's representative to not make an informed decision. She stated she was unaware who notified Resident #8's representative of the medication change.During an interview on 02/19/2025 at 4:20 p.m., LVN A stated nurses were responsible for obtaining medication consent for psychoactive medications. She stated nurses got the consent prior to giving the medication. She stated sometimes the DON would assist with getting psychoactive medications. LVN A stated there was a form that would be filled in on the electronic medical system under the observations section. She stated after the form was filled out then the process would be to print the form and get a physical signature on the form. She stated it was okay to get a verbal consent if person not available in person to sign the form and when a verbal was obtained the DON would be notified. She stated as far as she knew, there was not another process for medications like Seroquel that were antipsychotics.Record review of facility's policy titled Psychoactive Medications, dated 10/25/2017, reflected A psychotropic consent form explains the risks and benefits of psychotropic medication. The resident or their representative must provide documented consent prior to administration of a newly ordered psychotropic medication.Consent for antipsychotics must be in a written form. Phone or verbal consent is not allowed. Permission given by or a request made by the resident and/or representative does not serve as a sole justification for the medication itself.Record review of drugs.com accessed on 02/19/2026 at https://www.drugs.com/risperidone.html, revealed risperidone .Drug class: Atypical antipsychotics .Warnings Risperidone carries a Boxed Warning for increased risk of death in elderly patients with dementia-related psychosis. It is not approved for use in older adults with dementia-related psychosis.Most Common Side Effects Headache; Blurred vision, rash; Dizziness, drowsiness, tired feeling; Tremors, twitching or uncontrollable muscle movements, numbness; Depressed mood, agitation, anxiety, feeling restless; Back pain, muscle or joint pain, pain in your arms or legs; Upset stomach, constipation, dry mouth; Upper stomach pain, nausea, vomiting, diarrhea; Increased salivation; Cold symptoms such as a stuffy nose, sneezing, sore throat; Increased appetite, weight gain. High doses or long-term use of risperidone can cause a serious movement disorder that may not be reversible. The longer you use risperidone, the more likely you are to develop this disorder, especially if you are a woman or an older adult.

Based on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days, except if the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the residents medical record and indicate the duration for the PRN order for 2 of 7 residents reviewed for unnecessary medications. The facility failed to ensure Resident #40's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or document a rationale for the continued provision of the medication.The facility failed to ensure Resident #117's PRN Diazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or document a rationale for the continued provision of the medication. These failures could place residents at risk for adverse reactions and negative side effects from the administration of medication and dependence on unnecessary medications.Findings include: 1. Record review of Resident #40's electronic face sheet, dated 02/18/2026, revealed an [AGE] year-old female initially admitted to the facility on [DATE] with a recent admission date of 05/05/2025. Resident #40 was admitted with medical diagnoses which included dementia (a decline in mental ability), anxiety (a feeling or worry or nervousness), and abnormal weight loss. Record review of Resident #40's Quarterly MDS assessment, dated 01/11/2026, revealed in Section C - Cognitive Patterns, subsection C0100 Should Brief Interview for Mental Status (C0200-C0500) be Conducted? 0 was entered, which indicated No (resident is rarely/never understood). Section review of Section N - Medications, subsection N0415. High-Risk Drug Classes: Use and Indication, B. Antianxiety 1. Is taking and 2. Indication noted were checked. Record review of Resident #40's Comprehensive Care Plan, last revised 02/02/2026, revealed: Problem: The resident uses anti-anxiety medications, Interventions/Tasks Give anti-anxiety medications ordered by physician. Monitor/document side effect and effectiveness. Record review of Resident #40's electronic Physicians Orders revealed: LORazepam Oral Tablet 0.5 mg (Lorazepam) Give 1 tablet by mouth every 6 hours as needed for Combative/anxiety One 0.5mg tablet by mouth every 6 hours as needed. Order date 10/17/1015, Start Date 10/17/2025. A stop date was not included in the physician's order. Record review of Resident #40's November 2025 MAR revealed no doses of Lorazepam were administered. Record review of Resident #40's December 2025 MAR revealed no doses of Lorazepam were administered. Record review of Resident #40's January 2026 MAR revealed no doses of Lorazepam were administered. Record review of Resident #40's February 2026 MAR until 02/18/2026, revealed no doses of Lorazepam were administered. Record review of Resident #40's physician progress notes revealed no evidence of documented rationale to order PRN Lorazepam for more than 14 days. 2. Record review of Resident #117's electronic face sheet, dated 02/18/2026, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #117 had medical diagnoses which included dementia and chronic obstructive pulmonary disease (difficulty breathing). Record review of Resident #117's Annual MDS, dated [DATE], revealed in Section C-Cognitive Patterns, subsection C0500. BIMS Summary Score, the resident scored 7 out of 15, which indicated moderate cognitive impairment. Review of Section N - Medications, subsection N0415. High-Risk Drug Classes: Use and Indication revealed Resident #117 was receiving anti-anxiety medication. Record review of Resident #117's Comprehensive Care Plan, last revised 02/02/2026, revealed Focus: The resident requires antidepressant medication for new onset of anxiety with agitation. Goal: The resident will show decreased episodes of s/sx of anxiety and agitation . Interventions/Tasks: Monitor/document/report to MD PRN ongoing s/sx of anxiety, aggression, agitation. Record review of Resident #117's electronic Physicians Orders revealed: Diazepam Gel 10 mg/mL Apply to wrist topically every 4 hours as needed for Anxiety; Agitation. Order date 06/03/2025, start date 06/03/2025. Diazepam suspension 5 mg/0.5mL. Give 5 mg sublingually (under the tongue) every 4 hours as needed for Anxiety; Agitation. Order date 06/02/2025, start date 06/03/2025. A stop date was not noted in the physician's order. Record review of Resident #117's December 2025 MAR revealed 1 dose of diazepam suspension was administered. Record review of Resident #117's January 2026 MAR revealed 1 dose of diazepam suspension was administered and 2 doses of diazepam gel was administered. Record review of Resident #117's February 2026 MAR up until 02/18/2026, revealed no doses of diazepam suspension or diazepam gel were administered. Record review of Resident #117's physician progress notes revealed no evidence of documented rationale to order PRN diazepam for more than 14 days. During an interview on 02/19/2026 at 10:43 AM, RN-H stated she started working at facility one week ago. She explained the nurse who received orders was responsible for entering a 14-day stop date. She stated the DON was responsible for monitoring stop dates. RN-H stated training on receiving and entering PRN physician orders included her nursing education and a review of policies during new hire orientation. She was unable to state how failing to enter a stop date on psychotropic PRN medications may affect a resident.During an interview on 02/19/2026 at 11:01 AM, the DON stated the nurse who received an order for a PRN psychotropic medication was responsible for ensuring a stop date was entered. She explained monitoring the accuracy of orders entered which included a stop date was done by the nursing staff. The DON stated staff training consisted of reviewing the medication policies during new hire orientation and periodically. She stated her expectations were for a 14-day stop date to be entered when a new PRN medication order was put into the system. The DON stated the effect on residents of failing to enter a stop date for psychotropic PRN medications could have been a long-term medication effect and it could have impacted a resident's gradual dose reduction. During an interview on 02/19/2026 at 12:46 PM, ADON-A stated she thought all the nurses were entering stop dates as per policy. Record review of the facility's policy titled Psychotropic Drugs, revised 10/25/2027, revealed in part: The facility must will ensure that - 4. PRN orders for psychotropic drugs are limited to 14 days. and 5. PRN orders for anti-psychotic drugs are limited to 14 days .

Based on observation, interview and record review the facility failed to review the risks and benefits of bed rails with the resident or a resident representative and obtain informed consent prior to installation for 1 of 4 residents (Resident #22) reviewed for bed rail consents. The facility failed to obtain informed consent from Resident #22 or her representative or maintain evidence that Resident #22 or her representative had been provided with sufficient information so that they could make an informed decision prior to installing bed rails.This failure could place residents at risk for not being able to make an informed decision due to not having sufficient information on the risks of bed rail usage.Findings include:Record review of Resident #22's electronic face sheet, dated 02/19/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #22 had diagnoses which included dementia (a general term for a range of conditions affecting memory, thinking, and social abilities), and Alzheimer's disease (the most common cause of dementia, affecting memory, thinking, and behavior). Record review of Resident #22's quarterly MDS assessment, dated 01/10/2026, reflected a BIMS score of 12, which meant moderate cognitive impairment. Resident #22 used a walker, needed supervision or touching assistance with rolling in bed, going from lying to sitting, going from sitting to standing, and transferring from the bed to the chair. Record review of Resident #22's comprehensive care plan, reviewed on 02/19/2026, reflected the resident had an actual fall on 05/10/2024 and was assessed and provided a hand assist bar for assistance with transfers and maintain independence. Resident #22's care plan noted she needed assistance x 1 for transfers.Record review of Resident #22's electronic physician orders, reviewed on 02/19/2026, reflected no order for the use of bed rails.Record review of Resident #22's electronic records on 02/19/2026 revealed no evidence of an informed consent for the use of bed rails.During an observation and interview on 02/16/2026 at 10:31 a.m., Resident #22's bed had a mobility bar to the right of her bed. Resident #22 was sitting in a chair in her room. The right mobility bar was loose and moved approximately one inch when pushed against. Resident #22 stated she used the bar for getting out of bed. She stated she did not notice it was loose and did not know if she had told anyone about the loose bar. During an observation and interview on 02/19/2026 at 10:33 a.m., the DON stated she expected all residents to have an informed consent for mobility bars / bed rails prior to them being installed on a resident's bed. The DON stated she started working in the facility as the DON in October 2025 and she made sure all residents who utilized mobility bars had a consent along with other items for those bars. She stated she was unsure why she missed Resident #22 not having a consent for the mobility bar at that time. She stated the facility did not have to have a physician's order to install mobility bars because they were to promote independence and not used as a restraint. She stated Resident #22 used the bar to help transfer out of bed. She stated Resident #22 had the bar before she started working in the facility and did not know who was responsible for getting that consent prior to her becoming the DON. She stated she monitored that the consents were obtained. The DON stated consents were to inform residents and their representatives of the risks as well as the benefits of having those mobility bars. Resident #22 was lying in bed and had a mobility bar to the right of her bed during the interview. The mobility bar continued to be loose.During an interview on 02/19/2026 at 1:17 p.m., ADON-A stated she was not responsible for obtaining consents for bed rails or mobility bars. She stated she did not know who was responsible for obtaining those consents.During an interview and record review on 02/19/2026 at 1:24 p.m., the ADMN stated she expected facility policies and regulations to be followed. She stated she had been the ADMN of the facility for about 3 months and did not know why the consent had not been obtained and should have been obtained prior to bed rails being utilized. Record review of the facility's policy titled Bed Rails, dated November 8, 2026, reflected Consent - The resident and/or resident representative will provide consent for the use of rails prior to installation.

Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable and, in accordance with State and Federal laws, drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 26 residents (Resident # 25)reviewed for label and storage of drugs and biologicals. The facility failed to ensure Resident #25's medications were locked and labeled when unattended.This failure could place residents at risk of having access to unauthorized medications, leading to possible harm or drug diversions. Findings include: Record review of Resident #25's electronic face sheet, dated 02/19/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #25 had diagnoses which included multiple sclerosis (a chronic, inflammatory and autoimmune disease of the central nervous system that causes widespread damage to the protective covering of nerve fibers, leading to communication problems between the brain and the rest of the body) and pain in knee.Record review of Resident #25's quarterly MDS assessment, dated 02/06/2026, reflected a BIMS score of 11, which meant moderate cognitive impairment. Resident #25 was on high-risk medication in the class of antidepressant and opioid.Record review of Resident #25's comprehensive care plan, reviewed on 02/19/2026, reflected the following focused areas: Resident #25 required antidepressant medication, date initiated 08/23/2026, with intervention to give antidepressant medications ordered by physician; Resident #25 required anti-anxiety medication, date initiated 08/23/2026, with intervention to give anti-anxiety medications ordered by physician.Record review of Resident #25's MAR, dated 02/16/2026, reflected the following medications were given by MA-D that morning: Atorvastatin Calcium Oral Tablet 40 MG (Atorvastatin Calcium) Give 1 tablet by mouth one time a day; Lexapro Oral Tablet 5 MG (Escitalopram Oxalate) Give 1 tablet by mouth one time a day; Myrbetriq Oral Tablet Extended Release 24 Hour 25 MG (Mirabegron) Give 1 tablet by mouth one time a day; Potassium Chloride ER Oral Tablet Extended Release 10 MEQ (Potassium Chloride) Give 1 tablet by mouth one time a day; Thiamine HCl Oral Tablet 100 MG (Thiamine HCl) Give 1 tablet by mouth one time a day; Vitamin D3 Oral Tablet 25 MCG (1000 UT) (Cholecalciferol) Give 2 tablet by mouth one time a day; ZyrTEC Allergy Oral Tablet 10 MG (Cetirizine HCl) Give 1 tablet by mouth one time a day; Baclofen Oral Tablet 5 MG (Baclofen) Give 1 tablet by mouth two times a day; Carvedilol Oral Tablet 6.25 MG (Carvedilol) Give 1 tablet by mouth two times a day; Diroximel Fumarate Oral Capsule Delayed Release 231 MG (Diroximel Fumarate) Give 2 capsule by mouth two times a day. May take aspirin 325mg 30 minutes prior to Diroximel Fumarate oral capsule DR 231mg administration to reduce side effects; hydrOXYzine Pamoate Oral Capsule 50 MG (Hydroxyzine Pamoate) Give 1 capsule by mouth two times a day; Gabapentin Oral Tablet 600 MG (Gabapentin) Give 1 tablet by mouth three times a day.Record review of Resident #25's electronic medical record, on 02/16/2026, revealed no evidence of a completed assessment for self-administering of medication.During an observation and interview on 02/16/2026 at 09:35 a.m., Resident #25 was found to have 9 medications in a pill cup on her bedside table. Resident #25 was lying in bed during the observation. Resident #25 stated she did not want to get anyone in trouble and the medication aide usually did not leave medications on her table in a cup. She stated the medication aide knew she would take them. She would not give the name of the person who passed medications that morning.During an interview on 02/16/2026 at 10:17 a.m., MA-D stated she had not passed medications to Resident #25 that morning. She stated she placed the medications in a medication cup and handed them to Resident #25. She stated she saw Resident #25 raise the medication cup to her mouth but did not watch Resident #25 place the medication cup down. She stated she thought Resident #25 took all her medications. She stated the medication she placed in the pill cup would have been more than 9 and stated Resident #25 must not have swallowed all of them. She stated she knew she should have made sure all of the medications were gone out of the cup before leaving the room and thought that the resident had taken all of the medications. She stated a cup of medications on the bedside table could have led to another resident taking them or Resident #25 taking them at the wrong time leading to medication errors. During an interview on 2/16/2026 at 11:05 AM, the DON stated she expected medications not to be left at the beside. She stated she thought MA-D must have thought Resident #25 took all the medications, and that was why she left the room. The DON stated anyone who passed medications should have made sure all the medications were consumed. She stated medications should not be left unattended because it could cause other residents to take the medications or cause residents to take the medication at the wrong time. She stated she would re-educate nursing staff on proper medication administration. She stated she monitored that nursing staff administered medications appropriately and she had not been concerned about staff leaving medications at the bedside in the past. The DON stated she thought that was a one-time occurrence. Record review of the facility's policy titled Medication Storage in the Facility, dated 2025, reflected Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedure 1. [facility pharmacy] dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices where applicable. Medications are kept and stored in these containers. Transfer of medications from one container to another is done only by a pharmacist. 2. Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications (e.g. medication aides) are allowed unsupervised access to medications. Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access.

Based on interview and record review the facility failed to ensure that a resident received CPR in accordance with professional standards of practice for one (Resident #1) of six resident's reviewed for CPR. On [DATE] at 12:20 am, LVN A failed to initiate CPR on Resident #1 who was a full code status. Resident #1 expired on [DATE]. An Immediate Jeopardy was identified on [DATE] at 5:00 pm. The noncompliance began on [DATE] and ended on [DATE]. It was determined to be past non-compliance due to the facility having implemented action that corrected the non-compliance prior to the beginning of the investigation. This failure could affect residents who are full code status and could need CPR by placing them at risk of death. Findings included: Record review of Resident #1's admission Record, dated [DATE] revealed an [AGE] year-old female, with an original admission date of [DATE] and the latest readmission date of [DATE]. The resident expired on [DATE]. The resident had a primary diagnoses of unspecified dementia (the specific type of dementia cannot be clearly identified, despite the presence of cognitive decline and memory loss) and congestive heart failure (hearts ability to pump blood is compromised). The resident was under the care of hospice. Resident #1 was a full code. Resident #1 had a BIMS score of 14 indicating she was cognitively intact. Record review of Resident #1's Physician's Orders, dated [DATE], revealed an active order with a start date of [DATE] for full code. Record review of Resident #1's Care Plan, last revised on [DATE] revealed the following: Focus: Full Code/CPR in place. Goal: Resident has an order for CPR to be initiated will be followed. Interventions: Initiate CPR if the resident is without a heartbeat or not breathing. Notify EMS. Record review of Resident #1's progress noted, dated [DATE] at 3:40 am, by LVN A, revealed the following [in part]: [12:05 am] aide at this time has reported that patient is noted breathing abnormally. [12:07 am] This nurse went to assess pt and pt was noted semi-Fowlers (30 to 45 degree angle with the head elevated) in bed with head cocked to left side, pt appears to be taking deep breaths for air constantly at this time with eyes fixed as if she is imminent to passing. palpated for pulse and pulse is faint. skin is still warm to touch. [12:10 am to 12:15 am] Went to verify advance directive and was not found in hospice binder but did verify in PCC full code only. [12:20 am] returned to pt bedside and pt was noted unresponsive. aide prepared body immediately. A record review of Resident #1's vitals revealed there were no vitals documented in the Electronic Health Record on [DATE]. In an interview on [DATE] at 11:00 am, the DON said she did not know why LVN A did not initiate CPR on Resident #1. She said LVN A told her she was distracted by a phone call from her family member. In an interview on [DATE] at 1:40 pm, LVN A she said at the time of the incident on [DATE] at approximately 12:00 am, she had a lot going on, and said I had an emergency with my kids who were home alone and was distracted. In my head, all hospice patients have DNR's. My aide came and told me [Resident #1] took a turn, I went and saw her, and she was already basically gone. I went and looked at the hospice binder and did not see an advance directive. I looked in PCC (Electronic Health Record) and it said full code. I thought it was a mistake. I did not honor her code status. In an interview on [DATE] at 1:50 am, CNA B said on [DATE] at about 12:00 am, I went to check on and change [Resident #1] and she was having trouble breathing, I went and told [LVN A], the nurse went down with me to check her. [LVN A] said she didn't look good, and she went back to the nurses' station to look at computer. I stayed with [Resident #1], she got worse, she stopped breathing and had a blank staring off look. I went and got [LVN A] again. She came and took her vitals, told me she stopped breathing and passed, and told me to perform post-mortem care. [LVN A] did not initiate CPR. In an interview on [DATE] at 2:15 pm, the Medical Director said Resident #1 had an order for full code. He said it was his expectation for staff to follow the physician's orders. He said in this instance, failing to follow physician's orders had the potential that the resident's life could have been saved. In an interview on [DATE] at 3:19 pm, Resident #1's Family Member, he said LVN A called him sometime after midnight on [DATE] telling him that Resident #1 stopped breathing and did not have a DNR in place. He thought LVN A had told him CPR had been attempted but was too distraught to know for sure. In interview and record review on [DATE] at 10:30 am, the Administrator said he was no longer the Administrator of the facility since [DATE]. He said he was the Administrator of the facility during the time of the incident. He said he reported the incident and the LVN should have initiated CPR on Resident #1 who was a full code status. Record review of the facility policy Cardiopulmonary Resuscitation, not dated, revealed the following [in part]: Cardiopulmonary resuscitation (CPR) is a method of providing systemic circulation by manual chest compression and oxygen by mouth-to-mouth breathing or providing air to the lungs via ambu-bag. The procedure is preformed to prevent death following cardiac or pulmonary arrest . Record review of the facility policy Self Determination End of Life Measures, not dated, revealed the following [in part]: Policy: 2. Upon admission, the facility will provide the individual with a copy of her/her rights under Texas law concerning the right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives.3.The facility will respect the wishes of the resident as outlined in the advanced directive . A record review of the facility policy Resident Rights, not dated, revealed the following [in part]: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.A facility must 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 equality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Planning and Implementing Care - the Resident has the right to be informed of, participate in, his or her treatment including:b. The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and d uratin of care and any other factors related to the effectiveness of the plan of care. Self-Determination: The resident has the right to and the facility must promote and facilitate resident self-determination through support of the resident choice. 2. The Resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. 12. The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). The facility prior to investigator entrance on [DATE] completed the following corrections/interventions. The facility was evaluated to be in past noncompliance based on the corrections implemented prior to entrance. 1. Self-reporting protocol initiated on [DATE]. 2. [DATE] at 2:15 am, the Administrator was notified by the hospice nurse of Resident #1 passing that was full code and LVN A did not initiate CPR or contact emergency services. 3. Ad Hoc QAPI on [DATE] for Resident who was on hospice services but chose to have full code status, had passed away and the nurse did not initiate a code. 4. LVN A was immediately suspended on [DATE].5. The Administrator notified the DON, ADON, MD, Responsible Party, Social Services, Ombudsman, and Regional Team notified on [DATE]. Investigation started by the facility on [DATE]. Obtained witness statements. 7. The DON audited all resident code status on [DATE] - reviewed orders, care plans, DNRs. No errors were found. 8. Staff in-services were initiated on abuse/neglect, CPR, Advanced Directives, Resident Rights, Notification of Change, How to identify code status, and Following Physician Orders. Sign-in sheets observed. Quizzes were completed. The DON said all staff have been in-serviced except for a few PRN staff that hasn't worked in a while and before they return to work, they will have to complete the in-services before they will be allowed to work. Initiated [DATE]. 9. Safe surveys were conducted with residents on the LVNs hallway on [DATE], no further concerns were identified. 10. LVN A was terminated, and her nursing license was referred to the Texas Board of Nursing on [DATE]. 11. Daily monitoring by DON was ongoing. Verification of Correction 1: In an interview on [DATE] at 11:00 am, the DON said she received a call from the Administrator on [DATE] at 4:30 am in the morning about the incident. The LVN was immediately suspended and terminated after an investigation and her nursing licenses was referred to the Texas Board of Nursing all on [DATE]. The DON audited all residents' code status', making sure they were completed, care plans were correct, and physician's orders were reviewed. There were no errors found. A memo was put out for staff to not assume if a resident was on hospice care that did not mean they were not full code and how to find the code status in PCC (Electronic Health Record). In-servicing staff with a competency quiz was initiated. All staff had been in-serviced except for a few PRN staff who hadn't worked in a while. When they returned to work, they would be required to complete the in-services before being able to work. Hospice services had been contacted regarding the incident and reviewed with them the 2 residents that were currently under hospice care who were also full codes in the facility. Daily monitoring was ongoing at this time by the DON, including during the stand-up meetings to identify any evidence of any potential neglect, and during facility rounds were there any signs of staff performing or not performing their duties in a neglect manner. At the facility, per policy, CNAs were not CPR certified, only the nurses were. The facility policy states only 1 person must be in the facility per shift that is CPR certified. LVNs could not pronounce death, only RNs could do that. In this instance the LVN contacted hospice who came and pronounced death. Record review of the facility reporting protocol template indicated all areas of the self-reporting protocol had been completed, dated and signed by staff. Verification of Correction 2:In an interview on [DATE] at 2:20 pm, the Hospice DON said the incident was reviewed in their morning stand up meeting on [DATE]. She said the hospice nurse arrived at the facility an hour after the incident at approximately 1:00 am and noted that Resident #1 was full code status, and that CPR had not been initiated. The hospice nurse did contact Resident #1's family member and he did not want anything else done at that time. She contacted the Administrator of the facility on [DATE] at 2:15 am and reported the incident to him. Verification of Correction 3:Record review of the Ad Hoc QAPI meeting revealed the meeting was conducted on [DATE] with the following members attended: Medical Director, Administrator, DON, ADON #1, ADON #2 , MDS Nurse #1, MDS Nurse #2, Area Director of Operations, and the Regional Compliance Nurse. Verification of Correction 4:Record review of the Employee Disciplinary Report dated [DATE] revealed the LVN A was suspended for investigation of failing to do CPR. Verification of Correction 5:Record review of the Provider Investigation Report, dated [DATE] revealed the Administrator, DON, ADON, Medical Director, the Resident Representative, Social Services, Ombudsman and the facility Regional Team were notified that LVN A failed to initiate CPR or notify EMS for Resident #1 that was full code status. Verification of Correction 6:Record review of documentation including the Provider Investigation Report dated [DATE] and the Self-Reporting protocol dated [DATE] revealed the facility investigation of the incident was started on [DATE] at 2:15 am by the Administrator. Verification of Correction 7:Record review of the 13 sampled Resident Code Status' were reviewed that included the advanced directives, physician's orders, and care plans. No errors were found. Verification of Correction 8:Record review in-service training records sign-in sheets and quizzes revealed completion by all active staff. Interviews with the following 12 sampled staff revealed all stated they had received in-service training including abuse/neglect, advance directives, CPR, resident rights, code status' and following physician's orders that included completing a competency quiz. They were not allowed to work until the in-services had been completed. [DATE] at 1:50 pm, CNA BXXX[DATE] at 11:29 am, CMA CXXX[DATE] at 11:55 am, Social WorkerXXX[DATE] at 11:12 am, CMA DXXX[DATE] at 11:24 am, CNA E.9/11.25 at 11:27 am, CNA FXXX[DATE] at 11:34 am, LVN GXXX[DATE] at 11:38 am, LVN HXXX[DATE] at 11:44 am, Rehabilitation ManagerXXX[DATE] at 11:48 am, CNA IXXX[DATE] at 11:52 am, CMA JXXX[DATE] at 11:57 am, CNA K. Verification of Correction 9:Record review revealed the residents on LVN A's hallway were interviewed with no additional concerns identified regarding the LVN. The resident's all said staff were respectful and appropriate, denied staff were rude or spoken abusively to, felt safe, knew how to report abuse, who the abuse coordinator was and did not express any concerns with their treatment and care. In interviews with the following sampled residents revealed none of them expressed concerns with staff. [DATE] at 11:27 am, Resident #2XXX[DATE] at 11:31 am, Resident #4XXX[DATE] at 11:35 am, Resident #3XXX[DATE] at 11:41 am, Resident # 5XXX[DATE] at 11:45 am, Resident #6. Verification of Correction 10:Record review of LVN A's employee file revealed a termination date of [DATE]. Record review of referral to Texas Board of Nursing was completed on [DATE] at 2:54 pm. Record review revealed LVN A's CPR certification was current, expiring on 03/2027. Verification of Correction 11:Record review of documentation monitoring revealed it was on-going daily since [DATE]. No further concerns have been identified.

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to a meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #6, Resident #7) of 8 residents reviewed for comprehensive person-centered care plans.1. The facility failed to develop care plans based on assessed needs with measurable objectives in the areas of Hemiplegia/Hemiparesis, Hypertension, GERD, Dementia, and Anxiety for Resident #1.2. The facility failed to develop care plans based on assessed needs with measurable objectives in the areas of Parkinson's Disease, Hypertension, Diabetes Mellitus, diuretic therapy, edema, GERD, and renal failure for Resident #2.3. The facility failed to develop care plans based on assessed needs with measurable objectives in the areas of Parkinson's Disease, Diabetes Mellitus, and edema for Resident #3.4. The facility failed to develop care plans based on assessed needs with measured objectives in the areas of Anticoagulant Therapy, hypertension, bowel incontinence, GERD, and dementia for Resident #4.5. The facility failed to develop care plans based on assessed needs with measurable objectives in the areas of Diabetes, Atrial Fibrillation, Crohn's Disease, osteoporosis, asthma, and GERD for Resident #6. 6. The facility failed to develop care plans based on assessed needs with measurable objectives in the areas of Hemiplegia, Seizure Disorder, History of Vascular accident with residual right sided Hemiplegia, and COPD for Resident #7.These failures could affect the residents by placing them at risk for not receiving care and services to meet their needs.The findings included:Resident #1Record review of Resident #1's Facesheet, dated 07/03/2025, revealed Resident #1 was a [AGE] year-old female, with an admission date into the facility of 09/08/2023. Diagnoses included Unspecified Dementia (diagnosis given when a person's cognitive impairment was not clearly categorized into a specific type of dementia), Hemiplegia (paralysis on one side of the body) and Hemiparesis (weakness on one side of the body) following cerebral infarction (condition where a part of the brain tissue dies due to lack of blood flow) affecting left non-dominant side, Hypertension (condition where the force of blood against the artery wall was consistently too high), Generalized Anxiety Disorder (mental health condition characterized by excessive, uncontrollable, and often irrational worry about everyday events or activities), and GERD (digestive disorder where stomach acid flows back into the esophagus, causing symptoms like heartburn or regurgitation).Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1's BIMS score was 05, which indicated severe cognitive impairment. Section I - Active Diagnoses revealed Resident #1 had medically complex conditions, with diagnoses of Dementia, Generalized Anxiety Disorder, GERD, Hypertension, and Hemiplegia/Hemiparesis following cerebral infarction.Record review of Resident #1's Care Plan with recent review of 03/03/2025 revealed objectives lacking ability to be evaluated, quantified, and verified were: The resident will remain free of complications or discomfort related to Hemiplegia/Hemiparesis; the resident will remain free of complications related to hypertension through the review date; the resident will remain free of discomfort, complications, or s/sx related to dx of GERD; the resident will be free from s/sx of complications of cardiac problems; the resident will remain oriented to (person, place, situation, time) though the review date (related to Dementia); and the resident will have no indications of psychosocial well-being problems by/through review date.Resident #2Record review of Resident #2's Facesheet, dated 07/03/2025, revealed Resident #2 was a [AGE] year-old male, with an admission date into the facility of 09/03/2024. Diagnoses included Type II Diabetes Mellitus with foot ulcer (a chronic metabolic disorder characterized by high blood sugar levels due to the body's inability to properly use insulin and/or insufficient insulin production), Essential Hypertension (a condition characterized by persistently high blood pressure without a known secondary cause), Parkinsonism (a term used to describe a group of neurological disorders characterized by motor symptoms such as tremors, rigidity, and slow movement), Acute Kidney Failure (a sudden and rapid decrease in kidney function), localized Edema (condition characterized by swelling caused by fluid retention in body tissues), GERD (digestive disorder where stomach acid flows back into the esophagus, causing symptoms like heartburn or regurgitation), and enlarged and hypertrophic nails (abnormal thickening of the nail plate).Record review of Resident #2's Significant Change in Condition MDS, dated [DATE], revealed Resident #2's BIMS score was 15, which indicated intact cognition. Section I - Active Diagnoses revealed Resident #1 had medically complex conditions, with diagnoses of Anemia, GERD, Dementia, Diabetes Mellitus, Parkinsonism, and Essential Hypertension. Record review of Resident #2's Care Plan with recent review of 06/30/2025 revealed objectives lacking ability to be evaluated, quantified, and verified were: The resident will remain free of further s/sx, discomfort, or complications related to Parkinson's disease; [Resident #2] will remain free of complication related to hypertension; the resident will be free from any s/sx of hyperglycemia (a condition where there is too much glucose in the blood), have no complications related to diabetes, and the resident will be free from any s/sx of hypoglycemia (a condition where the level of glucose in your blood drops too low, often below 70 mg/dl); [Resident #2] will be free of any discomfort or adverse side effect of diuretic therapy; the resident's fluid balance will improve and not worsen; the resident will remain free from discomfort, complications, and s/sx related to dx of GERD; [Resident #2] will have no s/sx of complications relate to fluid overload through the review date (related to acute kidney disease); [Resident #2] will have no s/sx of complications related to fluid overload; the resident's ulcer (diabetic ulcer) will improve by review date; and the resident will maintain current level of cognitive function. Further review of comprehensive care plan reviewed there was no evidence of a focus, objective, or interventions related to enlarged and hypertrophic nails.Resident #3Record review of Resident #3's Facesheet, dated 07/01/2025, revealed Resident #3 was a [AGE] year-old female, with an admission date into the facility of 11/16/2024. Diagnoses included Neuroleptic induced Parkinsonism (a movement disorder that resembles Parkinson's disease but was caused by certain medications, particularly antipsychotics), Type II Diabetes Mellitus (a chronic metabolic disorder characterized by high blood sugar levels due to the body's inability to properly use insulin and/or insufficient insulin production), Edema (condition characterized by swelling caused by fluid retention in body tissues), Unspecified Dementia (diagnosis given when a person's cognitive impairment was not clearly categorized into a specific type of dementia), and GERD (digestive disorder where stomach acid flows back into the esophagus, causing symptoms like heartburn or regurgitation).Record review of Resident #3's Quarterly MDS, dated [DATE], revealed Resident #3's BIMS score was not calculated. C0100, Should Brief Interview for Mental Status (C0200 - C0500) be Conducted was coded 0 for No - resident was rarely/never understood; therefore, BIMS score was not determined. Section I - Active Diagnoses revealed Resident #3 had Other Neurological Condition, as I0020 was coded 07. Active diagnoses included Neuroleptic induced Parkinsonism, Unspecified Dementia, Edema, Primary Osteoarthritis, GERD, and Diabetes Mellitus. Record review of Resident #3's Care Plan with recent review of 12/13/2024 revealed objectives lacking ability to be evaluated, quantified, and verified were: The resident will remain free of further s/sx, discomfort, or complications related to Parkinson's disease; the resident will be free from any s/sx of hyperglycemia through review date; [Resident #3] will have no complications related to diabetes; the resident's fluid balance will improve or not worsen through the next review date; [Resident #3] will remain free from discomfort, complications, or s/sx related to dx of GERD; and [Resident #3] will maintain current level of cognitive function through review date. Further review of comprehensive care plan reviewed there was no evidence of a focus, objective, or interventions related to Primary Osteoarthritis. Resident #4Record review of Resident #4's Facesheet, dated 07/03/2025, revealed Resident #4 was an [AGE] year-old female, with an admission date into the facility of 01/30/2025. Diagnoses included Other Alzheimer's Disease (most common form, where a person experienced the effects of more than one type of dementia), Cellulitis (bacterial infection of the skin and underlying tissue caused by bacteria) of unspecified part of limb, Hypothyroidism (when the thyroid gland does not make and release enough hormone into the bloodstream), GERD (digestive disorder where stomach acid flows back into the esophagus, causing symptoms like heartburn or regurgitation), Paroxysmal Atrial Fibrillation (type of irregular heartbeat where the heart's upper chambers beat chaotically and rapidly, causing the heart to beat irregularly and often too fast), and Essential (Primary) Hypertension (a condition characterized by persistently high blood pressure without a known secondary cause).Record review of Resident #4's Quarterly MDS, dated [DATE], revealed Resident #4's BIMS score was 06, which indicated severe cognitive impairment. Section I - Active Diagnoses revealed Resident #4 had medically complex conditions, with diagnoses of Hypertension, Alzheimer's Disease, Anxiety Disorder, Hypothyroidism, Paroxysmal Atrial Fibrillation, and GERD. Record review of Resident #4's Care Plan with recent review of 05/01/2025 revealed objectives lacking ability to be evaluated, quantified, and verified were: The resident would be free from discomfort or adverse reactions related to anticoagulant use through the review date; the resident would remain free of complications related to hypertension through the review date; the resident would not have any complications r/t bowel incontinence; the resident will remain free from discomfort, complications, or s/sx related to dx of GERD through review date; the resident would be free from s/sx of complications of cardiac problems through review date; and the resident would maintain current level of cognitive function through the review date. Further review of comprehensive care plan reviewed there was no evidence of a focus, objective, or interventions related to cellulitis. Resident #6Record review of Resident #6's Facesheet, dated 07/03/2025, revealed Resident #6 was an [AGE] year-old female, with an admission date into the facility of 12/23/2020. Diagnoses included Legal blindness (a severe level of vision impairment, defined as having a visual acuity of 20/200 or less in the better-seeing eye with corrective lenses, or as restricted visual field of 20 degrees or less), Type II Diabetes Mellitus (a chronic metabolic disorder characterized by high blood sugar levels due to the body's inability to properly use insulin and/or insufficient insulin production), Atrial Fibrillation (type of irregular heartbeat where the heart's upper chambers beat chaotically and rapidly, causing the heart to beat irregularly and often too fast), Crohn's Disease (chronic inflammatory bowel disease that can affect any of part of the digestive tract), Hyperlipidemia (condition where there are elevated levels of lipids, including cholesterol and triglycerides, in the blood), Essential (Primary) Hypertension (a condition characterized by persistently high blood pressure without a known secondary cause), osteoporosis (a disease that weakens bones, making them more likely to break), GERD (digestive disorder where stomach acid flows back into the esophagus, causing symptoms like heartburn or regurgitation), Unspecified Asthma (a diagnosis of asthma where the specific type or severity was not documented), and Obstructive Sleep Apnea (a sleep disorder where the upper airway repeatedly collapse or becomes blocked during sleep, causing pauses in breathing or shallowing breathing). Record review of Resident #6's Annual MDS, dated [DATE], revealed Resident #6's BIMS score was 13, which indicated intact cognition. Section I - Active Diagnoses revealed Resident #1 had medically complex conditions, with diagnoses of Atrial Fibrillation, Hypertension, Crohn's Disease, Diabetes Mellitus, Hyperlipidemia, Thyroid Disorder, Legal blindness, Anxiety Disorder, and Gout.Record review of Resident #6's Care Plan with recent review of 08/14/2024 revealed objectives lacking ability to be evaluated, quantified, and verified were: [Resident #6] will have no complications related to diabetes through the review date; Resident will remain free from s/sx of pacemaker malfunction or failure through the review period; Resident will be free from discomfort or adverse reactions related to anticoagulant use through the review period; Resident will remain free from discomfort, complications, or s/sx related to gastrointestinal alterations through the review period; (related to osteoporosis) Resident will remain free from or at a level of discomfort acceptable to the resident through the review period; Resident will be free from s/sx of complications of poor circulation through the review period; Resident will remain free of complications related to hypertension through the review period; Resident will remain free of s/sx related to hypothyroidism through the review period; Resident will remain free of discomfort, complications, or s/sx related to dx of GERD through the review period; and Resident will maintain optimal quality of life within limitations imposed by visual function through the review period. Resident #7Record review of Resident #7's Facesheet, dated 07/03/2025, revealed Resident #7 was a [AGE] year-old male, with an admission date into the facility of 06/25/2025 . Diagnoses included Chronic Obstructive Pulmonary Disease (progressive lung disease that makes it hard to breathe), Epilepsy (neurological disorder characterized by seizures due to abnormal electrical activity in the brain), Hyperlipidemia (condition where there are elevated levels of lipids, including cholesterol and triglycerides, in the blood), Hemiplegia affecting right dominant side (paralysis on one side of the body), Primary generalized osteoarthritis (a degenerative joint disease characterized by the breakdown of cartilage, leading to pain, stiffness, and reduced range of motion in the affected joints), and Cerebral Infarction (a condition where a part of the brain was damaged due to a lack of blood supply. Record review of Resident #7's Annual MDS, dated [DATE], revealed Resident #7's BIMS score was 15, which indicated intact cognitive response. Section I - Active Diagnoses revealed Resident #7 had Debility (physical weakness, especially as a result of illness), Cardiorespiratory Conditions. Diagnoses included Hyperlipidemia, Seizure Disorder, Bipolar Disorder, Asthma, Chronic Obstructive Pulmonary Disease, and Cerebral Infarction. Record review of Resident #7's Care Plan with recent review of 08/14/2024 revealed objectives lacking ability to be evaluated, quantified, and verified were: The resident will be free from complications or discomfort related to Hemiplegia through the review date; the resident will be free from injury related to seizure activity through the review date; the resident will show improvement to maximum potential with mobility and cognition by review date (related to Cerebral Vascular Accident); resident will maintain current level of mobility (related to arthritis); and resident will have a stable mood (related to seizures). During an interview on 07/03/2025 at 10:32 a.m., the MDS Coordinator said the residents' goals and outcomes were developed through the IDT process. The MDS Coordinator said she was aware the outcomes were not measurable as written, and she had not been trained on how to write measurable outcomes.During an interview on 07/03/2025 at 12:01 p.m., the DON said the outcome for Resident #3, the resident would have fewer episodes thorough review date (in the area of behavior problems related to dementia) was vague and unmeasurable. The DON said the importance of having measurable outcomes was to show progress of the services that were provided to the resident. The DON said it was part of the monitoring process to determine if the residents met their goals with the appropriate service.During an interview on 07/03/2025 at 12:43 p.m., the Administrator said he expected all outcomes in the residents' care plans to be measurable. The Administrator said outcomes needed to be measurable to track data and ensure services were being provided accurately and consistently. Record review of the facility's policy, Comprehensive Care Planning, not dated, revealed, 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 timeframes to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on interviews and record reviews, the facility failed to make sure that the comprehensive care plan was prepared by an interdisciplinary team that included a nurse aide with responsibility for the resident for 8 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, and Resident #8) of 8 residents reviewed for care plans. The facility failed to ensure the nurse aides with responsibility for the residents were invited and attended the resident care plan conferences. These failures could place the residents at risk for not receiving the care and services to meet their needs.The findings included: Resident #1: Record review of Resident #1's Facesheet, dated 07/03/2025, revealed Resident #1 was a [AGE] year-old female, with an admission date into the facility of 09/08/2023. Diagnoses included Unspecified Dementia (diagnosis given when a person's cognitive impairment was not clearly categorized into a specific type of dementia). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1's BIMS score was 05, which indicated severe cognitive impairment. Resident #2 Record review of Resident #2's Facesheet, dated 07/03/2025, revealed Resident #2 was a [AGE] year-old male, with an admission date into the facility of 09/03/2024. Diagnoses included Type II Diabetes Mellitus with foot ulcer (a chronic metabolic disorder characterized by high blood sugar levels due to the body's inability to properly use insulin and/or insufficient insulin production). Record review of Resident #2's Significant Change in Condition MDS, dated [DATE], revealed Resident #2's BIMS score was 15, which indicated intact cognition. Resident #3 Record review of Resident #3's Facesheet, dated 07/01/2025, revealed Resident #3 was a [AGE] year-old female, with an admission date into the facility of 11/16/2024. Diagnoses included Neuroleptic induced Parkinsonism (a movement disorder that resembles Parkinson's disease but was caused by certain medications, particularly antipsychotics). Record review of Resident #3's Quarterly MDS, dated [DATE], revealed Resident #3's BIMS score was not calculated. C0100, Should Brief Interview for Mental Status (C0200 - C0500) be Conducted was coded 0 for No - resident was rarely/never understood; therefore, BIMS score was not determined. Resident #4 Record review of Resident #4's Facesheet, dated 07/03/2025, revealed Resident #4 was an [AGE] year-old female, with an admission date into the facility of 01/30/2025. Diagnoses included Other Alzheimer's Disease (most common form, where a person experienced the effects of more than one type of dementia). Record review of Resident #4's Quarterly MDS, dated [DATE], revealed Resident #4's BIMS score was 06, which indicated severe cognitive impairment. Resident #5 Record review of Resident #5's Facesheet, dated 07/03/2025, revealed Resident #5 was a [AGE] year-old female, with an admission date into the facility of 07/16/2018. Diagnoses included Cerebral Palsy, Unspecified (a group of neurological disorders that appear in infancy or early childhood and permanently affect a person's movement and muscle coordination. Record review of Resident #5's MDS, dated [DATE], revealed Resident #5's BIMS score was not calculated. C0100, Should Brief Interview for Mental Status (C0200 - C0500) be Conducted was coded 0 for No - resident was rarely/never understood; therefore, BIMS score was not determined. Resident #6 Record review of Resident #6's Facesheet, dated 07/03/2025, revealed Resident #6 was an [AGE] year-old female, with an admission date into the facility of 12/23/2020. Diagnoses included Legal blindness (a severe level of vision impairment, defined as having a visual acuity of 20/200 or less in the better-seeing eye with corrective lenses, or as restricted visual field of 20 degrees or less). Record review of Resident #6's Annual MDS, dated [DATE], revealed Resident #6's BIMS score was 13, which indicated intact cognition. Resident #7 Record review of Resident #7's Facesheet, dated 07/03/2025, revealed Resident #7 was a [AGE] year-old male, with an admission date into the facility of 06/25/2025 . Diagnoses included Chronic Obstructive Pulmonary Disease (progressive lung disease that makes it hard to breathe), Epilepsy (neurological disorder characterized by seizures due to abnormal electrical activity in the brain). Record review of Resident #7's Annual MDS, dated [DATE], revealed Resident #7's BIMS score was 15, which indicated intact cognition. Resident #8 Record review of Resident #8's Facesheet, dated 07/03/2025, revealed Resident #8 was a [AGE] year-old female, with an admission date into the facility of 03/11/2024. Diagnoses included Hemiplegia (paralysis on one side of the body) and Hemiparesis (weakness on one side of the body) following cerebral infarction (condition where a part of the brain tissue dies due to lack of blood flow) affecting Right dominant side. Record review of Resident #8's Quarterly MDS, dated [DATE], revealed Resident #8's BIMS score was 13, which indicated intact cognition. During an interview on 07/01/2025 at 7:57 a.m., CNA D said he did not attend or participate in the IDT meetings of any of the residents in the facility. CNA D said he had never been invited to attend. CNA D said he had important information to share at the meetings because he knew the residents very well since he interacted with the residents during his entire shift. CNA D said he knew what the residents liked and disliked and how to communicate with residents who were non-verbal. During an interview on 07/02/2025 at 1:39 p.m., CNA E said she did not attend care plan meetings and had not been invited to any of the residents' IDT care plan meetings who he provided services to in the facility. During an interview on 07/02/2025 at 3:25 p.m., CNA F said she did not attend care plan meetings. CNA F said the facility was often short staffed and the direct care could not leave the floor to attend a meeting. CNA F said she had never been invited. During an interview on 07/03/2025 at 10:32 a.m., the MDS Coordinator said the facility sent out notifications to the members of the IDT team. The MDS Coordinator said she did not invite the CNAs because she knew the CNAs had difficulty attending the care plan meetings due to their direct care responsibilities and the facility did not want to pull them off the halls. The MDS Coordinator said she was aware CNAs were required members of the IDT. During an interview on 07/03/2025 at 12:01 p.m., the DON said she was aware the CNAs were part of the IDT were required to attend the care plan meetings. The DON said it was important for the CNAs to be involved in the care planning process because the aides spent the most time with the residents and provided the actual services. Record review of the facility's policy, Comprehensive Care Planning, not dated, revealed, A comprehensive care plan will be - Prepared and/or contributed to by an interdisciplinary team, that includes but is not limited to -- *A nurse aide with the responsibility for the resident.

Based on observations, interview, and record review the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for 3 (Resident #1, Resident #3 and Resident # 7) of 7 residents reviewed for resident records. The facility failed to ensure weekly skin assessments were documented in the medical record for Resident #1, Resident #3, and Resident # 7. This failure could place residents at risk of having errors in care and treatment. The Findings included: Resident #1 Record review of Resident #1's face sheet dated 05/02/2025 revealed a [AGE] year-old-female admitted on [DATE], with the most recent admission on 06/14/2024 and with the following diagnoses: Alzheimer's disease, respiratory failure, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (weakness and partial paralysis of left side following a stroke). Record review of Resident #1's Significant Change MDS assessment dated [DATE] revealed, Section C- Cognitive Patterns: Resident #1 had a BIMS score of 5 (meaning severe cognitive impairment); Section GG-Functional Abilities: Resident #1 required substantial/maximal assistance for activities of daily living. Section M-Skin Conditions: Resident #1 had the risk of developing pressure ulcers/injuries and Resident #1 did not have pressure ulcers, wounds, or skin problems. Record review of Resident #1's care plan dated 02/18/2025 revealed Resident #1 required extensive assistance of 1 staff with transfers and activities of daily living. Record review of Resident #1's electronic medical chart revealed no evidence of weekly skin inspections completed weekly for the weeks of: 03/10/2025, 03/17/2025, 03/24/2025, 03/31/2025, 04/21/2025 and 04/28/2025. Further record review revealed Resident #1 did not have any skin issues and was admitted to hospital on 04/29/2025 due to an abscess to her tooth. Resident #3 Record review of Resident #3's face sheet dated 05/02/2025 revealed an [AGE] year-old-female admitted on [DATE], with the most recent admission on 08/19/2024 and the following diagnoses: Alzheimer's disease, Type 2 diabetes, age-related osteoporosis, and high blood pressure. Record review of Resident #3's Quarterly MDS assessment dated [DATE] revealed, Section C- Cognitive Patterns: Resident #3 had a BIMS score of 14 (meaning cognitively intact); Section GG-Functional Abilities: Resident #3 required substantial/maximal assistance or was dependent for activities of daily living. Section M-Skin Conditions: Resident #3 had the risk of developing pressure ulcers/injuries and Resident #3 had a stage 4 pressure ulcer, (open wound through multiple layers of skin and tissue) to right heel and sacrum (large triangular bone at the base of the spine). Record review of Resident #3's care plan dated 03/04/2025 revealed Resident #3 had a stage 4 pressure ulcer to her sacrum area and right l heel. Resident #3 was receiving hospice care. Record review of Resident # 3's physician's orders dated 05/02/2025 revealed: Start date: 08/19/2024 admit to {name} service. Start date: 01/30/2025: {Name wound care company} to consult for skin and wound conditions/prevention. Start date 04/04/2025: Cleanse stage 4 pressure wound to sacrum with wound cleanser, pat dry with gauze, pack with calcium alginate with silver, cover with non-border foam dressing 3 times a week and PRN as needed for Stage 4 pressure wound of the sacrum. Start date: 04/04/2025 Cleanse stage 4 pressure wound to sacrum with wound cleanser, pat dry with gauze, pack with calcium alginate with silver, cover with non-border foam dressing 3 times a week and PRN one time a day every Monday, Wednesday, Friday for Stage 4 pressure wound of the sacrum. Record review of Resident #3's electronic medical chart revealed no evidence of weekly skin inspections completed weekly for the weeks of 03/17/2025, 03/24/2025, 03/31/2025, 04/21/2025 and 04/28/2025. During an observation and interview on 05/01/2025 at 11:00 AM revealed Resident #3 was sitting up in her bed. Resident #3 stated the staff did frequent checks on her and changed her often. Resident #3 stated she did not have any concerns with her care from the staff. Resident #3 stated that she had some issues with her skin, but the facility was treating them and they were getting better. Resident #7 Record review of Resident #7's face sheet dated 05/02/2025 revealed a [AGE] year-old-female admitted on [DATE], and with the following diagnosed : Alzheimer's disease and high blood pressure. Record review of Resident #7's Significant Change MDS assessment dated [DATE] revealed, Section C- Cognitive Patterns: Resident #7 had a BIMS score of 4 (meaning severe cognitive impairment); Section GG-Functional Abilities: Resident #7 required Partial/moderate to substantial/maximal assistance for activities of daily living. Section M-Skin Conditions: Resident #7 had the risk of developing pressure ulcers/injuries and Resident #7 did not have pressure ulcers, wounds, or skin problems. Record review of Resident #7's care plan dated 03/31/2025 revealed Resident #7 required extensive assistance of 1 staff with transfers and activities of daily living. Resident #7 had potential for pressure ulcer development. Record review of Resident #7's electronic medical chart revealed no evidence of weekly skin inspections completed weekly for the weeks of 02/24/2025, 03/03/2025, 03/10/2025, 03/17/2025, 03,24,2025, 03/31/2025, 04/21/2025 and 04/28/2025. During an observation and interview on 05/02/2025 at 8:45 AM revealed Resident #7 received incontinent care and her skin was observed to have no redness or drainage. Resident #7 stated she did not have any concerns with her care at the facility. During an interview on 05/02/2025 at 1:15 PM the ADON stated charge nurses were responsible to complete skin assessments weekly. The ADON stated the CNAs completed shower sheets when they gave residents their showers. The ADON stated the CNAs were good about letting the nurses know when there was a change in the resident's skin. The ADON stated the weekly skin assessments were triggered for the charge nurses to complete weekly. The ADON did not have an explanation as to why skin assessments were not complete. During an interview on 05/02/2025 at 1:26 PM CNA A stated she completed skin sheets when providing showers for residents. CNA A stated if during showers she noticed a problem she would contact the charge nurse. CNA A stated Resident #1, Resident #3, and Resident #7 were on her hall, and she had completed skin sheets for each resident. CNA A stated Resident #1, Resident #3 and Resident #7 did not have any new concerns with their skin. During an interview on 05/02/2025 at 1:39 PM RN B stated the charge nurses were responsible for completing skin assessments weekly and were to be documented under Assessments in the electronic medical record. RN B stated Resident #1 and Resident # 7 were residents on her hall. RN B stated Resident #3 had been treated for a pressure ulcer on her sacrum and her left buttock. RN B stated Resident #3's wounds had gotten smaller. RN B stated she did not know why skin assessments had been missed. RN B stated the skin assessments would populate on the electronic medical system. RN B stated she would make sure to complete them before she ended her shift. RN B stated CNAs completed shower sheets, when they gave showers, and would document any new skin issues and would turn them into the charge nurse. RN B stated the nurses would sign the sheets after reviewing them. RN B stated she did not see any negative impact on the residents from skin assessments not being documented in the system, because the residents' skin was being assessed. During an interview on 05/02/2025 at 1:40 PM the DON stated her expectation was that skin assessments should have been completed weekly and documented on the weekly skin assessment in the electronic medical system. The DON stated the charge nurses were responsible to complete the weekly skin assessments. The DON stated herself and the ADON would help the nurses with completing the skin assessments. The DON stated the ADON was responsible to monitor the completion of weekly skin assessments by running reports. The DON stated there had been some changes with the electronic medical record system and that had made it harder to catch the missed assessments. The DON stated what led to the failure was the updates to the electronic medical record system and nurses having to help with other duties. The DON stated she did not think there was a negative effect on residents because she felt nurses were assessing residents' skin and they were failing to document. During an interview on 05/02/2025 at 1:55 PM the ADMN stated her expectation was that skin assessments were to be completed upon admission and weekly. The ADMN stated skin assessments should have been documented under the assessment tab in the electronic medical chart. The ADMN stated the weekly skin assessment was to be completed by the charge nurse for the residents on their hall. The ADMN stated the DON and ADON were supposed to have been monitoring to ensure the weekly skin assessments were completed. The ADMN stated the skin assessments were to have been monitored during the standard of care meeting. The ADMN stated the effect on residents could have been missed skin breakdown. The ADMN stated the failure of skin assessments not being completed could have been changes in the electronic medical record system. The ADMN stated the electronic medical record system failed to notify nurse that assessments were needed to be done. Record review of the facility policy titled, Skin assessment dated [DATE], revealed: All residents should have a skin assessment on a weekly basis completed in {name of electronic medical system.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free from accident hazards as was possible and each resident received adequate supervision and assistive devices to prevent accidents for 2 of 5 residents (Resident #1 & Resident #2) reviewed for accidents and supervision. 1. The facility failed to ensure Resident #1, and Resident #2 were properly supervised during smoke break to prevent agitation and altercations. These failures could place the residents at risk of injury. Findings included: Record review of Resident #1's electronic health record revealed a [AGE] year-old female, admitted [DATE], Diagnoses: hypertension (high blood pressure), unspecified dementia (brain degeneration) chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), major depressive disorder (persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities). Record review of Resident #1's electronic health record revealed the most recent Care Plan revision dated 03/19/25, date initiated of 12/13/24, revealed, Resident resides in SecureUnit .assist and monitor resident for off unit activities. Record review of Resident #1's progress note dated 3/16/25 at 1:54 pm revealed Experienced a behavior in the hallway. Resident to resident, agitated, cognitive impairment. Resident was yelling and she hit the male resident and he hit her back. Record review of Resident #2's electronic health record revealed a [AGE] year-old male, admitted [DATE], Diagnoses: cerebral infarction (blood flow to the brain interruption causing brain tissue damage), anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), adjustment disorder with mixed anxiety and depressed mood (struggle to cope with a significant stressor, experiencing both anxiety and depressed mood symptoms), personal history of transient ischemic attack and cerebral infarction without residual deficits (occurrence of mini stroke and blood flow to brain interrupted without lasting neurological problems), vascular dementia with agitation (behavioral disturbance featuring exaggerated motor activity and verbal/physical aggression). Record review of Resident #2's electronic health record revealed the most recent Care Plan revision dated 3/19/2025, initiated on 7/17/24, revealed, Resident is a smoker .2. Explain/Show where designated smoking areas are and smoking times-repeat PRN. 3. Monitor PRN when smoking to assure resident safety. Record review of Resident #1's Provider Investigation Report, dated 03/21/2025, revealed , Residents were waiting outside smoke porch door for staff member to come supervise smoke break. Resident #1 was yelling and hollering about smoke break being late. Resident #2 told Resident #1 to shup up. Resident #1 slapped at Resident #2's face and Resident #2 slapped back ay Resident #1's mid-section. Record review of Smoke Breaks and Department undated revealed Monday through Friday: 8:30am-activities, 11:00am-Southside CNA, 1:30pm -Dietary, 4:00pm-Activities, 6:00pm-housekeeping, 8:30pm - Northside CNA. Saturday & Sunday: 8:30am - Northside CNA, 11:00am - Southside CNA, 1:30pm - Dietary, 4:00pm - Northside CNA, 6:00pm-Housekeeping, 8:30pm-Southside CNA. Interview on 3/23/25 at 4:48 pm, CNA A stated Resident #1 was on secure unit. Staff got her and took her to smoke and bring her back every time. Interview on 3/23/25 at 5:01 pm, Resident #2 stated the residents yelled when staff were late, and Resident #1 was yelling, and staff were late that day and he told Resident #1 to be quiet and she hit him, and he hit her back. Resident #2 stated there were no injuries. Resident #2 stated staff were usually late on weekends, like 15 to 30 minutes late. Resident #2 stated that no staff were with them during that time, and they were waiting on staff. Observation on 3/23/25 at 5:57 pm at hall inside smoker door revealed a group of 8 residents waiting for smoke break. One female resident stated staff were usually 15 minutes late and today's schedule said housekeeping, but no one from housekeeping was there at 6:00 pm on a Sunday. Male resident stated sometimes they were 30 minutes late. Sign on wall near door stated smoking times and department responsible. Resident #2 came to the group and asked if anyone had come yet and residents told him no. Resident #2 stated he already went to north side of building staff to see if they would smoke the residents, and they said no. Observation on 3/23/25 at 6:10 pm revealed Resident #2 went to south side nurse's station. Resident #2 asked nurse who was going to smoke the residents and the nurse stated she can't because she gets bronchitis. Resident #2 asked if the aide could, and the nurse said she can't either because she just had stints put in. Resident #2 asked CNA B and she stated people are doing things and can Resident #2 give her 5 minutes. CNA B stated to Resident #2 not to get all crazy like yesterday and hit the walls and yell. Resident #2 stated he was just trying to get someone to smoke the residents, and he got frustrated. Residents taken out to smoke at 6:15pm. Interview on 3/23/25 at 6:15 pm with CNA B stated she was allergic to smoke, but someone has to take them. She stated facility has staff, but the schedule is not followed, and it is not logical. CNA B stated no one wants to take them. This happens a lot on weekends. Interview on 3/24/25 at 10:37 am, CNA B stated Saturday 3/22/25, she took the resident's out three times yesterday because no one else would take them out. CNA B stated she could hear staff over the intercom to get someone to take them (residents) out. Saturday Resident #2 got very upset and punched a wall and she understood; he was upset. CNA B stated she has seen residents wait an hour past smoke time. Saturday, they waited about 30 minutes before CNA B took them out one time, another time it was on time, and the last time CNA B took them out, but it was an hour late because she was working two halls all weekend and no one else would do it. She stated it was hard to do that and take all the smokers out. CNA B took the residents out at the 11am smoke break time and that was when Resident #2 punched the wall, because she did not get residents out until after 11:30 am. CNA B stated Resident #2 calmed down because CNA B took him out. She stated Resident #2 was the person that went around to get someone to smoke the residents. Interview on 3/24/25 at 10:56 am, the ADON stated she believed staff were running late for the smoke break when the incident between Resident #1 and Resident #2 occurred, and the smoke breaks were late on weekends. The ADON stated the schedule was created by AD and ADM and she told them to pick someone specific from each department, but she did not think that happened. She stated she had smokers tell her staff were late, and she told the DON and ADM. She stated they were aware of the weekend issue and have the smoking schedule posted everywhere. The ADON state the facility brought the hospitality aide on to make it better, but he did not work weekends. She stated the smoke break times was a failure. Interview on 3/24/25 at 12:25 pm, the AD stated he made the smoking schedule with the ADM, and he had a hospitality aide that did smoke breaks on Monday through Friday at 8:30 am, 11:00 am, and 1:30 pm. He stated there should be a floor tech at facility on 6:00 pm on Sundays that would be a part of housekeeping. The AD stated he heard from residents and staff that there is an issue on weekends and occasional evenings, and he was trying to figure it out. He stated he can only make suggestions and can't hold staff accountable. Staff bosses would be the ones to hold them accountable. The AD stated the facility, including the ADM, knew there was an issue when there was an altercation with Resident #1 and Resident #2. Interview on 3/24/25 at 2:00 pm with the ADM stated the smoke break was late the time of the incident with Resident #1 and Resident #2. The ADM stated the facility had a weekend floor tech, but he had open heart surgery and there was a breakdown in communication. Record review of Resident Rights undated revealed 2. The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. Under Respect and Dignity: 3. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health and safety of the resident or other residents.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for one (Resident #1) of three residents reviewed for infection control practices. The facility failed to ensure CNA A performed proper hand hygiene and glove changes while providing incontinence care to Resident #1. This failure could place residents at risk for the spread of infection. Findings included: Review of Resident #1's face sheet dated 01/10/25, revealed a 67- year- old female admitted to the facility on [DATE] with diagnoses including frequency of micturition (urinating), constipation, muscle weakness and Alzheimer's disease (neurological disorder). Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed Resident #1 required substantial/maximal assistance with most activities of daily living (ADLs). Resident #1 was always incontinent of bowel and bladder. Observation of incontinence care for Resident #1 on 01/09/25 at 2:55p.m. revealed CNA A washed her hands prior to donning gloves. CNA A removed Resident #1's brief that was soiled with urine and placed it on the bed close to resident. She did not completely remove it. CNA A wiped the resident from front to back. She retrieved a clean brief and placed it on top of the soiled brief. She did not change gloves but continued to clean the resident. Her gloves were visibly soiled with urine. CNA A did not wash her hands, change gloves, or perform hand hygiene before placing the clean brief underneath the resident. CNA A changed her gloves, and retrieved the old, soiled brief and placed on a trash can. CNA A removed her gloves and picked up the trash. She washed her hands before leaving Resident #1's room. In an interview on 01/09/24 at 3:06 p.m. with CNA A, she stated she should have changed her gloves before retrieving a clean brief and placing it underneath Resident #1. CNA A stated she has been in the facility for 2 years and received infection control training last month. She said cross contamination was going from clean to dirty. CNA A noted the resident could acquire an infection when she did not follow good infection control practices including changing gloves before retrieving the clean brief. CNA A stated she did not change her gloves because she was not thinking. During interview on 01/10/25 at 5:11 p.m., the DON acknowledged being aware of some of the concerns raised about infection control practice. She stated ADON B was responsible for infection control in the facility. The ADON trained and monitored staffs with return demonstration periodically. The DON stated aides were expected to follow standard precaution including washing hands and changing gloves while providing care. She stated the corporate nurse also trained staff annually. Review of the facility's infection control policy dated 04/27/22 reflected: Purpose: This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition. Important Points: o Doffing and discarding of gloves are required if visibly soiled o Always perform hand hygiene before and after glove use

Based on interview and record review the facility failed to ensure residents/resident's representative had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he/ she preferred for 2 of 26 residents (Resident #50 and Resident #114) reviewed for antipsychotic consents. 1. The facility failed to ensure Resident #50's HHSC Form 3713 for Ziprasidone (also known as Geodon an antipsychotic medication used to treat bipolar 1 disorder and schizophrenia) was signed by Resident #50 or Resident 50'ss responsible party. 2. The facility failed to ensure Resident #114's HHSC Form 3713 for Seroquel (an antipsychotic medication used to treat mental health disorders, such as schizophrenia) was signed by Resident #114 or Resident #114's responsible party. This failure could affect residents who received antipsychotics by placing them at risk of not being informed of their health status, to make informed decisions regarding their care. Findings included: Record review of Resident #50's electronic face sheet dated 12/04/2024 revealed a [AGE] year-old male admitted on [DATE] with the following diagnosis senile degeneration of (brain group of symptoms affecting memory, thinking and social abilities) schizoaffective disorder (mental health condition that includes hallucinations and delusions, depression and , mania), psychosis, and anxiety disorder. Record review of Resident #50's MDS assessment dated [DATE] revealed Section C- Cognitive Patterns: Resident #50 had a BIMS of 10 (meaning moderate cognitive impairment); Section N-Medications: Resident #50 had received antipsychotic medications during the previous 7-day period. Record review of Resident #50's physician order revealed: Ziprasidone HCL Oral Capsule 60 MG Give 1capsule by mouth two time a day related to schizoaffective disorder with a start date of 12/28/2023. Record review of Resident #50's December Medical Administration Record dated December 2024 revealed Resident #50 received Ziprasidone on 12/01/2024, 12/02/2024, 12/03/2024 and 12/04/2024. Record review of Resident #50's HHSC Form 3713 for Ziprasidone revealed no evidcnce of a signature by Resident #50 or their representative. Record review of Resident #114's electronic face sheet dated 12/04/2024 revealed [AGE] year-old male admitted on [DATE] with the following diagnosis unspecified Dementia, and insomnia. Record review of Resident #114's MDS assessment dated [DATE] revealed Section C- Cognitive Patterns: Resident #114 had a BIMS of 3 (meaning severe cognitive impairment); Section N-Medications: Resident #114 had received antipsychotic medications during the previous 7-day period. Record review of Resident #114's physician orders revealed: Seroquel Oral Tablet 25 MG Give 0.5 tablet by mouth one time a day related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (f03.90) give half of tablet to equal 12.5m . Seroquel oral tablet 25 mg (quetiapine fumarate) give 1 tablet by mouth one time a day related to unspecified, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (f03.90) with a start date of 11/14/2024. Record review of Resident #114's December Medical Administration Record dated December 2024 revealed Resident #114 received Seroquel on 12/01/2024, 12/02/2024, 12/03/2024 and 12/04/2024. Record review of Resident #114's HHSC Form 3713 for Seroquel revealed no evidence of a signature by Resident #114 or their representative. During an interview on 12/04/24 at 5:02 PM, the DON stated her expectation was that the antipsychotic consent should have been signed by the resident or resident's representative prior to Resident # 50 and Resident #114 were given and antipsychotic medication. The DON stated she was responsible to monitor the completion of resident's HHSC Form 3713, and she monitored during their weekly team meetings. The DON stated the effect on residents could have been residents and their representatives were not made aware of what medication residents were on and the side effects of the medications. The DON stated what led to the failure was the lack oversight by staff and staff turnover. Record review of facility policy titled Psychotropic Drugs dated 10/25/17 revealed A psychotropic consent from explains the risks and benefits of psychotropic medication. The resident or their representative must provide documented consent prior to administration of a newly offered psychotropic medication . Consent for antipsychotics must be in a written from. Phone o Seroquel r verbal consent is not allowed. Review of LTCR Provider letter titled Consent for Antipsychotic and Neuroleptic Medications dated May 5, 2022, accessed on 08/30/2024 at https://www.hhs.texas.gov/sites/default/files/documents/pl2022-11.pdf, revealed The prescriber of the medication, the prescriber's designee, or the NF' s medical director must complete Section I of Form 3713. HHSC cannot specify who can be the designee for the prescriber. Prescribers should consult their own board, such as the Texas Medical Board, to determine who can act as their designee. A prescriber can delegate the completion of Form 3713, Section I, if the prescriber's license permits it . The resident or the resident's legally authorized representative must sign Section II of Form 3713 (Consent for Antipsychotic or Neuroleptic Medication Treatment). The rule requires consent in writing by the resident or by a person authorized by law to consent on behalf of the resident. Verbal consent does not meet the rule requirements. NF staff cannot sign on behalf of the resident. Review of drugs.com accessed on 12/04/2024 at https://www.drugs.com, revealed Seroquel and Ziprasidone (Geodon) were Drug class: Atypical antipsychotics. Review of [NAME]-Term Care Regulatory Provider Letter date issued 05/05/2022 revealed: Under 26 TAC S554.1207, a resident receiving antipsychotic or neuroleptic medications must provide written consent. Written consent can also be given by a person authorized by law to consent on the resident ' s behalf. Consent for antipsychotic and neuroleptic medications must be documented on Texas Health and Human Services Commission (HHSC) Form 3713.

Based on observation, interviews, and record review, the facility failed to refer residents for PASRR screening and evaluation, with a newly evident mental disorder or related condition for level II PASRR review, 1 of 3 residents (Resident #107) in that: Resident #107 was not referred to the state-designated authority for PASRR re-evaluation upon evidence of past history significant for depression, anxiety, and PTSD when admitted to the facility on [DATE] with a negative PL1. This failure placed residents at risk of not receiving adequate services or care related to mental illnesses. Finding include: Record review of Resident #107's Facesheet, dated 12/03/2024, revealed Resident #107 was a [AGE] year-old male, with an admitted into the facility on [DATE]. Record review of Resident #107's Diagnosis Report, dated 12/03/2024, revealed Resident #107's admission primary diagnosis was Bipolar disorder, unspecified, effective 09/12/2023. Other diagnoses included Generalized Anxiety Disorder, which was dated 12/12/2023, and Post-traumatic stress disorder and major depressive disorder, dated effective 12/13/2023. Record review of Resident #107's Annual Minimum Data Set (MDS) assessment, dated 09/17/2024, indicated Resident #107 had a BIMS score of 15, which indicated intact cognitive response. Section I - Active Diagnoses revealed Resident #107 was coded a 13 which identified medically complex conditions. Active diagnoses identified were Anxiety disorder, depression, bipolar disorder, and post-traumatic stress disorder. Record review of Resident #107's PL1, dated 09/11/2023, revealed the referring entity documented Resident #107 had no previous history of mental illness by answering C0100 Is there evidence or an indicator this is an individual that has a Mental Illness? as no. Record review of Resident #107's progress note, dated 09/13/2023, completed by the PCP, revealed Resident #107 had a past history significant for depression, anxiety, and PTSD. Record review of Resident #107's Care Plan, dated initiated on 09/15/2023, revealed Resident #107 had a focus of, The resident has a psychosocial well-being problem (actual or potential) related illness/disease process due to history of trauma from working as a police officer in a large City, has been homeless, had a family member commit suicide when at a young age and resident was age 10. Resident has a diagnosis of bipolar. Review of Care Plan revealed Resident #107 had a focus of, The Resident has depression related to Bipolar maniac state. Record review of Resident #107's Psychiatric Progress Note, dated 10/11/2023, revealed Resident #107 was seen for mania following PCP med adjustments. Formal diagnoses included Bipolar disorder, current episode manic without psychotic features, moderate and Generalized anxiety disorder, active. Psychiatric medications were adjusted. Record review of Resident #107's Psychiatric Progress Note, dated 07/01/2024, revealed Resident #107 was seen due to symptoms of mania and his statement of, I think I need some help with my mood. Review revealed continued diagnoses of Bipolar disorder and Generalized anxiety disorder. Psychiatric medications were adjusted. During an observation on 12/03/2024 at 1:35 p.m., Resident #107 sat in the designated smoking area of the facility and smoked a cigarette. Resident #107 look around the area with a frown on his face. During an interview on 12/03/2024 at 1:39 p.m., Resident #107 said he was doing ok but he felt slightly nervous. Resident #107 said he had taken his medication, but he still felt anxious at times. Resident #107 said he saw the psychiatric doctor who came to the nursing facility and the psychiatric doctor adjusted his medication for anxiety. During an interview on 12/04/2024 at 2:28 p.m., the MDS Coordinator said Resident #107 came into the facility with no psychological diagnoses when he was admitted on [DATE] and had self-diagnosed himself with depression. MDS Coordinator said Resident #107 had been formally diagnosed with Post-traumatic stress disorder after admission on 09/11/2023. MDS Coordinator said she completed the Form 1012 on 12/03/2024 and was waiting for the doctor's signature. MDS Coordinator said she had submitted the PL1 in the portal to request a new PASRR evaluation be completed on Resident #107 on 12/03/2024. MDS Coordinator said the facility had an internal audit recently and recognized the facility had an issue with Resident #107's record and submitted the PL1. MDS Coordinator said she was not familiar with the Form 1012 prior to 12/03/2024 and was not aware that the form was required to be submitted. The MDS Coordinator provided the policy, PASRR Nursing Facility Specialized Services Policy and Procedure, dated as revised 03/06/2024, and stated the policy was the only policy the facility had in the area of PASRR specialized services. During an interview on 12/04/2024 at 3:30 p.m., the Area Director of Operations said the PASRR forms were monitored at a higher level than the facility. The Area Director of Operations said the corporate regional audit nurses inspected and audited, routinely, and provided feedback to the MDS Coordinators. The Area Director of Operations said the Form 1012 should have been completed and processed for Resident #107. During an interview on 12/04/2024 at 3:40 p.m., the Administrator said the MDS Coordinators were monitored by the facility and corporate staff and audited routinely. The Administrator said the Coordinator who did not complete the Form 1012 as required for Resident #107 when a suspicion of mental illness was present was an error and the form should have been completed and processed. Record review of the facility policy's, PASRR Nursing Facility Specialized Services Policy and Procedure, dated as revised 03/06/2024, revealed the policy did not address the process to take if a resident had a negative PL1 and the resident was diagnosed with a psychiatric diagnosis that could trigger a suspicion of eligibility for PASRR Mental Health services.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions for 2 of 6 medication carts (Hall B nurse medication cart & Hall A-D nurse medication cart) reviewed for medication labeling and storage. The facility failed to ensure Schedule II-V medications subject to abuse were stored so that shortage of medication was readily detectable for 1 of 2 medication rooms (Hall G-H medication room) reviewed for medication labeling and storage. 1. The facility failed to dispose of expired medications from Hall A-D nurse medication cart. 2. The facility failed to have pharmacy labels on 2 insulin flex pens from Hall B nurse medication cart. 3. The facility failed to have medication count sheets with controlled substances from Hall G-H medication room. These failures could place residents at risk of misappropriation of medications, receiving the wrong medication doses, and receiving medications with reduced therapeutic effects of medication. Findings Included: Resident #2 Record review of Resident #2's electronic face sheet dated 12/04/2024 revealed he was a [AGE] year-old male admitted to the facility on most recently on 09/11/2023 with diagnoses to include: type 2 diabetes. Record review of Resident #2's electronic physician orders dated 09/11/2023 revealed Lantus SoloStar Subcutaneous Solution Pen-Injector 100 unit/ml (Insulin Glargine) Inject 40 unit subcutaneously two time a day related to type 2 diabetes. Resident #111 Record review of Resident #111's electronic face sheet dated 12/04/2024 revealed she was a [AGE] year-old female admitted to the facility most recently on 01/05/2024 with diagnoses to include: type 2 diabetes. Record review of Resident #111's electronic physician orders dated 01/06/2024 revealed Insulin Lispro (1 unit dial) Subcutaneous Solution Pen-Injector 100 unit/ml (Insulin Lispro) Inject as per sliding scale: if 131-170 = 2 units; 171-210 = 3 units; 211-250 = 5 units; 251-290 = 6 units; 291-330 = 7 units; 331-400 = 8 units, subcutaneously four times a day related to type 2 diabetes. During an observation on 12/03/2024 at 8:33 AM, Hall G-H medication room revealed the medication refrigerator lock box affixed to refrigerator that included: 1. 1-30 ml bottle of lorazepam 2 mg/1 ml with Resident #21's name on pharmacy label. No evidence that medication had count sheet in H Hall binder behind refrigerator tab. 2. 1 medication bottle of buprenorphine/nalox 2-0.5 mg with Resident #93's name on pharmacy label and 23 individual wrapped films inside of bottle. No evidence that medication had count sheet in H Hall binder behind refrigerator tab. 3. 1 unopened medication box quantity of 30 buprenorphine/nalox 2-0.5mg with Resident #93's name on pharmacy label. CIII labeled on medication box. No evidence that medication had count sheet in H Hall binder behind refrigerator tab. During an observation on 12/03/2024 at 9:15 AM, Hall B nurse medication cart included 1 Lantus insulin flex pen for Resident #2 with resident's last name and open date of 11/24 and 1 Lispro insulin flex pen for Resident #111 with resident's last name and open date of 11/30. No evidence of prescribed dose observed on either flex pens. During an observation on 12/03/2024 at 11:43 AM, A-D Hall nurse medication cart included 1 bottle of OTC diphenhydramine 25 mg that had expiration date of 10/2024. During an interview on 12/03/2024 at 8:40 AM, LVN A stated nurses were supposed to count medications stored in locked controlled substance box when coming on shift. She stated she had not counted the medications that morning because she did not normally work Hall H and did not know that Hall H nurses' keys had the key to open controlled substance box in the medication room refrigerator. She stated she had not noticed count sheets for the 3 medications were not present at shift change. She stated the count sheets would be in the Hall H nurses binder for controlled substances behind the tab labeled Fridge. She stated not having count sheets could lead to medication being lost. During an interview on 12/03/2024 at 8:42 AM, LVN B stated medications stored in the locked box in the medication room refrigerator needed to have count sheets. She stated she remembered there being a discussion the night before about Lorazepam needed to be left in refrigerator when nurses were removing medications from the refrigerator for residents that no longer were at the facility or were discontinued. She felt the count sheet for lorazepam may have been misplaced during time when refrigerator medications were being removed the night before but did not know where it would be now. LVN B stated she had no knowledge of why the count sheets for buprenorphine/nalox 2-0.5mg were not present. She stated the count sheets should be kept in Hall H nurses' binder for narcotics as the H Hall nurse had keys to locked box. She stated not having a count sheet could lead to medication being lost. During an interview on 12/03/2024 at 8:57 AM, the DON stated she expected medication stored in locked controlled substance box in medication room refrigerator to have count sheets. She stated that nurses were responsible for making sure controlled medications had count sheets and should count the medications during shift change. She stated she did not have count sheet for Lorazepam or buprenorphine/nalox 2-0.5mg in her office. During an interview on 12/03/2024 at 9:15 AM, ADON C stated she did not know why insulin flex pens in Hall B treatment cart did not have pharmacy label on them. She stated that flex pen medications should have labels on them and that nurses were responsible for making sure medications were labeled. During an interview on 12/03/2024 at 11:43 AM, LVN D stated expired medications should not be left on medication carts. She stated she did not know why expired diphenhydramine was on Hall B medication cart, but it could be because that medication was not given often. She stated leaving expired medication on cart could lead to someone receiving expired medication. During an interview on 12/03/2024 at 4:08 PM, the DON stated that count sheets were required for any opioid medication or controlled medication. She stated scheduled III controlled substances should have count sheets per the facility's policy. She stated that she expected flex pens received from pharmacy to be labeled with resident's name, physician's name, directions for administration, and expiration date. She stated if flex pens were gotten out of emergency kit, then it would be appropriate to write the resident's name and date the medication was opened on pen and no label would be needed. She stated nurses would look at the order in the medication administration record prior to administering medication and did not feel any negative outcome would occur from flex pen not having direction for administration on them. She stated she expected medication to be removed from medication carts when it expired. She stated that medication aides and nurses were responsible for making sure expired medications were not left on medication carts. She denied any negative outcome had occurred from expired medication being left on cart but that it could lose effectiveness. She stated all nurses were responsible for making sure medications were labeled and stored correctly and that corporate and pharmacy monitored the nurses. During an interview on 12/04/2024 at 8:49 AM, LVN E stated she was familiar with H Hall and was working on that hall today. She stated the medication buprenorphine/nalox 2-0.5mg was not in the refrigerator the last day she had worked. She stated she had been off for several days. She stated she had reached out to Resident #93's family and asked them to please come and pick up medication since the facility had gotten buprenorphine filled from their pharmacy. LVN E stated in the past his family member would use outside pharmacies to get medication for the residents while they were waiting on Medicaid, but now used the facility's pharmacy. She did not know who had excepted the medication from family, but stated it should have had a count sheet if kept in facility's medication room refrigerator. She stated she had been counting Lorazepam prior to her being off work and did not know why count sheet was unable to be found on 12/03/2024 morning but that it was found and had been placed back in H Hall binder behind the Fridge tab so she was able to count it this morning. She stated that controlled medications should be counted during shift change. During an interview on 12/04/2024 at 9:11 AM, LVN F stated she had knowledge about G Hall and was working on G Hall today. She stated she did not count controlled medications that were stored in the refrigerator since the key to lock box was stored with H Hall keys. She stated she would only look at those count sheets if she were administering medication for her residents. She stated she had never administered the lorazepam or buprenorphine/nalox 2-0.5mg and did not ever look for those count sheets. During an interview on 12/04/2024 at 11:15 AM, the DON stated she had confirmed with Resident #93's family member that buprenorphine/nalox 2-0.5mg had been picked up from an outside pharmacy. The family member verified that the medication had been dropped off at the facility on 12/01/2024 when Resident #93 came back from being out on pass. The family member stated 7 doses had been given at home prior to being dropped off at the facility and that lined up with how many of the medication had been dispensed and how many the facility had on hand. She stated she had asked Resident #93's family member to pick up medication from the facility, but the family member wanted Resident #93 to go to outside physician and that was what caused the medication to be filled from outside pharmacy in the first place. During a telephone interview on 12/04/2024 at 9:30 AM, the pharmacy Regional VP stated he expected expired medication to be discarded. He stated diphenhydramine should not be administered past its expiration date. He stated medication would start losing effectiveness in general when it expired. He stated that Resident #2 had no record in the pharmacy's system that insulin Lantus had been pulled from emergency kit and on 11/18/2024 the pharmacy had filled 5 insulin Lantus flex pens. He stated Resident #111 had no record in the pharmacy's system that insulin Lispro had been pulled from emergency kit and on 11/29/2024 the pharmacy had filled 2 insulin Lispro flex pens. He stated directions were typically in the plastic bag or box insulin was dispensed in because there was only so much room on the pens. He stated no negative outcome would occur from label being missing since the most current orders would be in the medication administration record and the resident's last name and expiration date were written on pen. He stated pharmacies were required to label controlled medications on original boxes. He stated the medication box would have a Bold C with [NAME] numerals for the schedule of medication on the box for all controlled medications. During a telephone interview on 12/04/2024 at 12:15 PM, the pharmacy VP of clinical services stated he expected for controlled substances to have count sheets. He stated he felt the failure occurred due to the medications being filled by outside pharmacies that did not always know to send count sheet with medication. He stated he did expect facility staff to make a count sheet if none had been provided and that pharmacy consultants do monitor those count sheets were done. He stated not having count sheets for controlled substances could lead to misappropriation of medication but did not feel any negative outcome had occurred to the residents. The pharmacy VP of clinical services stated he expected medications to be discarded when they were expired and not be kept on medication cart. He stated nurses and medication aides were responsible for disposal of expired medications. He stated he did expect for insulin flex pens should be labeled but did state that labels could come off due to adhesive weakened from refrigeration. He stated, at a minimum, the label should have the residents name and date of expiration / opened on the flex pen if facilities pharmacy label had fallen off or medication obtained from an outside pharmacy. He stated that nurses have been trained to go off the medication administration record and physician orders for directions and did not feel any negative outcome would occur from flex pens not having directions present on them. He stated that pharmacy consultants monitored medications were stored and labeled correctly. Review of the policy titled, Medication Labeling, dated 2003 read in part: Medications dispensed by a pharmacy: All legend patient medication regardless of source shall be properly labeled as required in State regulations for Long Term Care Facilities .The nurse receiving the drugs assumes the responsibility for assuring that all items entering the facility are properly labeled. Any item improperly labeled shall be rejected and returned to the originating pharmacy or originating provider .All unit dose medication is labeled with the drug name, strength, lot number and date of expiration .When the multiple dose medication label cannot be attached directly to the multiple dose medication container because of size or shape, the Pharmacy will attach the medication label to the companion box or on a baggie and insert in the medication container. The medication container will have a small auxiliary label attached to it which will contain the prescription number, date, and resident name. After the medication is used it must always be returned immediately to the labeled box or baggie. Strip labels are not required on single dose containers .Directions for administration shall be as specific as possible. Review of the policy titled Storage of Controlled Substance revised on date 07/2012 read in part: The Controlled Substances Act of 1970 replaces existing laws regarding labeling, handling and accountability of narcotics, sedatives, stimulants and other drugs with abuse potential .Drugs listed in schedule II, III, and IV of the Federal Comprehensive Drug Abuse Prevention and Control Act of 1970 shall not be accessible to other than licensed nursing, pharmacy and medical personnel designated by the HOME. The Director of Nursing is designated by the facility to be responsible for the control of such drugs.

45458 Based on observation, interview, and record review, the facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for 4 of 26 Residents (Residents #8, #9, #120, and #376) and one (1) of one (1) kitchen. 1. Residents #8, #9, #120, and #376 voiced concerns of cold food, flavor, and/or texture. 2. One (1) of the three (3) foods sampled on the meal tray was cold. These failures could affect the residents by placing them at risk for malnutrition due to residents' decline in consumption in food, dissatisfaction of meals served, and residents to have unwanted weight loss. Findings include: Record review of Resident #120's Facesheet, dated 12/04/2024, revealed Resident #120 was a [AGE] year-old male, with an admitted into the facility of 09/12/2024. Diagnoses included Parkinson's disease (a progressive neurological condition that affects the brain and causes movement and non-movement issues) with dyskinesia (a range of movement disorders that involve involuntary muscle movements, such as tics, tremors, or spasms), with fluctuations (changes in the ability to move) and Depression (a serious mood disorder that can affect a person's thoughts, feelings, behavior, and sense of well-being). Record review of Resident #120's Admission MDS assessment, dated 09/16/2024, revealed Resident #120 had a BIMS score of 10 which indicated a moderate cognitive impairment. During an interview on 12/02/24 at 2:45 p.m., Resident #120 said the food was the only thing that he would consider that needed to be worked on. Resident #120 said breakfast was usually cold, and the food overall was not very good. Resident #120 said the lunch served on the day of the on-site visit was actually pretty good for once, but it was cold when he ate it. Record review of Resident #376's Facesheet, dated 12/03/2024, revealed Resident #376 was an [AGE] year-old male, with an admitted into the facility of 11/18/2024. Diagnoses included Type II Diabetes Mellitus without complications and Iron deficiency secondary to blood loss (chronic). Record review of Resident #376's Admission MDS, dated [DATE], revealed Resident #376's had a BIMS score of 15 which indicated an intact cognitive response. During an interview on 12/03/24 at 12:27 p.m., Resident #376 said the food was inconsistent and he thought the kitchen should be overhauled. Resident #376 said the food was often cold. Resident #376 said he never received condiments and the food tasted terrible. Resident #376 said he attended the monthly council meeting and residents talked about cold food every meeting. Record review of Resident #8's Facesheet, dated 12/04/2024, revealed Resident #9 was a [AGE] year-old female, with an admitted into the facility of 05/06/2004. Diagnoses included Other cerebrovascular disease (temporary blockage of an artery in the brain that causes stroke-like symptoms) and Gastro-esophageal reflux disease (a chronic condition that occurs when stomach contents leak into the esophagus). Record review of Resident #8's Annual MDS, dated [DATE], revealed Resident #9 had a BIMS score of 15 which indicated an intact cognitive response. During an interview on 12/03/2024 at 4:34 p.m., Resident #8 said the food being cold was brought up at every resident council meeting that was held on a monthly basis. Resident #8 said the was sent out of kitchen and by the time the aids passed the trays out, the food was not hot. During an observation on 12/02/2024 at 12:25 p.m., a test tray was requested. At 12:40 p.m., preparation of the test tray began, and the tray was placed on the serving cart for Hall G. Plate was picked up with suction cup. Meat placed on plate with mashed potatoes and spinach. Observed a slice of cheese to be placed on top of meatloaf and tray place on the bottom slot of the cart for Hall G. Staff placed a roll, cake, tea, silver ware, and a cover on the tray. At 12:48 p.m., Hall G serving cart left the kitchen and was placed outside the kitchen into the hallway. At 12:55 p.m., the test tray left the area and CNA J took possession of the cart, which she took to Hall G. During an interview on 12/02/2024 at 12:27 p.m., CNA J said the residents on Hall G often complained of tea being watered down and no condiments on the trays. CNA J said she observed no butter on the trays for the current meal. During an observation on 12/02/2024 at 1:10 p.m., the sample tray arrived at the conference room. At 1:11 p.m., the Dietary Manager took the temperature of the spinach, which was 117.5 degrees Fahrenheit, hamburger steak with cheese was 100.2 degrees Fahrenheit, and the mashed potatoes were 117.1 degrees Fahrenheit. The food was sampled by the Dietary Manager and surveyors. During an interview on 12/02/2024 at 1:10 p.m., the Dietary Manager said the food was cold and could be warmer. The Dietary Manager said the meatloaf hamburger could be warmer and would taster better. The Dietary Supervisor said the food temperature did not meet her expectations. The Dietary Supervisor said the residents would not eat the food at the present temperature. During record review of the facility's policy, Daily Food Temperature Control, dated 2012, revealed the facility would assure that food was served within acceptable ranges. 48883

Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 2 (Resident #1 and Resident #2) of 10 residents reviewed for multiple falls. The facility failed to implement a system for identifying fall patterns and implementing interventions to prevent falls that lead to emergency room visits with serious injury on [DATE] and [DATE] for Resident #1 and [DATE] and [DATE] for Resident #2. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 10:25 am. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems. These failures could place the residents at risk for falls, serious injuries, hospitalization s, and death. Findings include: Resident #1 Review of Resident #1's electronic face sheet revealed a [AGE] year-old male admitted to facility on [DATE] with diagnoses to include: dementia, depression, schizophrenia, and repeated falls. Review of Resident #1's Quarterly MDS assessment, dated [DATE], revealed a BIMS score of 15 which indicated no impaired cognition. Section J Health Conditions: Falls revealed no falls since admission or prior assessment. Review of Resident #1's Significant Change MDS assessment, dated [DATE], revealed a BIMS score of 11 which indicated moderate impaired cognition. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. Further review revealed: 0 falls with no injury, 0 falls with injury, and 1 fall with major injury. Review of Resident #1's Comprehensive Care Plan, initiated [DATE], revealed: Focus: The resident is at risk for falls. Goal: The resident will be free from falls through the review date. The resident will not sustain serious injury through review date. Interventions: Anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed., ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, keep furniture in locked position, Keep needed items, water in reach. Staff to make frequent visual checks to promote safety and reduce risk of fall, Physical therapy evaluate and treat as ordered or as needed, the resident needs a safe environment with: (even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Side fails as ordered, handrails on walls, personal items within reach. The resident needs activities that minimize the potential for falls while providing diversion and distraction. Further review of the Comprehensive Care Plan revealed no new interventions added or implemented since [DATE]. Review of Resident #1's Fall Event Nurses' Note, dated [DATE] at 4:48 PM, signed by LVN D, revealed: Resident #1 had an unwitnessed fall where he hit his head. Resident #1 was ambulating in hallway, and he fell in hallway face first. He bloodied his nose and received a bruise to the right side of his forehead. Doctor was notified and Resident #1 was sent to the emergency room for evaluation and treatment. Review of Resident #1's hospital clinical record, dated [DATE], revealed: Injuries: Subdural hematoma (blood around the brain), Hemorrhagic contusion right inferior temporal region (bleeding brain bruise), left periorbital hematoma (bruise around the eye), and left 7th, 9th, and 10th rib fractures. Resident #1 was discharged back to facility on [DATE]. Review of Resident #1's Fall Event Nurses' Note, dated [DATE] at 6:48 PM, signed by RN E, revealed: Resident #1 had an unwitnessed fall. Resident #1 fell and hit head on floor with laceration. Resident #1 was transferred to the emergency room . Review of Resident #1's hospital clinical record, dated [DATE], revealed: Injury: Laceration sustained to left parietal area (top rear of head) is clean, jagged, superficial, 2.6 by 7.5 centimeters. Wound care applied 5 stiches. Resident #1 was discharged back to facility on [DATE]. Review of the facility's incident log from [DATE]-[DATE], revealed Resident #1 had falls on [DATE] at 3:09 pm no injury, [DATE] at 6:15 pm with injury, [DATE] at 2:30 pm no injury, [DATE] at 4:40 pm no injury, [DATE] at 4:21 pm no injury, [DATE] at 4:07 pm no injury, [DATE] at 3:22 pm no injury, and [DATE] at 4:46 pm with injury. Review of Resident #1's Fall Risk Assessments dated [DATE] revealed a score of 13 High Risk, [DATE] score 18 High Risk, [DATE] score 21 High Risk, [DATE] score 21 High Risk, [DATE] score 18 High Risk, [DATE] score 20 High Risk, and [DATE] score 23 High Risk. Review of Resident #1's Care Plan Conference, dated [DATE] at 9:44 am signed by LVN F, revealed: Resident did not attend due to inability to understand care plan discussion. Family did not attend. Went over care plan, with no changes at this time. Continue current plan of care. Observation on [DATE] at 12:40 pm, revealed Resident #1 on the secure unit lying in bed no distress noted. Resident was alert but not oriented and not really communicating. Nurse and CNA were currently sitting at bedside. Observation on [DATE] at 9:30 am, revealed Resident #1 was lying in bed. The bed was in a low position. There was no siderail or handrails on the bed. Resident #1 had his eyes open and looked at the surveyor but did not speak. There were 3 CNAs in the resident's room. Resident #2 Review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted to facility on [DATE] with diagnoses to include: dementia, depression, anxiety, and unsteadiness on feet. Review of Resident #2's Significant Change MDS assessment, dated [DATE], revealed no BIMS score. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. 0 with no injury, 1 with injury, 1 with major injury. Review of Resident #2's Quarterly MDS assessment, dated [DATE], revealed no BIMS score. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. 0 with no injury, 1 with injury, 0 with major injury. Review of Resident #2's Comprehensive Care Plan, initiated [DATE], revealed: Focus: The resident is at risk for falls related to She has had actual falls since entering the facility due to poor gait and balance, dementia with poor safety awareness and judgment. Actual fall [DATE] Fall between bed and wall causing Right Rib Fracture and mild pneumothorax resulting in emergency room visit. Goal: The resident will not sustain serious injury through review date. Interventions: Anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, Ensure that the resident is wearing appropriate footwear when ambulating, Staff x 1 to assist with transfers, and the resident needs activities that minimize the potential for falls while providing diversion and distraction. Further review of the Comprehensive Care Plan revealed no new interventions added or implemented since [DATE]. Review of Resident #2's Fall Event Nurses' Note, dated [DATE] at 6:05 AM, signed by LVN G, revealed: Resident #2 had an unwitnessed fall. CNA reported that resident had fallen on the floor. This nurse went into residents' room and found her lying on the floor on her right side and screaming in pain and holding her right side at her rib cage. Having difficulty breathing at this time. Bedside toilet and table and walker all turned over on floor by her. Resident #2 was transferred to the emergency room . Review of Resident #2's hospital discharge record, dated [DATE], revealed: Diagnosis Fractured rib and head injury. Resident #2 was discharged back to the facility on [DATE]. Review of Resident #2's Fall Event Nurses' Note, dated [DATE] at 9:50 PM, signed by LVN H, revealed: Resident #2 had an unwitnessed fall. CNA noticed blood on resident's shirt and observed blood in residents' hair and notified nurse. I assessed resident and observed laceration to right side of resident's head. Resident was guarding right shoulder as well. Resident #2 was transferred to the emergency room . Review of Resident #2's hospital clinical record, dated [DATE], revealed: Abrasion on the right scalp and shoulder pain. Resident #2 was discharged back to the facility on [DATE]. Review of the facility's incident log from [DATE]-[DATE], revealed Resident #2 had falls on [DATE] at 11:00 pm with no injury, [DATE] at 5:44 am with injury, [DATE] at 10:00 am with no injury, and [DATE] at 8:15 pm with injury. Review of Resident #2's Fall Risk Assessments dated [DATE] revealed score 16 High Risk, [DATE] score 19 High Risk, [DATE] score 15 High Risk, [DATE] score 15 High Risk. Review of Resident #2's Care Plan Conference, dated [DATE] at 11:29 am signed by LVN F, revealed: Resident did not attend due to inability to understand care plan discussion. Resident #2's [family member] did attend. Went over care plan, with no changes at this time. Continue current plan of care. Observation on [DATE] at 4:00 pm, revealed Resident #2 ambulating up and down the hall. Resident seemed unsteady on her feet. Resident was wandering in and out of other residents' rooms. During an interview on [DATE] at 12:45 pm, LVN A stated Resident #1 had a history of falling. She stated she had been sitting in his room since his return from the hospital as much as she could because she did not want him to fall again. She stated Resident had a history of wandering and was only oriented to his name. She stated she was trying to increase supervision. She stated she had not been instructed to sit or monitor Resident #1 by the facility. She stated she just was because she was concerned. She stated she had spoken to the DON and informed her that Resident #1 needed 1:1 supervision but she was told the facility did not have the staff for that. She stated there was always 2 CNAs on the secure unit. LVN A stated Resident #2 had a history of wandering and falls also. She stated Resident #2 walks the unit continuously and it was almost impossible to keep an eye on her all the time. She stated Resident #2 had no new fall interventions that she was aware of. During an interview on [DATE] at 12:50 pm, CNA B stated he was working with another resident the day Resident #1 fell and was injured. He stated his coworker was in a room and he was assisting the nurse with another resident when he heard a loud noise. He stated he turned around and Resident #1 was lying face down in his doorway covered in blood. He stated he had seen Resident #1 in his bed 15 minutes prior to the fall. He stated he always tried to watch Resident #1 closely and made sure to check on him every 15 minutes when possible. He stated he had asked for help and spoke to the DON and Administrator about not having adequate staff to meet Resident #1's needs. He stated Resident #2 was also a high fall risk. He stated Resident #2 continuously wandered and was very unsteady. CNA B stated he felt 2 CNAs was not enough to monitor the residents and to prevent falls. He stated he was not aware of any new fall prevention interventions put in place for Resident #1 or Resident #2. During an interview on [DATE] at 2:00 pm, the DON stated she did not know much about Resident #1. She stated she had 130 residents and could not keep up with all of them. She stated she was not aware of any clinical issues with Resident #1 prior to the fall. She stated she was not aware of how many falls he had had but she knew he had a history of falls. She stated when a fall occurred the staff assessed the resident, notified the physician and family member, then completed an incident report. She stated she was not always notified of all falls, only falls with major injury. She stated falls were reviewed every morning during morning meeting. During an interview on [DATE] at 9:35 am, CNA B stated he was told this morning by the DON to keep resident #1 in his line of site at all times. He stated they did not increase the staffing and he still had to do his normal work and watch resident. #1. He stated he had not received any in-service regarding increased supervision for Resident #1 or Resident #2. During an interview on [DATE] at 10:40 am, the DON stated the facility had clinical meeting every morning to discuss day to day updates on all residents. She stated if a resident fell it would be discussed in the clinical meeting and new interventions should be put into place. She stated it was her responsibility to update the care plan with acute issues and new interventions. The DON stated she did not have any documentation of what was discussed in the clinical meeting she just made herself a to-do list. She stated she had missed multiple clinical meetings lately due to having to work the floor. She stated she did not have a system where she tracked falls. She stated falls were discussed in QAPI meetings monthly. She stated the facility just stated how may falls they had each month. The DON stated she was unaware of any QAPI plan specifically for falls or any fall prevention programs in place. She stated the possibility of getting Resident #1 a helmet was brought up by the family on ,d+[DATE] prior to the fall. The DON stated since Residents #1's return from the hospital on [DATE], she placed the resident on increased supervision. She stated she verbally in-serviced the staff on the secure unit and instructed them to always keep Resident #1 in line of site. She stated she did not increase staffing and did not document, or care plan the new intervention. She stated she obtained an order to refer Resident #1 to a neurologist, but she was unsure where the facility was in the process of getting that done. The DON stated she was unable to perform her clinical duties because she was working the floor or constantly putting out fires and she had not had the time do her responsibilities. She stated she did not feel that any further interventions could have been put in place to prevent the falls but agreed that the facility did not attempt any new interventions. Interview attempted on [DATE] at 11:00 am with both Medical Directors via phone. Called office and left message with no returned phone call. During an interview on [DATE] at 11:45 pm, the Administrator stated he monitored the number of falls in QAPI meetings and looked for trends, but he just looked at overall fall numbers not resident specific. He stated more interventions should have been put into place for Resident #1 and Resident #2 and it was ultimately his responsibility to ensure this was done. The Administrator stated he was notified of all falls and ensured all documentation was done. He stated he only investigated falls with injury or unwitnessed or suspicious falls. During an interview on [DATE] at 1:00 pm, CNA C stated Resident #1 had always had multiple falls. She stated she was working the day he fell and the day he returned. CNA C stated she was not aware of any new interventions being put into place. She stated Resident #2 got up quickly and fell before staff even knew that he was out of bed. She stated she tried to watch him closely but most of the time there was only 2 CNAs on the unit, and it was hard to provide 1:1 supervision. CNA denied being in-serviced or told to increase monitoring or supervision when Resident #1 returned to the facility. During an interview on [DATE] at 3:30 pm, the MDS Nurse stated she was not responsible for updating the care plan with acute or new issues. She stated she performed quarterly care plan conferences based on what was documented in the chart. She stated if the falls had been added to the care plan when they occurred and new interventions had been added then she would have discussed it in the care plan conferences. She stated it was not her responsibility to update the care plan. She stated the failure occurred because the DON had not added new interventions when the falls occurred. Review of facility policy titled, Preventive Strategies to Reduce Fall Risk, revised [DATE], revealed in part: Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. Procedure: 1. After risk is assessed, individualized nursing care plans will be implemented to prevent falls. The resident and family members will be educated on methods to prevent falls. Interventions will focus on manipulating the environment, educating the resident/family, implementing rehabilitation programs to improve functional ability, and care monitoring of medication side effects .5. Incident Reporting: Reported falls will be thoroughly investigated to assess fall risk factors and contributing factors in order to provide a safe environment for the resident(s). This was determined to be an Immediate Jeopardy (IJ) on [DATE]. The Administrator, and Director of Nurses were notified on [DATE] at 10:25 am that an Immediate Jeopardy was identified, and a Plan of Removal was requested at that time. The Administrator was provided with the IJ template on [DATE] at 10:25 am. The following Plan of Removal was accepted on [DATE] at 2:35 pm and included: Problem: F689 Accidents/Hazards Interventions: Resident #1's care plan was reviewed for fall prevention interventions by the DON/Regional Compliance nurse on [DATE]. o Helmet ordered for safety. o Refusal to use assistive devices. o PT/OT/ST o Offer diversions, activities, food, conversation, etc to reduce wandering. o Non-skid socks o Increased staff rounding Resident #2's care plan was reviewed for fall prevention interventions by the DON/Regional Compliance nurse on [DATE]. o Increase rounding to promote safety. o Ensure a safe environment free of clutter and obstructions. All residents with falls in the last 30 days were reviewed by DON/Regional Compliance Nurse on [DATE] to ensure that appropriate fall interventions are listed on the care plan. There were 50 falls with 26 residents noted in the review. A task on the POC Kiosk was added for all resident at high risk for easy identification by the DON, ADON, and Regional Compliance Nurse on [DATE]. The medical director was notified of the immediate jeopardy situation on [DATE] at 11:30pm by the Administrator. Ad Hoc QAPI meeting will be held on [DATE] to discuss the IJ and review plan of removal. In-services: The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following in-services. o Fall Prevention Policy o Care Plan Policy: Updating the care plan with fall prevention/safety interventions. o Abuse and Neglect. The following in-services were initiated by the Regional Compliance nurse, DON, and ADON on [DATE]. Any staff member not present or in-service on [DATE] will not be allowed to assume their duties until in-serviced. All new hires will be in-service at orientation. All agency staff will in serviced before assuming their assignment. All Staff: Abuse and Neglect Policy Notifying the charge nurse for any change in condition to include falls, pain or a change in mobility or transfer status. All Direct Care Staff: Abuse and Neglect Policy Fall Prevention Policy Notification of a change in condition policy include falls, pain, or a change in mobility or transfer status. How to identify a resident who is high risk for falls on the Kiosk or Care plan Monitoring: DON, Administrator, Designee will review all falls during the morning meeting to ensure appropriate interventions have been implemented. Monitoring will occur 5 days per week for a minimum of 6 weeks. DON, Administrator, Designee will review all falls during the weekly Standard of Care Meeting to ensure appropriate interventions have been implemented. Monitoring will occur weekly for a minimum of 6 weeks. Administrator or Designee will review the Event entry and ensure that care planned interventions are change with each fall during the weekly Standards of Care Meeting. Meeting will occur weekly, and monitoring will be in place for 6 weeks. Regional Compliance Nurse and/or ADO will monitor, on a weekly basis, that monitoring tools are in place and up to date. Monitoring of the facility's Plan of Removal through observations, interviews, and record reviews from [DATE] at 2:40 pm through [DATE] at 5:30 pm revealed: Review of Resident #1's comprehensive care plan revealed new interventions added on [DATE] to include: Continues PT/OT. Started OT in October for safety and strength. ST picked up for weight and cognition. PT started for strengthening endurance related to weakness to lower extremity. Date Initiated: [DATE] PT o Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Date Initiated: [DATE] Revision on: [DATE] o Ensure that the resident is wearing appropriate nonskid footwear or nonskid socks when ambulating Date Initiated: [DATE] Revision on: [DATE] o Helmet ordered by Therapy for prevention of head trauma Date Initiated: [DATE] Revision on: [DATE] o Keep needed items, water, etc, in reach. [DATE] Staff to increase visual checks to promote safety and reduce risk of fall Date Initiated: [DATE] Revision on: [DATE] o Resident offered and refuses to use assistive device for safety. Date Initiated: [DATE] o Staff x 1 to assist with transfers, staff to monitor while in room and when resident ambulating in hallway. Date Initiated: [DATE] Revision on: [DATE] o The resident needs a safe environment Date Initiated: [DATE] Revision on: [DATE]. Observation on [DATE] at 2:40 pm, Resident #1 was lying in bed with family members in his room. Observed staff in line of sight of Resident #1. Review of Resident #2's comprehensive care plan revealed new interventions added on [DATE] to include: o Ensure a safe environment free of clutter and obstructions. Date Initiated: [DATE] Revision on: [DATE] o Staff to increase rounding on resident to promote safety Date Initiated: [DATE]. Observation on [DATE] at 2:43, Resident #2 was sitting on couch in the lobby with staff beside her. Random record reviews revealed at least 6 of the 26 residents with falls in the last 30 days had their comprehensive care plans reviewed with new interventions added on [DATE]. Observation on [DATE] at 2:45 pm revealed CNA B accessing the POC Kiosk (computer system used by staff) and signing off on the high fall risk alert for Resident #1. Observed high fall risk alerts on 6 random residents. Review of an email dated [DATE], sent from the Medical Director to this surveyor, stated he was aware of the IJ, and he attended the QAPI meeting via phone. Review of a QAPI document dated [DATE] revealed d the IJ with signature page of all in attendance. In-services: Reviewed in-service information and signature sheets for in-service given by RCN to Administrator, DON, and ADON on Fall Prevention Policy, Care Plan Policy: Updating the care plan with fall prevention/safety interventions, and Abuse and Neglect During an interview on [DATE] at 3:00 pm, the Administrator and DON confirmed understanding of in-services titled: Fall Prevention Policy, Care Plan Policy: Updating the care plan with fall prevention/safety interventions, and Abuse and Neglect. During observation on [DATE] at 3:10 pm, revealed the DON educating 3 nurses, 9 CNAs, and 1 human resources staff that work the 6:30 am-6:30 pm shift, on Abuse and Neglect Policy, Fall Prevention Policy, Notification of a change in condition policy include falls, pain, or a change in mobility or transfer status, and how to identify a resident who is high risk for falls on the Kiosk or Care plan. Interview with 2 CNAs and 1 nurse verified understanding of in-service. During observation on [DATE] at 4:00 pm, revealed the DON educating 1 CNA and 1 medication aide that work the 2:00 pm- 10:100 pm shift, on Abuse and Neglect Policy, Fall Prevention Policy, Notification of a change in condition policy include falls, pain, or a change in mobility or transfer status, and how to identify a resident who is high risk for falls on the Kiosk or Care plan. During observation on [DATE] at 4:00 pm, revealed the DON educating 1 nurse who works 6:30 pm- 6:30 am shift via phone, on Abuse and Neglect Policy, Fall Prevention Policy, Notification of a change in condition policy include falls, pain, or a change in mobility or transfer status, and how to identify a resident who is high risk for falls on the Kiosk or Care plan. Interview with nurse verified understanding of in-service. The Administer, RCN, ADO, and DON were informed the Immediate Jeopardy was removed on [DATE] at 5:30 pm. The facility remained out of compliance at a severity level of harm and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review the facility failed to ensure residents received assistive devices to prevent accidents for one (Resident #1) of seven residents reviewed for falls with interventions. The facility failed to place a fall mat next to Resident #1's bed, and ensure the bed was in the lowest position, as was documented on the care plan and physician's orders [REDACTED]. The failure could affect 26 residents, who were identified as a fall risk and had interventions in place, by placing them at risk for additional falls and serious injuries. Findings included: Resident #1's MDS assessment, dated 04/01/16, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. The resident had moderately impaired vision, and moderately impaired cognitive skills for daily decision-making. She required extensive assistance with bed mobility and transfers, and she used a walker for mobility. The resident also had functional range of motion limitations in her lower extremities on one side. Resident #1's face sheet, dated 04/14/16, reflected her [DIAGNOSES REDACTED]. Resident #1's current, undated care plan reflected the resident was at high risk for falls related to being unaware of her safety needs, confusion, poor communication/comprehension, deconditioning, vision/hearing problems, gait/balance problems, incontinence. The care plan reflected Resident #1 did not call for assistance when needed, and she refused to use her call light. Also, the resident wished to be independent. The care planned interventions included having the call light within reach. Resident #1's current, undated care plan reflected the resident had a fall with serious injury related to unsteady gait and poor balance on 03/29/16. The fall was unwitnessed with no injuries. Also, on 04/10/16 the resident had a fall related to unsteady gait and balance. The care planned interventions included having the bed in the lowest position and placing a mat at the bedside. Resident #1's Fall-Risk Assessment, dated 03/25/16, reflected she was at high risk for falls due to intermittent confusion, required a wheelchair, had a balance problem while standing, decreased muscular coordination, and required the use of assistive devices. Resident #1's April 2016 Physician order [REDACTED]. The start date for this order was 04/01/16. Resident #1's Progress Notes written by LVN C on 03/31/16 reflected: Received new order for resident to have a floor mat bedsides her bed. and to keep bed in lowest position while in bed. floor mat applied next to bed and resident already has an electric bed that can be positioned in the lowest position while in bed. and we will continue to monitor. Resident with no s/s (sign/symptom) of injury noted s/p (status [REDACTED]. Continue with neuro checked and to monitor (sic). The facility's Provider Investigation Report reflected ADON A was attempting to locate a fall mat to place at Resident #1's bedside on 04/08/16; however, she left the facility that day without locating a mat. ADON A did not report that she did not locate a mat to place at Resident #1's bedside. Resident #8 fell next to her bed, and a fall mat was not in place when the fall occurred. Resident #1 told her family member she wanted to use the bathroom, and she thought she could transfer from her bed to her wheelchair without assistance. A written and signed statement by LVN C, dated 04/10/16, reflected around 8:35 a.m. LVN C went to Resident #1's room to check her vital signs and found the resident on the floor. Resident #1 was lying on her left side, facing her bed. The resident stated she was trying to get to her wheelchair. Resident #1 was lying in a puddle of urine. LVN C checked the resident for injuries with no signs or symptoms of pain. LVN C retrieved staff to assist her with turning the resident onto her back. Resident #1 was noted to have her left leg bent up at the knee. Resident #1 was unable to straighten her left leg. LVN C palpated the resident's arms and legs, and the resident complained of pain to her left upper leg and hip. No signs of abnormalities were noted. LVN C informed another nurse to call 911 and send the resident to the hospital. When LVN C had entered the room and found Resident #1 on the floor, the resident was holding her leg with her left hand. LVN C noted no objects were on the floor. A typed and signed statement by the Administrator, dated 04/11/16, reflected on 04/08/16 ADON A said she needed two fall mats. The Administrator told her she could find them in the clean linen closet and to ask the Maintenance Supervisor if she was unable to find one and to go from room to room looking in closets and under beds especially in rooms where a resident had discharged . ADON A told the Administrator Okay and the Administrator did not hear anything else about the mats. Resident #1's hospital records, dated 04/10/16, revealed she had a left intertrochanteric hip fracture (upper part of the thigh bone); which required surgery to repair the fracture. An interview on 04/14/16 at 12:13 p.m. with ADON A revealed Resident #1 fell three times at the facility. She stated the resident was independent prior to her first fall which occurred two to three weeks prior. She stated she care planned the fall mat as an intervention. She stated the resident had a mat in her old room, but had not had one in her new (current) room. ADON A stated Resident #1 moved rooms after her second fall, then changed rooms again on Friday (04/08/16). When asked why Resident #1's fall mat was not moved the new room, she stated maintenance or housekeeping would have been responsible for moving the resident's belongings. ADON A was asked what prompted her to look for a fall mat for Resident #1 on 04/08/16 when the order was dated 04/01/16. ADON A said she was looking for a mat for another resident. She said when she ended her shift on Friday (04/08/16), Resident #1 did not have a mat. She said the nurse on duty was LVN C, who was aware Resident #1 needed a fall mat. ADON A stated the Administrator had other people looking for a mat. She stated she asked the other ADONs if they had a mat, but they did not. ADON A stated she was not going to take a mat from another resident. She stated the Administrator called her Sunday (04/10/16) and told her Resident #1 fell and had a fracture. An interview on 04/14/16 at 1:46 p.m. with LVN C revealed Resident #1 fell in March 2016 and broke her right hip. She said the resident was more confused afterwards. She stated the resident would attempt to get up on her own. She stated Resident #1's bed was kept in the lowest position. She stated Resident #1 had changed rooms. She stated the resident had a fall mat when she was in a prior room. She stated she would expect staff to move the fall mat with the resident to her new room. LVN C stated she could not recall seeing a mat. LVN C stated the nurses should ensure fall interventions were in place and documented on the TAR. She said when a mat was ordered, the staff should ensure it was obtained. She stated if she could not locate a fall mat, she would let the Maintenance Director and her supervisor know. She stated she was working when the resident fell . She stated there was no fall mat by the bed, and the resident's room door was shut, which was not common for her. LVN C stated the resident said she was trying to get into her wheelchair. LVN C stated she assessed Resident #1 and could not turn her onto her right side. She stated the resident was grimacing. She stated with help from other staff she got the resident to turn onto her back and her left leg was bent. She stated the resident complained of pain to her left leg. LVN C stated there was urine on the floor. She stated the resident was sent to the hospital. An interview on 04/14/16 at 2:15 p.m. with CNA F revealed when a resident moved rooms, all the equipment in the room should move with them. An interview on 04/14/16 at 3:26 p.m. with ADON D revealed ADON A wrote an order for [REDACTED].#1 on 03/31/16. She stated she could not say whether or not the mat was placed in Resident #1's room. She stated the Friday before Resident #1 fell , ADON A was looking for a mat and the Administrator told her where to look. She stated ADON A left at the end of her shift without putting a mat in place. ADON D stated she received a call on Sunday about the resident's fall. She stated she did not know ADON A was looking for a mat for Resident #1. She stated ADON A told her she expected someone else to put the mat in place. An interview on 04/14/16 at 4:17 a.m. with CNA G revealed Resident #1 was very independent. She stated the resident did not like to ask for help. If Resident #1 had her door closed, she was up to something. She stated after Resident #1's first fall, she was different and had moments of confusion. An interview on 04/14/16 at 5:09 p.m. with LVN H revealed she worked the 6:30 p.m. to 6:30 a.m. shift the weekend Resident #1 fell . She stated she felt the fall mat was a tripping hazard because the resident would get up on her own. She stated the resident had not had a fall mat in her room and she did not know the resident was supposed to have a mat. LVN H thought she was told Resident #1 required a mat by LVN C. LVN H stated she was not aware if the facility had extra mats. LVN H stated Resident #1's bed was in a low position. She stated she would try to check on the resident frequently and keep her door open. Resident #1's April 2016 TAR reflected LVN C initialed Resident #1's bed was low and the floor mat was at bedside on 04/08/16. LVN H initialed on the same TAR sheet that Resident #1's bed was low and the mat was at bedside on 04/08/16 and 04/09/16. An interview via telephone on 04/15/16 at 2:16 p.m. with CNA B revealed she did not usually work on F hall (Resident #1' s hall). She stated she worked in the morning on Sunday, the day Resident #1 fell . When she checked on Resident #1 on Sunday, the resident's room door was shut. She said she was told Resident #1 liked to sleep in. She said the resident had surgery on one of her hips and needed assistance with ADL care, but wanted to be independent. When she went into Resident #1's room, she did not see a fall mat. CNA B said the resident's bed was not in a low position because she did not have to bend over or kneel down. She stated when she left Resident #1's room, she shut the door because that was how she found it. She was not told the resident was fall risk, needed to have her bed in a low position, or to have to a fall mat next to her bed. An interview on 04/18/16 at 8:59 a.m. with the Administrator revealed Resident #1 was able to raise and lower her bed due to having an electric bed. The Administrator stated Resident #1 was very independent. She stated the fall mat would be a tripping hazard for the resident, but, the resident's family member wanted the mat to be used. The Administrator stated she did not think a mat had ever been put in place for Resident #1. She stated she had visited the resident on several occasions and could not recall seeing a mat in her room. An interview on 04/18/16 at 10:12 a.m. with Resident #1 revealed she thought she could transfer herself from her bed to her wheelchair. She stated she fell and there was no mat on the floor, and she did not recall ever seeing a mat next to her bed. Resident #1 stated she had broken her other hip prior to the most recent fall, and the fracture to her left hip was her newest fracture. The resident was asked if she would move her bed up and down with the bed control. Resident #1 stated, Not that I recall. Resident #1 was lying in bed during the interview. The following sign was posted above her bed: Bed in lowest position at all times. Bed alarm while in bed. Chair alarm while in wheelchair. The facility's physician's orders [REDACTED]. Purpose: To monitor and ensure the accuracy and completeness of the medication orders, treatment orders and ADL order for each resident. The facility's Preventive Strategies to Reduce Fall Risk policy, dated 05/20/11, reflected the following: 13. Environment: Keep bed in low position. Keep the bed wheels locked. Use mobility handles or ¼ (quarter) rails in bed, low bed, scoop mattress, bolsters, or any combination of the previous. Place the call light and other objects within easy reach. Use bed/chair alarm systems to monitor unsafe activity as needed. Maintain adequate illumination in bedrooms and bathrooms. Maintain non-slip floor surface. Keep hallway clear. Provide grab bars and toilet risers in the bathroom. The Order Listing Report, dated 04/18/16 and provided by the Administrator, reflected 25 residents identified with interventions in place to reduce falls and/or injury.

Based on interview and record review, it was determined the facility failed to provide one (Resident #1) of six residents, who were reviewed for quality of care, the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. 1. RN I failed to thoroughly assess Resident #1 on 06/19/15 and 06/20/15 when he exhibited non-verbal signs of pain after a fall. 2. LVN F and RN I failed to contact Resident #1's physician on 06/19/15 and 06/20/15 after receiving multiple reports of non-verbal signs of pain following a fall. 3. LVN B, LVN F and RN I failed to obtain pain medication for Resident #1 on 06/18/15, 06/19/15 and 06/20/15 after receiving reports of Resident #1's non-verbal signs of pain during movement or care. These failures caused Resident #1 to have unrelieved pain from a [MEDICAL CONDITION] and delayed [DIAGNOSES REDACTED]. Findings included: Resident #1's MDS assessment, dated 06/12/15, reflected the resident was an [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had moderately impaired cognitive skills with both short-term and long-term memory problems with the ability to sometimes be understood by others and sometimes able to understand others. The resident required extensive assistance with bed mobility and transfers. The resident was unable to answer whether there was presence of pain when the assessment was conducted, and he did not exhibit any non-verbal signs/symptoms of pain. An Event Nurses' Note (incident report), dated 06/17/15 at 5:50 p.m., reflected Resident #1 was sitting at the dining room table when he leaned over and fell to the floor. An assessment was done and no pain, bruising, bleeding, or discomfort was noted. The resident was also noted to have good range of motion to his bilateral lower extremities. This report was documented by LVN B. A Nurses' Note, dated 06/18/15 at 3:30 p.m., reflected Resident #1 complained of pain during a therapy session when his right leg was moved. The resident's physician was notified, and an x-ray was ordered to rule out a possible fracture. The note reflected Resident #1 had a fall the night before, but he did not have any complaints of pain until going to therapy for exercise. The facility's Provider Investigation Report had the following attached Witness Statement, dated 06/30/15, written by CNA A reflected Resident #1 was placed in a wheelchair to transport him to the dining room for lunch because the resident was still walking funny. CNA A's statement reflected on 06/18/15 Resident #1 could not roll over on either side because he was in a lot (sic) of pain. She documented that she reported this to the nurse, and the nurse told her the resident had a fall the night before. An interview on 07/14/15 at 12:40 p.m. with LVN B, who worked on the 6:30 a.m. to 6:30 p.m. shift, revealed she was in the dining room on the morning of 06/17/15 when she found Resident #1 lying on the floor on his left side. She stated she evaluated the resident, and he had good range of motion in his extremities. LVN B stated Resident #1 did not show signs of pain when she moved his extremities, and he was able to stand up with assistance. He was transferred to a wheelchair, and the resident was taken back to his room and put back to bed. LVN B stated, on 06/18/15, Physical Therapist C reported to her that Resident #1 was exhibiting signs of pain when they tried to work with him. She stated a portable x-ray was ordered on [DATE]. An interview on 07/14/15 at 12:00 p.m. with Therapy Assistant D revealed on 06/18/15, while working with Resident #1, it was painful for the resident to get out of bed. He stated he could see by the resident's face that the resident was in pain. He stated he informed Physical Therapist C about the resident's pain. An interview on 07/15/15 at 10:15 a.m. with Physical Therapist C revealed, during attempts at therapy on 06/18/15, Resident #1 showed facial expressions of pain. Physical Therapist C stated she evaluated the resident at that time, and she informed LVN B and the DON of her observations. Physical Therapist C stated she recommended an x-ray of the resident's right hip. A Physical Therapy Treatment Encounter Note, dated 06/18/15, reflected Resident #1 exhibited pain when attempts were made to move his right lower extremity. The note reflected nursing staff were notified for follow-up, and nursing staff reported that Resident #1 had a fall the day before (06/17/15). A Nurses' Note, dated 06/18/15 at 4:00 p.m., reflected the x-ray was done at that time. The x-ray report, dated 06/18/15, reflected there was no radiographic evidence of an acute fracture to Resident's #1's right hip. The facility's Provider Investigation Report reflected the Administrator documented an interview with LVN G, who worked the 6:30 p.m. to 6:30 a.m. shift on 06/18/15, and LVN G stated Resident #1 slept as usual on his shift. LVN G stated he did not receive any reports of Resident #1 being in pain on his shift. An interview on 07/14/15 at 1:15 p.m. with CNA E, who worked the 6:00 a.m. to 2:00 p.m. shift, revealed she was assigned to provide care to Resident #1 on the day shift on 06/19/15, 06/20/15, and 06/21/15. CNA E stated Resident #1's behavior seemed different on those days. He was usually walking around. On the Friday 06/19/15 he would just lie in bed. When she tried to move him or change him he would grab her hand and squeeze hard. On Saturday 06/20/15, CNA E transferred Resident #1 to a chair. He refused to move from the chair when she wanted to check him for incontinent care. He refused to eat and made moaning sounds when they transferred him back to bed at the end of the shift. CNA E reported these to LVN F. On Sunday 06/21/15, Resident #1 refused to get out of bed. CNA E did not want to move him. When she touched him, he yelled and grabbed her neck and squeezed it hard. She related these observations to LVN K. LVN K came and evaluated the resident. An x- ray was ordered for his right hip. The facility's Provider Investigation Report had the following attached Witness Statement written by CNA M on 06/29/15 reflected: While trying to change resident, resident became very resistant. Resident (#1) yelled out every time he was turned like he was in pain. He (Resident #1) was very stiff and did not want to be bothered at all. Myself and the other aide I was working with thought it was a good idea to get (Resident #1) up out of bed since he had been laying in bed for the past couple of days. We continued to get resident dressed and then stand him up. Resident was very unsteady when standing him up. We put him in a wheelchair from that point, we had to help resident with everything including eating. I worked A hall with resident on June 20th, 2015. An interview on 07/14/15 at 1:30 p.m. with CNA H, who worked the 6:00 a.m. to 2:00 p.m. shift, revealed she was assigned to provide care to Resident #1 on 06/19/15, 06/20/15 and 06/21/15. On those days, she stated Resident #1 grabbed at her hands and grimaced in pain when she tried to provide him with care. She described Resident #1 as refusing to move and pulling away from her during care. She stated the resident also refused to eat on Saturday 06/20/15, and she reported all of this to LVN B and LVN F. The facility's Provider Investigation Report had the following attached Witness Statement written by CNA H, dated 06/29/15, reflected: On the 18th of June (Resident #1) stayed in bed and was eating all meals. When moved to be changed he would grimace and grab your hand or arm because he was in pain. On the 19th he stayed in bed again due to the same effect of grabbing a hold of your arm due to pain I noticed him changing his eating habits to less & less eating notified charge nurse (LVN B) throughout the day there was no change in pain, was worse when we changed him on the 21st no change in pain notified charge nurse (LVN K) and told her that he (Resident #1) would grimace and grab a hold of your arm due to pain. She (LVN K) then ordered an x-ray to be done on (Resident #1). An interview on 07/14/15 at 1:50 p.m. with LVN F, who signed in as the charge nurse on the day shift on Resident #1's hallway on both 06/19/15 and 06/20/2015, revealed CNAs reported to her that Resident #1 was acting differently. LVN F stated she observed the resident eating, and he did not act like he was in pain. LVN F stated the resident's family visited the resident, and they thought he was over-sedated so they asked that his medication [MEDICATION NAME] be held. When asked how she evaluated him, LVN F stated she turned him, and he showed no sign of pain. She stated she asked Resident #1 if he was in pain, and the resident just grunted. A second interview on 07/15/15 at 10:05 a.m. with LVN F revealed after the CNAs reported that Resident #1 was in pain she went to his room. She stated she went to Resident #1's room, and the resident's family was with him. LVN F stated the family thought Resident #1 was sedated so she offered to hold the resident's ordered [MEDICATION NAME]. She stated she turned Resident #1, and he did not show any signs of pain. LVN F stated she could not remember if Resident #1 was prescribed any pain medication on 06/19/15 and 06/20/15. LVN F was asked if the resident's physician was notified about Resident #1's new behaviors or requested pain medication for the resident, and she stated she could not remember. The Staffing Coordinator documented the following interview with CNA J on 06/29/15: (CNA J) stated that on the 20th (06/20/15) she worked 10-6a (10:00 p.m. to 6:00 a.m. shift) and that (Resident #1) was very quiet, not his usual self. When she was changing him he started moaning like he was in pain when she was turning him. She then stopped what she was doing and went and got the charge nurse; (RN I) and (RN I) informed (CNA J) that he (Resident #1) had fallen a couple of days. (RN I) explained to her that (Resident #1) had an x-ray and everything came back clear. (CNA J) then changed him very carefully, and he slept the rest of the night. An interview on 07/14/15 at 5:30 p.m. with RN I, who worked the 6:30 p.m. to 6:30 a.m. shift, revealed she saw a report on the 24-hour sheet reflecting Resident #1 had a recent fall, and a x-ray of the resident's hip was negative for fracture. She stated one of the CNAs asked her what was wrong with Resident #1 because when the resident was turned he moaned. She stated she went to the resident's room, and she observed him lying on his back. RN I stated Resident #1 did not seem to be in pain at that time. She stated she told the CNAs not to move the resident that evening, and she would see how he was in the morning. RN I was asked if this was the facility policy for evaluating residents, and she stated she was new and did not know the facility policy. RN I stated she did not move Resident #1 to evaluate if he was in pain, and she did not know Resident #1's norm. She explained it was busy, but she knew that was no excuse. RN I was asked what she thought she should have done, and she stated she should have given Resident #1 a Tylenol. RN I stated she got in trouble for not completing documentation. Review of Resident #1's clinical record revealed there were no nursing notes or pain assessments documented for 06/19/15 and 06/20/15. Review of Resident #1's MAR for June 2015 revealed there was no documented evidence reflecting Resident #1 was administered pain medication from 06/18/15 through 06/20/15. A Nurses' Notes entry written by LVN K on 06/21/15 at 7:50 a.m. reflected Resident #1 was unable to go out on pass with his family member because he was experiencing pain when his right leg was moved. It was noted that Resident #1 grabbed onto the CNAs anytime his right leg was moved during changing. An interview on 07/14/15 at 2:30 p.m. with LVN K revealed she was the charge nurse for Resident#1's hall on Sunday 06/21/15. LVN K explained that 06/21/15 was Father's Day, and the resident's family was coming to the facility to pick him up so she told the CNAs to get the resident ready. LVN K stated the CNAs took her into Resident #1's room, and when they tried to move him, he became stiff and his eyes widened. She stated Resident #1 pulled back and grabbed the CNAs' hands when they touched his right leg. LVN K stated she tried to touch Resident #1's leg, and she had the same results. LVN K stated Physician L was in the building, and Physician L examined Resident #1. New orders were received for an x-ray and pain medication. The x-ray was positive for [MEDICAL CONDITION] hip, and Resident #1 was sent to the hospital. An interview on 07/15/15 at 3:30 p.m. with Physician L revealed he was contacted on 06/18/15 about Resident #1's fall, and the resident's complaints of pain during therapy. Physician L stated he ordered an x-ray of Resident #1's right hip and knee. He stated the x-ray report of revealed negative for fracture. Physician L stated on 06/21/15 he learned of Resident #1 resisting care, and he ordered a second x-ray. The second x-ray showed a [MEDICAL CONDITION] hip. He explained that fractures will not always be visible on x-ray. Physician L stated Resident #1 was sent to the hospital after the second x-ray and pain medication was prescribed on 06/21/15. A Nurses' Note, dated 06/21/15 at 9:45 a.m., reflected the physician was notified of Resident #1's increased pain. The physician ordered an x-ray of the resident's right hip. A Nurses' Note, dated 06/21/15 at 10:45 a.m., reflected the resident had increased pain in his right leg. The resident's family member requested that pain medication be administered to the resident. A new order was obtained to administer [MEDICATION NAME] 50 mg one to two tablets every six hours as needed. An interview on 07/14/15 at 2:15 p.m. with Resident #1's family member revealed after Resident #1 returned from a hospital visit on 06/12/15 for dehydration he was not the same. The family member stated Resident #1 was not up walking around because he was too weak and he was not eating. In regards to Resident #1's [MEDICAL CONDITION], the family member stated he/she was at the facility on Sunday, 06/21/15, and Resident #1 was in bed. The family member stated Resident #1 would not let the family members touch him, and the resident was in pain. The family member stated an x-ray was done that day, and then the resident was sent to the hospital. A Nurses' Note, dated 06/21/15 at 12:20 p.m., reflected the x-ray results of Resident #1's right hip revealed a fracture to the right femur. The resident was transferred to the hospital for evaluation and treatment. The x-ray report, dated 06/21/15, reflected Resident #1 had an acute intertrochanteric right femoral fracture. A Telephone Order, dated 06/21/15, reflected an order for [REDACTED]. Review of Resident #1's clinical record revealed there were no other orders between 06/18/15 through 06/20/15 for the resident to receive a pain medication. Also, there were no prior physician orders [REDACTED].#1. The June 2015 MAR indicated [REDACTED]. The ED Physician Documentation, dated 06/21/15 at 12:53 p.m., reflected Resident #1 was admitted to the hospital with [REDACTED]. The physician noted that the resident was unable to communicate intelligibly. The hospital discharge summary, dated 06/25/15, for Resident #1 revealed he had surgery for [REDACTED]. An interview on 07/15/15 at 10:00 a.m. with the DON revealed Resident #1 had experienced a decline in condition after his most recent hospitalization . When he returned from the hospital, she stated he was not the same. On Thursday, 06/17/15, she stated she was aware that the Physical Therapist notified nursing that Resident #1 had pain in his leg when it was moved. She stated the resident was grimacing in pain. The DON stated an x-ray was ordered, and she instructed LVN B to watch the resident. She explained that she then went on vacation and was not at the facility. She was told that an x-ray was done on Friday, 06/18/15, and it was negative for fracture. On Sunday, 06/21/15, she stated LVN K wanted to have another x-ray ordered, and the second x-ray revealed a fracture. The DON stated it was protocol for the nurses to do seven day documentation post fall to include doing neurological checks and calling the physician if the resident had any discomfort. The DON acknowledged the nurses did not call Physician L on 06/19/15 and 06/20/15 to report pain or request pain medication for Resident #1. The DON was asked if it was expected that nurses move residents' extremities when conducting an assessment, and she stated, I would. The facility's Provider Investigation Report and attached documents reflected the facility conducted in-service training on 06/30/15 and 07/01/15 for nurses. The in-service record reflected the nurses received instruction on the following: If a resident is having pain or a CNA reports a resident is complaining of pain, a pain assessment MUST be done and pain medication given, if a resident does not have orders for pain meds. Dr. (doctor) must be notified and order for pain obtained if Dr. does not order pain meds then DON must be notified. The in-service was conducted by the DON. Additional in-services for the following topics were also held from 06/30/15 through 07/07/15 with nursing staff: - Contacting DON and/or Administrator of issues obtaining X-ray results times more than 12 hrs. (hours) - Documentation of Changes (Interact) in the Kiosk - Assessment of Pain and Pain Management - Documenting Assessment in Nurses Notes - Falls to remain on the 24hr report until all follow-up documentation is completed. - Call Administrator and/or DON for all falls with an injury. The facility's current Notifying the Physician of Significant Change in Status policy and procedure, dated 03/11/13, reflected: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. This facility utilizes the INTERACT tool, Change in Condition - When to Notify the MD/NP/PA to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition requires Immediate notification of the physician or Non-immediate/Report on Next Work day notification of the physician. 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. .7. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, the physician's orders [REDACTED]. The Resident List Report, dated 07/14/15, reflected 19 residents resided on Hall A where Resident #1 resided.

Based on observation, interviews and record review, it was determined the facility failed to immediately consult with the one of four sampled resident's (Resident #1's) physician when an incident occurred which required physician intervention. Resident #1 swallowed two poker chips. LVN E waited four hours before contacting the physician's office. LVN E was unaware the person they gave report to was an office manager instead of the physician's nurse practitioner or nurse. Eight hours later Resident #1 suddenly collapsed and was in full [MEDICAL CONDITION]. CPR was initiated. EMS personnel removed two poker chips from his throat. The resident was transferred to the local hospital and expired. On [DATE], an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm and a scope of pattern. The facility was monitoring the implementation of their plan of removal and ensuring all staff received the in-service training regarding immediate consultation with a resident's physician. Failure to ensure each resident's physician was consulted immediately when an incident of swallowing an inedible object occurred placed 30 residents, who were identified as at risk of swallowing inedible objects, at risk of a delay in evaluation and treatment, and potential death. Findings included: 1. On [DATE], at approximately 9:00 AM, while the surveyor was in the facility investigating an unrelated allegation, the ADM and DON notified the surveyor that Resident #1 had expired on Monday night ([DATE]). The surveyor was told Resident #1 had swallowed two poker chips at 10:20 AM on Monday ([DATE]). The resident expired later that same evening. 2. On [DATE] at approximately 2:00 p.m., the DON showed the survey two poker chips which were identified as the same type poker chips the resident swallowed. The poker chips measured approximately 1.375 inches in diameter. This is slightly larger than a .50 cent coin, which measures 1.205 inches in diameter. 3. The facility's Provider Investigative Report, dated [DATE], reflected Resident #1, a severely cognitively impaired resident on the secured unit, was observed by AA H placing a poker chip in his mouth and appearing to swallow the chip at approximately 10:20 AM on [DATE]. The resident was assessed and had no signs or symptoms of distress. The physician ' s office was notified about 2:00 PM and the Office Manager informed the nurse to continue to monitor the resident. The resident showed no signs of distress until immediately after eating his dinner meal about 6:30 PM, at which time he collapsed to the floor and was in complete [MEDICAL CONDITION]. CPR was begun by facility staff and EMS was called. During attempts at intubation by EMS, two poker chips were removed from the resident's throat. Resident #1 was transferred to the local hospital and was pronounced dead. 4. Review of Resident #1's clinical record provided the following evidence - a. The [DATE] physician's orders [REDACTED]. The resident was ordered a Pureed diet, large portions. b. The most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired for daily decision-making. c. Review of the Comprehensive Plan of Care dated [DATE] and updated [DATE] revealed Resident #1 exhibited behaviors of wandering, pushing other residents, grabbing food from other residents' trays, and resistance with ADLs. Interventions included monitoring and charting behaviors every shift and report to the physician. d. A Care Plan, dated [DATE] and updated [DATE], reflected Resident #1 was at risk for aspiration related to impaired swallowing. Interventions included to properly identify the at risk client with an appropriate ID band and to notify physician of changes as indicated. e. A nurses' note, dated [DATE] at 10:20 AM, documented by LVN E reflected Resident #1 grabbed a poker chip during activities and swallowed it. The resident showed no signs of choking while swallowing the item. Vital signs were within normal limits. The resident was ambulating up and down the hallway, and no signs of distress were noted. The plan was to continue to monitor the resident to see if the poker chip was passed through the stool. f. A nurses' note, dated [DATE] at 6:45 PM, documented by LVN J reflected she saw Resident #1 fall in the hallway on A Hall. She checked him for breath sounds and heart rate and none were noted. She removed food from his mouth. Abdominal compressions were begun and the resident was frequently turned on his side to remove food from his mouth. Suctioning of food was attempted but unsuccessful. 911 was called and upon their arrival, they removed two poker chips from the resident's throat. At 7:00 PM, the resident was transferred to the local hospital via ambulance. The resident's daughter, the DON, ADON B and the physician were notified. At 7:45 PM, the hospital called and reported the resident had expired. At 10:00 P,M the local police officers were at the facility investigating Resident #1's death. 5. An interview with LVN E on [DATE] at 9:10 AM revealed she was informed by AA H on [DATE] about 10:30 AM Resident #1 had swallowed a poker chip during an activity with the residents on the secured unit (A Hall). She stated she (LVN E) asked the AA if the resident had any symptoms and was told he did not. LVN E stated she assessed him and he was breathing without difficulty. His vital signs were within normal limits and bowel sounds were present. Her supervisor, ADON B, told her to complete an incident report, assess the resident and then monitor him for distress. LVN E stated she observed Resident #1 being fed lunch and he ate well and fast, as usual. She stated at 2:00 PM she called the resident's physician. She stated she waited until then so she could monitor him and have more to report to the physician. LVN E asked to speak with the "nurse" and was connected to a person named (later identified as the physician's Office Manager)) LVN E informed her what had happened and how they were monitoring the resident. She stated the "nurse" told her it sounded as if the facility was doing all they could do, and she would notify the physician. She also stated if the physician had any other orders, he would let them know. LVN E stated she monitored the resident for the remainder of her shift. She stated he was wandering on the secured unit as usual and did not appear to be in distress. She said she did not take his vital signs again. LVN E stated she ended her shift at 2:45 PM and left the facility. LVN E stated she had been speaking with the same "nurse" for some time regarding Resident #1 and other residents under the care of their physician and had received medical advice and orders. She stated she did not know the "nurse's" complete name or title, but assumed she was a nurse or physician's assistant. LVN E further stated if the physician was needed after hours, he would answer the phone, but during the office hours, she was always referred to "nurse" (the physician's Office Manager). 6. Interview on [DATE] at approximately 11:00 AM with the DON revealed the resident had swallowed the poker chips at 10:20 AM. He stated the resident ate 100% of the noon meal. The DON stated AA H had told LVN E Resident #1 had swallowed the poker chips, and LVN E called the PCP (primary care physician). The DON stated the staff at the PCP's office told them to just monitor the resident. The DON stated the resident ate the dinner meal. He stated Resident #1 was pacing and then collapsed. 7. An interview on [DATE] at 11:00 AM with the physician's office staff, who had spoken to LVN E, revealed she identified herself to the surveyor as the Office Manager. She stated she received a call on [DATE] (she was unclear of the time as she did not document the conversation) from a nurse at the facility. She stated the nurse told her about Resident #1 swallowing a poker chip, but was not in distress. She stated the facility nurse told her they would continue to monitor Resident #1, and she informed them to send the resident to the local hospital if he experienced any problems. The office staff member stated she did not notify the physician of the incident. She stated the physician called her the following day and informed her the resident had expired. 8. An interview with the DON and ADM on [DATE] at 11:20 AM revealed they were not aware the physician's Office Manager was the person their facility nurses had been contacting and receiving physician's order [REDACTED]. 9. An interview with ADON B on [DATE] at 11:25 AM revealed she was told by LVN F on [DATE] about 10:30 AM, Resident #1 had swallowed a poker chip. She stated when she spoke to AA H, she told her the resident grabbed the poker chip, swallowed it and walked off down the hall. ADON B stated she informed LVN E to assess him, complete an incident report and to continue to monitor his behavior, vital signs and meal intake. She stated LVN E told her the resident's vital signs were within normal limits and he had bowel sounds present. ADON B stated she next saw Resident #1 about 5:00 PM, and he was pacing the halls, which was usual behavior for him. 10. An interview with LVN J on [DATE] at 4:20 PM revealed she arrived to work at 3:00 M on [DATE]. She stated that during report, LVN E told her Resident #1 had swallowed a poker chip earlier that day. She stated she was told the physician was called, and they were told to monitor the resident's bowel movements. She stated she assessed for bowel sounds and they were present and "hyperactive." She stated it was the first time she had worked on the secured unit (A Hall), and she was not familiar with the residents. She had seen Resident #1 in the hallway before and knew he paced constantly. She stated after 3:00 PM the resident was pacing as usual and seemed to be in no distress. LVN J stated the resident was served his dinner meal about 6:00 PM. Resident #1 fed himself and ate very quickly. He stated he left the dining room to go to the hallway and she saw him collapse on the floor. She stated she had observed pink vomitus in his mouth, so turned him onto his side and cleared it. CPR was begun and 911 was called. Suctioning was attempted, but the "tip" was clogged. She stated when EMS arrived, they removed two poker chips from his throat. LVN J stated Resident #1 had not regained consciousness before leaving for the hospital. She was notified by the hospital later the resident had expired. 11. Review of the facility's current policy entitled "Notifying the Physician of Significant Change in Status," revised [DATE], revealed "...1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record." 12. On [DATE] at 3:51 PM, the ADM, DON, and Marketer G were notified an Immediate Jeopardy (IJ) had been identified for failure to ensure nursing staff immediately consulted Resident #1 ' s physician when he swallowed two poker chips and subsequently expired.. A Plan of Removal was requested for the IJ. 13. The ADM was notified on [DATE] at 6:40 PM the Plan of Removal was accepted. 14. The facility's Plan of Removal included the following: a. An in-service was initiated on [DATE] regarding notifying the physician of any change in condition. The majority of available licensed staff had been in-serviced by [DATE]. All staff lacking the in-service after that date would not be allowed to assume their duties until the in-service was completed. The in-service included the need to identify the individual to whom the staff was speaking to and to take orders from physicians and/or nurses only. b. An in-service was initiated on [DATE] regarding notifying the physician and family of any incident. Additionally, to notify the medical director of any incident if the attending physician could not be contacted. The majority of available licensed staff had been in-serviced by [DATE]. All staff lacking the in-service after that date would not be allowed to assume their duties until the in-service had been completed. c. All PRN (as needed) staff would be required to complete all the above mentioned in-services and training before they were allowed to work on the floor. d. All new staff would be in-serviced and trained by Nurse Management during orientation, prior to working. e. The QA compliance sub-committee, consisting of the ADM, the DON, the three ADONs, the Human Resources Coordinator, the Admissions Coordinator, the Marketer, the Receptionist, the Maintenance Supervisor, the Activities Director, the Business Office Manager and Assistant, the Dietary Supervisor, and the MDS Coordinators, would meet on [DATE] to discuss and review all concerns identified. The QA Committee would meet again on [DATE]. 15. Individual interview with ADON A, LVN L, LVN M, CNA D, CNA I revealed each had attended the in-service trainings. They each new that if a resident swallowed an inedible object they were to need to transfer a resident to the hospital ER if he swallowed any object and ensure he/she received orders only from a physician, RN, LVN, PA or NP. The interviews occurred on [DATE] at 9:25 AM, 935 AM, 9:40 AM, 9:45 AM, 9:50 AM, 9:55 AM, respectively. 16. On [DATE], the ADM and DON provided written documentation of in-services and staff from all three shifts who received training in the following areas: residents who put foreign objects in their mouth, reporting incidents, notifying the physician of changes in condition, transferring residents to the hospital after swallowing non-food items, taking orders from only authorized sources, notification of the Medical Director, abuse and neglect, and daily rounds for monitoring of small objects. 17. An interview with the DON on [DATE] at 10:15 AM revealed he believed LVN E had properly assessed Resident #1 after he had swallowed the poker chip. He stated because the resident exhibited no symptoms of choking, she conferred with ADON B and monitored the resident for further side effects. The LVN and ADON had informed the direct care staff to monitor bowel movements of the resident for the passing of the poker chip. However, due to the potential for danger, the physician should have been notified immediately. And the nurses should not have assumed they were speaking with a nurse at the physician's office. The DON stated he was also unaware they had been speaking with and receiving orders/recommendations/medical advice from an office manager. 18. While the IJ was removed on [DATE], the facility remained out of compliance due to continuing to in-service staff and monitoring the implementation of the plan of removal. 19. Review of revised care plans, presented by the DON on [DATE], identified 30 residents as at risk for swallowing dangerous, non-food items with the potential for choking and death.

Based on observation, interview and record review, the facility failed to implement their policies and procedures to prohibit neglect for one of four sampled residents (Resident #1) reviewed for neglect. 1) Failed to provide Resident #1 , a resident with a known history of placing inedible objects in his mouth, received the appropriate level of supervision. 2) Failed to immediately consult Resident #1's physician when an incident occurred which required physician intervention. Resident #1, who had a history of [REDACTED]. LVN E waited four hours before contacting the physician's office. LVN E was unaware the person they gave report to was an office manager instead of the physician's nurse practitioner or nurse. Eight hours later, Resident #1 suddenly collapsed and was in full [MEDICAL CONDITION]. CPR was initiated. EMS personnel removed two poker chips from his throat. The resident was transferred to the local hospital and expired. On [DATE], an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm and a scope of pattern. The facility was monitoring the implementation of their plan of removal and ensuring all staff received the in-service training regarding immediate consultation with a resident's physician. Failure to ensure each resident's physician was consulted immediately when an incident of swallowing an inedible object occurred placed 30 residents, who were identified as at risk of swallowing inedible objects, at risk of a delay in evaluation and treatment, and potential death. Failure to ensure a residents received the appropriate level of supervision, placed all 30 residents, identified by the facility as at risk of swallowing inedible objects, at risk of serious injury, harm or death. Findings included: 1. Review of the facility's policies reflected the following: a. The facility's current policy/procedure entitled Abuse/Neglect, revised [DATE], included "...Definitions ...6. Neglect: Failure to provide essential needs or protection for a person incapable of providing for him/herself independently or harming or threatening with harm; can be committed by self or other... b. The facility's current Behavior Management Policy with a revision date of [DATE] revealed the following: i) Behavior management utilizes techniques such as area limitations and limit setting and behavior modification depending on individual needs. One goal is to have the resident modify his behavior for optimal functioning and well-being. ii) Procedures include: monitoring for appropriate behavior and intervening before harmful behavior is expressed. Allow wandering for those with dementia and utilize an alarm system in order to monitor location and prevent harmful situations. Place this resident on frequent checks to ensure safety. Provide diversion or redirect attention away from negative behaviors. Document behavior modification on the interdisciplinary plan of care. Monitor effectiveness of interventions. c. The facility's current policy entitled "Notifying the Physician of Significant Change in Status," revised [DATE], revealed "...1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record." 2. On [DATE], at approximately 9:00 AM, while the surveyor was in the facility investigating an unrelated allegation, the surveyor was informed by the ADM and DON Resident #1 had expired on Monday night ([DATE]). The surveyor was told Resident #1 had swallowed two poker chips at 10:20 AM on Monday ([DATE]). The resident expired later that same evening. 3. On [DATE] at approximately 2:00 PM, the DON showed the surveyor two poker chips which were identified as the same type poker chips the resident swallowed. The poker chips measured approximately 1.375 inches in diameter. This is slightly larger than a .50 cent coin, which measures 1.205 inches in diameter. 4. The facility's Provider Investigative Report, dated [DATE], reflected Resident #1, a severely cognitively impaired resident on the secured unit, was observed by AA H placing a poker chip in his mouth and appearing to swallow the chip at approximately 10:20 AM on [DATE]. The resident was assessed and had no signs or symptoms of distress. The physician's office was notified about 2:00 PM and the Office Manager informed the nurse to continue to monitor the resident. The resident showed no signs of distress until immediately after eating his dinner meal about 6:30 PM, at which time he collapsed to the floor and was in complete [MEDICAL CONDITION]. CPR was begun by facility staff and EMS was called. During attempts at intubation by EMS, two poker chips were removed from the resident's throat. Resident #1 was transferred to the local hospital and was pronounced dead. 5. Review of Resident #1's clinical record reflected the following: a. The [DATE] physician's orders [REDACTED]. The resident was ordered a Pureed diet, large portions. b. The most recent Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #1 was severely cognitively impaired for daily decision-making. His mood was assessed as having little interest in doing things, trouble concentrating, restlessness and being easily annoyed. His behavior was assessed as physical behavior symptoms toward others and other behavioral symptoms not directed toward others (e.g., pacing, rummaging), plus wandering occurred daily. The MDS assessment did not capture the behavior of placing inedible objects in his mouth. c. The Comprehensive Plan of Care, dated [DATE] and updated [DATE], revealed Resident #1 exhibited behaviors of wandering, pushing other residents, grabbing food from other residents' trays, and resistance with ADLs. Interventions included monitoring and charting behaviors every shift and report to the physician. d. Also, a Care Plan, dated [DATE] and updated [DATE], reflected Resident #1 was at risk for aspiration related to impaired swallowing. Interventions included to properly identify the at risk client with an appropriate ID band and to notify physician of changes as indicated. e. The Care Plans, dated [DATE], [DATE] and [DATE], did not address his behavior of placing inedible objects in his mouth. f. A Social Work Progress Note, dated [DATE], reflected the resident's quarterly care plan meeting was held, and discussion included Resident #1's continued wandering about the memory care unit daily, touching other residents' food and staff having to provide calm re-direction with reassurance. There was no documented evidence they had discussed his behavior of placing inedible objects in his mouth. g. Psychiatric Evaluation/Progress Note, dated [DATE], reflected Resident #1 was "doing fine" as reported by staff, was eating and sleeping "okay" and no behavioral issues were noted. Basically the same verbiage was written on the [DATE] Psychiatric Progress Note. h. A document titled Creative Solutions in Health Care Nursing Summary (a monthly nursing summary), dated [DATE] and completed by LVN E, reflected Resident #1 did not speak or interact with staff or residents. His cognitive skills for daily decision-making were severely impaired. The resident's behaviors were noted as wandering in and out of rooms and taking food from other residents' trays. i. A nurse's note, dated [DATE] at 10:20 AM and signed by LVN E, reflected Resident #1 grabbed a poker chip during activities and swallowed it. The resident showed no signs of choking while swallowing the item. Vital signs were within normal limits. The resident was ambulating up and down the hallway, and no signs of distress were noted. The plan was to continue to monitor the resident to see if the poker chip was passed through the stool. j. A nurse's note, dated [DATE] at 6:45 PM and completed by LVN J, reflected she saw Resident #1 fall in the hallway on A Hall. She checked him for breath sounds and heart rate and none were noted. She removed food from his mouth. Abdominal compressions were begun and the resident was frequently turned on his side to remove food from his mouth. Suctioning of food was attempted but unsuccessful. 911 was called and upon their arrival, they removed two poker chips from the resident's throat. At 7:00 PM, the resident was transferred to the local hospital via ambulance. The resident's daughter, the DON, ADON B and the physician were notified. At 7:45 PM, the hospital called and reported the resident had expired. At 10:00 PM the local police officers were at the facility investigating Resident #1's death. 5. An interview, via telephone, with AA H on [DATE] at 3:25 PM revealed she conducted activities on the secured unit. She stated Resident #1 would "grab" other residents' food and drinks. She stated that on [DATE], Resident #1 was wandering about while she was conducting an activity of sorting poker chips with a group of residents. She said he walked over and she thought he was coming to participate. She stated she turned her head and then looked back at him, he was placing a poker chip in his mouth. AA H stated she yelled, "Help!" She stated she could not recall names of staff on the unit at the time of the incident. She stated she tried to get the poker chip from him, but he would not open his mouth. She said "they" checked him, and he seemed like his normal self. AA H stated the resident was in bed around 3:00 PM the same day. She stated the resident was pretty easy to redirect, but she could not get him to sit for anything. AA H stated there was no nurse on the secured unit at the time of the incident. She said Resident #1 swallowed the chip "like it was nothing". During the interview with AA H, the surveyor asked AA H if anyone had told her Resident #1 would put inedible objects in his mouth. She stated, "No." AA H stated she had never seen him put inedible objects in his mouth before. The surveyor asked AA H how long she had worked at the facility. AA H stated she had been employed at the facility for four months and had worked on the secured unit for a month and a half. AA H stated she had activities such as coloring and musical instruments, and Resident #1 had never grabbed a [MEDICATION NAME] or anything else. 6. An interview with LVN E on [DATE] at 9:10 AM revealed she described Resident #1 as a non-verbal resident, who constantly walked around in the secured unit and would take food and drinks from other residents' trays. She stated until she was informed by AA H on [DATE] about 10:30 AM that Resident #1 had swallowed a poker chip during an activity, she had never seen him put foreign objects in his mouth. She stated she (LVN E) asked the AA if the resident had any symptoms and was told he did not. LVN E stated she assessed him and he was breathing without difficulty. His vital signs were within normal limits and bowel sounds were present. Note: The Event Nurses' Notes, completed by LVN E on [DATE] at 10:20 AM, documented his vital signs ,[DATE] BP, 97.4 F, pulse 81 and respiration 18. During the above interview with LVN E she stated she had been told by her supervisor, ADON B, to complete an incident report, assess the resident and then monitor him for distress. She added that she waited to consult with Resident #1's physician so she could monitor him and have more to report to the physician. LVN E stated she observed Resident #1 being fed lunch and he ate well and fast, as usual. She stated at 2:00 PM, she called the resident's physician. She stated when she called the physician's office, she asked to speak with the "nurse" and was connected to a person named (later identified as the physician's Office Manager). LVN E informed her what had happened and how they were monitoring the resident. She stated the "nurse" told her it sounded as if the facility was doing all they could do, and she would notify the physician. She also stated if the physician had any other orders, he would let them know. LVN E stated she monitored the resident for the remainder of her shift. She stated he was wandering on the secured unit as usual and did not appear to be in distress. She said she did not take his vital signs again. LVN E stated she ended her shift at 2:45 PM and left the facility. LVN E further revealed she had been speaking with the same "nurse" from the physician's office for some time regarding Resident #1 and other residents under the care of Resident #1's physician and had received medical advice and orders. She stated she did not know the "nurse's" complete name or title, but assumed she was a nurse or physician's assistant. LVN E further stated if the physician was needed after hours, he would answer the phone, but during the office hours, she was always referred to "nurse" (the physician's Office Manager). 7. An interview with the DON on [DATE] at approximately 11:00 AM revealed after the incident of swallowing the poker chips, Resident #1 ate 100% of his noon meal. The DON stated AA H had told LVN E Resident #1 had swallowed the poker chips, and LVN E called the PCP (primary care physician). The DON stated the staff at the PCP's office told them to just monitor the resident. The DON stated Resident #1 also ate his dinner meal. He stated Resident #1 was pacing and then collapsed. 8. An interview with the physician's office staff member who had spoken to LVN E, on [DATE] at 11:00 AM , revealed she identified herself as the Office Manager. She stated she received a call on [DATE] (she was unclear of the time as she did not document the conversation) from a nurse at the facility. She stated the nurse told her about Resident #1 swallowing a poker chip, but was not in distress. She stated the facility nurse told her they would continue to monitor Resident #1, and she informed them to send the resident to the local hospital if he experienced any problems. The office staff member stated she did not notify the physician of the incident. She stated the physician called her the following day and informed her the resident had expired. 9. An interview with the DON and ADM on [DATE] at 11:20 PM, the DON stated he was aware the physician's office was not contacted until several hours after Resident #1 swallowed the poker chips. The ADM and DON stated they were not aware the facility nurses had been contacting the physician's Office Manager instead of the physician's nurse. 10. An interview with ADON B on [DATE] at 11:25 AM revealed she was told by LVN F on [DATE] about 10:30 AM, Resident #1 had swallowed a poker chip. She stated when she spoke to AA H, she told her the resident grabbed the poker chip, swallowed it and walked off down the hall. ADON B stated she informed LVN E to assess him, complete an incident report and to continue to monitor his behavior, vital signs and meal intake. She stated LVN E told her the resident's vital signs were within normal limits and he had bowel sounds present. She stated the resident had a tongue projection and rarely was still, so it was very difficult to see inside his mouth. The resident did not have teeth. ADON B stated Resident #1 walked by and grabbed food, liquids and anything in sight. He was served double portions at meals. She was not aware of him putting anything else in his mouth. She stated she told AA H to take away the poker chips, which was done immediately. ADON B stated she next saw Resident #1 about 5:00 PM, and he was pacing the halls, which was usual behavior for him. 11. An interview with CNA D on [DATE] at 1:40 PM revealed about one month prior, the LVN (no longer employed at the facility) passing medication on the secured unit briefly left the medication cart unattended. CNA D stated she then saw Resident #1 with a glass vial of Insulin in his mouth. She and another CNA struggled to get the bottle away from him. They notified the LVN. CNA D stated she saw Resident #1 frequently take food from other residents, but never saw him choke. She stated she had made AA H aware he would put objects in his mouth. 12. Additional review of Resident #1's clinical record to include nurses' notes and Event Nurses' Notes (used for documenting accidents and incidents), provided no evidence of the incident involving Resident #1 placing a glass vial of insulin in his mouth. 13. An interview with the Regional Nurse, ADM and ADON B on [DATE] at 3:45 PM revealed they were not aware of the incident in which Resident #1 put an Insulin vial in his mouth. 14. An interview with LVN G on [DATE] at 2:00 PM revealed she did not witness the incident of Resident #1 swallowing the poker chip. She said she worked on different halls. LVN F stated she saw Resident #1 around 10:00 AM. She said AA H stuck her head out of the dining room, and reported Resident #1 was putting poker chips in his mouth. She stated she told AA H to try to prevent him from doing that. LVN F said she was at the front of the hall preparing medications, and by the time she had put her meds away, Resident #1 was walking towards her. She said he was sticking out his tongue and chewing on his shirt. She stated she did not see anything in his mouth. The surveyor inquired how LVN F looked in the resident's mouth. LVN F said she asked Resident #1 to let her look in his mouth, and he pushed her out of the way. She said she left the hall afterwards. LVN F stated she had seen him around lunch or shortly after and he seemed fine. The surveyor inquired as to whether or not she was aware or had been informed about Resident #1's behaviors. She stated she was told to continually monitor the medication cart, because Resident #1 would grab things. The surveyor asked LVN F what types of things Resident #1 would grab from the med cart. LVN F stated he would grab yogurt. The surveyor asked LVN F if she was aware of a time Resident #1 had put an insulin bottle in his mouth. She stated, "No." She said she knew about his grabbing food and drink items from the other residents. The surveyor asked LVN F if any other residents on the secured unit had similar behaviors. LVN F stated, " (Resident #2) would touch things and lick her fingers." She said Resident #2 took wooden tongue blades off the medication cart, put them in her mouth, and then gave them back. 15. An interview with CNA I on [DATE] at 9:55 AM revealed she saw Resident #1 swallow Play-Doh during an activity once. She stated she notified the nurse at the time, and the Play-Doh was taken away. She stated Resident #1 ate quickly in large bites; however she had never seen him choke. 16. Additional review of Resident #1's clinical record to include nurses' notes and Event Nurses' Notes (used for documenting accidents and incidents), provided no evidence of the incident involving Resident #1 putting Play-Doh in his mouth. 17. Interview with CNA D on [DATE] at 10:00 AM revealed Resident #1 paced the hall most of the time. She stated he was known to pick up anything and everything and put it in his mouth. She said he took other residents' food. CNA D stated it was hard to stop him from stealing their food. CNA D stated Resident #1 once got an empty insulin bottle off the medication cart and put it in his mouth. She stated it was hard to monitor the resident because they were busy with the other residents on the unit. The surveyor asked CNA D if there were other residents with similar behaviors. The CNA stated there were no others with a similar behavior. She added there were some residents who took other residents' food. 18. An interview with CNA C on [DATE] at 1:50 PM revealed she was working on the day Resident #1 swallowed the poker chip. She stated she did not observe the incident, but was told about it and was told to monitor the resident for bowel movements and to check for the poker chip. She stated she had not seen any ill effects by the time she left her shift at 2:00 PM. She said she had seen AA H conduct activities with small parts, such as poker chips and marbles, in the past. She stated she had warned AA H Residents #1 and #3 would try to put things in their mouths. She stated she had seen Resident #3 put a marble and a poker chip in her mouth previously. She stated she had not seen Resident #1 with a foreign object in his mouth before, except for his shirt, which he sucked on. CNA C stated she and other CNAs would try to watch the residents as closely as they could. 19. Interview on [DATE] at 3:31 PM with the ADM revealed the facility used to have a nurse posted on the secured unit. The ADM stated she was told by a state employee they could not have the nurse in the Secured Unit, because there was "nowhere" for them to be. 20. An interview with LVN J on [DATE] at 4:20 PM revealed she arrived to work at 3:00 PM on [DATE]. She stated that during report, LVN E told her Resident #1 had swallowed a poker chip earlier that day. She stated she was told the physician was called, and they were told to monitor the resident's bowel movements. She stated she assessed for bowel sounds and they were present and "hyperactive." She stated it was the first time she had worked on the secured unit (A Hall), and she was not familiar with the residents. She had seen Resident #1 in the hallway before and knew he paced constantly. She stated after 3:00 PM the resident was pacing as usual and seemed to be in no distress. LVN J stated the resident was served his dinner meal about 6:00 PM. Resident #1 fed himself and ate very quickly. He stated he left the dining room to go to the hallway and she saw him collapse on the floor. She stated she had observed pink vomitus in his mouth, so turned him onto his side and cleared it. CPR was begun and 911 was called. Suctioning was attempted, but the "tip" of the suctioning tube was clogged. She stated when EMS arrived, they removed two poker chips from his throat. LVN J stated Resident #1 had not regained consciousness before leaving for the hospital. She was notified by the hospital later the resident had expired. 21. An interview with the AD on [DATE] at 8:25 AM revealed upon hiring AA H, she (AA H) completed two to three weeks of training with activities in all areas of the building. She stated AA H had been working on the Secured Unit (A Hall) for a few months. The AD made rounds to ensure safety. The AD stated before the incident with Resident #1, no one had complained to her about AA H and the use of poker chips. She stated she was aware the poker chips were in the activity closet, and she saw the residents sorting them one day. She stated she was aware of Resident #1 taking others' food and drinks from the food cart, but was not aware he would put inedible objects in his mouth. The AD stated she would begin to have activities, which were more appropriate and safe for the Secured Unit residents. She and another AA would rotate working with the residents. 22. On [DATE] at 3:51 PM, the ADM, DON, and Marketer G were notified an Immediate Jeopardy (IJ) had been identified for failure to ensure nursing staff immediately consulted Resident #1 ' s physician when he swallowed two poker chips and subsequently expired.. A Plan of Removal was requested for the IJ. 23. The ADM was notified on [DATE] at 6:40 PM the Plan of Removal was accepted. 24. The facility's Plan of Removal included the following: a. An in-service was initiated on [DATE] regarding notifying the physician of any change in condition. The majority of available licensed staff had been in-serviced by [DATE]. All staff lacking the in-service after that date would not be allowed to assume their duties until the in-service was completed. The in-service included the need to identify the individual to whom the staff was speaking to and to take orders from physicians and/or nurses only. b. An in-service was initiated on [DATE] regarding notifying the physician and family of any incident. Additionally, to notify the medical director of any incident if the attending physician could not be contacted. The majority of available licensed staff had been in-serviced by [DATE]. All staff lacking the in-service after that date would not be allowed to assume their duties until the in-service had been completed. c. An abuse/neglect in-service was initiated on [DATE], and the majority of staff had been in-serviced by [DATE]. All staff lacking the in-service after that date would not be allowed to assume their duties until the in-service had been completed. d. An in-service on Interact and Early Warning Tool was initiated on [DATE]. All staff lacking the in-service after that date would not be allowed to assume their duties until the in-service had been completed. e. An in-service on Activities, specifically on not using small objects for an activity on the secured unit, A Hall was initiated on [DATE]. The in-service included all activities would be supervised. f. An in-service on Activities in the Legacy Program, removing small objects and observations, was completed on [DATE]. (The Legacy Program was for the residents on another hall in the facility where MR residents resided.) g. The facility removed all small objects being used for activities on the secured unit, A Hall on [DATE]. h. An audit was conducted on [DATE] of each resident room on the secured unit to identify any potential object, which could cause injury and an audit was conducted for those other residents identified as being at risk for putting objects in their mouths. Those items were removed from the residents' rooms on [DATE]. i. On [DATE], the DON and three ADONs interviewed staff members (CNAs, nurses, therapists, activity staff) by walking the halls, room by room, and reviewing the charts to assist in identifying residents at risk. Each resident's care plan was revised to specifically identify the potential risk. j. An in-service on [DATE] was completed regarding ADONs making rounds daily on the secured unit in each resident room to ensure all small objects were removed from each resident room. k. Daily rounds were to be completed in the morning by ADONs and/or the DON during the weekdays to monitor compliance for potential objects, which could be swallowed, and ensure they were not accessible to the at-risk residents of the entire facility. The weekend supervisor would perform the rounds on Saturday and Sunday. Documentation of the daily rounds would be submitted to the DON and/or ADM for review. l. An in-service was conducted on [DATE] to ensure every resident who swallowed an object was sent to the local hospital for evaluation. The majority of available licensed staff had been in-serviced by [DATE]. All staff lacking the in-service after that date would not be allowed to assume their duties until the in-service had been completed. m. The behavior monitoring record for each resident identified to be at-risk, was modified to include placing non-food items in the mouth. ADONs would conduct daily rounds to monitor the completion of behavior monitoring documents and the documents would be turned in to the DON daily. n. The choking emblem (an image of a person with his/her hands at his/her throat) was placed on each resident's door to easily identify residents at potential risk on [DATE]. The staff was in-serviced beginning [DATE] regarding the meaning of the choking emblem. The majority of available nursing staff had been in-serviced by [DATE]. All staff lacking the in-service after that date would not be allowed to assume their duties until the in-service had been completed. o. A list of residents who were currently identified as being at risk for swallowing non-food items would be placed at each nurse's station. Nursing staff were in-serviced regarding the location of the list on [DATE]. The majority of available nursing staff had been in-serviced by [DATE]. All staff lacking the in-service after that date would not be allowed to assume their duties until the in-service had been completed. p. All residents who were identified as being at risk for swallowing non-food items would have a "task" added to the electronic ADL documentation system starting on [DATE]. Nursing staff would electronically acknowledge the fact the resident was at risk for swallowing non-food items. The majority of available nursing staff had been in-serviced by [DATE]. All staff lacking the in-service after that date would not be allowed to assume their duties until the in-service had been completed. q. Administrative nursing staff would continually monitor residents and using staff feedback and observation, would update the residents who were at risk for swallowing non-food items. If needed, a choking emblem would be placed on the resident's door, the "task" would be added to the electronic ADL documentation system for the resident and administrative nursing staff would ensure the lists of at-risk residents was updated at each nursing station. r. During daily rounds, the administrative staff would randomly ask at least five nursing staff members per day what the choking emblem signified and where they could locate information, if they had a question whether a resident was at risk for swallowing a non-food object. s. A representative of the secured unit would attend morning stand-up meeting to assist in identifying potential risks and issues needing quick resolution and was initiated on [DATE]. t. A charge nurse would be assigned and stationed on the secured unit, beginning on [DATE], for the 7 AM to 3 PM shift and the 3 PM to 11 PM shift. The 11 PM to 7 AM shift would be monitored by existing staff. The 11 PM to 7 AM nurse would be instructed to complete rounds every two hour and to document their findings on a "round sheet." The DON/designee would monitor their documented findings daily. u. All PRN staff would be required to complete all the above mentioned in-services and training before they were allowed to work on the floor. v. All new staff would be in-serviced and trained by Nurse Management during orientation, prior to working. w. The QA compliance sub-committee, consisting of the ADM, the DON, the three ADONs, the Human Resources Coordinator, the Admissions Coordinator, the Marketer, the Receptionist, the Maintenance Supervisor, the Activities Director, the Business Office Manager and Assistant, the Dietary Supervisor, and the MDS Coordinators, would meet on [DATE] to discuss and review all concerns identified. The QA Committee would meet again on [DATE]. 25. On [DATE] at 10:00 AM, surveyor observations confirmed the following: a. Small objects had been removed from all resident rooms for residents identified as at risk for swallowing, choking on non-food items. b. A list of all residents identified as at-risk for swallowing/choking on non-food items was found in binders at each nursing station. c. Choking emblems were displayed above resident doors on residents identified to be at risk for swallowing/choking on non-food items. d. The electronic ADL documentation system included the "task" to acknowledge residents identified to be at risk for swallowing/choking on non-food items. 26. Individual interview with ADON A, CNA K, LVN L, LVN M, CNA D, CNA I revealed each had attended the in-service trainings and new which residents were at risk of swallowing inedible objects, knew to monitor the residents, knew to ensure there were no small objects available for the resident to potentially swallow, and each knew the meaning of the choking emblem tags on a door to a resident room or a resident's wheelchair. a. The ADON stated stated she began making daily rounds to ensure no small items were in at-risk residents' rooms. The ADON stated if a resident swallowed an item, he was to be sent to the hospital. The ADON stated nurses knew now to question the discipline any outside staff to whom they were speaking. b. LVN L and LVN M each stated the training included the need to transfe

Based on observation, interview and record review, the facility failed to implement their written policies and procedures for one of four sampled residents (Resident #1) reviewed for neglect. 1) Failed to provide Resident #1 , a resident with a known history of placing inedible objects in his mouth, received the appropriate level of supervision. 2) Failed to immediately consult Resident #1's physician when an incident occurred which required physician intervention. Resident #1, who had a history of [REDACTED]. LVN E waited four hours before contacting the physician's office. LVN E was unaware the person they gave report to was an office manager instead of the physician's nurse practitioner or nurse. Eight hours later, Resident #1 suddenly collapsed and was in full [MEDICAL CONDITION]. CPR was initiated. EMS personnel removed two poker chips from his throat. The resident was transferred to the local hospital and expired. On [DATE], an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm and a scope of pattern. The facility was monitoring the implementation of their plan of removal and ensuring all staff received the in-service training regarding immediate consultation with a resident's physician. Failure to ensure each resident's physician was consulted immediately when an incident of swallowing an inedible object occurred placed 30 residents, who were identified as at risk of swallowing inedible objects, at risk of a delay in evaluation and treatment, and potential death. Failure to ensure a residents received the appropriate level of supervision, placed all 30 residents, identified by the facility as at risk of swallowing inedible objects, at risk of serious injury, harm or death. Findings included: 1. Review of the facility's policies reflected the following: a. The facility's current policy/procedure entitled Abuse/Neglect, revised [DATE], included "...Definitions ...6. Neglect: Failure to provide essential needs or protection for a person incapable of providing for him/herself independently or harming or threatening with harm; can be committed by self or other... b. The facility's current Behavior Management Policy with a revision date of [DATE] revealed the following: i) Behavior management utilizes techniques such as area limitations and limit setting and behavior modification depending on individual needs. One goal is to have the resident modify his behavior for optimal functioning and well-being. ii) Procedures include: monitoring for appropriate behavior and intervening before harmful behavior is expressed. Allow wandering for those with dementia and utilize an alarm system in order to monitor location and prevent harmful situations. Place this resident on frequent checks to ensure safety. Provide diversion or redirect attention away from negative behaviors. Document behavior modification on the interdisciplinary plan of care. Monitor effectiveness of interventions. c. The facility's current policy entitled "Notifying the Physician of Significant Change in Status," revised [DATE], revealed "...1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record." 2. On [DATE], at approximately 9:00 AM, while the surveyor was in the facility investigating an unrelated allegation, the surveyor was informed by the ADM and DON Resident #1 had expired on Monday night ([DATE]). The surveyor was told Resident #1 had swallowed two poker chips at 10:20 AM on Monday ([DATE]). The resident expired later that same evening. 3. On [DATE] at approximately 2:00 PM, the DON showed the surveyor two poker chips which were identified as the same type poker chips the resident swallowed. The poker chips measured approximately 1.375 inches in diameter. This is slightly larger than a .50 cent coin, which measures 1.205 inches in diameter. 4. The facility's Provider Investigative Report, dated [DATE], reflected Resident #1, a severely cognitively impaired resident on the secured unit, was observed by AA H placing a poker chip in his mouth and appearing to swallow the chip at approximately 10:20 AM on [DATE]. The resident was assessed and had no signs or symptoms of distress. The physician's office was notified about 2:00 PM and the Office Manager informed the nurse to continue to monitor the resident. The resident showed no signs of distress until immediately after eating his dinner meal about 6:30 PM, at which time he collapsed to the floor and was in complete [MEDICAL CONDITION]. CPR was begun by facility staff and EMS was called. During attempts at intubation by EMS, two poker chips were removed from the resident's throat. Resident #1 was transferred to the local hospital and was pronounced dead. 5. Review of Resident #1's clinical record reflected the following: a. The [DATE] physician's orders [REDACTED]. The resident was ordered a Pureed diet, large portions. b. The most recent Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #1 was severely cognitively impaired for daily decision-making. His mood was assessed as having little interest in doing things, trouble concentrating, restlessness and being easily annoyed. His behavior was assessed as physical behavior symptoms toward others and other behavioral symptoms not directed toward others (e.g., pacing, rummaging), plus wandering occurred daily. The MDS assessment did not capture the behavior of placing inedible objects in his mouth. c. The Comprehensive Plan of Care, dated [DATE] and updated [DATE], revealed Resident #1 exhibited behaviors of wandering, pushing other residents, grabbing food from other residents' trays, and resistance with ADLs. Interventions included monitoring and charting behaviors every shift and report to the physician. d. Also, a Care Plan, dated [DATE] and updated [DATE], reflected Resident #1 was at risk for aspiration related to impaired swallowing. Interventions included to properly identify the at risk client with an appropriate ID band and to notify physician of changes as indicated. e. The Care Plans, dated [DATE], [DATE] and [DATE], did not address his behavior of placing inedible objects in his mouth. f. A Social Work Progress Note, dated [DATE], reflected the resident's quarterly care plan meeting was held, and discussion included Resident #1's continued wandering about the memory care unit daily, touching other residents' food and staff having to provide calm re-direction with reassurance. There was no documented evidence they had discussed his behavior of placing inedible objects in his mouth. g. Psychiatric Evaluation/Progress Note, dated [DATE], reflected Resident #1 was "doing fine" as reported by staff, was eating and sleeping "okay" and no behavioral issues were noted. Basically the same verbiage was written on the [DATE] Psychiatric Progress Note. h. A document titled Creative Solutions in Health Care Nursing Summary (a monthly nursing summary), dated [DATE] and completed by LVN E, reflected Resident #1 did not speak or interact with staff or residents. His cognitive skills for daily decision-making were severely impaired. The resident's behaviors were noted as wandering in and out of rooms and taking food from other residents' trays. i. A nurse's note, dated [DATE] at 10:20 AM and signed by LVN E, reflected Resident #1 grabbed a poker chip during activities and swallowed it. The resident showed no signs of choking while swallowing the item. Vital signs were within normal limits. The resident was ambulating up and down the hallway, and no signs of distress were noted. The plan was to continue to monitor the resident to see if the poker chip was passed through the stool. j. A nurse's note, dated [DATE] at 6:45 PM and completed by LVN J, reflected she saw Resident #1 fall in the hallway on A Hall. She checked him for breath sounds and heart rate and none were noted. She removed food from his mouth. Abdominal compressions were begun and the resident was frequently turned on his side to remove food from his mouth. Suctioning of food was attempted but unsuccessful. 911 was called and upon their arrival, they removed two poker chips from the resident's throat. At 7:00 PM, the resident was transferred to the local hospital via ambulance. The resident's daughter, the DON, ADON B and the physician were notified. At 7:45 PM, the hospital called and reported the resident had expired. At 10:00 PM the local police officers were at the facility investigating Resident #1's death. 5. An interview, via telephone, with AA H on [DATE] at 3:25 PM revealed she conducted activities on the secured unit. She stated Resident #1 would "grab" other residents' food and drinks. She stated that on [DATE], Resident #1 was wandering about while she was conducting an activity of sorting poker chips with a group of residents. She said he walked over and she thought he was coming to participate. She stated she turned her head and then looked back at him, he was placing a poker chip in his mouth. AA H stated she yelled, "Help!" She stated she could not recall names of staff on the unit at the time of the incident. She stated she tried to get the poker chip from him, but he would not open his mouth. She said "they" checked him, and he seemed like his normal self. AA H stated the resident was in bed around 3:00 PM the same day. She stated the resident was pretty easy to redirect, but she could not get him to sit for anything. AA H stated there was no nurse on the secured unit at the time of the incident. She said Resident #1 swallowed the chip "like it was nothing". During the interview with AA H, the surveyor asked AA H if anyone had told her Resident #1 would put inedible objects in his mouth. She stated, "No." AA H stated she had never seen him put inedible objects in his mouth before. The surveyor asked AA H how long she had worked at the facility. AA H stated she had been employed at the facility for four months and had worked on the secured unit for a month and a half. AA H stated she had activities such as coloring and musical instruments, and Resident #1 had never grabbed a [MEDICATION NAME] or anything else. 6. An interview with LVN E on [DATE] at 9:10 AM revealed she described Resident #1 as a non-verbal resident, who constantly walked around in the secured unit and would take food and drinks from other residents' trays. She stated until she was informed by AA H on [DATE] about 10:30 AM that Resident #1 had swallowed a poker chip during an activity, she had never seen him put foreign objects in his mouth. She stated she (LVN E) asked the AA if the resident had any symptoms and was told he did not. LVN E stated she assessed him and he was breathing without difficulty. His vital signs were within normal limits and bowel sounds were present. Note: The Event Nurses' Notes, completed by LVN E on [DATE] at 10:20 AM, documented his vital signs ,[DATE] BP, 97.4 F, pulse 81 and respiration 18. During the above interview with LVN E she stated she had been told by her supervisor, ADON B, to complete an incident report, assess the resident and then monitor him for distress. She added that she waited to consult with Resident #1's physician so she could monitor him and have more to report to the physician. LVN E stated she observed Resident #1 being fed lunch and he ate well and fast, as usual. She stated at 2:00 PM, she called the resident's physician. She stated when she called the physician's office, she asked to speak with the "nurse" and was connected to a person named (later identified as the physician's Office Manager). LVN E informed her what had happened and how they were monitoring the resident. She stated the "nurse" told her it sounded as if the facility was doing all they could do, and she would notify the physician. She also stated if the physician had any other orders, he would let them know. LVN E stated she monitored the resident for the remainder of her shift. She stated he was wandering on the secured unit as usual and did not appear to be in distress. She said she did not take his vital signs again. LVN E stated she ended her shift at 2:45 PM and left the facility. LVN E further revealed she had been speaking with the same "nurse" from the physician's office for some time regarding Resident #1 and other residents under the care of Resident #1's physician and had received medical advice and orders. She stated she did not know the "nurse's" complete name or title, but assumed she was a nurse or physician's assistant. LVN E further stated if the physician was needed after hours, he would answer the phone, but during the office hours, she was always referred to "nurse" (the physician's Office Manager). 7. An interview with the DON on [DATE] at approximately 11:00 AM revealed after the incident of swallowing the poker chips, Resident #1 ate 100% of his noon meal. The DON stated AA H had told LVN E Resident #1 had swallowed the poker chips, and LVN E called the PCP (primary care physician). The DON stated the staff at the PCP's office told them to just monitor the resident. The DON stated Resident #1 also ate his dinner meal. He stated Resident #1 was pacing and then collapsed. 8. An interview with the physician's office staff member who had spoken to LVN E, on [DATE] at 11:00 AM , revealed she identified herself as the Office Manager. She stated she received a call on [DATE] (she was unclear of the time as she did not document the conversation) from a nurse at the facility. She stated the nurse told her about Resident #1 swallowing a poker chip, but was not in distress. She stated the facility nurse told her they would continue to monitor Resident #1, and she informed them to send the resident to the local hospital if he experienced any problems. The office staff member stated she did not notify the physician of the incident. She stated the physician called her the following day and informed her the resident had expired. 9. An interview with the DON and ADM on [DATE] at 11:20 PM, the DON stated he was aware the physician's office was not contacted until several hours after Resident #1 swallowed the poker chips. The ADM and DON stated they were not aware the facility nurses had been contacting the physician's Office Manager instead of the physician's nurse. 10. An interview with ADON B on [DATE] at 11:25 AM revealed she was told by LVN F on [DATE] about 10:30 AM, Resident #1 had swallowed a poker chip. She stated when she spoke to AA H, she told her the resident grabbed the poker chip, swallowed it and walked off down the hall. ADON B stated she informed LVN E to assess him, complete an incident report and to continue to monitor his behavior, vital signs and meal intake. She stated LVN E told her the resident's vital signs were within normal limits and he had bowel sounds present. She stated the resident had a tongue projection and rarely was still, so it was very difficult to see inside his mouth. The resident did not have teeth. ADON B stated Resident #1 walked by and grabbed food, liquids and anything in sight. He was served double portions at meals. She was not aware of him putting anything else in his mouth. She stated she told AA H to take away the poker chips, which was done immediately. ADON B stated she next saw Resident #1 about 5:00 PM, and he was pacing the halls, which was usual behavior for him. 11. An interview with CNA D on [DATE] at 1:40 PM revealed about one month prior, the LVN (no longer employed at the facility) passing medication on the secured unit briefly left the medication cart unattended. CNA D stated she then saw Resident #1 with a glass vial of Insulin in his mouth. She and another CNA struggled to get the bottle away from him. They notified the LVN. CNA D stated she saw Resident #1 frequently take food from other residents, but never saw him choke. She stated she had made AA H aware he would put objects in his mouth. 12. Additional review of Resident #1's clinical record to include nurses' notes and Event Nurses' Notes (used for documenting accidents and incidents), provided no evidence of the incident involving Resident #1 placing a glass vial of insulin in his mouth. 13. An interview with the Regional Nurse, ADM and ADON B on [DATE] at 3:45 PM revealed they were not aware of the incident in which Resident #1 put an Insulin vial in his mouth. 14. An interview with LVN G on [DATE] at 2:00 PM revealed she did not witness the incident of Resident #1 swallowing the poker chip. She said she worked on different halls. LVN F stated she saw Resident #1 around 10:00 AM. She said AA H stuck her head out of the dining room, and reported Resident #1 was putting poker chips in his mouth. She stated she told AA H to try to prevent him from doing that. LVN F said she was at the front of the hall preparing medications, and by the time she had put her meds away, Resident #1 was walking towards her. She said he was sticking out his tongue and chewing on his shirt. She stated she did not see anything in his mouth. The surveyor inquired how LVN F looked in the resident's mouth. LVN F said she asked Resident #1 to let her look in his mouth, and he pushed her out of the way. She said she left the hall afterwards. LVN F stated she had seen him around lunch or shortly after and he seemed fine. The surveyor inquired as to whether or not she was aware or had been informed about Resident #1's behaviors. She stated she was told to continually monitor the medication cart, because Resident #1 would grab things. The surveyor asked LVN F what types of things Resident #1 would grab from the med cart. LVN F stated he would grab yogurt. The surveyor asked LVN F if she was aware of a time Resident #1 had put an insulin bottle in his mouth. She stated, "No." She said she knew about his grabbing food and drink items from the other residents. The surveyor asked LVN F if any other residents on the secured unit had similar behaviors. LVN F stated, " (Resident #2) would touch things and lick her fingers." She said Resident #2 took wooden tongue blades off the medication cart, put them in her mouth, and then gave them back. 15. An interview with CNA I on [DATE] at 9:55 AM revealed she saw Resident #1 swallow Play-Doh during an activity once. She stated she notified the nurse at the time, and the Play-Doh was taken away. She stated Resident #1 ate quickly in large bites; however she had never seen him choke. 16. Additional review of Resident #1's clinical record to include nurses' notes and Event Nurses' Notes (used for documenting accidents and incidents), provided no evidence of the incident involving Resident #1 putting Play-Doh in his mouth. 17. Interview with CNA D on [DATE] at 10:00 AM revealed Resident #1 paced the hall most of the time. She stated he was known to pick up anything and everything and put it in his mouth. She said he took other residents' food. CNA D stated it was hard to stop him from stealing their food. CNA D stated Resident #1 once got an empty insulin bottle off the medication cart and put it in his mouth. She stated it was hard to monitor the resident because they were busy with the other residents on the unit. The surveyor asked CNA D if there were other residents with similar behaviors. The CNA stated there were no others with a similar behavior. She added there were some residents who took other residents' food. 18. An interview with CNA C on [DATE] at 1:50 PM revealed she was working on the day Resident #1 swallowed the poker chip. She stated she did not observe the incident, but was told about it and was told to monitor the resident for bowel movements and to check for the poker chip. She stated she had not seen any ill effects by the time she left her shift at 2:00 PM. She said she had seen AA H conduct activities with small parts, such as poker chips and marbles, in the past. She stated she had warned AA H Residents #1 and #3 would try to put things in their mouths. She stated she had seen Resident #3 put a marble and a poker chip in her mouth previously. She stated she had not seen Resident #1 with a foreign object in his mouth before, except for his shirt, which he sucked on. CNA C stated she and other CNAs would try to watch the residents as closely as they could. 19. Interview on [DATE] at 3:31 PM with the ADM revealed the facility used to have a nurse posted on the secured unit. The ADM stated she was told by a state employee they could not have the nurse in the Secured Unit, because there was "nowhere" for them to be. 20. An interview with LVN J on [DATE] at 4:20 PM revealed she arrived to work at 3:00 PM on [DATE]. She stated that during report, LVN E told her Resident #1 had swallowed a poker chip earlier that day. She stated she was told the physician was called, and they were told to monitor the resident's bowel movements. She stated she assessed for bowel sounds and they were present and "hyperactive." She stated it was the first time she had worked on the secured unit (A Hall), and she was not familiar with the residents. She had seen Resident #1 in the hallway before and knew he paced constantly. She stated after 3:00 PM the resident was pacing as usual and seemed to be in no distress. LVN J stated the resident was served his dinner meal about 6:00 PM. Resident #1 fed himself and ate very quickly. He stated he left the dining room to go to the hallway and she saw him collapse on the floor. She stated she had observed pink vomitus in his mouth, so turned him onto his side and cleared it. CPR was begun and 911 was called. Suctioning was attempted, but the "tip" of the suctioning tube was clogged. She stated when EMS arrived, they removed two poker chips from his throat. LVN J stated Resident #1 had not regained consciousness before leaving for the hospital. She was notified by the hospital later the resident had expired. 21. An interview with the AD on [DATE] at 8:25 AM revealed upon hiring AA H, she (AA H) completed two to three weeks of training with activities in all areas of the building. She stated AA H had been working on the Secured Unit (A Hall) for a few months. The AD made rounds to ensure safety. The AD stated before the incident with Resident #1, no one had complained to her about AA H and the use of poker chips. She stated she was aware the poker chips were in the activity closet, and she saw the residents sorting them one day. She stated she was aware of Resident #1 taking others' food and drinks from the food cart, but was not aware he would put inedible objects in his mouth. The AD stated she would begin to have activities, which were more appropriate and safe for the Secured Unit residents. She and another AA would rotate working with the residents. 22. On [DATE] at 3:51 PM, the ADM, DON, and Marketer G were notified an Immediate Jeopardy (IJ) had been identified for failure to ensure nursing staff immediately consulted Resident #1 ' s physician when he swallowed two poker chips and subsequently expired.. A Plan of Removal was requested for the IJ. 23. The ADM was notified on [DATE] at 6:40 PM the Plan of Removal was accepted. 24. The facility's Plan of Removal included the following: a. An in-service was initiated on [DATE] regarding notifying the physician of any change in condition. The majority of available licensed staff had been in-serviced by [DATE]. All staff lacking the in-service after that date would not be allowed to assume their duties until the in-service was completed. The in-service included the need to identify the individual to whom the staff was speaking to and to take orders from physicians and/or nurses only. b. An in-service was initiated on [DATE] regarding notifying the physician and family of any incident. Additionally, to notify the medical director of any incident if the attending physician could not be contacted. The majority of available licensed staff had been in-serviced by [DATE]. All staff lacking the in-service after that date would not be allowed to assume their duties until the in-service had been completed. c. An abuse/neglect in-service was initiated on [DATE], and the majority of staff had been in-serviced by [DATE]. All staff lacking the in-service after that date would not be allowed to assume their duties until the in-service had been completed. d. An in-service on Interact and Early Warning Tool was initiated on [DATE]. All staff lacking the in-service after that date would not be allowed to assume their duties until the in-service had been completed. e. An in-service on Activities, specifically on not using small objects for an activity on the secured unit, A Hall was initiated on [DATE]. The in-service included all activities would be supervised. f. An in-service on Activities in the Legacy Program, removing small objects and observations, was completed on [DATE]. (The Legacy Program was for the residents on another hall in the facility where MR residents resided.) g. The facility removed all small objects being used for activities on the secured unit, A Hall on [DATE]. h. An audit was conducted on [DATE] of each resident room on the secured unit to identify any potential object, which could cause injury and an audit was conducted for those other residents identified as being at risk for putting objects in their mouths. Those items were removed from the residents' rooms on [DATE]. i. On [DATE], the DON and three ADONs interviewed staff members (CNAs, nurses, therapists, activity staff) by walking the halls, room by room, and reviewing the charts to assist in identifying residents at risk. Each resident's care plan was revised to specifically identify the potential risk. j. An in-service on [DATE] was completed regarding ADONs making rounds daily on the secured unit in each resident room to ensure all small objects were removed from each resident room. k. Daily rounds were to be completed in the morning by ADONs and/or the DON during the weekdays to monitor compliance for potential objects, which could be swallowed, and ensure they were not accessible to the at-risk residents of the entire facility. The weekend supervisor would perform the rounds on Saturday and Sunday. Documentation of the daily rounds would be submitted to the DON and/or ADM for review. l. An in-service was conducted on [DATE] to ensure every resident who swallowed an object was sent to the local hospital for evaluation. The majority of available licensed staff had been in-serviced by [DATE]. All staff lacking the in-service after that date would not be allowed to assume their duties until the in-service had been completed. m. The behavior monitoring record for each resident identified to be at-risk, was modified to include placing non-food items in the mouth. ADONs would conduct daily rounds to monitor the completion of behavior monitoring documents and the documents would be turned in to the DON daily. n. The choking emblem (an image of a person with his/her hands at his/her throat) was placed on each resident's door to easily identify residents at potential risk on [DATE]. The staff was in-serviced beginning [DATE] regarding the meaning of the choking emblem. The majority of available nursing staff had been in-serviced by [DATE]. All staff lacking the in-service after that date would not be allowed to assume their duties until the in-service had been completed. o. A list of residents who were currently identified as being at risk for swallowing non-food items would be placed at each nurse's station. Nursing staff were in-serviced regarding the location of the list on [DATE]. The majority of available nursing staff had been in-serviced by [DATE]. All staff lacking the in-service after that date would not be allowed to assume their duties until the in-service had been completed. p. All residents who were identified as being at risk for swallowing non-food items would have a "task" added to the electronic ADL documentation system starting on [DATE]. Nursing staff would electronically acknowledge the fact the resident was at risk for swallowing non-food items. The majority of available nursing staff had been in-serviced by [DATE]. All staff lacking the in-service after that date would not be allowed to assume their duties until the in-service had been completed. q. Administrative nursing staff would continually monitor residents and using staff feedback and observation, would update the residents who were at risk for swallowing non-food items. If needed, a choking emblem would be placed on the resident's door, the "task" would be added to the electronic ADL documentation system for the resident and administrative nursing staff would ensure the lists of at-risk residents was updated at each nursing station. r. During daily rounds, the administrative staff would randomly ask at least five nursing staff members per day what the choking emblem signified and where they could locate information, if they had a question whether a resident was at risk for swallowing a non-food object. s. A representative of the secured unit would attend morning stand-up meeting to assist in identifying potential risks and issues needing quick resolution and was initiated on [DATE]. t. A charge nurse would be assigned and stationed on the secured unit, beginning on [DATE], for the 7 AM to 3 PM shift and the 3 PM to 11 PM shift. The 11 PM to 7 AM shift would be monitored by existing staff. The 11 PM to 7 AM nurse would be instructed to complete rounds every two hour and to document their findings on a "round sheet." The DON/designee would monitor their documented findings daily. u. All PRN staff would be required to complete all the above mentioned in-services and training before they were allowed to work on the floor. v. All new staff would be in-serviced and trained by Nurse Management during orientation, prior to working. w. The QA compliance sub-committee, consisting of the ADM, the DON, the three ADONs, the Human Resources Coordinator, the Admissions Coordinator, the Marketer, the Receptionist, the Maintenance Supervisor, the Activities Director, the Business Office Manager and Assistant, the Dietary Supervisor, and the MDS Coordinators, would meet on [DATE] to discuss and review all concerns identified. The QA Committee would meet again on [DATE]. 25. On [DATE] at 10:00 AM, surveyor observations confirmed the following: a. Small objects had been removed from all resident rooms for residents identified as at risk for swallowing, choking on non-food items. b. A list of all residents identified as at-risk for swallowing/choking on non-food items was found in binders at each nursing station. c. Choking emblems were displayed above resident doors on residents identified to be at risk for swallowing/choking on non-food items. d. The electronic ADL documentation system included the "task" to acknowledge residents identified to be at risk for swallowing/choking on non-food items. 26. Individual interview with ADON A, CNA K, LVN L, LVN M, CNA D, CNA I revealed each had attended the in-service trainings and new which residents were at risk of swallowing inedible objects, knew to monitor the residents, knew to ensure there were no small objects available for the resident to potentially swallow, and each knew the meaning of the choking emblem tags on a door to a resident room or a resident's wheelchair. a. The ADON stated stated she began making daily rounds to ensure no small items were in at-risk residents' rooms. The ADON stated if a resident swallowed an item, he was to be sent to the hospital. The ADON stated nurses knew now to question the discipline any outside staff to whom they were speaking. b. LVN L and LVN M each stated the training included the need to transfer a resident

Based on observation, interview and record review, it was determined the DON and ADM failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of four residents reviewed for known risks of placing non-food items in his mouth. 1) The ADM failed to supervise and monitor the managerial staff (DON) to ensure the prevention of Resident #1 swallowing the poker chips and prompt notification and treatment by the physician. 2) The DON failed to implement facility policies to supervise and monitor the licensed nursing and direct care staff to ensure facility staff were aware of Resident #1's history of placing inedible objects in his mouth to prevent Resident #1 from swallowing two poker chips. 3) The DON failed to supervise and monitor the secured unit for safety for the residents by ensuring activities for these residents did not involve using objects, which could be hazardous. The Activities Assistant was unaware Resident #1 put inedible objects in his mouth, and she used small objects (e.g., poker chips and marbles) with activities in the secured unit 4) The DON failed to implement facility policies to supervise and monitor the licensed nursing staff to ensure the physician was promptly consulted when Resident #1 swallowed the poker chips and ensured staff were aware of the person's credentials to whom they were giving report. Staff waited four hours to call the physician's office and were unaware the person they gave report to was an office manager instead of the physician, nurse practitioner or nurse. Staff also took orders from the office manager. On [DATE], an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance due to continuing to in-service staff and monitoring the implementation of the Plan of Removal. This failure resulted in Resident #1 swallowing an inedible object, choking and expiring. This failure placed the 30 residents, identified as being at risk for placing inedible objects in their mouth, at risk for the potential of serious injury, harm, or death. Findings included: 1. On [DATE], at approximately 9:00 AM, while the surveyor was in the facility investigating an unrelated allegation, the surveyor was informed by the ADM and DON Resident #1 had expired on Monday night ([DATE]). The surveyor was told Resident #1 had swallowed two poker chips at 10:20 AM on Monday ([DATE]). The resident expired later that same evening. 2. On [DATE] at approximately 2:00 PM, the DON showed the surveyor two poker chips which were identified as the same type poker chips the resident swallowed. The poker chips measured approximately 1.375 inches in diameter. This is slightly larger than a .50 cent coin, which measures 1.205 inches in diameter. 3. The facility's Provider Investigative Report, dated [DATE], reflected Resident #1, a severely cognitively impaired resident on the secured unit, was observed by AA H placing a poker chip in his mouth and appearing to swallow the chip at approximately 10:20 AM on [DATE]. The resident was assessed and had no signs or symptoms of distress. The physician's office was notified about 2:00 PM and the Office Manager informed the nurse to continue to monitor the resident. The resident showed no signs of distress until immediately after eating his dinner meal about 6:30 PM, at which time he collapsed to the floor and was in complete [MEDICAL CONDITION]. CPR was begun by facility staff and EMS was called. During attempts at intubation by EMS, two poker chips were removed from the resident's throat. Resident #1 was transferred to the local hospital and was pronounced dead. 4. Review of Resident #1's clinical record reflected the following: a. Review of Resident #1's Review of Resident #1's [DATE] physician's orders [REDACTED]. The resident was ordered a Pureed diet, large portions. b. Review of the most recent Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #1 was severely cognitively impaired for daily decision-making. His mood was assessed as having little interest in doing things, trouble concentrating, restlessness and being easily annoyed. His behavior was assessed as physical behavior symptoms toward others and other behavioral symptoms not directed toward others (e.g., pacing, rummaging), plus wandering occurred daily. The MDS assessment did not capture the behavior of placing inedible objects in his mouth. c. Review of the Comprehensive Plan of Care, dated [DATE] and updated [DATE], revealed Resident #1 exhibited behaviors of wandering, pushing other residents, grabbing food from other residents' trays, and resistance with ADLs. Interventions included monitoring and charting behaviors every shift and report to the physician. d. A Care Plan, dated [DATE] and updated [DATE], reflected Resident #1 was at risk for aspiration related to impaired swallowing. Interventions included to properly identify the at risk client with an appropriate ID band and to notify physician of changes as indicated. The Care Plans, dated [DATE], [DATE] and [DATE], did not address his behavior of placing inedible objects in his mouth. e. A Social Work Progress Note, dated [DATE], reflected the resident's quarterly care plan meeting was held, and discussion included Resident #1's continued wandering about the memory care unit daily, touching other residents' food and staff having to provide calm re-direction with reassurance. There was no documented evidence they had discussed his behavior of placing inedible objects in his mouth. f. Psychiatric Evaluation/Progress Note, dated [DATE], reflected Resident #1 was "doing fine" as reported by staff, was eating and sleeping "okay" and no behavioral issues were noted. Basically the same verbiage was written on the [DATE] Psychiatric Progress Note. g. Documentation entitled Creative Solutions in Health Care Nursing Summary (a weekly nursing summary), dated [DATE] and completed by LVN E, reflected Resident #1 did not speak or interact with staff or residents. His cognitive skills for daily decision-making were severely impaired. The resident's behaviors were noted as wandering in and out of rooms and taking food from other residents' trays. h. A nurses' note dated [DATE] at 10:20 AM and signed by LVN E, reflected Resident #1 grabbed a poker chip during activities and swallowed it. The resident showed no signs of choking while swallowing the item. Vital signs were within normal limits. The resident was ambulating up and down the hallway, and no signs of distress were noted. The plan was to continue to monitor the resident to see if the poker chip was passed through the stool. i. A nurses' note, dated [DATE] at 6:45 PM and completed by LVN J, reflected she saw Resident #1 fall in the hallway on A Hall. She checked him for breath sounds and heart rate and none were noted. She removed food from his mouth. Abdominal compressions were begun and the resident was frequently turned on his side to remove food from his mouth. Suctioning of food was attempted but unsuccessful. 911 was called and upon their arrival, they removed two poker chips from the resident's throat. At 7:00 PM, the resident was transferred to the local hospital via ambulance. The resident's daughter, the DON, ADON B and the physician were notified. At 7:45 PM, the hospital called and reported the resident had expired. At 10:00 PM the local police officers were at the facility investigating Resident #1's death. 5) An interview, via telephone, on [DATE] at 3:25 PM with Activity Assistant (AA) H revealed she conducted activities on the secured unit. She stated Resident #1 would "grab" other residents' food and drinks. She stated that on [DATE], Resident #1 was wandering about while she was conducting an activity of sorting poker chips with a group of residents. She said he walked over and she thought he was coming to participate. She stated she turned her head and then looked back at him, he was placing a poker chip in his mouth. AA H stated she yelled, "Help!" She stated she could not recall names of staff on the unit at the time of the incident. She stated she tried to get the poker chip from him, but he would not open his mouth. She said "they" checked him, and he seemed like his normal self. AA H stated the resident was in bed around 3:00 PM the same day. She stated the resident was pretty easy to redirect, but she could not get him to sit for anything. AA H stated there was no nurse on the secured unit at the time of the incident. She said Resident #1 swallowed the chip " like it was nothing " . During the interview with AA H, the surveyor asked AA H if anyone had told her Resident #1 would put inedible objects in his mouth. She stated, "No." AA H stated she had never seen him put inedible objects in his mouth before. The surveyor asked AA H how long she had worked at the facility. AA H stated she had been employed at the facility for four months and had worked on the secured unit for a month and a half. AA H stated she had activities such as coloring and musical instruments, and Resident #1 had never grabbed a [MEDICATION NAME] or anything else. 6) An interview with LVN E on [DATE] at 9:10 AM revealed she described Resident #1 as a non-verbal resident, who constantly walked around in the secured unit and would take food and drinks from other residents' trays. She stated until she was informed by AA H on [DATE] about 10:30 AM that Resident #1 had swallowed a poker chip during an activity, she had never seen him put foreign objects in his mouth. She stated she (LVN E) asked the AA if the resident had any symptoms and was told he did not. LVN E stated she assessed him and he was breathing without difficulty. His vital signs were within normal limits and bowel sounds were present. Note: The Event Nurses' Notes, completed by LVN E on [DATE] at 10:20 AM, documented his vital signs ,[DATE] BP, 97.4 F, pulse 81 and respiration 18. During the above interview with LVN E she stated she had been told by her supervisor, ADON B, to complete an incident report, assess the resident and then monitor him for distress. She added that she waited to consult with Resident #1's physician so she could monitor him and have more to report to the physician. LVN E stated she observed Resident #1 being fed lunch and he ate well and fast, as usual. She stated at 2:00 PM, she called the resident's physician. She stated when she called the physician's office, she asked to speak with the "nurse" and was connected to a person named (later identified as the physician's Office Manager). LVN E informed her what had happened and how they were monitoring the resident. She stated the "nurse" told her it sounded as if the facility was doing all they could do, and she would notify the physician. She also stated if the physician had any other orders, he would let them know. LVN E stated she monitored the resident for the remainder of her shift. She stated he was wandering on the secured unit as usual and did not appear to be in distress. She said she did not take his vital signs again. LVN E stated she ended her shift at 2:45 PM and left the facility. LVN E further revealed she had been speaking with the same "nurse" from the physician ' s office for some time regarding Resident #1 and other residents under the care of Resident #1's physician and had received medical advice and orders. She stated she did not know the "nurse's" complete name or title, but assumed she was a nurse or physician's assistant. LVN E further stated if the physician was needed after hours, he would answer the phone, but during the office hours, she was always referred to "nurse" (the physician's Office Manager). 7) Interview on [DATE] at approximately 11:00 AM with the DON revealed the resident had swallowed the poker chips at 10:20 AM. He stated the resident ate 100% of the noon meal. The DON stated AA H had told LVN E Resident #1 had swallowed the poker chips, and LVN E called the PCP (primary care physician). The DON stated the staff at the PCP's office told them to just monitor the resident. The DON stated the resident ate the dinner meal. He stated Resident #1 was pacing and then collapsed. 8) An interview on [DATE] at 11:00 AM with the physician's office staff, who had spoken to LVN E, revealed she identified herself to the surveyor as the Office Manager. She stated she received a call on [DATE] (she was unclear of the time as she did not document the conversation) from a nurse at the facility. She stated the nurse told her about Resident #1 swallowing a poker chip, but was not in distress. She stated the facility nurse told her they would continue to monitor Resident #1, and she informed them to send the resident to the local hospital if he experienced any problems. The office staff member stated she did not notify the physician of the incident. She stated the physician called her the following day and informed her the resident had expired. 9) An interview with the DON and ADM on [DATE] at 11:20 PM revealed they were not aware the physician's Office Manager facility nurses had been contacting to reach the physician was not a nurse. The DON was aware the nurses had received orders and medical advice from the physician's Office Manager for all the physician's residents at one time or another. He stated he was aware the physician's office was contacted several hours later after the swallowing incident with Resident #1. 10) An interview with ADON B on [DATE] at 11:25 AM revealed she was told by LVN F on [DATE] about 10:30 AM, Resident #1 had swallowed a poker chip. She stated when she spoke to AA H, she told her the resident grabbed the poker chip, swallowed it and walked off down the hall. ADON B stated she informed LVN E to assess him, complete an incident report and to continue to monitor his behavior, vital signs and meal intake. She stated LVN E told her the resident's vital signs were within normal limits and he had bowel sounds present. She stated the resident had a tongue projection and rarely was still, so it was very difficult to see inside his mouth. The resident did not have teeth. ADON B stated Resident #1 walked by and grabbed food, liquids and anything in sight. He was served double portions at meals. She was not aware of him putting anything else in his mouth. She stated she told AA H to take away the poker chips, which was done immediately. ADON B stated she next saw Resident #1 about 5:00 PM, and he was pacing the halls, which was usual behavior for him. 11) An interview with CNA D on [DATE] at 1:40 PM revealed about one month prior, the LVN (no longer employed at the facility) passing medication on the secured unit briefly left the medication cart unattended. CNA D stated she then saw Resident #1 with an empty glass vial of Insulin in his mouth. She and another CNA struggled to get the bottle away from him. They notified the LVN. CNA D stated she saw Resident #1 frequently take food from other residents, but never saw him choke. She stated she had made AA H aware he would put objects in his mouth. 12) Additional review of Resident #1's clinical record to include nurses' notes and Event Nurses' Notes (used for documenting accidents and incidents), provided no evidence of the incident involving Resident #1 placing a glass vial of insulin in his mouth. 13) An interview with the Regional Nurse, ADM and ADON B on [DATE] at 3:45 PM revealed they were not aware of the incident in which Resident #1 put an Insulin vial or Play-Doh in his mouth. 14) Interview on [DATE] at 2:00 PM with LVN F revealed she did not witness the incident of Resident #1 swallowing the poker chip. She said she worked on different halls. LVN F stated she saw Resident #1 around 10:00 AM. She said AA H stuck her head out of the dining room, and reported Resident #1 was putting poker chips in his mouth. She stated she told AA H to try to prevent him from doing that. LVN F said she was at the front of the hall preparing medications, and by the time she had put her meds away, Resident #1 was walking towards her. She said he was sticking out his tongue and chewing on his shirt. She stated she did not see anything in his mouth. The surveyor inquired how LVN F looked in the resident's mouth. LVN F said she asked Resident #1 to let her look in his mouth, and he pushed her out of the way. She said she left the hall afterwards. LVN F stated she had seen him around lunch or shortly after and he seemed fine. The surveyor inquired as to whether or not she was aware or had been informed about Resident #1's behaviors. She stated she was told to continually monitor the medication cart, because Resident #1 would grab things. The surveyor asked LVN F what types of things Resident #1 would grab from the med cart. LVN F stated he would grab yogurt. The surveyor asked LVN F if she was aware of a time Resident #1 had put an insulin bottle in his mouth. She stated, "No." She said she knew about his grabbing food and drink items from the other residents. The surveyor asked LVN F if any other residents on the secured unit had similar behaviors. LVN F stated, "(Resident #2) would touch things and lick her fingers." She said Resident #2 took wooden tongue blades off the med cart, put them in her mouth, and then gave them back. 15) An interview with CNA I on [DATE] at 9:55 AM revealed she saw Resident #1 swallow Play-Doh during an activity once. She stated she notified the nurse at the time, and the Play-Doh was taken away. She stated Resident #1 ate quickly in large bites; however she had never seen him choke. 16) Additional review of Resident #1's clinical record to include nurses' notes and Event Nurses' Notes (used for documenting accidents and incidents), provided no evidence of the incident involving Resident #1 putting Play-Doh in his mouth. 17) Interview on [DATE] at 10:00 AM with CNA D revealed Resident #1 paced the hall most of the time. She stated he was known to pick up anything and everything and put it in his mouth. She said he took other residents' food. CNA D stated it was hard to stop him from stealing their food. CNA D stated Resident #1 once got an empty insulin bottle off the medication cart and put it in his mouth. She stated it was hard to monitor the resident because they were busy with the other residents on the unit. The surveyor asked CNA D if there were other residents with similar behaviors. The CNA stated there were no others with a similar behavior. She added there were some residents who took other residents' food. 18) An interview with CNA C on [DATE] at 1:50 PM revealed she was working on the day Resident #1 swallowed the poker chip. She stated she did not observe the incident, but was told about it and was told to monitor the resident for bowel movements and to check for the poker chip. She stated she had not seen any ill effects by the time she left her shift at 2:00 PM. She said she had seen AA H conduct activities with small parts, such as poker chips and marbles, in the past. She stated she had warned AA H Residents #1 and #3 would try to put things in their mouths. She stated she had seen Resident #3 put a marble and a poker chip in her mouth previously. She stated she had not seen Resident #1 with a foreign object in his mouth before, except for his shirt, which he sucked on. CNA C stated she and other CNAs would try to watch the residents as closely as they could. 19) Interview on [DATE] at 3:31 PM with the ADM revealed the facility used to have a nurse posted on the secured unit. The ADM stated she was told by a state employee they could not have the nurse in the Secured Unit, because there was "nowhere" for them to be. 20) An interview with LVN J on [DATE] at 4:20 PM revealed she arrived to work at 3:00 PM on [DATE]. She stated that during report, LVN E told her Resident #1 had swallowed a poker chip earlier that day. She stated she was told the physician was called, and they were told to monitor the resident's bowel movements. She stated she assessed for bowel sounds and they were present and "hyperactive." She stated it was the first time she had worked on the secured unit (A Hall), and she was not familiar with the residents. She had seen Resident #1 in the hallway before and knew he paced constantly. She stated after 3:00 PM the resident was pacing as usual and seemed to be in no distress. LVN J stated the resident was served his dinner meal about 6:00 PM. Resident #1 fed himself and ate very quickly. He stated he left the dining room to go to the hallway and she saw him collapse on the floor. She stated she had observed pink vomitus in his mouth, so turned him onto his side and cleared it. CPR was begun and 911 was called. Suctioning was attempted, but the "tip" of the suctioning tube was clogged. She stated when EMS arrived, they removed two poker chips from his throat. LVN J stated Resident #1 had not regained consciousness before leaving for the hospital. She was notified by the hospital later the resident had expired. 21) An interview with the AD on [DATE] at 8:25 AM revealed upon hiring AA H, she (AA H) completed two to three weeks of training with activities in all areas of the building. She stated AA H had been working on the Secured Unit (A Hall) for a few months. The AD made rounds to ensure safety. The AD stated before the incident with Resident #1, no one had complained to her about AA H and the use of poker chips. She stated she was aware the poker chips were in the activity closet, and she saw the residents sorting them one day. She stated she was aware of Resident #1 taking others' food and drinks from the food cart, but was not aware he would put inedible objects in his mouth. The AD stated she would begin to have activities, which were more appropriate and safe for the Secured Unit residents. She and another AA would rotate working with the residents. 22) Review of the facility's current Behavior Management Policy with a revision date of [DATE] revealed the following: i) Behavior management utilizes techniques such as area limitations and limit setting and behavior modification depending on individual needs. One goal is to have the resident modify his behavior for optimal functioning and well-being. ii) Procedures include: monitoring for appropriate behavior and intervening before harmful behavior is expressed. Allow wandering for those with dementia and utilize an alarm system in order to monitor location and prevent harmful situations. Place this resident on frequent checks to ensure safety. Provide diversion or redirect attention away from negative behaviors. Document behavior modification on the interdisciplinary plan of care. Monitor effectiveness of interventions. 23) Review of the facility's current policy/procedure entitled Abuse/Neglect, revised [DATE], included "...Definitions ...6. Neglect: Failure to provide essential needs or protection for a person incapable of providing for him/herself independently or harming or threatening with harm; can be committed by self or other... 24) Review of the facility's current policy entitled "Notifying the Physician of Significant Change in Status," revised [DATE], revealed "...1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record." 25) On [DATE] at 3:51 PM, the ADM, DON, and Marketer G were notified an Immediate Jeopardy (IJ) had been identified for failure to ensure nursing staff immediately consulted Resident #1's physician when he swallowed two poker chips and subsequently expired.. A Plan of Removal was requested for the IJ. 26) The ADM was notified on [DATE] at 6:40 PM the Plan of Removal was accepted. 27) The facility's Plan of Removal included the following: a. An in-service was initiated on [DATE] regarding notifying the physician of any change in condition. The majority of available licensed staff had been in-serviced by [DATE]. All staff lacking the in-service after that date would not be allowed to assume their duties until the in-service was completed. The in-service included the need to identify the individual to whom the staff was speaking to and to take orders from physicians and/or nurses only. b. An in-service was initiated on [DATE] regarding notifying the physician and family of any incident. Additionally, to notify the medical director of any incident if the attending physician could not be contacted. The majority of available licensed staff had been in-serviced by [DATE]. All staff lacking the in-service after that date would not be allowed to assume their duties until the in-service had been completed. c. An abuse/neglect in-service was initiated on [DATE], and the majority of staff had been in-serviced by [DATE]. All staff lacking the in-service after that date would not be allowed to assume their duties until the in-service had been completed. d. An in-service on Interact and Early Warning Tool was initiated on [DATE]. All staff lacking the in-service after that date would not be allowed to assume their duties until the in-service had been completed. e. An in-service on Activities, specifically on not using small objects for an activity on the secured unit, A Hall was initiated on [DATE]. The in-service included all activities would be supervised. f. An in-service on Activities in the Legacy Program, removing small objects and observations, was completed on [DATE]. (The Legacy Program was for the residents on another hall in the facility where MR residents resided.) g. The facility removed all small objects being used for activities on the secured unit, A Hall on [DATE]. h. An audit was conducted on [DATE] of each resident room on the secured unit to identify any potential object, which could cause injury and an audit was conducted for those other residents identified as being at risk for putting objects in their mouths. Those items were removed from the residents' rooms on [DATE]. i. On [DATE], the DON and three ADONs interviewed staff members (CNAs, nurses, therapists, activity staff) by walking the halls, room by room, and reviewing the charts to assist in identifying residents at risk. Each resident's care plan was revised to specifically identify the potential risk. j. An in-service on [DATE] was completed regarding ADONs making rounds daily on the secured unit in each resident room to ensure all small objects were removed from each resident room. k. Daily rounds were to be completed in the morning by ADONs and/or the DON during the weekdays to monitor compliance for potential objects, which could be swallowed, and ensure they were not accessible to the at-risk residents of the entire facility. The weekend supervisor would perform the rounds on Saturday and Sunday. Documentation of the daily rounds would be submitted to the DON and/or ADM for review. l. An in-service was conducted on [DATE] to ensure every resident who swallowed an object was sent to the local hospital for evaluation. The majority of available licensed staff had been in-serviced by [DATE]. All staff lacking the in-service after that date would not be allowed to assume their duties until the in-service had been completed. m. The behavior monitoring record for each resident identified to be at-risk, was modified to include placing non-food items in the mouth. ADONs would conduct daily rounds to monitor the completion of behavior monitoring documents and the documents would be turned in to the DON daily. n. The choking emblem (an image of a person with his/her hands at his/her throat) was placed on each resident's door to easily identify residents at potential risk on [DATE]. The staff was in-serviced beginning [DATE] regarding the meaning of the choking emblem. The majority of available nursing staff had been in-serviced by [DATE]. All staff lacking the in-service after that date would not be allowed to assume their duties until the in-service had been completed. o. A list of residents who were currently identified as being at risk for swallowing non-food items would be placed at each nurse's station. Nursing staff were in-serviced regarding the location of the list on [DATE]. The majority of available nursing staff had been in-serviced by [DATE]. All staff lacking the in-service after that date would not be allowed to assume their duties until the in-service had been completed. p. All residents who were identified as being at risk for swallowing non-food items would have a "task" added to the electronic ADL documentation system starting on [DATE]. Nursing staff would electronically acknowledge the fact the resident was at risk for swallowing non-food items. The majority of available nursing staff had been in-serviced by [DATE]. All staff lacking the in-service after that date would not be allowed to assume their duties until the in-service had been completed. q. Administrative nursing staff would continually monitor residents and using staff feedback and observation, would update the residents who were at risk for swallowing non-food items. If needed, a choking emblem would be placed on the resident's door, the "task" would be added to the electronic ADL documentation system for the resident and administrative nursing staff would ensure the lists of at-risk residents was updated at each nursing station. r. During daily rounds, the administrative staff would randomly ask at least five nursing staff members per day what the choking emblem signified and where they could locate information, if they had a question whether a resident was at risk for swallowing a non-food object. s. A representative of the secured unit would attend morning stand-up meeting to assist in identifying potential risks and issues needing quick resolution and was initiated on [DATE]. t. A charge nurse would be assigned and stationed on the secured unit, beginning on [DATE], for the 7 AM to 3 PM shift and the 3 PM to 11 PM shift. The 11 PM to 7 AM shift would be monitored by existing staff. The 11 PM to 7 AM nurse would be instructed to complete rounds every two hour and to document their findings on a "round sheet." The DON/designee would monitor their documented findings daily. u. All PRN staff would be required to complete all the above mentioned in-services and training before they were allowed to work on the floor. v. All new staff would be in-serviced and trained by Nurse Management during orientation, prior to working. w. The QA compliance sub-committee, consisting of the ADM, the DON, the three ADONs, the Human Resources Coordinator, the Admissions Coordinator, the Marketer, the Receptionist, the Maintenance Supervisor, the Activities Director, the Business Office Manager and Assistant, the Dietary Supervisor, and the MDS Coordinators, would meet on [DATE] to discuss and review all concerns identified. The QA Committee would meet again on [DATE]. 28) On [DATE] at 10:00 AM, observation confirmed the following: a) Small objects had been removed from all resident rooms for residents identified as at risk for swallowing, choking on non-food items. b) A list of all residents identified as at-risk for swallowing/choking on non-food items was found in binders at each nursing station. c) Choking emblems were displayed above resident doors on residents identified to be at risk for swallowing/choking on non-food items. d) The electronic ADL documentation system included the "task" to acknowledge residents identified to be at risk for swallowing/choking on non-food items. 29) Interviews with staff revealed the following: a. An interview with ADON A on [DATE] at 9:25 AM revealed she had attended in-services and was aware of the meaning of the choking emblem tags on the doors and wheelchairs. She stated she began making daily rounds to ensure no small items were i