Based on interview and record review, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who completed a training course approved by the State for 1 of 1 facility reviewed for Activity Director qualifications. The facility failed to hire a qualified Activity Director. This failure could place residents at risk of not receiving a program of activities that meets their assessed activity needs. Findings include: Interview on an undisclosed date and time, anonymous resident revealed that he did not receive an activity calendar. Interview on 07/06/2026 at 2:45 p.m., the materials director revealed that she had her Activities Director qualification, but she would not be providing it for the facility. The Material Director stated that she put her resignation in a week ago and would not be taking on the new role to cover for the Activity Director who had left the facility. Interview with a confidential group at an undisclosed date and time revealed that the group of residents were aware of there no longer being an activity director in the facility. The group stated that they had not received the activity calendar for July 2026. The group also stated that they had to have the Administrator sit in at their monthly resident council meeting due to lack of Activity Director. Interview on 07/09/2026 at 3:30 p.m., the DON stated she was aware that there was no activity director. The DON stated to her knowledge the residents were still having activities. The DON stated that resident council was affected by not having someone keep minutes and with help assembling the meeting. DON stated that the residents missed resident rights being discussed. Interview on 07/09/2026 at 4:35 p.m., the Administrator stated that she was aware that the facility did not have an activity director. Administrator stated that activity director was responsible for activities in the facility and resident council. The Residents were at risk of missing activities and not knowing their rights. The Administrator stated that she was in the process of hiring another Activity Director and it had only been a few weeks without an activity director. The Administrator stated that prior to the previous Activity Director leaving she created an activity calendar for July and had only been gone a few weeks but did not state exact amount of time the facility was without an activity director. Record review of the personnel file revealed no documentation of Activity director at this time with a certification, completion of an approved Activity Director training course, qualifying licensure, or other documentation demonstrating the facility met the needs and qualifications of activities director. It is unknown when a qualified activity director last worked at the facility. Record review of Recreation Services policy dated 01/2015 revealed each facility will have a director responsible for the provision of recreation services. Director requirements recreation services director will be qualified according to state requirements.
Every finding on record at Greenville Health & Rehabilitation Center
Greenville, Texas · CCN 675020
39 findings across 7 inspections, in the inspector's own words, 19 of them at actual harm or above.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.
Inspection of July 9, 2026
20 findingsBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety for 1 of 1 kitchen reviewed. The facility did not ensure:1. Food items were labeled and dated.2. The ice scoop holder was clean.3. The microwave was clean and free of food debris.4. The deep fryer was clean and had clear grease.5. The exterior of the blender was clean.6. Can opener blade was clean.7. Hair restraints were worn.8. [NAME] L had a clean spoon before stirring the pureed chicken. These failures could place residents at risk for foodborne illness.Findings included: During an initial tour observation and interview with the Dietary Manager on 07/06/26 beginning at 10:31 a.m. until 10:56 a.m. the following was revealed: 1. [NAME] M and the Dietary's Manager's hairnets were not covering their entire head. The Dietary Manager hair net only covered half of her head and [NAME] M had loose hair sticking out. 2. A bag of garlic bread undated and unsealed was found in the walk-in cooler. 3. A bag of puffy pastries undated and unsealed was found in the walk-in cooler. 4. A box that included 14 unsalted margarines undated was found in walk-in cooler. 5. The ice machine scoop holder had several brown and white pieces floating in the bottom. 6. Can opener blade had a black substance buildup. 7. Inside the microwave was a brown buildup. 8. The exterior of the blender had a tan buildup. 9. The deep fryer had golden food crumbs of various sizes observed on the inside surfaces. During an observation and interview on 07/07/26 at 11:50 a.m., [NAME] L removed the spoon from the prep sink and mixed the pureed chicken before washing. The Dietary Manager stated she should have washed the spoon first before stirring the pureed chicken. The Dietary Manager had [NAME] L discard the chicken. The Dietary Manager stated this failure put residents at risk for foodborne illness. An attempted telephone interview on 07/09/26 at 12:05 p.m., with Dietary Aide B was unsuccessful, unable to leave voicemail. During a telephone interview on 07/09/26 at 2:35 p.m., the Dietician stated she expected food to be dated and sealed. The Dietician stated she expected hairnets to be covering the entire head. The Dietician stated the ice scoop, and grease should be changed once a week. The Dietician stated the fryer should be cleaned after every use. The Dietician stated the can opener blade, blender, and microwave should be cleaned after every use. The Dietician stated she monitored by monthly observations and had not had any issues since April 2026. The Dietician stated she did have an issue in May 2026 during breakfast where a staff did not wash the spoon prior to using it and a verbal in-service was done to discuss the proper way to prevent cross contamination. The Dietician could not recall the staff member. The Dietician stated these failures could potentially put residents at risk for foodborne illness and cross contamination. During an interview on 07/09/26 at 2:53 p.m., [NAME] L stated all staff were responsible for dating food products and ensuring food was sealed. [NAME] L stated the can opener blade, microwave, and exterior of the blender should be cleaned after every use by the cook. [NAME] L stated the cooks were responsible for cleaning the fryer and changing the grease once a week. [NAME] L stated she should have washed the spoon first before stirring the pureed chicken. [NAME] L stated these failures could possibly cause food borne illness and cross contamination. During an interview on 07/09/26 at 2:59 p.m., the Dietary Manager stated cleanliness was important in the kitchen, so staff were not spreading germs or contaminating anything. The Dietary Manager stated she was responsible for making sure the kitchen was cleaned appropriately. The Dietary Manager stated food should be labeled and sealed by all staff. The Dietary Manager stated the aides were responsible for cleaning the ice scoop holder daily. The Dietary Manager stated the cooks were responsible for cleaning the can opener blade, microwave, blender and the fryer daily. The Dietary Manager stated hair nets should be worn while in the kitchen and covering the entire head without loose hair sticking out. The Dietary Manager stated she was responsible for monitoring and overseeing by daily walk throughs and when there was an isolated issue that staff were verbally in serviced and if a widespread issue a paper in service was completed. The Dietary Manager stated these failures could potentially put residents at risk for cross contamination and food borne illness. During an interview on 07/09/26 at 6:47 p.m., the Administrator stated she expected food to be dated/sealed, hair nets covering the entire head without loose hair sticking out. The Administrator stated all staff should be ensuring the ice scoop holder, blender, microwave and the fryer cleaned daily. The Administrator stated the grease should be changed at least weekly. The Administrator stated [NAME] L should have washed the spoon first prior to stirring the pureed chicken. The Administrator stated these failures could potentially put residents at risk for cross contamination, and food borne illness. Record review of the facility's policy titled, Equipment Cleaning Procedures revised 05/2018 reflected . It is the policy of this facility that all dietary equipment and the environment are cleaned and sanitized in a manner that meets local (if applicable), state, and federal regulations.Routine cleaning will be practiced on a regular basis in order to keep all dietary equipment and the environment safe, sanitary, and in compliance with state and federal regulations. Cleaning Frequency.: Daily: Equipment and items that are used in food preparation should be cleaned and sanitized after each use. Kitchen and storeroom floors should be swept and mopped daily.Weekly: If the fryer is used frequently (five or more times a week), clean weekly. Record review of the facility's policy titled, Personal Hygiene revised 09/12/23 reflected . Dietary employees will maintain proper food safety practices through proper personal hygiene. Proper hand-washing techniques and exclusion of infectious individuals from handling food are critical for prevention of foodborne illness.9. Dietary employees shall wear proper hair restraints. at all times while working in the kitchen. Staff that work serving in the dining room do not need to wear hair restraints. Any staff and/or vendors entering the kitchen must comply with hair restraints and hand-washing policies. Record review of the facility's policy titled, Frozen and Refrigerated Foods Storage revised 11/16/17 reflected . 9. Items stored in the refrigerator must be dated upon receipt, unless they contain a manufacturer use by, sell by, best by date, or a date delivered. Most pick stickers do have the delivery date on the sticker. They must also be dated with an expiration date unless they have one from the manufacturer. Record review of FDA 2-402.11, dated 2022, revealed FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE_SERVICE and SINGLE-USE ARTICLES.
Based on observation, interview, and record review, the facility failed to ensure the resident environment was as free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents for 3 of 22 residents (Resident #2, Resident #7, and Resident #13) reviewed for accidents and hazards. 1. The facility did not have a process to reassess elopement risk and safety for Resident #13 after elopement. 2. The facility failed to ensure Resident #7 did not have insect spray in her room. 3. The facility failed to ensure Resident #2 did not have the purple top microdot disinfectant wipes in her bathroom. These failures could place residents at risk of accidents that could result in serious injury, harm, or impairment. Findings included: 1. Record review of Resident #13's face sheet, dated 07/09/26, reflected Resident #13 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included encephalopathy (group of conditions that caused brain dysfunction) and dementia (a condition that affects memory and the ability to perform daily activities) without behavioral disturbance, psychotic disturbance (a collection of symptoms that affect the mind with loss of contact with reality), mood disturbance and anxiety (persistent feelings of fear or worry). Record review of Resident #13's quarterly MDS assessment, dated 05/08/26, reflected Resident #13 made herself understood, and understood others. Resident #13's BIMS score was 3, which reflected her cognition was severely impaired. Record review of Resident #13's comprehensive care plan, initiated 05/17/26, reflected Resident #13 was at risk for wandering/elopement related to cognitive impairment, and at risk for injury related to dementia, and poor safety awareness. Resident #13 did have exit wandering behaviors however; Resident #13 was able to push door open but had difficulty to physically leave facility without assistance. Resident #13 often attempts to leave through double doors and requires wheelchair for assistance. The care plan interventions included attempt to determine any pattern or cause of wandering. Record review of Resident #13's order summary report, dated 07/09/26, reflected monitor placement of wander guard bracelet every shift with start date 07/03/26. Record review of Resident #13's elopement/wandering risk assessment, dated 05/17/26 reflected Resident #13 was at low risk for elopement. Record risk of Resident #13's elopement/wandering risk assessment, dated 07/08/26 reflected Resident #13 was at risk for elopement. During an interview on 07/08/26 at 10:09 a.m., the DON stated she was not aware of the elopement attempts on 06/09/26 first incident when Resident #13 opened the door and made it halfway through when the CNA was able to pull her back inside. The DON stated the incident was discussed 06/10/26 the next morning in morning meeting, but she did not follow up to ensure the elopement/wandering risk was updated. The DON stated the Social Worker was responsible for completing a wandering/elopement assessment the following day. During an interview on 07/08/26 at 10:44 a.m., the Social Worker stated she had never been asked to complete an elopement assessment for Resident #13. The Social Worker stated she did not know was responsible for completing the assessment after Resident #13 attempted to elope. During an interview on 07/08/26 at 11:11 a.m., the Administrator stated she was not aware of the first incident on 06/09/26 when Resident #13 attempted to elope. The Administrator stated the first incident was not discussed during the morning meeting. The Administrator stated she expected the staff to let her know about all incidents. The Administrator stated she was aware Resident #13 had wandering behaviors when seeking the restroom. The Administrator stated she was aware that there were no interventions put in place to prevent wandering. The Administrator stated the nurse that was aware of the incident was responsible for reassessing Resident #13 for elopement. The Administrator stated it was important for Resident #13 to be assessed for safety. During an interview on 07/09/26 at 11:30 a.m., RN P stated she spoke with the DON and was instructed to reassess Resident #13 for elopement/wandering. RN P stated she got distracted and forgot to complete the assessment. RN P stated it was important to ensure the assessment was completed for resident safety. 2. Record review of Resident #7's face sheet, dated 07/09/26, reflected Resident #7 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #7's quarterly MDS assessment, dated 05/15/26, reflected Resident #7 made herself understood, and understood others. Resident #7's BIMS score was 15, which reflected her cognition was intact. Record review of Resident #7's comprehensive care plan, revised on 01/22/26, reflected Resident #7 had an ADL Self Care Performance Deficit and was at risk for not having her needs met in a timely manner. The care plan interventions included: ensure/provide a safe environment. During an interview and observation on 07/06/26 at 12:16 p.m., Resident #7 had a bottle labeled Hot Shot Flying Insect spray sitting on her dresser. Resident #7 stated she had her family member to bring it because she had gnats. Resident #7 stated she was unsure if the facility knew she had it. During an interview on 07/09/26 at 10:37 a.m., CNA G stated all staff were responsible for ensuring items were stored properly and securely. CNA G stated she had seen the insect spray and tried to remove it but Resident #7 would not let her. CNA G stated she did not report it to the charge nurse, DON or Administrator. CNA G stated the insect spray should not be in the facility for residents' safety. During an interview on 07/09/26 at 10:54 a.m., RN K stated all staff were responsible for ensuring items were stored properly and securely. RN K stated she was not aware of the insect spray being on Resident #7's dresser. RN K stated the insect spray should not be in the building. RN K stated it was important to ensure items were not left in the residents' room for residents' safety. During an interview on 07/09/26 at 6:12 p.m., the DON stated insect spray should not be in the building because the chemical was not approved for the facility. The DON stated all staff were responsible for ensuring items were stored properly and securely. The DON stated she monitored compliance by daily rounds. The DON stated it was important to ensure insect spray was not left in resident's room for residents' safety. During an interview on 07/09/26 at 6:47 p.m., the Administrator stated insect spray was not allowed in the facility. The Administrator stated she was not aware this item was stored at the resident's bedside. The Administrator stated she made daily rounds and had found things at bedside that should not have been left at the bedside. be left. The Administrator stated she educated the family members and residents. The Administrator stated it was important to ensure items were not left at the bedside for residents' safety. 3. Record review of Resident #2's face sheet dated 07/06/2026 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus (chronic metabolic disease characterized by high blood sugar levels), anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure), and major depressive disorder (serious mental health condition characterized by persistent sadness, hopelessness, and loss of interest in activities). Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated she understood others and made herself understood. The MDS also indicated she had a BIMS score of 15 which meant she was cognitively intact. The MDS also indicated she was also incontinent of urine and required maximal assistance with toileting, dressing, and bed mobility, independent with eating, and she required total assistance with transfers. During an observation and interview on 07/06/2026 at 1:39 PM Resident #2 was lying in her bed and she had a container of purple top microdot disinfectant wipes in her bathroom on the back of the toilet. Resident #2 said a staff member must have left them because she did not place them there. Resident #2 said she did not ever use the bathroom. During an interview on 07/09/2026 at 6:17 PM The DON said the purple top microdot disinfectant wipes should not be available to residents or left in their rooms. The DON said the purple top microdot wipes should be in a locked cart or in medication room locked to ensure staff were wiping down their carts. The DON said the purple top disinfectant wipes should not be in resident rooms at all and all staff were responsible for ensuring the wipes were not left in resident rooms. The DON said she completed rounds every morning and she monitored for things left out. The DON said the failure placed a risk for safety for other residents who wander to get their hands on the wipes. During an interview on 07/09/2026 at 6:52 PM The Administrator said the purple tops disinfectant wipes should not be in the resident rooms. The Administrator said all staff were responsible for ensuring the purple top wipes were not left in the residents' rooms. The Administrator said the failure placed a risk for residents getting a hold of the wipes and harming themselves. Record review of the Safety Data Sheet .dated 08/21/24 reflected. Classification of Substance or Mixture. Physical Hazards. Flammable Aerosol.keep out of reach of children. Record review of the Incident/Accident Policy .revised 11/17 reflected. It is the policy of this facility to report and investigate all incidents and accidents that occur in the facility or on facility property in a timely manner. Incident: an unusual or unexpected event that is not consistent with the routine operation of the facility or the routine care of the resident.1. Immediately assess the condition of the person(s) involved in the incident/accident. The policy provided by the facility gave no relevant reference regarding hazardous material.
Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 6 residents (Resident #1, Resident #2, and Resident #55) room reviewed for infection control practices and enhanced barrier precautions. 1. The facility failed to ensure OT Q used the proper PPE while providing care to Resident #1 on 07/08/2026. 2. The facility failed to ensure CNA C wiped correctly and performed hand hygiene while providing incontinent care for Resident #2 on 07/06/26. 3. The facility did not ensure The Floor Tech used the proper PPE before entering Resident #55's room on 07/06/26. These failures could place residents at the facility at risk for cross-contamination and the spread of infection.Findings included: 1)Record review of Resident #1's face sheet dated 07/09/2026 indicated he was a [AGE] year-old male who re-admitted to the facility on [DATE]. His diagnoses included kidney failure (when the kidney function is less than 15% and can no longer filter waste products from the blood), heart failure (serious condition where the heart muscle does not pump blood efficiently), chronic obstructive pulmonary disease (a progressive lung condition that restricts airflow and makes it hard to breathe), and high blood pressure. Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated he could make himself understood and he understood others. The MDS also indicated he had a BIMS score of 15 which meant he was cognitively intact. The MDS also indicated Resident #1 had an indwelling catheter for urinating and he required maximal assistance with toileting. The MDS indicated he required moderate assistance with transfers, bed mobility, and bathing, and he could eat independently. Record review of Resident #1's comprehensive care plan revised 7/7/2026 indicated he had a urinary catheter, and he required enhanced barrier precautions and staff must use gown and gloves during high-contact resident care activities that could possibly result in transfer of MDROs to hands and clothing of staff. (e.g., residents with wounds or indwelling medical devices). The care plan also indicated he was at risk for urinary tract infections and injury with interventions to provide catheter care per the facility policy. During an observation on 07/08/2026 at 8:50 AM OT Q was fastening the brief for Resident #1 when surveyor walked in. When surveyor walked in Resident #1's room OT Q did not have a gown but had gloves on. Resident #1 had a enhanced barrier precaution sign on his door and PPE hanging on his door. During an interview on 07/08/2026 at 9:25 AM OT Q said he probably should have had on his gown and gloves but was not really providing catheter care. He said he was placing a new brief on, but the failure placed a risk for infection or cross-contamination. During an interview on 07/09/2026 at 6:33 PM The DON said her expectation was for the staff to use the enhanced barrier precautions any time care was being provided to Resident #1. The DON said the failure placed a risk for infection being spread. During an interview on 07/09/2026 at 7:06 PM The Administrator said her expectation was for the staff to wear the proper PPE which was gown and gloves while providing care for Resident #1. The Administrator said that was the reason Resident #1 had signs and boxes of PPE. The Administrator said the failure placed a risk for spread of disease. 2) Record review of Resident #2's face sheet dated 07/06/2026 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE]. Her diagnoses included type 2 diabetes mellitus (chronic metabolic disease characterized by high blood sugar levels), anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure), and major depressive disorder (serious mental health condition characterized by persistent sadness, hopelessness, and loss of interest in activities). Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated she understood others and made herself understood. The MDS also indicated she had a BIMS score of 15 which meant she was cognitively intact. The MDS also indicated she was also incontinent of urine and required maximal assistance with toileting, dressing, and bed mobility, independent with eating, and she required total assistance with transfers. Record review of Resident #2's comprehensive care plan last revised 07/01/2026 indicated she had an ADL self-care performance deficit and was dependent on staff for toileting, transfers, and bathing. During an observation on 07/06/2026 at 2:00 PM Resident #2 was lying in bed when CNA C and LVN F came in to change her. CNA C and LVN F explained to Resident #2 what they were going to do. CNA C wiped Resident #2's perineal area from front to back and then assisted LVN F to turn her to her side and wiped the buttocks without changing her gloves. CNA C then wiped Resident #2's back side from back to front with the same wipe. CNA C then removed her gloves and did not perform hand hygiene prior to new gloves being applied and then applied a clean brief. CNA C then applied baby oil and changed her gloves but did not perform hand hygiene. Then she pulled up the covers and moved the bed next to the wall. She did hand hygiene when leaving the room. During an interview 07/08/2026 at 10:54 AM CNA C said she was supposed to change her gloves after providing incontinent care from the front to the back. CNA C said she wiped from down to up and should not have on the buttocks. CNA C said she was supposed to change her gloves and complete hand hygiene from dirty to clean to stop the spreading of infection. During an interview on 07/09/2026 at 6:37 PM The DON said she expected the staff to all understand and provide perineal care correctly and wipe from front to back especially on a woman. The DON said the CNAs should wash hands before and after care and she expected the CNAs to be using hand sanitizers between glove changes. The DON said the nurses and herself were responsible for ensuring the staff correctly perineal care. The DON said check offs for proper perineal care were completed periodically as well as upon hire and then when she had any issues she started to increase the frequency. During an interview on 07/09/2026 at 7:09 PM The Administrator said her expectation was for proper perineal care and proper hand hygiene to be completed by all staff. The Administrator said the nursing administration (DON, ADON) were responsible for ensuring the staff provided proper perineal care and hand hygiene. The Administrator said proficiency checks were completed upon hire, annually, and as needed. The Administrator said the failure placed a risk for spread of disease and create situations for urinary tract infections. 3) Record review of Resident #55's face sheet dated 07/09/2026 indicated he was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included dementia (progressive decline in cognitive abilities, such as memory, thinking, and reasoning), anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure), high blood pressure, and benign prostatic hyperplasia (disease in which the prostate grows in size causing weak stream and frequent urination). Record review of Resident #55's quarterly MDS assessment dated [DATE] indicated he was able to understand others and made himself understood. The MDS also indicated he had a BIMS score of 10 which meant he had moderate cognitive impairment. The MDS also indicated he required touching assistance with toileting and showers, and he was independent with eating, bed mobility, and dressing. Record review of Resident #55's comprehensive care plan dated 06/29/2026 indicated he had a urinary tract infection that required the use of an antibiotic and the infection required the staff to use contact isolation precautions. During an observation and interview on 07/06/2026 at 11:40 AM Resident #55's door had a sign for contact precautions visible with the isolation PPE supplies on the door. When the Floor tech went into Resident #55's room and check the sanitizer dispenser, he took old one out of the room then went to the environmental door and changed it out without PPE on. The Floor Tech said he was in his own little world and said he didn't touch anything but the hand dispenser. The Floor Tech said he should have put on PPE because he could have contracted something or spread it to someone else. The Floor Tech then went in the environmental room and washed his hands and returned to Resident #55's room and sanitized the door and environmental room door. During an interview on 07/09/2026 at 6:35 PM the DON said she expected the maintenance man and anyone else to wear the proper PPE for contact isolation. The DON said the failure placed a risk for infection. The DON said she was responsible for ensuring that everyone was aware and signage was there for a reason. During an interview on 07/09/2026 at 7:07 PM The Administrator said she expected The Floor Tech to wear the proper PPE before entering the contact isolation room. The Administrator said the failure placed a risk for spread of disease. Record review of the facility policy, dated 2/20/2020, Hand Hygiene indicated Policy: All staff will perform proper hand hygiene procedures to prevent the spread of.2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table.When, during resident care, moving from a contaminated body site to a clean body site.6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Record review of the facility policy, dated 10/24/2022, Infection Prevention and Control Program indicated Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. c. All staff shall use personal protective equipment (PPE) according to established facility policy.6. Enhanced Barrier Precautions EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.
Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 3 of 23 (Residents #13, #11, and #1) residents reviewed for care plans. 1. The facility failed to implement Resident #13's physician recommendation for placement on the secure unit. 2. The facility failed to ensure Resident #11 was care planned for his splint. 3. The facility failed to ensure Resident #1 was care planned for activities. These failures could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings included: 1.Record review of Resident #13's face sheet, dated 07/09/26, reflected Resident #13 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included encephalopathy (group of conditions that caused brain dysfunction) and dementia (a condition that affects memory and the ability to perform daily activities) without behavioral disturbance, psychotic disturbance (a collection of symptoms that affect the mind with loss of contact with reality), mood disturbance and anxiety (persistent feelings of fear or worry). Record review of Resident #13's quarterly MDS assessment, dated 05/08/26, reflected Resident #13 made herself understood, and understood others. Resident #13's BIMS score was 3, which reflected her cognition was severely impaired. Record review of Resident #13's comprehensive care plan, initiated 05/17/26, reflected Resident #13 was at risk for wandering/elopement related to cognitive impairment, and at risk for injury related to dementia, and poor safety awareness. Resident #13 did have exit wandering behaviors however; Resident #13 was able to push door open but had difficulty to physically leave facility without assistance. Resident #13 often attempts to leave through double doors and requires wheelchair for assistance. The care plan interventions included attempt to determine any pattern or cause of wandering. Record review of Resident #13's elopement/wandering risk assessment dated [DATE] reflected Resident #13 was at low risk. Record review of Resident #13's progress note dated 06/09/26 written by LVN F at 3:45 p.m. reflected an alarm was heard from Hall 100, resident had opened door at end of hall, had made it about halfway through and the CNA pulled resident in wheelchair back inside. Resident #13 redirected, alarm turned off and Administrator notified. Record review of Resident #13's incident report dated 06/09/26 written by LVN D at 6:15 p.m. reflected Resident #13 was heard being told to go to the room to wait for assistance to the bathroom. LVN D went to Resident #13's room to see where Resident #13 was and saw that she was not in there due to hearing the alarm on Hall 100 going off. LVN D opened the door and found Resident #13 standing up behind the wheelchair in the grass with socks on. Record review of Resident #13's progress note dated 06/09/26 written by LVN D at 6:41 p.m. reflected she notified Resident #13's physician and made him aware and he suggested Resident #13 to be transferred to a lock down unit. During an interview on 07/07/26 at 10:50 a.m., LVN D stated she reported the recommendation to the DON when she called to notify her about finding Resident #13 approximately 10 feet from the exit door. During an interview on 07/08/26 at 10:09 a.m., the DON stated she was not aware of the first incident when Resident #13 opened the door and made it halfway through when the CNA was able to pull her back inside. The DON was aware of the physician's recommendation for the secure unit but did not follow up with the Social Worker on her progress of placement. The DON stated Resident #13 would constantly search for the bathroom. The DON stated they had not put any interventions in place related to Resident #13 seeking the bathroom. The DON stated the incident was discussed the next morning (06/09/26) in morning meeting. The DON stated during morning meetings she usually reviewed the progress notes, but she did not the following day. The DON stated the Social Worker had made several referrals to facilities that had secure units but Resident #13 was denied. The DON stated she did not follow up to see if any more referrals were made. During an interview on 07/08/26 at 10:44 a.m., the Social Worker stated the incident was discussed in the morning meeting on 06/10/26 including finding a secure unit for Resident #13. The Social Worker stated she was instructed to hold off by the Administrator because she needed to speak with Resident #13's family member further. During an interview with Resident#13's family member on 07/08/26 at 10:56 a.m., family member said she was not aware of the physician recommendation for the secure unit. During an interview on 07/08/26 at 11:11 a.m., the Administrator stated she was not aware of the first incident on 06/09/26 when Resident #13 attempted to elope. The Administrator stated the first incident was not discussed during the morning meeting. The Administrator stated she expected the staff to let her know about all incidents. The Administrator stated she never told the Social Worker to hold off on finding a secure unit. The Administrator stated she was aware Resident #13 had wandering behaviors when seeking the restroom. The Administrator stated she was aware that there were no interventions put in place to prevent wandering. During an interview on 07/09/26 at 10:31 a.m., Resident #13's physician stated he expected the nurse that received the order for Resident #13 to be transferred to a lock down unit to put the order in electronic records and discuss it with the DON. 2. Record review of a Resident #11's face sheet, dated 03/26/26, indicated a [AGE] year-old male who was re-admitted to the facility on [DATE] with diagnoses which included dementia (loss memory), right hand contractures (a permanent tightening or shortening of muscles, tendons, skin, or other connective tissues that prevents the normal movement of a joint), muscle weakness, and depressive disorder (persistently depressed mood). Record review of Resident #11's quarterly MDS, dated [DATE], indicated Resident #11 sometimes made himself understood and rarely understood others. Resident #11 had difficulty with recall, and his BIMs score was 02, which indicated severe cognitive impairment. The MDS indicated Resident #11 required extensive assistance with bed mobility, dressing, personal hygiene, and bathing. Record review of Resident #11's comprehensive care plan, revised date of 05/12/26, revealed no care plan for his splint. Record review of Resident #11's physician order dated 06/25/26, indicated: Right resting hand splint to be worn as tolerated during waking hours every day shift related to muscle wasting. During an observation and interview on 07/07/26 at 9:38 a.m., Resident #11 was sitting up in his chair without anything on his right hand. Resident #11 did not answer when asked about his splint. During an interview on 07/07/26 at 4:14 p.m., CNA B said Resident #11 had a splint but was missing on Friday (07/3/26). She said she reported the splint missing to LVN A. She said prior to the splint being missing Resident #11 was wearing it. During an interview on 07/09/26 at 11:09 a.m., LVN A said she was Resident #11's charge nurse. LVN A said unknown staff reported his splint missing. She said she had talked with therapy, Occupational Therapist Q and he said they were going to order him a new splint. She said prior to Resident #11's splint being misplaced he was wearing his splint. During an interview on 07/09/26 at 11:24 a.m., the Rehab Director said Resident #11 should have a splint to his right hand. He said he was aware the splint was missing and they were going to order a new splint. He said Resident #11 was receiving therapy and was wearing his splint prior to it being misplaced. During an interview on 07/09/26 at 4:50 p.m., the MDS Coordinator said she was responsible for the care plans. She said acute care plans were a team effort. She said acute care plans should be done as soon as possible. She looked at Resident #11's care plan and verified his splint had not been care planned. She said a care plan was done to paint a picture of the resident and his/her care. During an interview on 07/09/26 at 5:34 p.m., the DON said care plans were a team effort. She said the MDS nurse was the overseer. She said if Resident #11 had an order for a splint to be worn then it should have been care planned. She said she was not aware his splint had not been care planned. During an interview on 07/09/26 at 6:09 p.m., the Administrator said she expected Resident #11 to have a care plan for his right-hand splint. She said the IDT worked together on care plans and the MDS Coordinator was the overseer. She said she expected care plans to be updated anytime there was a change in condition. She said care plans were done so staff would be aware of the resident's preference. 3. Record review of Resident #1's face sheet dated 07/09/2026 indicated he was a [AGE] year-old male who re-admitted to the facility on [DATE] with diagnoses which included kidney failure (when the kidney function is less than 15% and can no longer filter waste products from the blood), heart failure (serious condition where the heart muscle does not pump blood efficiently), chronic obstructive pulmonary disease (a progressive lung condition that restricts airflow and makes it hard to breathe), and high blood pressure. Record review of Resident #1's admission MDS assessment dated [DATE] indicated his activity preferences were very important to him. Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated he could make himself understood and he understood others. The MDS also indicated he had a BIMS score of 15 which meant he was cognitively intact. The MDS indicated he required moderate assistance with transfers, bed mobility, and bathing, and he could eat independently. Record review of Resident #1's comprehensive care plan dated 4/12/2026 indicated he did not have a care plan for activities. During an observation and interview on 07/07/2026 at 9:09 AM Resident #1 was up in his wheelchair sitting in his room. Resident #1 said he did not have an activity calendar for the month of July to know what was going on, or an activity director. The activity calendar on his personal fridge was dated June 2026. During an interview on 07/09/2026 at 5:40 PM The MDS Nurse said The Activity Director was responsible for inputting the care plans for activities for residents. The MDS Nurse said the failure placed a risk for staff not knowing what activities Resident #1 liked and what kept him active mentally and physically. During an interview on 07/09/2026 at 6:29 PM The DON said all residents should have a care plan in place. The DON said the AD was responsible for ensuring the resident had the care plan in place, and the failure placed a risk for staff not being aware of what Resident #1 liked and enjoyed and how he completed activities. During an interview on 07/09/2026 at 7:03 PM The Administrator said Resident #1 should have had a care plan for activities. The Administrator said the AD was responsible for completing the care plan for activities. The Administrator said the facility did not have an AD but anyone in the IDT team (DON, ADON, MDS Nurse) could have completed a care plan for Resident #1. The Administrator said the failure placed a risk for staff not knowing Resident #1's needs or preferences and the needs or preferences would not be met. Record review of the facility policy Comprehensive Care Plans, dated 2/10/2021, indicated Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive
Based on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 3 of 6 medication carts (Hall 100, 300 and 400) reviewed for pharmacy services. 1.The facility failed to ensure over the counter medication was not expired on hall 100 cart. 2.The facility failed to ensure Resident #17's Novolog R (a short-acting human insulin used to control blood sugar in adults and children with diabetes) insulin was not expired on Hall 300 nurse's cart. 3. The facility failed to ensure Resident #30's Calcitonin Salmon nasal solution (a synthetic hormone used to treat postmenopausal osteoporosis in women) was not expired and Resident #4's Budesonide suspension (used to treat an itchy or runny nose, sneezing, or other symptoms caused by hay fever) was dated when opened on hall 400's nurse's cart. These failures could place the residents at risk of not having medications available for use, or receiving therapeutic doses of their medication Findings included1.During an observation on 07/07/26 at 12:09 p.m., Hall 100 medication aide's cart revealed eye drops undated, Geri-Tussin expired 5/26 and Calcium 600 with vitamin D expired 5/26/26.2. During an observation on 07/07/26 at 12:29 p.m., Hall 300 nurse's cart revealed Resident #17's Novolog R with a date of 05/30/26. 3.During an observation on 07/07/26 at 12:49 p.m., Hall 400 nurse's cart revealed Resident # 30's Calcitonin Salmon nasal solution expired 07/05/26, and Resident #4's Budesonide suspension was open and not dated.During an interview on 07/07/26 at 12:55 a.m., LVN D said all medications should be dated when opened. She said the nurse who opened these medications should have put a date on each of them. LVN D said all nurses should be held accountable for ensuring medications were dated; she said including herself. She said if medications were given past the manufacturer or expiration date, then they may not be as effective.During an interview on 07/07/26 at 1:30 p.m., MA E said expired medications or medications with unopened dates should not be on the cart. She said they did not have a system in place to check the carts.During an interview on 07/09/26 at 3:29 p.m., the facility's physician said he expected staff to pass medications as ordered and not to give expired medications.During an interview on 07/09/26 at 5:15 p.m., LVN A said she does look at the insulin medications because they were only good for 28 days. She said she was unaware of a system they had in place to check medication carts but if she worked on the weekend she would check the carts for expired meds. She said if she looked at a medication and could not read the date written on the insulin or any other medication, she would discard the medication and get another one. She said all multipacket medications should be dated. She said all medication should match what the physician had ordered. She said if a resident received an expired medication or the wrong dose of medication it could cause an adverse reaction.During an interview on 07/09/26 at 5:34 p.m., The DON said she expected the nurses to read the MAR and give medication as ordered. She said she expected all medication to be on the cart as ordered. She said the insulin, albuterol solutions and inhalers should be dated when opened and discarded when expired. The DON said the medication aide or nurse who opened the insulin and/or inhalers were responsible for dating them. She said she was the overseer of nursing. The DON said by not dating the insulin or inhalers when opened the staff would be unaware of when they expired. She said since these medications had a certain number of days before they would expire and if not given during those time frames, it could cause the medications not to be as effective. During an interview on 07/09/26 at 6:09 p.m., the Administrator said she expected the nurses and medication aides to give medication as ordered. She said the nurses were responsible for ensuring they removed expired medications from the carts and did not give any expired medications. She said the DON was responsible for monitoring and overseeing by rounding. The Administrator said if expired meds were given, they may not be as effective. Record review of the facility policy medication storage dated 01/20/2021 indicated Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored, dated and labeled according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.
Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, for 2 of 23 (Resident # 47 and Resident #2) residents medication reviewed for medications storage. 1. The facility failed to ensure Resident #47 did not have Nystatin powder in her bedside dresser.2. The facility failed to ensure Resident #2 did not have sore throat spray on her personal refrigerator and nystop (nystatin external powder) (fungal powder used for yeast rashes) on her dresser beside her personal refrigerator.These failures could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications, or expired medications. Findings included: 1. Record review of Resident #47's face sheet, dated 07/09/26, reflected Resident #47 was a [AGE] year-old female, admitted to the facility on [DATE] and re-admitted [DATE] with a diagnosis which included dementia (memory loss), depression (sadness), and muscle weakness. Record review of Resident #47's quarterly MDS assessment, dated 06/09/26, reflected Resident #47 made herself understood, and was understood by others. Resident #47's BIMS score was 15, which reflected her cognition was intact. The MDS indicated she received ointment/medication during the 7-day look back period. Record review of Resident #47's comprehensive care plan, revised 03/02/26, indicated, Resident #47 was at risk for increase in falls/injury due to use of personal safety device related to motorized wheelchair. Resident #47 had an actual wound (laceration) to her left shin. The intervention was for staff to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or firm surface. Record review of Resident #47's physician order, dated 01/08/26 indicated, Nystatin External Powder 100000 units per gram, apply to red areas topically every 12 hours as needed for yeast rash. During an interview on 07/07/26 at 11:41 a.m., LVN F said she said she did not see any medication left in Resident #47's room but said medication was not supposed to be left in any rooms because of the risk of other residents getting the medication. She said the nurse who took the medication in the room should have taken it out. During an interview on 07/08/26 at 9:56 a.m., CNA H said she said she saw the medication on Resident #47's bedside over the weekend (unsure of which date) and told LVN A. She said she had seen other medication such as creams in other residents' rooms. She said the nurses were aware. During an interview on 07/09/26 at 3:29 p.m., the facility's physician said he expected staff to pass medications as ordered and not to give expired medications. During an interview on 07/09/26 at 5:15 p.m., LVN A said no medication should be left at bedside for safety reasons. During an interview on 07/09/26 at 5:34 p.m., the DON said the nurses were responsible for ensuring they removed any products (chemicals or medication) brought into the room with them and then stored them in a medication cart or in a medication room. She said Nystatin should not be left in the room because it contained chemicals and a resident could ingest it. She said she was the overseer of nursing. During an interview on 07/09/26 at 6:09 p.m., the Administrator said the nurses were responsible for ensuring they removed Nystatin before exiting a resident's room. She said she expected the nurses and medication aides to give medication as ordered. She said the DON was responsible for monitoring and overseeing by rounding. The Administrator said no medication should not be left in a resident's room for risk of swallowing. 2. Record review of Resident #2's face sheet dated 07/06/2026 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus (chronic metabolic disease characterized by high blood sugar levels), anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure), and major depressive disorder (serious mental health condition characterized by persistent sadness, hopelessness, and loss of interest in activities). Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated she understood others and made herself understood. The MDS also indicated she had a BIMS score of 15 which meant she was cognitively intact. The MDS also indicated she was also incontinent of urine and required maximal assistance with toileting, dressing, and bed mobility, independent with eating, and she required total assistance with transfers. Record review of Resident #2's comprehensive care plan dated 11/02/2023 indicated she had a rash with interventions to give anti-pruritic medication as ordered by the doctor and monitor and document side effects. Record review of Resident #2's order summary report dated 07/06/2026 indicated she had an order for: nystatin external powder 100000 unit/gram (nystatin(topical)) apply to skin folds topically as needed for yeast rash with a start date of 10/11/2025 and no end date. During an observation and interview on 07/06/2026 at 1:36 PM Resident #2 was lying in her bed and she had a bottle of nystop fungal powder on her dresser beside her personal refrigerator and a bottle of sore throat spray on top of her personal refrigerator. Resident #2 said the nurse (she couldn't remember her name) applied the powder on her all the time and she used the sore throat spray as she needed it. Resident #2 said she was not aware the nystop was left in the room, but she did know the sore throat spray was on top of her personal refrigerator. Resident #2 said she had other residents wander in her room at times and understood why she should not have medications in her room. During an interview on 07/09/2026 at 6:39 PM The DON said the expectation was for the meds to not be left at bedside and never use other resident medications. The DON said there were residents who wanted to keep medications and self-medication, there were steps to take, but she did not encourage self-medication. The DON said the failure placed a risk for medications at bedside being taken by other residents, Resident #2 not using appropriately, and other resident getting the medications and using it inappropriately or drinking. During an interview on 07/09/2026 at 7:10 PM The Administrator said the medications should not be left in any resident rooms. The Administrator said all medications should be locked in the medication carts or the medication room. The Administrator said the CNAs and nurses were responsible as the department managers. The Administrator said the failure placed a risk for residents getting into the medications and getting sick. Record review of the facility policy medication storage dated 01/20/2021 indicated Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored, dated and labeled according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel will have access to the keys to locked compartments.
Based on observations, and interviews, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 residents (Residents #27 and #38) and one lunch meal reviewed for food and nutrition services. The facility failed to ensure dietary staff provided food that was palatable and had an appetizing temperature on 07/06/26 and 07/07/26. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss.Findings included: During an interview on 07/06/26 at 1:00 p.m., Resident #38 stated the food could be more seasoned and served hotter. During an interview on 07/06/26 at 1:08 p.m., Resident #27 stated the food was served cold and could be more seasoned. Resident #27 stated he ate in his room during meal service. During an observation and interview on 07/07/26 at 1:42 p.m., the lunch tray was sampled by the Administrator and 5 surveyors. The sample tray consisted of pork loin which was lukewarm and dry; the broccoli was lukewarm and bland; and rice that had the texture of sticky rice. The Administrator stated the pork loin could have been warmer and more tender; the broccoli could have been warmer and more salt added; and the rice tasted sticky but should have the texture of steamed rice and could have been warmer. During an interview on 07/09/26 at 10:37 a.m., CNA G stated residents had complained to her about food. CNA G stated the residents had described the food as slopped. CNA G stated when the residents complained she would go ask the dietary staff for an alternative. CNA G stated she had reported the complaints to the charge nurse, DON and Administrator. CNA G stated residents not eating their food could potentially cause weight loss. During an interview on 07/09/26 at 10:54 a.m., RN K stated she had not had any residents complain about food being cold or bland. RN K stated she would offer an alternative and report to the Dietary Manager, DON and Administrator. RN A stated residents not eating their food could potentially cause weight loss and malnutrition. During a telephone interview on 07/09/26 at 2:35 p.m., the Dietician stated she had not heard any residents complain about food being cold or bland. The Dietician stated she got a test tray in June 2026 and it passed. The Dietician stated a substitute was always available. The Dietary Manager stated it was important to ensure food was palatable and had an appetizing temperature to prevent malnutrition. During an interview on 07/09/26 at 2:59 p.m., the Dietary Manager stated she had complaints about the food being cold but not bland. The Dietary Manger stated she told the residents before if there were any issues to come directly to her and she would try her best to fix it. The Dietary Manager stated she did follow up on those complaints and the residents seemed to be pleased. The Dietary Manager stated she monitored meal service including food quality daily by interviewing residents and tray sampling. The Dietary Manager stated there were no issues found with food quality during her tray sampling. The Dietary Manager stated it was important to ensure food was palatable and had an appetizing temperature to prevent weight loss. During an interview on 07/09/26 at 6:12 p.m., the DON stated she expected food to be palatable and at an appetizing temperature. The DON stated she has had staff and residents complained to her about the food being cold and not seasoned. The DON stated she could not state any residents specific. The DON stated she had reported all complaints to the Administrator. The DON stated she had not had a test tray. The DON stated it was important to ensure food was palatable and had an appetizing temperature to prevent weight loss. During an interview on 07/09/26 at 6:47 p.m., the Administrator stated she expected food to be at the appropriate temperature and seasoned for palatability. The Administrator stated she has had complaints about the food being cold and bland. The Administrator stated she monitored by test trays and rounds during meal service. The Administrator stated she in-serviced the dietary staff verbally when complaints came to her. The Administrator stated it was important to ensure food was palatable and had an appetizing temperature to prevent weight loss, malnutrition and overall quality of life. The Administrator stated the facility did not have a policy for palatable food.
Based on observation, interview and record review the facility failed to ensure Resident #39 had the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition for 1 of 5 residents (Resident #39) reviewed for resident rights. The facility failed to provide communication or translation assistance to effectively communicate with Resident #39.This failure could place residents at risk for declining and diminishing quality of life, and neglect.Findings included: Record review of face sheet dated 7/9/2026 revealed Resident #39 was a [AGE] year-old male admitted to the facility on [DATE] with the diagnosis of dementia (loss of memory, thinking and reasoning skills). Record review of care plan date initiated 04/07/2025 revealed Activities: Resident #39 was dependent on staff for cognitive stimulation, activity attendance, and social interaction related to cognitive impairment and is at risk for isolation. Record review of Quarterly MDS dated [DATE] revealed Resident #39 had a BIMs of 05 which indicated severe cognitive impairment. MDS assessment revealed Resident #39 was of Spanish origin and Mexican. MDS assessment revealed Resident #39's preferred language was Spanish. Record review of order summary revealed Resident #39 had an order for 'Resident able to understand rights' started on 01/03/2025. Observation on 07/06/2026 at 10:25 a.m. revealed Resident #39 speaking to speech therapists in Spanish. No observation of any other employee speaking to him in Spanish or using translation assistance. Interview on 07/06/2026 at 10:30 a.m., the speech therapists revealed that Resident #39 could not see out of his right eye, write or read. The Speech Therapist revealed Resident #39 chooses to speak in Spanish most of the time. The Speech Therapist stated that she only knew some Spanish but was not fluent and resident frequently asked what did you say and repeat that please. The Speech Therapist stated that it was Resident #39's right to speak in his preferred language and to be spoken to in his preferred language. Interview on 07/06/2026 at 10:31 a.m. with Resident #39 was limited due to communication barrier. Translation app was used to assist with communication. Resident responded to questions asked by shaking his head indicating he was not sure what was being said by staff and stating Mande (asking for clarification). Resident #39 stated no one spoke Spanish at the facility and only some people understood him. Interview on 07/06/2026 at 2:45 p.m., the LVN D stated that she used google translate to assist in communication. LVN D stated that Resident #39 had difficulty seeing out of his right eye and Resident #39 spoke 'broken Spanish' and understood some English. LVN D stated that she called the resident family to assist in communication, but she felt bad calling late at night. Interview on 07/07/2026 at 11:30 a.m., Resident #39's family member stated that the facility called her to assist in translation. The family member stated that resident was primarily Spanish speaking and could understand very little English. The resident's choice of language was Spanish to understand his care. Interview on 07/07/2026 at 1:35 p.m. the NA G stated Resident #39 was primarily Spanish speaking although he could understand some English. NA G stated that she used translate on her phone to sometimes communicate, however, Resident #39 did not always understand it. NA G stated it would have been helpful to have a source to understand what he was saying and help the staff communicate with Resident #39. NA G stated she knew of only 2 staff members who knew Spanish but they were not at the facility 24 hours a day. Interview on 07/09/2026 at 3:40 p.m., the RN K stated to her knowledge that no one has used google translate. RN K stated that she knew some Spanish enough to communicate with him. RN K stated that Resident #39 speaks some English. Interview on 07/09/2026 at 3:54 p.m., DON stated she expected them to address Resident #39 in his preferred language. DON stated that Resident #39 was at risk of not having effective communication. Interview on 07/09/2026 at 4:30 p.m., Administrator stated that she expected the staff to address Resident #39 in his preferred language of Spanish. Administrator stated Resident #39 was at risk of his care and needs not being met due to his primary language being used to communicate with Resident #39. The Administrator stated that Resident #39 had the right to be spoken to in his preferred language. Record review of Resident Rights policy dated 2/20/2026 revealed residents had the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.
Based on observation, interview and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 3 residents (Resident #54) reviewed for therapeutic diets. The facility failed to ensure Resident #54 received a magic shake and fortified pudding as ordered by the physician 07/06/2026. This failure could place residents at risk for poor intake, weight loss, unmet nutritional needs, choking, and aspiration (when food or drinks enter the lungs).Finding included: Record review of the face sheet dated 07/09/2026 revealed Resident #54 was a [AGE] year-old male admitted to the facility on [DATE] with the diagnosis of major depressive disorder (severe sadness). Record review of Resident #54's care plan revision date 07/15/2024 revealed he was care planned for ADLs self-care performance deficit and is at risk of not having their needs met in a timely manner with an intervention of eating: setup and clean-up assistance. Resident #54 was care planned for nutritional status for regular large portion diet and at nutritional risk related to adult failure to thrive. Care plan intervention listed as provide, serve diet as ordered and provide and serve supplements as ordered. Record review of Annual MDS dated [DATE] revealed Resident #54 had a BIMS of 03 indicating severe cognitive impairment. MDS indicated Resident #54 had an active diagnosis of Malnutrition or risk for Malnutrition. MDS assessment indicated Resident #54 eating functional ability was setup or clean-up assistance. Record review of order summary report dated 07/09/2026 revealed Resident #54 had an order for regular diet and texture, regular consistency, plate guard, add fortified foods at all meals started on 04/10/2026. Resident #54 had an order for magic cup with meals started on 02/12/2026. Record review of meal ticket for the lunch meal dated 07/06/2026 revealed Resident #54 was supposed to receive a magic cup-1cup, fortified pudding-4oz, and plate guard. Observation on 07/06/2026 at 12:20 p.m. revealed resident sitting in the assisted dining room without his magic shake and fortified pudding. Observation revealed resident did not receive his order and only ate about 50% of his plate. Interview on 07/06/2026 at 12:23 p.m., Resident #54 stated that he was supposed to get a magic shake and fortified pudding. Interview on 07/06/2026 at 12:35 p.m., NA G revealed on multiple occasions Resident #54 had not received his prescribed magic shake and fortified pudding. NA G stated that Resident #54 did not require assistance with meals but did have nutritional supplements for weight loss. Interview on 07/06/2026 at 3:35 p.m., LVN D stated that she was not aware Resident #54 did not receive his ordered magic shake and fortified pudding. LVN D stated that the magic shake and fortified pudding was prescribed for weight loss and to prevent weight loss. LVN D stated that Resident #54 was at further risk of weight loss because he did not receive his prescribed therapeutic diet. Interview on 07/09/2026 at 1:30 p.m., the Registered Dietitian stated Resident #54 magic shake and fortified pudding was ordered and it was there for a reason. The Registered Dietitian stated the magic shake and fortified pudding was for malnutrition and high risk of weight loss. The Registered Dietitian stated she expected the facility to provide the magic shake and fortified pudding according to the order. Interview on 07/09/2026 at 3:09 p.m., the Dietary Manager revealed she expected Resident #54 to receive the correct therapeutic diet. The Dietary Manager stated that it was on the ticket and he was supposed to receive the magic shake and fortified pudding. The Dietary Manager stated she was responsible for placing the shake and fortified pudding on the tray. The Dietary Manager stated Resident #54 was at risk of not receiving the proper nutrition and weight loss. Interview on 07/09/2026 at 4:14 p.m., the DON stated she was not aware that Resident #54 was not offered or provided his shake or pudding. The DON said Resident #54 was at risk of weight loss and poor appetite. Interview on 07/09/2026 at 4:46 p.m., the Administrator stated she expected Resident #54 to receive his therapeutic diet according to physician order. The Administrator stated the diet should have been provided by dietary. The Administrator stated that the nurses were responsible for checking the trays. Record review of Menu Planning Guidelines and Procedure dated 7/12/2024 revealed menus will be followed and served as written. If a menu change or substitution is necessary, the Menu Change or Substitution Policy will be followed. A substitution log should be completed by the DSM as needed and then presented to the consulting RD for review/signature. Record review of following physician orders revised on 9/28/2021 revealed for consulting physician/practitioner orders received via telephone, the nurse will: a. Document the order on the physician order form, notating the time, date, name and title of the person providing the order, and the signature and title of the person receiving the order. b. Follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record. c. Carry out and implement physician orders Record review of Diet, Nutrition, and Hydration policy dated 3/2016 revealed Diet order: A diet order is a prescription written by the attending Physician, Practitioner or Registered Dietitian to change a resident's diet or establish a diet for a new admission. Diets may be liberalized to allow more freedom in meal selection. Therapeutic and calorie restricted diets are available for residents who are not candidates for liberalized diets. Diet textures and fluid consistencies are ordered or changed by the Speech Language Pathologist. House Supplements: The physician, practitioner or Dietitian may choose to order House supplements to provide residents with additional Calories and Protein. The term house supplement will cover all items listed in the supplement rotation guide, this allows for rotating of various supplements and foods, so that residents do not become dissatisfied with the same shake day after day. The physician order should state frequency of the supplement. All procedures for supplements should be followed. One serving will be provided per ordered supplement.
Based on observation, interviews, and record review, the facility failed to ensure that residents were free of significant medication errors for 1 of 1 resident (Resident #59) reviewed for insulin administration. The facility did not ensure LVN D did not administered Resident #59 expired Novolog (insulin medication) on 07/07/26.This failure could place residents at risk of medical complications and prevent them from receiving the therapeutic effects of their medications.Findings included:Record review of Resident #59's face sheet, dated 07/09/26, reflected Resident #59 was a [AGE] year-old male, admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Type 2 diabetes mellitus (lifelong condition where the pancreas makes little or no insulin, which leads to high blood sugar levels), stroke, and high blood pressure. Record review of Resident #59's quarterly MDS assessment, dated 06/16/26, indicated Resident #59 made himself understood and understood others. Resident #59's BIMS score was 15, which indicated his cognition was intact. The MDS indicated he received insulin over the 7-day look-back period.Record review of Resident #59's physician order dated 11/13/25, reflected an order for: Novolin R Solution (Insulin Regular Human) Inject as per sliding scale: if 0 - 200 = 0 units; 201 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 -400 = 8 units; 401 - 450 = 10 units Greater than 450 notify the physician, subcutaneously before meals and at bedtime related to diabetes.Record review of Resident #59's comprehensive care plan dated 06/11/26 indicated Resident #59 had diabetes mellitus. The care plan interventions were for staff to monitor blood sugar as ordered by the physician. Administer sliding scale insulin if ordered. For any blood sugars not within the acceptable parameters as dictated by the physician, document and notify the physician.During an observation and interview on 07/07/26 at 11:04 a.m., LVN D took Resident #59's blood sugar with a reading of 208. LVN D prepared Resident #59's Novolog and administered 2 units to Resident #59's left arm. LVN D reviewed the insulin vial and said she could not read the date on the bottle but looked like it was 05/05/26. She said if so, the insulin had expired. She said giving expired medication may not be effective. She disposed of the Novolog insulin and got him a new vial.During an interview on 07/09/26 at 3:29 p.m., the facility's physician said he expected staff to pass meds as ordered and not to give expired medicationsDuring an interview on 07/09/26 at 5:34 p.m., the DON said she expected nurses not to give expired insulin. The DON said she expected the nurses to look at insulin before given and if expired to discard it and get a new vial. She said she was the oversee of nursing. She said they did not have a system in place for checking medication carts. The DON said if Resident #59 received expired insulin, it might not be effective.During an interview on 07/09/26 at 6:09 p.m., the Administrator said she expected insulin to be dated and discarded when it expired. She said she did not expect nurses to give expired insulin. The Administrator said the DON and ADON were responsible for monitoring to ensure no expired medication was not on the cart. The Administrator said risk of expired medication could make the medication not effective or cause a resident to become sick. Record review of the facility's policy titled, Medication -Treatment Administration and Documentation Guidelines, revised 04/06/23, indicated, Anticipated Outcome: To provide a process for accurate, timely administration and documentation of medication and treatments. Fundamental Information Medication are administered according to manufacturer's guidelines unless otherwise indicated by physician order. Process: 1. Verify labels accurately reflect the physician orders on the Electronic Medication Administration Record (EMAR) and Electronic Treatment Administration Record (ETAR) prior to administering patient medications and treatments. 2. Verify administration accuracy by checking the medication with the EMAR three (3) times. 4. Administer the medication according to the physician order.Record review of the facility's policy titled, Medication Labeling and Storage, revised February 2023, indicated, Policy: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Policy Interpretation and Implementation: Medication Storage1.Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Medication Labeling: 5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.
Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene for 1 of 6 residents (Resident #5) reviewed for ADL care.The facility failed to ensure Resident #5 was showered on 06/30/26, 07/02/26, or 07/04/26. This failure could place residents at risk of not receiving care/services, decreased quality of life, and loss of dignity. Findings included:1.Record review of Resident #5's face sheet, dated 07/09/26, indicated a [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses which included Atrial fibrillation, also known as heart failure (a heart condition characterized by an irregular and often rapid heartbeat), Dementia (a general term for the loss of thinking, remembering, and reasoning abilities), and lack of coordination.Record review of Resident #5's quarterly MDS assessment, dated 06/26/26, indicated Resident #5 made herself understood and understood others. Her BIMs score was a 13, which indicated she was cognitively intact. The MDS indicated she required maximal assistance for bathing, bed mobility, dressing, and transferring. The MDS did not indicate she refused care.Record review of Resident #5's care plan revised 06/07/22 indicated Resident #5 had an ADL self-care performance deficit requiring total assistance with bathing. The interventions were for staff to provide shower, shave, oral care, hair care, and nail care per schedule and when needed. Record review of the shower sheets from 06/30/26 through 07/06/26 did not indicate Resident #5 received a shower.During an observation and interview on 07/06/26 at 11:19 a.m., Resident #5 was in bed. Her hair was oily and she said she was not getting her showers 3 times a week on Tuesday, Thursday and Saturday. She said she was lucky to get a shower 1 time a week. She said she had not had a shower since last Saturday (06/27/26). She said she was stinky. During an interview on 07/08/26 at 11:00 a.m., CNA G said Residents #5 do complain about not receiving their baths from the 2pm-10pm shifts. She said they were not always able to give the residents showers because of time and all the duties they had to complete. She said the DON was aware.During an interview on 07/08/26 at 3:00 p.m., CNA E who worked on 2pm-10pm shift said residents received baths when they had time. She said Resident #5 does refuse to take showers at times. She said she thought she gave Resident a shower last week but was unsure.During an interview on 07/09/26 at 9:50 a.m., CNA H said Resident #5 had complained to her that she was not receiving her showers from 2pm-10pm. She said she asked her to give her a shower about 2 weeks ago and she did. She said Resident #5 does not generally refuse care.During an interview on 07/09/26 at 10:50 a.m., CNA C said Resident #5 had complained to her that she was not receiving her showers from 2pm-10pm. She said Resident #5's shower days were Tuesday, Thursday and Saturday. She said she did ask her to give her a shower on 07/04/26 on the 6am-2pm shift but she did not have time. She said she did report to an unknown nurse about Resident #5 saying she was not receiving her showers. She said Resident #5 was aware and knew if she had a shower or not.During an interview on 07/09/26 at 5:34 p.m., the DON said she expected showers to be given according to the shower schedule. She said the staff was aware of the shower days. She said she was aware they had shower issues, but it had gotten better. She said she was unaware of Resident #5 missed showers. She said if a resident refused his/her shower(s) then the charge nurse was supposed to document it in his/her chart and notify her. She said showers should be given for cleanliness and prevention of skin breakdown.During an interview on 07/09/26 at 6:09 p.m., the Administrator said she expected the residents to receive their baths and expected the staff to document if they did not receive them. The Administrator said the charge nurse was responsible for ensuring the showers were completed. She said showers were given for sanitary and infection reasons.Record review of the facility policy titled, Activities of Daily Living Care Guidelines, dated 02/11/21, indicated Anticipated Outcome: Residents will receive essential services for activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene. Process: Residents participate in and receive the following person-centered care: Bathing: includes grooming activities such as shaving, and brushing teeth and hair.
Based on observation, interview, and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services 1 of 3 (Resident #1) residents reviewed for indwelling catheter. 1. The facility failed to ensure Resident #1's indwelling catheter (tube inserted into bladder) was secured on 07/06/26, 07/07/2026, and 07/08/26. These failures could affect residents with an indwelling urinary catheter and place them at risk of urethral tears, discomfort, infection, and lack of dignity.Findings included: Record review of Resident #1's face sheet dated 07/09/2026 indicated he was a [AGE] year-old male who re-admitted to the facility on [DATE] with diagnoses which included kidney failure (when the kidney function is less than 15% and can no longer filter waste products from the blood), heart failure (serious condition where the heart muscle does not pump blood efficiently), chronic obstructive pulmonary disease (a progressive lung condition that restricts airflow and makes it hard to breathe), and high blood pressure. Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated he could make himself understood and he understood others. The MDS also indicated he had a BIMS score of 15 which meant he was cognitively intact. The MDS also indicated Resident #1 had an indwelling catheter for urinating and he required maximal assistance with toileting. The MDS indicated he required moderate assistance with transfers, bed mobility, and bathing, and he could eat independently. Record review of Resident #1's comprehensive care plan revised 7/7/2026 indicated he had a urinary catheter, and he was at risk for urinary tract infections and injury with interventions to provide catheter care per the facility policy. During an observation on 07/06/2026 at 11:38 AM Resident #1 was rolling himself in his wheelchair in the hallway. He had shorts on and a catheter drainage bag on left side of chair with no strap or securement device on his leg. During an observation and interview on 07/07/2026 at 9:09 AM Resident #1 was up in his wheelchair in his room. Resident #1 said he had not had a catheter strap in place for about 2 weeks. Resident #1 had on shorts and surveyor could see that he did not have a catheter securement device or strap in place. During an observation and interview on 07/08/2026 at 8:50 AM OT Q was in Resident #1's room completing care and fastening the brief for Resident #1 when surveyor walked in. Resident #1 had a worn catheter securement device hanging on catheter drainage line and OT Q said the catheter securement device should have been attached to resident's leg. OT Q said the failure of the catheter lock for catheter not attached correctly caused it to be hanging and could have pulled the catheter. OT Q said he was going to tell the nurse. LVN A came into Resident #1's room with OT Q and she replaced the securement device. LVN A said the catheter securement device should always be in place to prevent pain and discomfort. During an interview on 07/09/2026 at 6:32 PM the DON said her expectation was for Resident #1 was to always have a catheter strap or securement device in place. The DON said the charge nurses and CNAs were responsible and the CNAs should have notified the charge nurse if not in the room. The DON said the failure placed a risk for resident pulling the catheter out or injury. During an interview on 07/09/2026 at 7:05 PM The Administrator said her expectation was for Resident #1 to always have a catheter strap or secure device. The Administrator said the nurses were responsible for ensuring the strap or securement device was in place and CNAs were responsible to notify the nurses if they were aware. The Administrator said the failure placed a risk for the catheter shifting and tangling causing pain or injury. Record review of the facility policy Indwelling Foley Catheters Guidelines dated 05/23/2014 indicated Anticipated Outcome The facility shall identify and assess patients with an indwelling catheter or at risk for catheterization, provide appropriate treatment and services. Properly secure indwelling catheters after insertion to prevent movement and urethral traction.
Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 6 residents (Residents #4 and Resident #8) reviewed for respiratory care.1.The facility failed to ensure Resident #4's oxygen was set at 3 liters per nasal cannula on 07/07/26 and 07/08/26 and HHN (handheld nebulizer) was bagged on 07/06/26, 07/07/26, and 07/08/26.2.The facility failed to ensure Resident #8's oxygen was set at 2 liters per nasal cannula on 07/07/26.These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.Findings included:Record review of Resident #4's face sheet, dated 07/09/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease also known as COPD (is a progressive, incurable lung disease that restricts airflow and causes breathing difficulty), hypoxia (a condition in which your body or specific tissues do not receive enough oxygen to function properly), dementia (a loss of mental functioning such as, thinking, memory, mood and behavior), and diabetes (high blood sugars).Record review of Resident #4's quarterly MDS assessment, dated 05/25/26, indicated Resident #4 understood and was understood by others. Resident #4's BIMS score was 05, which indicated her cognition was severely impaired. The MDS indicated Resident #4 required assistance with toileting, bed mobility, dressing, personal hygiene, transfers, and eating. The MDS indicated she received oxygen during the 7-day look-back period. The MDS did not indicate she received nebulizer treatments during the 7-day look back period.Record review of Resident #4 's comprehensive care plan, revised on 03/01/23, indicated Resident #4 had impaired respiratory status and was at risk for shortness of breath, respiratory distress, increased anxiety, and hypoxia. The intervention was to provide oxygen therapy as ordered.Record review of Resident #4 's comprehensive care plan, revised on 05/19/26, did not indicate any nebulizer treatments.Record review of Resident #4's physician order dated 04/28/26 indicated oxygen at 3 liter per nasal cannula every shift related COPD.Record review of Resident #4's physician order dated 05/19/26 indicated Budesonide give 1 vial inhale orally every shift for COPD.Record review of Resident #4's medication administration record dated 07/01/26 through 07/06/26 indicated she received a breathing treatment of Budesonide Inhalation Suspension 0.5 milligram/2 milliliter (Budesonide (Inhalation)1 vial inhale orally every shift for COPD.During an observation and interview on 07/07/26 at 8:43 a.m., Resident #4 oxygen was noted at 2/5 liters and had a hand-held nebulizer with tubing on her nightstand, not bagged. Resident #4 said she had a breathing treatment last night. During an observation and interview on 07/07/2026 at 9:11a.m., MA E was in Resident #4's room giving medication and said the HHN was not in a bag but should be for infection reasons.During an observation and interview on 07/08/26 at 11:36 a.m., LVN A said she was the nurse for Resident #4. LVN A verified Resident #4 had a nebulizer tubing not bagged, and oxygen was set at 2 liters per nasal cannula. She said nebulizer tubing should be bagged when not in use for infection reasons. She said oxygen should be set as ordered to prevent respiratory issues.2.Record review of Resident #8's face sheet, dated 07/09/26, indicated a [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses which included dependence on supplemental oxygen (occurs when your body requires a continuous or intermittent supply of extra oxygen to maintain healthy blood oxygen levels), congestive heart failure (occurs when the heart muscle doesn't pump blood as well as it should), and anxiety (a feeling of fear, dread, and uneasiness).Record review of Resident #8's physician orders dated 04/04/25 indicated oxygen at 2 liters per minute via nasal cannula continuously for diagnosis of COPD.Record review of Resident #8's care plan revised date of 04/28/25, indicated she required oxygen for congestive heart failure. The intervention was for staff to apply oxygen as ordered.Record review of Resident #8's quarterly MDS assessment, dated 06/16/26, indicated Resident #8 made herself understood and was understood by others. The MDS indicated her BIMS score was a 04 which meant she was severely cognitively impaired. The MDS indicated Resident #8 required assistance with dressing, personal hygiene, toileting, bathing, bed mobility, transfers, and for eating. The MDS during the 7-day look-back period indicated Resident #8 was receiving oxygen.During an observation on 07/06/26 at 10:12 a.m., Resident #8 was in bed with oxygen applied at 2.5 liters. No distress noted.During an observation and interview on 07/07/26 at 3:07 p.m., Resident #8 was in her bed with oxygen at 2.5 liters via nasal cannula. No distress noted. Resident #8 said her oxygen should be set at 2 liters. During an interview on 07/08/26 at 11:33 a.m., LVN A said she was Resident #8's nurse. She looked and verified Resident #8's oxygen was set at 2.5 liters. LVN A went to look at Resident #8's order and said she should be at 2 liters. She said she would turn her oxygen to 2 liter as ordered. She said the nurses were responsible to look at all oxygen every shift. She said failure to have oxygen as ordered could lead to respiratory issues such as shortness of breath. During an interview on 07/09/26 at 5:34 p.m., the DON said the nurses were responsible for ensuring oxygen was on as ordered and HHN tubing was bagged. She said she and the ADON did random rounds. She said it was important to store tubing in a bag when not in use to prevent infection and apply oxygen as ordered to prevent increased confusion or respiratory issues such as poor oxygen exchange. During an interview on 07/09/26 at 6:09 p.m., the Administrator said if a resident had an order for oxygen, it should be applied. She said HHN tubing should be bagged. She said the nurses were responsible for ensuring the oxygen was set at the ordered rate, and tubing was bagged when not in use. She said nurse management were the overseers. She said failure to apply oxygen at the correct rate could affect their health and unbagged tubing could lead to infection control issues. Record review of the facility's policy titled Oxygen Administration, revised date of 01/05/20, indicated, Policy: To describe methods for delivering oxygen to improve tissue oxygenation. Procedure:1. Verify Physician Order.
Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 7.14 %, based on 3 errors out of 28 opportunities, which involved 2 of 5 residents (Residents #59, and Resident #4) reviewed for medication administration. 1. The facility failed to ensure LVN D did not administer insulin to Resident #49 on [DATE]that had expired on [DATE]. 2. The facility failed to ensure MA E administered Potassium (an essential mineral that is needed by all tissues in the body. It is sometimes referred to as an electrolyte), and Slow Magnesium (a dietary supplement formulated with magnesium chloride and calcium to support muscle, nerve, and cardiovascular health) as ordered by the physician for Resident #4 on [DATE].These failures could place residents at risk of not receiving the intended therapeutic benefit of their medications or receiving them as prescribed by the physician's orders. Findings included:1. Record review of Resident #59's face sheet, dated [DATE], reflected Resident #59 was a [AGE] year-old male, admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Type 2 diabetes mellitus (lifelong condition where the pancreas makes little or no insulin, which leads to high blood sugar levels), stroke, and high blood pressure. Record review of Resident #59's quarterly MDS assessment, dated [DATE], indicated Resident #59 made himself understood and understood others. Resident #59's BIMS score was 15, which indicated his cognition was intact. The MDS indicated he received insulin over the 7-day look-back period.Record review of Resident #59's physician order dated [DATE], reflected an order for: Novolin R Solution (Insulin Regular Human) Inject as per sliding scale: if 0 - 200 = 0 units; 201 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 -400 = 8 units; 401 - 450 = 10 units Greater than 450 notify the physician, subcutaneously before meals and at bedtime related to diabetes.Record review of Resident #59's comprehensive care plan dated [DATE] indicated Resident #59 had diabetes mellitus. The care plan interventions were for staff to monitor blood sugar as ordered by the physician. Administer sliding scale insulin if ordered. For any blood sugars not within the acceptable parameters as dictated by the physician, document and notify the physician.During an observation and interview on [DATE] at 11:04 a.m., LVN D took Resident #59's blood sugar with a reading of 208. LVN D prepared Resident #59's Novolog and administered 2 units to Resident #59's left arm. LVN D reviewed the insulin vial and said she could not read the date on the bottle but looked like it was [DATE]. She said if so, the insulin had expired. She said giving expired medication may not be effective. 2. Record review of Resident #4's face sheet, dated [DATE], revealed a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses to include Congestive heart failure also known as CHF (is a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), Chronic Obstructive Pulmonary Disease also known as COPD (is a progressive, incurable lung disease that restricts airflow and causes breathing difficulty), hypoxia (a condition in which your body or specific tissues do not receive enough oxygen to function properly), dementia (a loss of mental functioning such as, thinking, memory, mood and behavior), and diabetes (high blood sugars).Record review of Resident #4's quarterly MDS assessment, dated [DATE], indicated Resident #4 understood and was understood by others. Resident #4's BIMS score was 05, which indicated her cognition was severely impaired. The MDS indicated Resident #4 required assistance with toileting, bed mobility, dressing, personal hygiene, transfers, and eating. The MDS did not indicate she received Potassium or Slow Magnesium. Record review of Resident #4 's comprehensive care plan, revised on [DATE] did not indicate a care plan for potassium or Slow Magnesium. Record review of Resident #4's physician order dated [DATE], indicated Resident #4 had an order for the following: Potassium Chloride extended-release oral tablet extended release 20 MEQ (Potassium Chloride) Give 1 tablet by mouth in the morning for CHF.Slow-Mag Oral Tablet Delayed Release 71.5-119 MG (Magnesium Chloride-Calcium Carbonate) Give 1 tablet by mouth every 12 hours for Supplement.During an observation on [DATE] at 9:59 a.m., MA E checked the Medication Administration Record for Resident #4 and then gave 1 tablet of Slow Magnesium which contained Calcuim-212mg, Magnesium128mg and Chloride 373mg.During an observation on [DATE] at 9:59 a.m., MA E checked the MAR for Resident #4 and did not give Potassium as ordered.During an interview on [DATE] at 12:58 p.m., MA E said she gave Resident #4, 1 tablet of Slow Magnesium which contained Calcuim-212mg, Magnesium128mg and Chloride 373mg. She said since the order read to give 1 tablet of Slow-Mag Oral Tablet Delayed Release 71.5-119 MG, she said she gave the wrong dose. She said since it was a supplement she was not sure how it could affect the resident. MA E said she thought she gave Resident #4 her Potassium 20 MEQ, but she looked on the cart and Resident #4 did not have any Potassium on the cart. She said the DON pulled it from the emergency kit.During an interview on [DATE] at 2:09 p.m., the DON said she did not pull Potassium out of the emergency kit for Resident #4.During an interview on [DATE] at 5:34 p.m., the DON said she expected nurses not to give expired insulin, and/or medication aides to give the wrong medication or not to give medication as ordered. The DON said she expected the medication aides and nurses to read the MAR and give medication as ordered. The DON said she was aware of Resident #4 missing some medications but not Potassium. She said she had reached out to the physician about the Slow Magnesium, and he had given new orders. The DON said if residents did not receive the ordered dose, or expired medication they may not be receiving the therapeutic dose.During an interview on [DATE] at 6:09 p.m., the Administrator said she expected medications to be administered by the physician's orders and for there not to be any mistakes. The Administrator said the DON and ADON were responsible for monitoring to ensure medication errors did not occur. The Administrator said expired medication could affect residents depending on the medication and why ordered.Record review of the facility policy titled, Physician Orders, dated [DATE], indicated, Policy: The policy provides guidance on receiving and following physician orders.Record review of the facility's policy titled, Medication -Treatment Administration and Documentation Guidelines, revised [DATE], indicated, Anticipated Outcome: To provide a process for accurate, timely administration and documentation of medication and treatments. Fundamental Information Medication are administered according to manufacturer's guidelines unless otherwise indicated by physician order. Process: 1. Verify labels accurately reflect the physician orders on the Electronic Medication Administration Record (EMAR) and Electronic Treatment Administration Record (ETAR) prior to administering patient medications and treatments. 2. Verify administration accuracy by checking the medication with the EMAR three (3) times. 4. Administer the medication according to the physician order.Record review of the facility's policy titled, Medication Labeling and Storage, revised February 2023, indicated, Policy: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Policy Interpretation and Implementation: Medication Storage1.Medications and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Medication Labeling: 5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.
Based on observations, interviews, and record reviews the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals for 1 resident reviewed (Resident #54) for special eating equipment and assistance when consuming meals. The facility failed to provide Resident #54's physician ordered plate guard on 07/06/2026. These failures could place residents at risk for weight loss, diminished independence, and self-esteem. Findings included: Record review of face sheet dated 07/09/2026 revealed Resident #54 was a [AGE] year-old male admitted to the facility on [DATE] with the diagnosis of major depressive disorder (severe sadness). Record review of care plan for Resident #54 revision date 07/15/2024 revealed he was care planned for ADLs self-care performance deficit and was at risk of not having his needs met in a timely manner with an intervention of eating: setup and clean-up assistance. Resident #54 was care planned for nutritional status for regular large portion diet and was at nutritional risk related to adult failure to thrive. Care plan intervention listed as provide, serve diet as ordered and provide and serve supplements as ordered. Record review of Annual MDS dated [DATE] revealed Resident #54 had a BIMS of 03 indicating severe cognitive impairment. MDS indicated Resident #54 had an active diagnosis of Malnutrition or risk for Malnutrition (body is not getting the right balance of protein or calorie nutrients). MDS assessment indicated Resident #54 eating functional ability was setup or clean-up assistance. Record review of order summary report dated 07/09/2026 revealed Resident #54 had an order for regular diet and texture, regular consistency, plate guard, add fortified foods at all meals started on 04/10/2026. Record review of meal ticket for the lunch meal dated 07/06/2026 revealed Resident #54 was supposed to receive a plate guard. Observation on 07/06/2026 at 12:32 p.m., Resident #54 did not receive a plate guard until surveyor intervention. Observation revealed Resident #54 had food falling off his plate. Interview on 07/06/2026 at 12:35 p.m., Resident #54 stated that sometimes he did not receive the plate guard. Resident #54 stated that it helped him eat his food. Interview on 07/06/2026 at 12:40 p.m., NA G stated that she had told the Dietary staff that he needed a plate guard multiple times and frequently he does not receive the plate guard. NA G stated that Resident #54 needed the plate guard to assist him in eating due to weight loss. Interview on 07/06/2026 at 3:35 p.m., LVN D stated that she was not aware Resident #54 did not receive his ordered plate guard. LVN D stated that the plate guard was prescribed for assistance in eating and to prevent weight loss. LVN D stated that Resident #54 was at further risk of weight loss because he did not receive his prescribed therapeutic assistive device. Interview on 07/09/2026 at 1:35 p.m., the Registered Dietitian stated Resident #54 cannot feed himself appropriately without the plate guard. The Registered Dietitian stated that she expected the facility to provide a plate guard to Resident #54 every meal. The Registered Dietitian stated Resident #54 was at risk of malnutrition because Resident #54 was not able to adequately feed himself. Interview on 07/09/2026 at 3:09 p.m., the Dietary Manager revealed she expected Resident #54 to receive his plate guard. The Dietary Manager stated she expected Resident #54 meal ticket to be followed. The Dietary Manager stated cook and herself were responsible for the plate guard. The Dietary Manager stated that she was the Dietary Aide during the Lunch meal and the plate guard was not given on accident. The Dietary Manager stated that the plate guard was an assistive device used to assist Resident #54 in eating and Resident #54 was at risk of weight loss. Interview on 07/09/2026 at 3:40 p.m., the DON stated that the plate guard was to keep the food on the plate and assist Resident #54 in eating. The DON stated that it was the nurses responsibility to check the trays prior to Resident #54 receiving his food. The DON stated that she was in the dining room when Resident #54 did not receive the plate guard and she was unable to explain why he did not receive the plate guard. Record review of adaptive eating devices policy dated 7/22/2021 revealed the facility must provide special eating equipment and utensils for residents who need them. If the resident has been seen by an Occupational Therapist, they may have recommended specific equipment and purchased these items for the resident. Food and Nutrition services should also keep extra pieces of all equipment needed by residents so that it can be washed and sanitized each meal. The therapy department can help to determine what equipment is needed. At a minimum food and nutrition services should keep on hand, deep dish divided plates or plate guards, sippy cups and variety of adaptive
Based on interview and record review the facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service for 1 out of 7 (Dietary Aide B) dietary staff. The facility did not ensure Dietary Aide B had a current food handler permit. This failure could place residents who consumed food prepared from the kitchen at-risk of foodborne illness or nutritional deficiencies. Findings include: Review of the food handler's certificates of completion provided by the facility on 07/06/2026 at 2:00 p.m., revealed the following:Dietary Aide B had a food handler certificate that expired on 07/15/25. During an interview on 07/07/26 at 4:15 p.m., Dietary Aide B stated she was not aware her food handler permit was expired. Dietary Aide B stated it was important to have a food handler certificate to know how to handle food and prevent cross contamination or infection. During an interview on 07/09/26 at 2:59 p.m., the Dietary Manager stated she was responsible for ensuring staff completed their food handler certificate training every 2 years. The Dietary Manager stated she reviewed the certificates weekly but overlooked the actual day it expired. The Dietary Manager stated this failure could potentially put residents at risk for food borne illness and cross contamination. During an interview on 07/09/26 at 6:47 p.m., the Administrator stated she expected the Dietary Manager to ensure the dietary staff had their food handler certificates before they expired. The Administrator stated this failure could potentially put residents at risk for food borne illness and cross contamination. Record review of the facility's policy titled Certified Food Protection Professional and Food Safety Training revised 11/14/17 reflected. 6. The food establishment shall maintain on premises a certificate of completion of the food handles training course for each employee.
Based on observation, interview, and record review, the facility failed to ensure the meals served met the nutritional needs of residents for 1 of 1 meal (the lunch meal) reviewed for meal service. The facility failed to ensure the Dietary Manager followed the recipe for preparing fortified pudding on 07/06/26.This failure could place residents at risk for weight loss, not having their nutritional needs met, and a decreased quality of life. Findings included:1. Record review of Resident #58's face sheet, dated 07/09/26, indicated a [AGE] year-old male who was re-admitted to the facility on [DATE] with diagnoses which included protein-calorie malnutrition (is defined as a condition resulting from inadequate intake of protein and calories, often due to decreased oral intake), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), anxiety (a feeling of fear, dread, and uneasiness), and dysphagia (difficulty swallowing).Record review of Resident #58's quarterly MDS assessment, dated 04/30/26, indicated Resident #58 made himself understood and was understood by others. The MDS indicated his BIMs score was a 15 which indicated he was cognitive intact. The MDS indicated Resident #58 required assistance with dressing, personal hygiene, toileting, bathing, bed mobility, transfers, and independent with eating. The MDS during the 7-day look-back period did not indicate Resident #58 had weight loss.Record review of Resident #58's physician's order dated 09/30/24, indicated Regular diet Regular texture, Regular consistency. Add fortified foods to every meal related to protein calorie malnutrition.Record review of Resident #58's care plan revised on 05/06/25 indicated Resident #58 had potential nutritional problems related to malnutrition and impaired cognition. The intervention was for staff to serve diet as ordered. During an observation on 07/06/26 at 12:30 p.m., Resident #58 was in the dining room eating pudding. His tray card read fortified pudding.During an observation and interview on 07/07/26 at 2:14 p.m., the Dietary Manager said they made the fortified pudding with condensed milk for the pudding served on 07/06/26. She reviewed the recipe and said it called for regular milk. She said the fortified pudding was not made correctly because she used condensed milk. She said the recipe was not followed. She said the risk of not following the recipe could lead to weight loss.During an interview on 07/09/26 at 2:47 p.m., the dietician said the dietary staff should follow the recipe when making the fortified pudding. She said residents who usually receive fortified pudding were at risk for malnutrition and weight loss. During an interview on 07/09/26 at 5:34 p.m., the DON said she expected the dietary staff to follow the recipe. She said the Dietary Manager was the overseer of the kitchen. She said Resident #58 was ordered fortified pudding because he was at risk of weight loss.During an interview on 07/09/26 at 6:09 p.m., the Administrator said she expected the kitchen to follow the recipe when preparing food in the kitchen. She said the Dietary Manager was the overseer of the kitchen. She said residents often received fortified pudding for weight loss.Record review of the facility's policy titled, Diets, Nutrition and Hydration, revised March 2016, indicated, Fundamental Information: The facility will provide each resident with three meals daily. Each meal will be provided according to physician orders, Facility Diet Manual, and menu spread sheet.
Based on interview and record review the facility failed to accommodate residents' food preferences for 1 of 6 residents (Resident #17) reviewed for nutrition. The facility failed to honor Resident #17's preference for no apples for the lunch meal on 07/06/2026. This failure could place residents at risk for a decrease in resident choices, diminished interest in meals, and weight loss. Finding including:Record review of the face sheet dated 07/09/2026 revealed Resident #17 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cerebral infarction due to embolism of right cerebellar artery (dead brain tissue caused by a blocked blood vessel). Observation on 07/06/2026 at 12:25 p.m., Resident #17 had apples on her tray. Interview on 07/06/2026 at 12:30 p.m., Resident #17 stated she does not like apples and wished to have a substitution for the apples on her meal. Resident #17 stated that she requested a substitution but had not received one. Interview on 07/06/2026 at 12:35 p.m., the Dietary Manager stated that she should have substituted the apples for Resident #17 but she did not because she forgot. The Dietary Manger stated that she was the dietary aid for the day and did not realize she did not supply Resident #17. Interview on 07/09/2026 at 2:45 p.m., the Registered Dietitian stated that she expected Dietary to substitute the apples for another fruit available. The Registered Dietitian stated that she expected the dietary to have available substitutes for Resident #17. Interview on 07/09/2026 at 3:00 p.m., the Dietary Manager revealed that she expected Resident #17 to receive her preference to prevent weight loss and quality of life. Resident #17 was at risk of not receiving the proper nutrition. Interview on 07/09/2026 at 4:09 p.m., the DON stated that she expected that Resident #17 receive her preference or substitution. Resident #17 was at risk of weight loss or malnutrition. The DON stated that the nurse checks the trays and she expected the ticket meal to be followed and match the tray accordingly. Interview on 07/09/2026 at 4:44 p.m., the Administrator stated that she expected Resident #17 to receive her preference or a substitution. Resident #17 was at risk of not eating her preferred foods. The Administrator stated that nurses were responsible for checking the trays and dietary was responsible for providing the substitution. Record review of Instructions for completing Meal Choice Form dated 2/16/2017 revealed a meal choice form would be completed for each resident and should be followed according to the meal ticket. Record review of Menu Planning Guidelines and Procedure dated 7/17/2024 revealed Additional alternative/substitute foods will be kept on hand for quick preparation and service in the event a resident refuses all foods served.
Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 3 (Resident #12) residents reviewed for quality of care. The facility failed to perform wound care for 3 days 7/4, 7/5, and 7/6 for Resident #12 with a toe wound with cellulitis. This failure could place residents at risk for not receiving appropriate care and treatment, a decreased quality of life, and pressure ulcers. Finding including: Record review of face sheet dated 07/09/2026 revealed Resident #12 was a [AGE] year-old female admitted to the facility on [DATE] with the diagnosis of type 2 diabetes mellitus with hyperglycemia (metabolic disorder that affects how the pancreas controls blood sugar with high blood sugar). Record review of care plan revealed Resident #12 was care planned for risk of complications of impaired circulation related to elevated cholesterol with the intervention to inspect the foot, ankle, and calf skin for changes in the skin. Record review of annual MDS dated [DATE] revealed Resident #12 had a BIMS of 15 indicating no cognitive impairment. MDS assessment indicated Resident #12 was at risk of developing pressure ulcers. Record review of order summary report dated 07/09/2026 revealed Resident #12 had an order for wound care to the right great toe:Order started 07/04/2026 Cleanse right great toe with normal saline, pat dry, and apply calcium alginate, cover with band aid daily every day shift. Record review of progress note dated 06/30/2026 revealed Resident #12 reported a toe wound to the right big toe by the NA G to the nurse on duty. Progress note revealed the toe had a blister, was inflamed and warm to touch. Record review of skin assessment issue dated 07/04/2026 revealed a new documented skin issue identified by the DON acquired in house. Measurements revealed a length (cm): 0.2 Width (cm): 0.2 Depth (cm): 0.1 Undermining (tissue at the edge of the injury had separated from the deeper tissue underneath): No. Tunneling(wound created hidden passageways under the skin) =: No. Record review of the treatment record revealed blanks in the record for 7/4 and 7/5 indicating wound care was not documented for Resident #12 indicating it was not completed. Observation on 07/06/2026 at 11:00 a.m. revealed Resident #12's right great toe was red, open and had a sore without a bandage on it. Interview on 07/06/2026 at 11:05 a.m., Resident #12 revealed the staff had not put a bandage on her toe while in the facility. Resident #12 stated she had had a sore on her toe since 6/30/2026. Resident #12 stated she had cellulitis (infection of the skin) of the right toe. Resident #12 stated that no wound care had been done on her toe. Observation on 07/07/2026 at 9:00 a.m., revealed Resident #12 had not had wound care done because there was no bandage on the toe. Interview on 07/09/2026 at 1:45 p.m., LVN D stated she was unaware of the order for wound care on Resident #12. LVN D stated that Resident #12 had cellulitis and was at risk of wound worsening and sepsis (infection). LVN D stated that she did not complete wound care on 7/4, 7/5, and 7/6 of July 2026. LVN D stated she was responsible for Resident #12 wound care. Interview on 07/09/2026 at 3:00 p.m., ADON stated she was responsible for overseeing wound care for Resident #12. ADON stated that she expected wound care to be completed according to physician order daily. ADON stated that she was unaware Resident #12 was not receiving scheduled daily wound care. Interview on 07/09/2026 at 3:35 p.m., the DON stated she was not aware that the wound care was not getting completed. Resident #12 had cellulitis to the toe. The DON stated there is 24-hour care and she expected nurses to complete the task if they check off documentation that the nurse had completed the task of wound care. The DON stated that if it was on point of care t should have been completed according to the wound care orders. Resident #12 was at risk of sepsis and worsening wounds. Interview on 07/09/2026 at 4:40 p.m., the Administrator stated that she expected wound care orders to be followed. Administrator stated that Resident #12 was at risk of wound worsening. Administrator stated that the nurses were responsible for doing the wound care and ADON was responsible for overseeing the nurse to ensure wound care is completed. Record review of wound care management policy review date on 2/10/2021 revealed wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.
Inspection of May 12, 2025
6 findingsBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24-hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (which included the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State Law through established procedures for 3 of 23 residents (Resident #'s 9, Resident #126, and Resident #54) reviewed for abuse and neglect. The facility failed to report timely to HHSC when CNA D and CNA E attempted an ATM transaction on 02/21/25 using Resident #9's debit card associated with his personal bank account. The facility failed to ensure that CNA E, LVN FF, and LVN YY reported the resident-to-resident altercation between Residents #126 and Resident #54 to the Administrator, who was the abuse coordinator, immediately on 02/22/25, which resulted in the Administrator not learning of the altercation until 02/25/25. The non-compliance was identified as PNC. The IJ began on 02/21/25 and ended on 02/25/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for further potential neglect due to unreported and uninvestigated allegations of abuse and neglect. Findings included: 1)Record review of Resident #9's face sheet dated 05/09/25 indicated he was an [AGE] year-old male who readmitted to the facility on [DATE] with the diagnoses dementia, anxiety, hear failure, high blood pressure, and lack of coordination. Record review of Resident #9's quarterly MDS dated [DATE] indicated he made himself understood and understood others. The MDS also indicated he had a BIMS score of 8 which meant he had moderate cognitive impairment. Record review of Resident #9's care plan revised on 04/07/25 indicated he had impaired cognition and was at risk for further decline with a goal of his needs being met timely, dignity maintained, and current level of functioning maintained. During an interview on 05/08/25 at 4:40 p.m., CNA E stated she and CNA D were leaving for break on 02/23/25 when Resident #63 asked her if she could go and withdraw $200 from the ATM. CNA E stated Resident #63 handed her a card and gave her the pin number to the card. CNA E stated she did not know at the time the card belonged to Resident #9 until she tried to withdraw the money and suspicious fraud popped up on the screen. CNA E stated she called the facility and spoke with CNA N and had her to put Resident #63 on the phone. CNA E stated when Resident #63 got on the phone she stated she told him that was not his card and Resident #63 stated Yes, I know, go ahead, and bring it back. We have to call Resident #9's family member to fix the card because the same thing happened yesterday. CNA E stated she brought the card back and gave it to Resident #63 and told him to give it back to Resident #9. She said she gave it back to Resident #63 instead of Resident #9 because that was who she got the card from. CNA E stated she did not report the incident to the Administrator until Monday 02/24/25 when an incident happened between CNA N and another resident. CNA E stated she was suspended that 02/24/25. CNA E stated there had been several occasions she witnessed Resident #63 going to get money from Resident #9 and handing it to Laundry V, CNA N, and Housekeeping C. CNA E stated CNA N's aunt charged Resident #9 $1,000 to take him to Walmart and CNA N's cousin charged Resident #9 $600 to take him to another city. CNA E stated Resident #29's family member has charged Resident #9 $1,000 to go to the bank. CNA E stated Resident #29 and Resident #37 also took money from Resident #9. CNA E stated she did not report any of those incidents to the ADM because the ADM was already aware. CNA E stated she also heard the ADM was taking money from Resident #9. During an interview on 05/06/25 at 1:41 p.m., MA UU stated she heard about Resident #63 taking money from Resident #9. MA UU stated she had also heard Resident #29's family member taking Resident #9 to the bank. MA UU stated she reported what she had heard to the ADM. MA UU stated she could not recall the exact date. During an interview on 05/08/25 05:13 PM the Administrator said she was not aware of any staff members taking Resident #9's money. She said she asked Resident #9 about his money on several occasions, and he told her he was giving out money to residents if they needed it. The Administrator said she called Resident #9's family member and told them about him giving away his money to residents in the facility. She said the VA came to the facility to assess Resident #9 and what he was doing with his money and the VA said he had the right to give his money away because his BIMS was high. The Administrator said Resident #9 gave Resident #63 his card to use. She said she knew CNA D and CNA E went to the gas station to get some chicken and for a red soda. The Administrator said she was not aware of the $200 the CNAs attempted to get. She said CNA D and CNA E both were suspended on 02/24/25. She said it was not acceptable for staff to get Resident #9's card. She said she never got any money from Resident #9. The Administrator said misappropriation was the state guideline but Resident #9 gave Resident #63 his card to use so that made it not misappropriation. She said CNA D and CNA E did not get money. The Administrator said the police said it was not misappropriation if Resident #9 gave it to Resident #63. During an observation and interview on 05/09/25 at 2:21 PM, Resident #9 said he gave Resident #63 his debit card to use 1 time on an unrecalled date. He told Resident #63 he could have between $20-$30. He said Resident #63 did pay him back for the money. The surveyor asked if he knew Resident #63 was giving others his debit card, including staff, and Resident #9 said he was unaware and he did not authorize Resident #63 to give his debit card to anyone else. Resident #9 and the surveyor reviewed some of his bank statements. After reviewing the bank statements dated 1/16/25-2/14/25, he and the surveyor saw some charges on 02/07/25 that reflected Resident #9 made an ATM withdrawal 3 times for $203, and $103, totaling $918in a day. Resident #9 put his head down and said he did not know about those charges in a shaky voice. Resident #9 became saddened and teary-eyed after discussing the charges on his bank account. The surveyor went to get ADON AA, and she witnessed Resident #9 say he had not given staff permission to use his card, and he authorized Resident #63 to use his card, but not for those amounts and he had not been to an ATM. During a telephone interview on 05/09/25 at 2:58 p.m., CNA D stated she, and CNA E were going to lunch on 02/23/25 and CNA E told her to stop at the store so she could withdraw some money for Resident #63. CNA D stated, I had no dealing with card, I was just the driver. During an interview on 05/09/25 at 4:41 p.m., the ADM stated she had taken Resident #9 to the bank to get his statements so she could see if any money was withdrawn from the account when Resident #63 gave Resident #9 bank card to CNA E and CNA N. The ADM stated the bank was not going to give him another card because of the fraudulent activity. The ADM stated, I agreed with the lady at the bank. The ADM stated on Monday (02/24/25) there was a risk call made that included herself, the DON, the Regional Consultant Nurse and the Regional Operations to discuss the incident about CNA E, CNA D, Residents #63 and #9 and another incident with CNA D. The ADM stated she stated during the call during the investigation her and the DON found out by CNA D that CNA E was given Resident #9 card by Resident #63 and was told to withdraw $200. The ADM stated during the call she told the regional people CNA E attempted to withdraw the money but was unsuccessful. The ADM stated she told them she suspended CNA E and was told by the Regional Operations Manger she should have never suspended her just written her up because there was no money taken. The ADM stated she was told by Resident #9 sister to take Resident #9 to a funeral home to take out a pre-burial policy because Resident #9 would not let the sister take him. The ADM stated she took out #13,034.41 and $500 to start him a trust fund at the facility. The ADM stated she and Laundry V took him to the funeral home to take out the policy. During an interview on 05/09/25 at 5:45 p.m., the BOM stated the ADM told her when she took Resident #9 to the bank after the incident with CNA E, CNA N and Resident #63 the card was put on hold. The BOM stated the ADM did not elaborate if the bank put the card on hold or if she initiated it. The BOM stated she was told by the ADM she did get bank statements that day (02/24/25). The BOM stated Resident #9's family member had brought statements in (on an unknown date) before the incident between CNA E, CNA N, and Resident #63 because she wanted to know what all the withdrawals were for. The BOM stated she told her she would look into it and that was when the BOM spoke with the ADM about the withdrawals of the bank acct. The BOM stated the ADM told her she would look into it. The BOM stated the issue was brought up several times in morning meetings and the ADM stated she was looking into it. The BOM stated it got to a point the ADM stated, We're done talking about that. Record review of the facility patient questionnaires for 4 other residents dated 02/24/25 completed by the Social Worker indicated no other residents had any concerns with abuse. Record review of the facility in-service for Allegations of Abuse and the abuse coordinator dated 02/24/25 indicated staff members across all shifts had been in-serviced over the abuse and neglect policy, contacting the Administrator immediately, to speak directly with the Administrator to report allegations, not to text allegations, and to call the DON as the second choice if the Administrator was not available. Record review of the facility associate disciplinary memorandum dated 02/24/25 indicated CNA D was suspended pending investigation. Record review of the facility associate disciplinary memorandum dated 02/24/25 indicated CNA E was suspended pending investigation. Record review of the time sheet for CNA D dated 02/20/25-02/27/25 indicated the last time CNA D clocked in the facility on 02/24/25 at 06:14 AM and clocked out of the facility on 02/24/25 at 09:48 AM and her status was now terminated. Record review of the time sheet for CNA E dated 02/20/25-02/27/25 indicated the last time CNA D clocked in the facility on 02/24/25 at 06:14 AM and clocked out of the facility on 02/24/25 at 10:01 AM and returned to work on 02/26/25 at 01:27 PM. 2.Record review of Resident #126's face sheet, dated 05/12/25, indicated a [AGE] year-old male who was readmitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, also known as COPD (a long-term lung disease that makes breathing difficult), stroke and dementia (diseases that affect memory, thinking, and the ability to perform daily activities). Record review of Resident #126's quarterly MDS assessment, dated 01/26/25, indicated Resident #126 usually understood and was usually understood by others. Resident #126's BIMS score was 03, which meant he was severely cognitively impaired. The MDS indicated Resident #126 required total assistance with toileting, bed mobility, dressing, transfers, personal hygiene, and eating. The MDS did not indicate any behaviors. A record review of Resident #126's care plan, revised on 03/30/25, indicated Resident #126 had an alteration in musculoskeletal status related to contracture of bilateral (both) upper extremities. The intervention was for staff to anticipate and meet his needs. Record review of Resident #126's nurses' notes dated 02/25/25, written by ADON XX revealed she was notified by CNA VV about an incident that occurred in the television room on 02/22/25 after lunch. CNA VV said she was informed by Resident #37 that Resident #54 hit Resident #126 in the head three times. ADON XX assessed Resident #126 from head to toe with no skin issues noted. ADON XX then notified the abuse coordinator and the DON. Resident #126 was unable to give any details related to the incident due to his cognitive impairment. Record review of Resident #126's skin assessment dated [DATE] did not indicate any skin issues. 3. Record review of Resident #54's face sheet, dated 05/07/25, indicated a [AGE] year-old male who was readmitted to the facility on [DATE] with diagnoses which included depression (sadness), anxiety (characterized by excessive and persistent worry, fear, and nervousness) and dementia (diseases that affect memory, thinking, and the ability to perform daily activities). Record review of Resident #54's quarterly MDS assessment, dated 03/28/25, indicated Resident #54 understood and was understood by others. Resident 54 BIMS score was 05, which meant his cognition was severely impaired. The MDS indicated Resident #54 required help with toileting, bed mobility, dressing, transfers, personal hygiene, and was independent with eating. The MDS indicated Resident #54 has verbal and physical behavior. Record review of Resident #54's care plan, revised on 10/14/24, indicated Resident #54 had a Behavioral Problem as evidenced by aggressive behaviors. The interventions were for staff to assist the resident to a calm, quiet area if he starts to become agitated. Record review of Resident #54's skin assessment dated [DATE] did not indicate any skin issues. During a phone interview on 05/09/25 at 8:50 a.m., CNA E said she was walking down the hall towards the lounge area when she saw Resident #54 hit Resident #126 in the head three times. She said she removed Resident #126 to safety and then reported to LVN FF and LVN YY. She said Resident #54 had a history of hitting others. She said Resident #54 said Resident #126 was talking about him. She said Resident #126 does not talk. During a phone interview on 05/09/25 at 9:47 a.m., LVN YY said he was Resident #126 and Resident #54's nurse. He said he vaguely remembered them. He said he did not recall a resident-to-resident altercation. He said he was newly hired at the facility and did not know all the steps he needed to take to complete an incident or skin assessment. He said as he continued to work at the facility, he became aware of filling out an incident report, skin assessment, and reporting to the Administrator. He said if a resident-to-resident altercation occurred, he should have reported it to the Administrator. During an interview on 05/09/25 at 11:45 a.m., LVN FF said she was a nurse on duty when Resident #126 and Resident #54 had the altercation on 02/22/25. She said CNA E told her she was walking down the hall toward the lounge area when she saw Resident #54 hit Resident #126 on the top of his head. She said as she was about to assess the situation, the charge nurse (LVN YY) for Resident #126 and Resident #54 came out from the medication room, and she reported the incident to him. She said she was not aware LVN YY did not report the incident to the Administrator or DON until a few days later, when she was questioned by the Administrator. She said she knew the incident should have been reported to the Administrator as soon as it happened but thought LVN YY reported since he was their charge nurse. During an interview on 05/09/25 at 4:47 p.m., the DON said she expected staff to report any abuse to the Administrator when they were made aware. She said they were not aware of Resident #54 hitting Resident #126 in the head until CNA VV heard it from Resident #37 on 02/25/25. She said that upon their investigation, CNA E said she saw Resident #54 hit Resident #126 in the head three times and separated them. She said CNA E reported the altercation to her charge nurse, LVN YY. She said they spoke with LVN YY, but he did not remember why he did not report it to the Administrator. She said then she spoke to LVN FF, who said she was on duty when the incident occurred between Resident #54 and Resident #126. LVN FF said CNA E reported it to her, and then she reported to their nurse, LVN YY. She said LVN FF thought LVN YY had reported the incident to the Administrator and did the assessment and incident report. She said both residents were assessed on 02/25/25 with no injuries noted. She said they did an in-service on reporting abuse. The DON said it was important to report and investigate abuse/neglect to prevent further abuse/neglect from occurring. During a phone interview on 05/09/25 at 6:03 p.m., the Administrator said she was unaware of Resident #126 and Resident #54's altercation that occurred on 02/22/25 until 02/25/25. She said once she became aware, the nurses assessed both residents, and the investigation process began. She said she then reported to HHSC. She said the resident-to-resident altercation should have been reported to her, and her responsibility was to protect the residents and report to HHSC within 2 hours of the incident. She said the staff was aware that she was the abuse coordinator and should have reported the allegation of abuse to her. She said they did an in-service with staff on reporting. The Administrator said when allegations were not reported promptly, abuse could continue to occur, and residents could be in danger if the abuse/neglect was continuing. Record review of the facility's in-service on reporting dated 02/25/25, revealed an in-service on resident-to-resident altercations.1.Immediately separate residents, 2. Place aggressor on 1:1 supervision and document, 3. Contact Administrator immediately, 4. License nurses will complete a head-to-toe assessment on both residents and document, 5. Notify family and doctor, 6.License nurse will complete an incident report, 7.Refer resident to psych services for clearance, 8.Update care plan for behaviors, 9.Educate staff on abuse/neglect and resident to resident altercations. Record review of the facility's in-service on abuse dated 02/25/25, revealed an in-service on reporting to the abuse coordinator. 1 contact the Administrator, 2. Notify Immediately and do not wait, 3. Do not text, you must call the Administrator, if no answer then keep calling, 4.The DON is second choice to call if administrator is out or does not return your call after several attempts. Record review of the Texas Unified Licensure Information Portal, also noted as TULIP (an online system for submitting long-term care licensure applications), indicated the facility reported the intake regarding the resident-to-resident altercation involving Resident #126 and Resident #54 on 02/25/25. During interviews conducted on 5/10/2025 at 04:22PM - 5/10/2025 at 06:04 PM the Administrator, DON, ADON AA, ADON XX, MDS Nurse, CNA F, CNA G, CNA L, CNA N, CNA O, MA T, MA T,CNA B, CNA D, CNA E, RN H, MA K, LVN M, CNA P, CNA Q, CNA R, CNA S, CNA U, Van Driver V, MA W, CNA X, MA Y, CNA Z, MA BB, LVN CC, LVN DD, CNA EE, LVN FF, MA GG, RN HH, Dishwasher KK, Dietary Aide LL, [NAME] MM, LVN OO, LVN PP, CNA QQ, CNA RR, CNA SS, LVN TT, MA UU, CNA VV, and RNC WW indicated they had been in-serviced on the facilities abuse and neglect policy. The staff indicated a resident had the right to be free from abuse including misappropriation of property, and allegations should be reported immediately to the abuse coordinator. Record review of the facility policy titled Abuse, Neglect, Exploitation, revised 10/24/22, indicated, policy: it is the policy of this facility to provide protection for the health, wealth, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury. II.Employee Training: A. New employees will be educated on abuse, neglect, exploitation, and misappropriation of resident property during initial orientation. B. Existing staff will receive annual education through planned In-services and as needed. C. Training topics will include: 1. Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation. 2. Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property. 3. Recognizing signs of abuse, neglect, exploitation, and misappropriation of resident property, such as physical or psychoactive indicators. 4. Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources IV. Identification of Abuse, Neglect, and Exploitation A. The facility assists staff to understand the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff-to-resident abuse and certain resident-to-resident altercations Reporting: A. The facility reports abuse and abuse allegations that include: I. Reporting allegations involving staff-to-resident abuse, resident-to-resident altercations, injuries of unknown source, misappropriation of resident property/exploitation, and mistreatment. 2. Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies (e.g., law enforcement when applicable) within specified timelines: A. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or B. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The non-compliance was identified as PNC. The IJ began on 02/21/25 and ended on 02/25/25. The facility had corrected the noncompliance before the survey began.
Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to follow their policy on abuse for 1 of 23 residents (Resident #9) reviewed for abuse. The facility failed to implement their abuse policy and failed to protect Resident #9 from misappropriation of his personal funds when CNA D and CNA E attempted an ATM transaction on 02/21/25 using Resident #9's debit card associated with his personal bank account. The facility failed to implement their policy when they failed to conduct an investigation of misappropriation of Resident #9's monies and unauthorized transactions. An IJ was identified on 05/09/25. The IJ template was provided to the facility on [DATE] at 06:29 PM. While the IJ was removed on 05/12/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could cause residents to have misappropriation of their property and financial distress. Findings included: Record review of the facility policy Policy and Procedures: Abuse, Neglect and Exploitation dated 10/24/22 indicated: Policy: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property Record review of Resident #9's face sheet dated 05/09/25 indicated he was an [AGE] year-old male who readmitted to the facility on [DATE] with the diagnoses dementia, anxiety, hear failure, high blood pressure, and lack of coordination. Record review of Resident #9's quarterly MDS dated [DATE] indicated he made himself understood and understood others. The MDS also indicated he had a BIMS score of 8 which meant he had moderate cognitive impairment. Record review of Resident #9's care plan revised on 04/07/25 indicated he had impaired cognition and was at risk for further decline with a goal of his needs being met timely, dignity maintained, and current level of functioning maintained. During an interview on 05/08/25 at 4:40 p.m., CNA E stated she and CNA D were leaving for break on 02/23/25 when Resident #63 asked her if she could go and withdraw $200 from the ATM. CNA E stated Resident #63 handed her a card and gave her the pin number to the card. CNA E stated she did not know at the time the card belonged to Resident #9 until she tried to withdraw the money and suspicious fraud popped up on the screen. CNA E stated she called the facility and spoke with CNA N and had her to put Resident #63 on the phone. CNA E stated when Resident #63 got on the phone she stated she told him that was not his card and Resident #63 stated Yes, I know, go ahead, and bring it back. We have to call Resident #9's family member to fix the card because the same thing happened yesterday. CNA E stated she brought the card back and gave it to Resident #63 and told him to give it back to Resident #9. She said she gave it back to Resident #63 instead of Resident #9 because that was who she got the card from. CNA E stated she did not report the incident to the Administrator until Monday 02/24/25 when an incident happened between CNA N and another resident. CNA E stated she was suspended that 02/24/25. CNA E stated there had been several occasions she witnessed Resident #63 going to get money from Resident #9 and handing it to Laundry V, CNA N, and Housekeeping C. CNA E stated CNA N's aunt charged Resident #9 $1,000 to take him to Walmart and CNA N's cousin charged Resident #9 $600 to take him to another city. CNA E stated Resident #29's family member has charged Resident #9 $1,000 to go to the bank. CNA E stated Resident #29 and Resident #37 also took money from Resident #9. CNA E stated she did not report any of those incidents to the ADM because the ADM was already aware. CNA E stated she also heard the ADM was taking money from Resident #9. During an interview on 05/06/25 at 1:41 p.m., MA UU stated she heard about Resident #63 taking money from Resident #9. MA UU stated she had also heard Resident #29's family member taking Resident #9 to the bank. MA UU stated she reported what she had heard to the ADM. MA UU stated she could not recall the exact date. During an interview on 05/08/25 05:13 PM the Administrator said she was not aware of any staff members taking Resident #9's money. She said she asked Resident #9 about his money on several occasions, and he told her he was giving out money to residents if they needed it. The Administrator said she called Resident #9's family member and told them about him giving away his money to residents in the facility. She said the VA came to the facility to assess Resident #9 and what he was doing with his money and the VA said he had the right to give his money away because his BIMS was high. The Administrator said Resident #9 gave Resident #63 his card to use. She said she knew CNA D and CNA E went to the gas station to get some chicken and for a red soda. The Administrator said she was not aware of the $200 the CNAs attempted to get. She said CNA D and CNA E both were suspended on 02/24/25. She said it was not acceptable for staff to get Resident #9's card. She said she never got any money from Resident #9. The Administrator said misappropriation was the state guideline but Resident #9 gave Resident #63 his card to use so that made it not misappropriation. She said CNA D and CNA E did not get money. The Administrator said the police said it was not misappropriation if Resident #9 gave it to Resident #63. During an observation and interview on 05/09/25 at 2:21 PM, Resident #9 said he gave Resident #63 his debit card to use 1 time on an unrecalled date. He told Resident #63 he could have between $20-$30. He said Resident #63 did pay him back for the money. The surveyor asked if he knew Resident #63 was giving others his debit card, including staff, and Resident #9 said he was unaware and he did not authorize Resident #63 to give his debit card to anyone else. Resident #9 and the surveyor reviewed some of his bank statements. After reviewing the bank statements dated 1/16/25-2/14/25, he and the surveyor saw some charges on 02/07/25 that reflected Resident #9 made an ATM withdrawal 3 times for $203, and $103, totaling $918in a day. Resident #9 put his head down and said he did not know about those charges in a shaky voice. Resident #9 became saddened and teary-eyed after discussing the charges on his bank account. The surveyor went to get ADON AA, and she witnessed Resident #9 say he had not given staff permission to use his card, and he authorized Resident #63 to use his card, but not for those amounts and he had not been to an ATM. During a telephone interview on 05/09/25 at 2:58 p.m., CNA D stated she, and CNA E were going to lunch on 02/23/25 and CNA E told her to stop at the store so she could withdraw some money for Resident #63. CNA D stated, I had no dealing with card, I was just the driver. During an interview on 05/09/25 at 4:41 p.m., the ADM stated she had taken Resident #9 to the bank to get his statements so she could see if any money was withdrawn from the account when Resident #63 gave Resident #9 bank card to CNA E and CNA N. The ADM stated the bank was not going to give him another card because of the fraudulent activity. The ADM stated, I agreed with the lady at the bank. The ADM stated on Monday (02/24/25) there was a risk call made that included herself, the DON, the Regional Consultant Nurse and the Regional Operations to discuss the incident about CNA E, CNA D, Residents #63 and #9 and another incident with CNA D. The ADM stated she stated during the call during the investigation her and the DON found out by CNA D that CNA E was given Resident #9 card by Resident #63 and was told to withdraw $200. The ADM stated during the call she told the regional people CNA E attempted to withdraw the money but was unsuccessful. The ADM stated she told them she suspended CNA E and was told by the Regional Operations Manger she should have never suspended her just written her up because there was no money taken. The ADM stated she was told by Resident #9 sister to take Resident #9 to a funeral home to take out a pre-burial policy because Resident #9 would not let the sister take him. The ADM stated she took out #13,034.41 and $500 to start him a trust fund at the facility. The ADM stated she and Laundry V took him to the funeral home to take out the policy. During an interview on 05/09/25 at 5:45 p.m., the BOM stated the ADM told her when she took Resident #9 to the bank after the incident with CNA E, CNA N and Resident #63 the card was put on hold. The BOM stated the ADM did not elaborate if the bank put the card on hold or if she initiated it. The BOM stated she was told by the ADM she did get bank statements that day (02/24/25). The BOM stated Resident #9's family member had brought statements in (on an unknown date) before the incident between CNA E, CNA N, and Resident #63 because she wanted to know what all the withdrawals were for. The BOM stated she told her she would look into it and that was when the BOM spoke with the ADM about the withdrawals of the bank acct. The BOM stated the ADM told her she would look into it. The BOM stated the issue was brought up several times in morning meetings and the ADM stated she was looking into it. The BOM stated it got to a point the ADM stated, We're done talking about that. This was determined to be an Immediate Jeopardy (IJ) on 05/09/2025 at 06:24 PM. The Administrator was provided with the IJ template on 05/09/2025. The following Plan of Removals was accepted on 05/12/2025 at 02:57 PM. The plan of removal was accepted on 5/12/2025 at 2:57 p.m., and included: Immediate Action Taken: H. On 5/9/2025 the DON completed an assessment on Resident #9 to determine if resident was having any emotional distress related to this incident. The resident stated he was fine and was attending church services. The assessment was conducted privately prior to church services. I. On 5/9/2025 the DON completed a Comprehensive Trauma screen on the resident, and resident will be referred to psychology services for further evaluation. On 5/9/2025 The V.A. Social Worker was contacted by the facility regarding the need of the resident needing a psychology evaluation related to this incident. J. On 5/9/2025 the Regional Director of Operations provided 1:1 in-service with the Regional Nurse Consultant on the facility's abuse, Neglect, and Misappropriations policy. K. On 5/9/2025 the Regional Nurse Consultant provided 1:1 education to the facility DON on the Abuse, Neglect, and Misappropriations policy. This was completed on 5/9/25. L. On 5/9/2025 the DON started in-service education with all staff on the facility's Abuse, Neglect, Misappropriations policy, including post-test. This was completed at 8:00pm on 5/9/2025, and no staff will be allowed to work until they have completed their education. M. On 5/8/2025 the Administrator was suspended by the Regional Director of Operations pending investigation. N. On 5/12/2025 the resident will be taken to his bank by the Maintenance Director and Social Services to obtain a new debit card. Residents' family will be encouraged to go as well. Resident does have an active Trust fund in the facility and has access to immediate funds if he chooses. Residents have made 10 trust fund withdrawals in April 2025, and 4 in May 2025. O. On 5/8/2025 the Misappropriation incident was reported to HHSC by the DON. P. On 5/8/2025 the Misappropriation incident was also reported to the local law enforcement agency. Q. On 5/9/2025 the incident was reported to HHSC by the DON regarding Resident #63 not being authorized to use Resident #9's debit card. R. Resident #63 was discharged from the facility on 5/7/2025 and did not have access to resident # 9's debit card. S. On 5/8/2025 the facility started an investigation into the incident; the investigation was completed on 5/10/2025 at 12:00 pm. T. On 5/9/2025 C.N.A. E was suspended by the DON related to the incident. U. C.N.A. D was suspended on 2/24/2025 and never returned to work. 2. Identification of Residents Affected or Likely to be Affected: A. Starting 5/7/25 the Social Worker/designee will complete alert resident interviews 3 x week for 3 weeks, then weekly x 6 weeks to validate that all residents are allowed to make choices about aspects of his/her life in the facility, including financial choices. This will be reviewed after each interview is completed by the DON and Social Services so any issues, if applicable, can be addressed immediately. B. The Regional Nurse Consultant will oversee this process weekly x 6 weeks. 5. On 5/9/25 the facility's DON notified the Medical Director regarding the Immediate Jeopardy the facility received related to failure to implement the abuse policy 6. On 5/9/25 the facility conducted an Ad Hoc QAPI meeting to discuss Misappropriation, and implementation of the abuse policy and sustaining compliance. The surveyor confirmed the following actions had been implemented sufficiently to remove the immediacy by: Record review of Resident #9's emotional assessment was completed by the DON on 5/09/2025 with no issues noted. Record review of Resident #9's Comprehensive Trauma assessment was completed by the DON on 5/09/2025 with no trauma found. Record review of a referral for Resident #9 dated 5/09/2025 to the VA Social Worker for psychological services. Record review of the Administrator's suspension form dated 5/08/2025 indicated she was suspended pending investigation. Record review of the DON's in-service on the facilities Resident Rights policy dated 5/09/2025. Record review of the Regional Nurse Consultant's 1:1 in-service with the DON on the Abuse, Neglect, and Misappropriation policy which indicated it was the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property Record review of the Regional Director of Operation's 1:1 in-service with the Regional Nurse Consultant on the Abuse, Neglect, and Misappropriation policy indicated it was the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property Record review of the in-service provided to all disciplines across all shifts on the facility's Abuse, Neglect, Misappropriation policy dated 5/09/2025 conducted by the DON. The in-service also included a post test. During an observation on 5/12/2025 at 09:45 AM Resident #9 was driven to his financial institution where he was able to obtain a new debit card to his personal account. During an interview on 5/12/2025 at 11:54 AM Resident #9 said he had obtained a working debit card to his personal account. Record review of the reportable incident on 5/08/2025 to HHSC regarding Resident #9's misappropriation. Record review of the police report #25-313884 dated 5/08/2025 indicated the local authority was notified of the unauthorized use of Resident #9's debit card. Record review of the reportable incident on 5/09/2025 to HHSC indicated the reporting of Resident #63's unauthorized use of Resident #9's debit card. Record review of Resident #63's electronic record indicated he had discharged from the facility on 5/07/2025. Record review of the facility's investigation regarding the incident #1008525 determined to be reported on 05/08/25 and the investigation was ongoing. Record review of CNA E's personnel record indicated she had been suspended on 02/24/25 pending investigation. Record review of CNA D's personnel record indicated she was suspended on 2/24/2025 and never returned to work. During an interview on 5/10/2025 at 06:11 PM the Medical Director indicated he was made aware by the DON of the facility's immediate jeopardy regarding failure to implement the abuse policy regarding misappropriation. During interviews conducted on 5/10/2025 at 04:22 PM - 5/10/2025 06:04 PM the Administrator, DON, ADON AA, ADON XX, MDS Nurse, CNA F, CNA G, CNA L, CNA N, CNA O, MA T, MA T,CNA B, CNA D, CNA E, RN H, MA K, LVN M, CNA P, CNA Q, CNA R, CNA S, CNA U, Van Driver V, MA W, CNA X, MA Y, CNA Z, MA BB, LVN CC, LVN DD, CNA EE, LVN FF, MA GG, RN HH, Dishwasher KK, Dietary Aide LL, [NAME] MM, LVN OO, LVN PP, CNA QQ, CNA RR, CNA SS, LVN TT, MA UU, CNA VV, and RNC WW indicated they had been in-serviced on the facilities abuse and neglect policy. The staff indicated a resident had the right to be free from abuse including misappropriation of property, and allegations should be reported immediately to the abuse coordinator. The Administrator was informed the Immediate Jeopardy was removed on 05/12/2025 at 11:54 AM. The facility remained out of compliance at a severity level of potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated due to the facility's need to monitor the implementation of the plan of removal.
Based on observation, interview and record review, the facility to ensure that the residents had the right to self determination and that the facility promoted and facilitated resident self-determination for 1 (Resident #9) of 23 resident who were reviewed for resident rights. The facility failed to ensure Resident #9's right to make choices about aspects of his life that were significant to the resident by not ensuring his right to have access to a working debit card attached to his personal funds for his own daily use. The facility failed to prevent the Administrator from purchasing a pre-need funeral plan in the amount of $13, 034.41 when Resident #9 had expressed to his family member he did not want a pre-need funeral plan. An IJ was identified on 05/09/25 at 06:24 PM. While the IJ was removed on 05/12/25 at 11:54 AM, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents with the ability to make choices at risk of having their rights violated, diminished quality of life and unmet needs. Findings included: Record review of Resident #9's face sheet dated 05/09/25 indicated he was an [AGE] year-old male who readmitted to the facility on [DATE] with the diagnoses dementia, anxiety, hear failure, high blood pressure, and lack of coordination. Record review of Resident #9's quarterly MDS dated [DATE] indicated he made himself understood and understood others. The MDS also indicated he had a BIMS score of 8 which meant he had moderate cognitive impairment. Record review of Resident #9's care plan revised on 04/07/25 indicated he had impaired cognition and was at risk for further decline with a goal of his needs being met timely, dignity maintained, and current level of functioning maintained. Record review of Resident #9's trust funded prepaid funeral benefits dated 04/08/25 indicated he used a cashier's check in the amount of $13, 034.31 to purchase a prepaid funeral. During an interview on 05/08/25 at 06:00 PM Resident #9's family member said she did not have any control over his money. She said when she received the bank statements she would bring them to the facility. The family member said she had attempted to purchase a prepaid funeral plan for Resident #9 at one point, but he did not want her to do so. She said she was aware of people on the outside of the facility coming to pick him up and use his money but it was nothing she could do. During an interview on 05/09/25 at 08:00 AM CNA U said she told the administrator repeatedly Resident #63 was using Resident #9 for his money. She said the ADM told her it was none of the facility's business. CNA U said the ADM told her She had this under control and that the ADM was going to go have him spend all of his money today. CNA U said the ADM said, she was going to go make him go make him spend all his money so that's how they were going to solve this. CNA U said the ADM said she was taking him did a funeral arrangements. During an interview on 05/09/25 at 2:21 p.m., Resident #9 said he kept his own debit card and he gave Resident #63 his debit card to use 1 time. He told Resident #63 he could have between $20-$30. He said Resident #63 did pay him back for the money. The surveyor asked if he knew Resident #63 was giving others his debit card, including staff, and Resident #9 said he was unaware and he did not authorize Resident #63 to give his debit card to anyone else. Resident #9 and the surveyor reviewed some of his bank statements. After reviewing the bank statements dated 1/16/25-2/14/25, he and the surveyor saw some charges on 02/07/25 that reflected Resident #9 made an ATM withdrawal 3 times for $203, and $103, totaling $918in a day. Resident #9 put his head down and said in a shaky voice he did not know about those charges. Resident #9 became saddened and teary-eyed after discussing the charges on his bank account. The surveyor went to get ADON AA, and she witnessed Resident #9 say he had not given staff permission to use his card, and he authorized Resident #63 to use his card, but not for those amounts. During an interview on 05/09/25 at 4:41 p.m., the ADM stated she had taken Resident #9 to the bank on 02/24/25 to get his statements so she could see if any money was withdrawn from the account when Resident #63 gave Resident #9's bank card to CNA E and CNA N. She said Resident #9 kept his bank card for his own use. The ADM stated the bank was not going to give him another card because of the fraudulent activity. The ADM stated, I agreed with the lady at the bank. The ADM stated on a Monday (02/24/25) there was a risk call made that included herself, the DON, the Regional Consultant Nurse and the Regional Operations to discuss the incident about CNA E, CNA N, Residents #63 and #9 and another incident with CNA N. The ADM stated during the call on 02/24/25. The ADM said during the investigation she and the DON found out by CNA N that CNA E was given Resident #9's card by Resident #63 and was told to withdraw $200. The ADM stated during the call she told the regional people CNA E attempted to withdraw the money but was unsuccessful. The ADM stated she told them she suspended CNA E and was told by the Regional Operations Manager she should have never suspended her, just written her up because there was no money taken. The ADM stated she was told by Resident #9's family member who was not his POA or guardian to take Resident #9 to a funeral home to take out a pre-burial policy because Resident #9 would not let the family member take him. The ADM stated she took out $13,034.31 and $500 to start a trust fund at the facility. The ADM stated she, and Laundry V took him to the funeral home to take out the policy because he would not let his sister get one. During an interview on 05/09/25 at 5:45 p.m., the BOM stated the ADM told her when she took Resident #9 to the bank after the incident with CNA E, CNA N and Resident #63 the card was put on hold. The BOM stated the ADM did not elaborate if the bank put the card on hold or if she initiated it. The BOM stated she was told by the ADM she did get bank statements that day (02/24/25). The BOM stated Resident #9's family member had brought statements in (on an unknown date) before the incident between CNA E, CNA N, and Resident #63 because she wanted to know what all the withdrawals were for. The BOM stated she told her she would look into it and that was when the BOM spoke with the ADM about the withdrawals of the bank acct. The BOM stated the ADM told her she would look into it. The BOM stated the issue was brought up several times in morning meetings and the ADM stated she was looking into it. The BOM stated it got to a point the ADM stated, We're done talking about that. During an observation on 05/09/25 at 6:15 p.m. the surveyor observed Resident #9 with the BOM attempting to purchase an item out the vending machine using his bank card, but the transaction was denied. This was determined to be an Immediate Jeopardy (IJ) on 05/09/2025 at 06:24 PM. The Administrator was provided with the IJ template on 05/09/2025. The following Plan of Removals was accepted on 05/12/2025 at 02:57 PM. The plan of removal was accepted on 5/12/2025 at 2:57 p.m., and included: A. On 5/9/2025 the ADON completed an assessment on Resident #9 to determine if the resident was having any emotional distress related to this incident. The resident stated he was fine and was attending church services. The assessment was conducted privately prior to church services. B. On 5/9/2025 the DON completed a Comprehensive Trauma screen on the resident, and on 5/9/2025 The V.A. Social Worker was contacted by the facility regarding the need of the resident needing a Psychology evaluation related to this incident. C. On 5/9/2025 the Regional Nurse Consultant provided 1:1 in-service with the DON on the facility's Resident Rights policy that includes: Prior to or upon admission, the social service designee, or another designated staff member, will inform the resident and/or the resident's representative of the resident's rights and responsibilities, Information about residents' rights and responsibilities will be given to the resident both orally and in writing, Information about resident rights will be given to the resident in a language that the resident understands to the extent possible, considering impediments which may be created by the resident's health and mental status. If a resident's knowledge of English or the predominant language of the facility is inadequate for comprehension, a means to communicate the information concerning rights and responsibilities in a language familiar to the resident will be made available and implemented. The facility will have written translations of its statements of rights and responsibilities in commonly encountered foreign languages, if/as applicable. Large print texts of the facility's statement of resident rights and responsibilities should be available. The facility will promptly inform residents of any changes to State or Federal laws relating to resident rights or facility rules. Receipt of any such changes must be acknowledged in writing. A posting of names, addresses, and phone numbers of all pertinent state client advocacy groups will be available in the facility. The facility prominently displays written information regarding how to apply for and use Medicare and Medicaid benefits. All residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression. The right to be fully informed of and participate in or refuse treatment, noting that before initiating or increasing a psychotropic medication, the resident must be notified of and have the right to participate in their treatment, including the right to accept or decline medication. The financial rights to make decisions pertaining to their personal finances. The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents. D. On 5/9/2025 the DON started in-service education with all staff on the facility's Resident Right's policy. This was completed at 8:00pm and no staff will be allowed to work until they have completed their education. E. On 5/8/2025 the Administrator was suspended by the Regional Director of Operations pending investigation. F. On 5/8/2025 the Misappropriation was reported to HHSC by DON. G. On 5/12/2025 the resident will be taken to his bank by the Maintenance Director and Social Services to obtain a new debit card. The residents' family will be encouraged to go as well. The resident does have an active Trust fund in the facility and has access to immediate funds if he chooses. The Resident has made 10 trust fund withdrawals in April 2025, and 4 in May 2025. 1. Identification of Residents Affected or Likely to be Affected: A. On 5/9/2025 the nurse manager on duty completed alert resident questionnaires to determine if any other resident was not allowed to make choices about aspects of his/her life in the facility. The questionnaire included financial choices as well. No other residents were found to be affected by this practice. 2. Actions to Prevent Occurrence/Recurrence: A. Starting 5/7/25 the Social Worker/designee will complete alert resident interviews 3 x week for 3 weeks, then weekly x 6 weeks to validate that all residents are allowed to make choices about aspects of his/her life in the facility, including financial choices. This will be reviewed after each interview is completed by the DON and Social Services so any issues, if applicable, can be addressed immediately. 3. On 5/9/25the facility's DON notified the Medical Director regarding the Immediate Jeopardy the facility received related to Self-determination and Resident Rights. 4. On 5/9/25 the facility conducted an Ad Hoc (created or done as necessary) QAPI meeting to discuss Resident Self-Determination and Resident Rights and sustaining compliance. The surveyor confirmed the following actions had been implemented sufficiently to remove the immediacy by: Record review of Resident #9's emotional assessment revealed it was completed by the DON on 5/09/2025 and indicated there were no issues. Record review of Resident #9's Comprehensive Trauma assessment revealed it was completed by the DON on 5/09/2025 and indicated there was no trauma present. Record review of a referral for Resident #9 dated 5/09/2025 to the VA Social Worker for psychological services. Record review of the Administrator's suspension form dated 5/08/2025 indicated she was suspended pending investigation. Record review of the DON's in-service on the facility's Resident Rights policy dated 5/09/2025 provided by the Regional Nurse Consultant included upon admission the resident or their representative would be informed of the resident's rights orally and written. The in-service included all residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression. The policy included financial rights to make decisions pertaining to their personal finances. Record review of the staff in-service of the Resident Right's policy provided by the DON on 5/09/2025 and would be on-going with all staff across all shifts and disciplines in-serviced prior to being allowed to work. During an observation on 5/12/2025 at 09:45 AM revealed Resident #9 was driven to his financial institution where he was able to obtain a new debit card to his personal account. During an interview on 5/12/2025 at 11:54 AM Resident #9 said he had obtained a working debit card to his personal account. Record review of the questionnaires of 4 alert residents completed by the nurse manager. The questionnaires included the right to make choices about aspects of their life including finances. The questionnaires indicated there were no other residents with concerns regarding their rights including financial rights. Record review of the Ad Hoc QAPI meeting completed on 05/09/25 indicated the DON, MD, BOM, MDS nurse, Activity Director, Treatment Nurse, Social Worker, ADON AA, and ADON XX were present. During an interview on 5/10/2025 at 06:11 PM the Medical Director indicated he was made aware by the DON of the facility's immediate jeopardy regarding Self-determination and Resident Rights. During interviews conducted on 5/10/2025 at 4:22 PM-5/10/2025 at 06:04 PM with the Administrator, DON, ADON AA, ADON XX, MDS Nurse, CNA F, CNA G, CNA L, CNA N, CNA O, MA T, MA T,CNA B, CNA D, CNA E, RN H, MA K, LVN M, CNA P, CNA Q, CNA R, CNA S, CNA U, Van Driver V, MA W, CNA X, MA Y, CNA Z, MA BB, LVN CC, LVN DD, CNA EE, LVN FF, MA GG, RN HH, Dishwasher KK, Dietary Aide LL, [NAME] MM, LVN OO, LVN PP, CNA QQ, CNA RR, CNA SS, LVN TT, MA UU, CNA VV, and RNC WW indicated they had been in-serviced on Self-determination and Resident Rights. The staff indicated a resident had the right to have access to their personal finances. The Administrator was informed the Immediate Jeopardy was removed on 05/12/2025 at 11:54 AM. The facility remained out of compliance at a severity level of potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated due to the facility's need to monitor the implementation of the plan of removal.
Based on interview, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 2 of 23 residents reviewed for misappropriation of resident property. (Resident # 9 and Resident #63) The facility failed to protect Resident #9 from misappropriation of his personal funds when CNA D and CNA E attempted an ATM transaction for $200.00 on 2/21/2025 with unauthorized use of Resident #9's debit card. The facility failed to protect Resident #9 from misappropriation when Resident #63 used Resident #9's debit card and gave it to CNA E and CNA D to withdraw money that was not authorized by Resident #9 to allow CNA E and CNA D to use his debit card. The facility failed to prevent unauthorized transactions on Resident #9's debit card account on 1/27/25, 2/6/25, 2/7/25, and 2/10/25. An IJ was identified on 05/09/25. The IJ template was provided to the facility on [DATE] at 06:29 PM. While the IJ was removed on 05/10/25, the facility remained out of compliance at a scope isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk for decreased quality of life, misappropriation of property, and financial distress. Findings included: Record review of Resident #9's face sheet dated 05/09/25 indicated he was an [AGE] year-old male who readmitted to the facility on [DATE] with the diagnoses dementia and anxiety. Record review of Resident #9's quarterly MDS dated [DATE] indicated he made himself understood and understood others. The MDS also indicated he had a BIMS score of 8 which meant he had moderate cognitive impairment. Record review of Resident #9's care plan revised on 04/07/25 indicated he had impaired cognition and was at risk for further decline with a goal of his needs being met timely, dignity maintained, and current level of functioning maintained. The care plan interventions included keep routine consistent and try to keep caregivers consistent, and monitor/document/report to physician any changes in cognitive function. Record review of the facility associate discplinary memorandum dated 02/24/25 indicated CNA D was suspended pending investigation. Record review of Resident #9's checking account statement dated 01/16/25-02/14/25 indicated there were transactions at the ATM: 1)01/27/25 in the amount of $103.00, $2.00 and $103.00, $2.00 and $203.00, $2.00 and $203.00 2)2/06/2025 in the amount of $103.00, $2.00, $203.00, $2.00 3)2/7/25 in the amount of $103.00; $2.00; $203.00; $2.00 4)2/10/2025 in the amount of $103.00; $2.00, $203.00, $2.00 5) 2/10/2025 Temu charge in the amount of $20.25 and $277.89 During an interview on 05/5/25 at 02:22 PM CNA D stated a lot of staff would go to the store for Resident #63 and purchased things knowing the card did not belong to Resident #63. CNA D stated she never returned back to the facility to work because it's a lot of messy stuff going on and people taking advantage of that man card. During an interview on 05/08/25 at 4:40 p.m., CNA E stated her, and CNA D were leaving for break when Resident #63 asked her if she could go and withdraw $200 from the ATM. CNA E stated Resident #63 handed her a card and gave her the pin number to the card. CNA E stated she did not know at the time the card belonged to Resident #9 until she tried to withdraw the money and suspicious fraud popped up on the screen. CNA E stated she called to the facility and spoke with CNA N and had her to put Resident #63 on the phone. CNA E stated when Resident #63 got on the phone she stated she told him that was not his card and Resident #63 stated yes, I know, go ahead, and bring it back. We have to call his family member to fix the card because the same thing happened yesterday. CNA E stated she brought the card back and gave it to Resident #63 and told him to give it back to Resident #9. CNA E stated she did not report the incident to the Administrator until Monday (02/24/25) when an incident happened between CNA N and another resident. CNA E stated she was suspended that 02/24/25. CNA E stated there had been several occasions she witnessed Resident #63 going to get money from Resident #9 and handing it to Laundry V, CNA N, and Housekeeping C. CNA E stated CNA N's family member charge Resident #9 $1,000 to go to Walmart and CNA N' family member charged him $600 to take him to (city) Texas. CNA E stated Resident #29 family member has charged him $1,000 to go to the bank. CNA E stated Resident #29 and Resident #37 also takes money from Resident #9. CNA E stated she did not report any of these incidents to the ADM because was already aware. CNA E stated she also heard the ADM was taking money from Resident #9. During an interview on 05/06/25 at 1:41 p.m., MA UU stated she has heard about Resident #63 taking money from Resident #9. MA UU stated she had also heard Resident #29's family member coming to take Resident #9 to the bank. MA UU stated she reported what she had heard to the ADM. MA UU stated she could not recall the exact date. During an interview on 05/08/25 05:13 PM The Administrator said she was not aware of any staff members taking Resident #9's money. She said she asked Resident #9 about his money, and he told her he was giving out money to residents if they needed it. The Administrator said she called Resident #9's family member and told them about him giving away his money to residents in the facility. She said the VA came to the facility to assess Resident #9 and what he was doing with his money and the VA said he had the right to give his money away because his BIMS was high. The Administrator said Resident #9 gave Resident #63 his card to use. She said she knew CNA D and CNA E went to the gas station to get some chicken for a red soda. The Administrator said she said she was not aware of the $200 the CNAs attempted to get. She said CNA D and CNA E both were suspended on 02/24/25. She said it was not acceptable for staff to get Resident #9's card. She said she never got any money from that Resident #9. The Administrator said misappropriation was the state guideline but Resident #9 gave Resident #63 his card to use so that made it not misappropriation. She said CNA D and CNA E did not get money. The Administrator said the police said it was not misappropriation if Resident #9 gave it to Resident #63. During an interview on 05/09/25 at 1:41 p.m., Laundry aide V said she did not take any money from Resident #9, and he did not offer her any money. She said she was aware of Resident #63 getting money from Resident #9. She said the Administrator was aware that Resident #63 had taken Resident #9's money, but nothing was done about it. She said she took the Administrator and Resident #9 to the bank several times and once to the funeral home. She said she stayed on the bus, so she was unaware of what occurred while at the bank or the funeral home. During an observation and interview on 05/09/25 at 2:21 PM, Resident #9 said he gave Resident #63 his debit card to use 1 time. He told Resident #63 he could have between 20-30 dollars. He said Resident #63 did pay him back for the money. The surveyor asked if he knew Resident #63 was giving others his debit card, including staff, and Resident #9 said he was unaware and he did not authorize Resident #63 to give his debit card to anyone else. Resident #9 and the surveyor reviewed some of his bank statements. After reviewing the bank statements, he and the surveyor saw some charges on 02/07/25, showing Resident #9 made an ATM withdrawal 3 times for 203 dollars, and 103 dollars, totaling 918 dollars in a day. Resident #9 put his head down and said he did not know about those charges in a shaky voice. Resident #9 became saddened and teary-eyed after discussing the charges on his bank account. The surveyor went to get ADON AA, and she witnessed Resident #9 say he had not given staff permission to use his card, and he authorized Resident #63 to use his card, but not for those amounts. During a telephone interview on 05/09/25 at 2:58 p.m., CNA D stated her, and CNA E was going to lunch and CNA E told her to stop at the store so she could withdraw some money for Resident #63. CNA D stated, I had no dealing with card, I was just the driver. During an interview on 05/09/25 at 4:41 p.m., the ADM stated she had taken Resident #9 to the bank to get his statements so she could see if any money was withdrawn from the account when Resident #63 gave Resident #9 bank card to CNA E and CNA N. The ADM stated the bank was not going to give him another card because of the fraudulent activity. The ADM stated, I agreed with the lady at the bank. The ADM stated on Monday (02/24/25) there was a risk call made that included she, DON, Regional Consultant Nurse and the Regional Operations to discuss the incident about CNA E, CNA D, Residents #63 and #9 and another incident with CNA D. The ADM stated she stated during the call during the investigation her and the DON found out by CNA D that CNA E was given Resident #9 card by Resident #63 and was told to withdraw $200. The ADM stated during the call she told the regional people CNA E attempted to withdraw the money but was unsuccessful. The ADM stated she told them she suspended CNA E and was told by the Regional Operations Manager she should have never suspended her just written her up because there was no money taken. The ADM stated she was told by Resident #9 family member to take Resident #9 to a funeral home to take out a pre-burial policy because Resident #9 would not let his family member take him. The ADM stated she took out $13,034.41 And $500 to start him a trust fund at the facility. The ADM stated her, and Laundry V took him to the funeral home to take out the policy. During an interview on 05/09/25 at 5:45 p.m., the BOM stated the ADM told her when she took Resident #9 to the bank after the incident with CNA E, CNA D and Resident #63 the card was put on hold. The BOM stated the ADM did not elaborate if the bank put the card on hold or if she initiated it. The BOM stated she was told by the ADM she did get bank statements that day. The BOM stated Resident #9 family member had brought statements in before the incident between CNA E, CNA D, and Resident #63 because she wanted to know what all the withdrawals was for. The BOM stated she told her she would look into and that was when the BOM spoke with the ADM about the withdrawals of the bank account. The BOM stated the ADM told her She would look into it. The BOM stated the issue was brought up several times in morning meetings and the ADM stated she was looking into it. The BOM stated it got to a point the ADM stated, were done talking about that. Record review of the facility policy Policy and Procedures: Abuse, Neglect and Exploitation dated 10/24/22 indicated: Policy: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property This was determined to be an Immediate Jeopardy (IJ) on 05/09/2025 at 06:24 PM. Administrator was provided with the IJ template on 05/09/2025. The following Plan of Removals was accepted on 05/12/2025 at 02:57 PM. The plan of removal was accepted on 5/12/2025 at 2:57 p.m., and included: Immediate Action Taken: V. On 5/9/2025 DON completed an assessment on Resident # 9 to determine if resident was having any emotional distress related to this incident. The resident stated he was fine and was attending church services. The assessment was conducted privately prior to church services. W. On 5/9/2025 the DON completed a Comprehensive Trauma screen on the resident, and resident will be referred to Psychology services for further evaluation. On 5/9/2025 The V.A. Social Worker was contacted by the facility regarding the need of the resident needing a Psychology evaluation related to this incident. X. On 5/9/2025 the Regional Director of Operations provided 1:1 in-service with the Regional Nurse Consultant on the facility's abuse, Neglect, and Misappropriations policy. Y. On 5/9/2025 The Regional Nurse Consultant provided 1:1 education to the facility DON on the Abuse, Neglect, and Misappropriations policy. This was completed on 5/9/25. Z. On 5/9/2025 DON started in-service education with all staff on the facility's Abuse, Neglect, Misappropriations policy, including post-test. This was completed at 8:00pm on 5/9/2025, and no staff will be allowed to work until they have completed their education. AA. On 5/8/2025 the Administrator was suspended by the Regional Director of Operations pending investigation. BB. On 5/12/2025 the resident will be taken to his bank by the Maintenance Director and Social Services to obtain a new debit card. Residents' family will be encouraged to go as well. Resident does have an active Trust fund in the facility and has access to immediate funds if he chooses. Residents have made 10 trust fund withdrawals in April 2025, and 4 in May 2025. CC. On 5/8/2025 the Misappropriation incident was reported to HHSC by DON. DD. On 5/8/2025 the Misappropriation incident was also reported to the local law enforcement agency. EE. On 5/9/2025 this incident was reported to HHSC by DON regarding resident # 63 not being authorized to use resident #9 debit card. FF. Resident # 63 was discharged from the facility on 5/7/2025 and does not have access to resident # 9 debit card. GG. On 5/8/2025 the facility started an investigation into the incident, the investigation was completed on 5/10/2025 at 12:00 pm. HH. On 5/9/2025 C.N.A. E was suspended by the DON related to this incident. II. C.N.A. D was suspended on 2/24/2025 and never returned to work. 2. Identification of Residents Affected or Likely to be Affected: A. Starting 5/7/25 the Social Worker/designee will complete alert resident interviews 3 x week for 3 weeks, then weekly x 6 weeks to validate that all residents are allowed to make choices about aspects of his/her life in the facility, including financial choices. This will be reviewed after each interview is completed by the DON and Social Services so any issues, if applicable, can be addressed immediately. B. The Regional Nurse Consultant will oversee this process weekly x 6 weeks. 7. On 5/9/25the facility's DON notified the Medical Director regarding the Immediate Jeopardy the facility received related to failure to implement the abuse policy 8. On 5/9/25 the facility conducted an Ad Hoc QAPI meeting to discuss Misappropriation, and implementation of the abuse policy and sustaining compliance. The surveyor confirmed the following actions had been implemented sufficiently to remove the immediacy by: Record review of Resident #9's emotional assessment was completed by the DON on 5/09/2025. Record review of Resident #9's Comprehensive Trauma assessment was completed by the DON on 5/09/2025. Record review of a referral dated 5/09/2025 to the VA Social Worker for psychological services. Record review of the Administrator's suspension form dated 5/08/2025 indicated she was suspended pending investigation. Record review of the DON's in-service on the facilities Resident Rights policy dated 5/09/2025. Record review of the Regional Nurse Consultant's 1:1 in-service with the DON on the Abuse, Neglect, and Misappropriation policy. Record review of the Regional Director of Operation's 1:1 in-service with the Regional Nurse Consultant on the Abuse, Neglect, and Misappropriation policy. Record review of the in-service on the facility's Abuse, Neglect, Misappropriation policy dated 5/09/2025 conducted by the DON. The in-service also included a post test. During an observation on 5/12/2025 Resident #9 was driven to his financial institution where he was able to obtain a new debit card to his personal account. During an interview on 5/12/2025 at 11:54 AM Resident #9 said he had obtained a working debit card to his personal account. Record review of the reportable incident on 5/08/2025 to HHSC with intake #1008525 regarding Resident #9's misappropriation. Record review of the policy report # dated 5/08/2025 indicated the local authority was notified of the unauthorized use of Resident #9's debit card. Record review of the reportable incident on 5/09/2025 to HHSC with intake #1008767 indicated the reporting of Resident #63's unauthorized use of Resident #9's debit card. Record review of Resident #63's electronic record indicated he had discharged from the facility on 5/07/2025. Record review of the facility's investigation regarding the incident #--- with the completion date of 5/10/2025. Record review of CNA E's personnel record indicated she had been suspended pending investigation. Record review of CNA D's personnel record indicated she was suspended on 2/24/2025 and never returned to work. During an interview on 5/10/2025 the Medical Director indicated he was made aware by the DON of the facility's immediate jeopardy regarding failure to implement the abuse policy regarding misappropriation. During interviews conducted on 5/10/2025 - 5/12/2025 the Administrator, DON, ADON AA, ADON XX, MDS Nurse, CNA F, CNA G, CNA L, CNA N, CNA O, MA T, MA T,CNA B, CNA D, CNA E, RN H, MA K, LVN M, CNA P, CNA Q, CNA R, CNA S, CNA U, Van Driver V, MA W, CNA X, MA Y, CNA Z, MA BB, LVN CC, LVN DD, CNA EE, LVN FF, MA GG, RN HH, Dishwasher KK, Dietary Aide LL, [NAME] MM, LVN OO, LVN PP, CNA QQ, CNA RR, CNA SS, LVN TT, MA UU, CNA VV, and RNC WW indicated they had been in-serviced on the facilities abuse and neglect policy. The staff indicated a resident had the right to be free from abuse including misappropriation of property, and allegations should be reported immediately to the abuse coordinator. The Administrator was informed the Immediate Jeopardy was removed on 05/12/2025 at 11:54 AM. The facility remained out of compliance at a severity level of potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated due to the facility's need to monitor the implementation of the plan of removal.
Based on interviews, and record review the facility failed to protect the resident's right to be free from physical abuse by a staff member for 1 of 23 residents (Resident #34) reviewed for resident abuse. 1. The facility did not ensure Resident #34 was free from abuse when CNA D grabbed her shirt and pulled her towards her to question her about another resident and then hit her on her left arm on 02/23/25. The non-compliance was identified as PNC. The IJ began on 02/23/25 and ended on 02/24/25. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of Resident #34's face sheet dated 05/09/25 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses cerebral infarction (also known as a stroke, which results from dead tissue in the brain) , depression, anxiety disorder, high blood pressure, and diabetes mellitus. Record review of Resident #34's quarterly MDS dated [DATE] indicated she was able to understand others and she was understood by others. The MDS also indicated she had a BIMS score of 15 which meant she was cognitively intact. Resident #34 used a walker and a wheelchair for mobility, and she was independent with all ADL's except setup for showers. Record review of Resident #34's care plan revised on 03/25/25 indicated she had impaired cognition and was at risk for a further decline in cognitive and functional abilities related to: cardiovascular accident, pain, anxiety, DM, depression. The care plan interventions included: identify yourself at each interaction, face resident when speaking and make eye contact, reduce any distractions, and use task segmentation to support short term memory deficits. Record review of the facility's PIR dated 03/03/25 with an incident category of abuse was signed by the Administrator on 03/03/25. The provider investigation report indicated Resident #34 reported CNA D grabbed her shirt and hit her on her arm. The PIR also indicated the incident was witnessed by Resident #61. The PIR indicated the facility completed a head-to-toe assessment of Resident #34, CNA D was suspended pending investigation, police were notified, the staff were in-serviced on abuse and neglect, a psych evaluation was completed for Resident #34, and the family and physician were notified as a response to the abuse incident. Record review of Resident #34's skin observation worksheet dated 02/24/25 indicated she had on skin issues and no redness to her arm after CNA D hit her on her left arm. Record review of Resident #34's progress notes dated 02/24/25 at 09:50 AM completed by LVN M indicated the resident reported to LVN M, CNA D roughed her up on 02/23/25 and Resident #34 said CNA D grabbed Resident #34 by her shirt, jerking her towards her, questioning her about a situation with another resident, and then slapped her on her left shoulder. LVN M reported the allegation to the Administrator and the DON. LVN M charted she completed a head-to-toe assessment, and no red marks, bruises, nor abrasions were noted. Record review of Resident #34's psychological visit note dated 02/24/25 indicated she was seen by the facility psychological company social worker on 02/24/25 from 01:15PM to 02:10 PM for anxiety and depression related to the abuse incident on 02/23/25. The visit note included Clinician reflectively listened as the client described a situation that took place with a staff member the day before in which a staff laid hands on her. Client explained events that had proceeded the confrontation that she learned about later and had made the staff angry. Clinician comforted the client and informed her that in no way was it her fault. Clinician helped the client to write a statement about what had happened to her. The facility is aware and handling the situation. Patient's compliance has been excellent. Patient's mood was moderately improved subsequent to the session. Record review of the police incident report dated 02/24/25 indicated the local police department was called related to Resident #34 being assaulted by a staff member. Resident #34 told the officer that CNA D grabbed her and slapped her on the arm, but she did not have any injuries and she did not want to pursue any charges. Record review of the facility patient questionnaires for 4 other residents dated 02/24/25 completed by the Social Worker indicated no other residents had any concerns with abuse. Record review of the facility in-service for Allegations of Abuse and the abuse coordinator dated 02/24/25 indicated staff members across all shifts had been in-serviced over the abuse and neglect policy, contacting the Administrator immediately, to speak directly with the Administrator to report allegations, not to text allegations, and to call the DON as the second choice if the Administrator was not available. Record review of the facility associate discplinary memorandum dated 02/24/25 indicated CNA D was suspended pending investigation. Record review of the time sheet for CNA D dated 02/20/25-02/27/25 indicated the last time CNA D clocked in the facility on 02/24/25 at 06:14 AM and clocked out of the facility on 02/24/25 at 09:48 AM and her status was now terminated. During an interview on 05/05/25 at 09:34 AM Resident #34 said she was in her room with Resident #61 and CNA D grabbed her by her shirt and pulled her towards her and said, Why didn't you tell me this was not his card and pushed her back. Resident #34 said she did not know what she was talking about, but CNA D told her she did know because she was his bottom Bitch. Resident #34 said CNA D hit her on her left shoulder. She said she held it in and did not tell anyone until the next day on 02/24/25, she reported the incident to LVN M. Resident #34 said the cops came to the facility, but she did not want to press charges on CNA D but did not want her working at the facility anymore. Resident #34 said she had not had any other problems with abuse in the facility. During an interview on 5/5/25 at 2:22 PM CNA D stated she grabbed Resident #34 by the shirt asking where another resident was. CNA D said she did tell Resident#34 she knew where he was. CNA D said she never called her a bitch or hit her on the arm. CNA D said she was looking for Resident #34's friend because her name was mentioned about a debit card being used that belonged to a resident. CNA D stated Resident #34's family member, Resident #61, was in the room when the incident occurred. CNA D said she was suspended on 02/24/25 and she decided not to come back to work. During an interview on 05/08/25 at 03:04 PM Resident #61 said CNA D came into her room and was looking for Resident #34. She said CNA D wanted to see Resident #34 about a credit card. Resident #61 said CNA D waited and grabbed Resident #34 by her shirt when she came into the room. Resident #61 said Resident #34 told CNA D she did not know, and CNA D said yes, she did know because she was his bottom bitch. Resident #61 said CNA D hit Resident #34 on her left shoulder and said, this isn't funny and threw gloves at her and then left the room. During an interview on 05/08/25 at 06:47 PM the DON said Resident #34 reported the incident about CNA D to LVN M. She said she talked with Resident #34, and she told her CNA D grabbed her by her shirt and hit her on her left arm. The DON said she was fearful and upset on 02/24/25. The DON said she interviewed CNA D and she said she grabbed Resident #34's shirt but she was joking. The DON said she suspended CNA D on 02/24/25 and she quit. She said she would have fired CNA D because the incident was confirmed. During an interview on 05/08/25 at 3:05 PM the Administrator said she was the abuse coordinator for the facility. The Administrator stated once the facility learned of the allegation, they reported the incident, the CNA was suspended, they notified the police and investigated to protect all the residents. During interviews conducted on 5/10/2025 at 04:22PM - 5/10/2025 at 06:04 PM the Administrator, DON, ADON AA, ADON XX, MDS Nurse, CNA F, CNA G, CNA L, CNA N, CNA O, MA T, MA T,CNA B, CNA D, CNA E, RN H, MA K, LVN M, CNA P, CNA Q, CNA R, CNA S, CNA U, Van Driver V, MA W, CNA X, MA Y, CNA Z, MA BB, LVN CC, LVN DD, CNA EE, LVN FF, MA GG, RN HH, Dishwasher KK, Dietary Aide LL, [NAME] MM, LVN OO, LVN PP, CNA QQ, CNA RR, CNA SS, LVN TT, MA UU, CNA VV, and RNC WW indicated they had been in-serviced on the facilities abuse and neglect policy. The staff indicated a resident had the right to be free from abuse including misappropriation of property, and allegations should be reported immediately to the abuse coordinator. Record review of the facility policy Policy and Procedures: Abuse, Neglect and Exploitation dated 10/24/22 indicated: Policy: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property The non-compliance was identified as PNC. The IJ began on 02/23/25 and ended on 02/24/25. The facility had corrected the noncompliance before the survey began.
Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 17 resident (Resident #'s 62) reviewed for accidents. The facility failed to have a system in place to identify transfer needs of Resident #62 identified as high risk for falls to prevent injuries. The facility failed to evaluate and revise interventions after Resident #62 who was identified as being at risk for fall and suffered injuires from falls. The facility failed to ensure CNA B used a gait belt during transfer on 01/06/25 which resulted in a fractured left ankle for Resident #62. The facility failed to ensure CNAs B and L performed a correct mechanical lift transfer on 05/05/25 for Resident #62. These failures could place residents at risk of accidents that could result in serious injury, harm, impairment, or death. Findings included: Record review of Resident #62's face sheet dated 05/06/25 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses dementia, history of falling, muscle weakness, and lack of coordination. Record review of Resident #62's significant change MDS dated [DATE] indicated she made herself understood and understood others. The MDS also indicated she had a BIMS score of 12 which meant she had moderate cognitive impairment. The MDS indicated Resident #62 had lower extremity impairment on one side and required maximal assistance with transfers. The MDS also indicated Resident #62 had a fall related to a fracture within the last month. Record review of Resident #62's admission MDS dated [DATE] indicated she did not have any extremity impairments. The MDS also indicated she was dependent on staff for transfers. Record review of Resident #62's care plan dated 03/18/25 indicated she had an ADL self-care performance deficit and was at risk for not having her needs met in a timely manner with interventions for her to have 1 person assist with transfers. The care plan did not indicate Resident #62 was a high risk for falls or the staff needed to use a hoyer lift for transfers. The care plan also indicated Resident #62 had a potential for falls with the only intervention being a fall risk screening upon admission and quarterly to identify risk factors. Record review of Resident #62's fall risk assessment, dated 11/28/22, indicated she was a high risk for falls. During an interview on 05/05/25 at 10:44 AM Resident #62 said she had the leg brace on her left foot due to a CNA transferring her from her bed to her chair causing her ankle to pop and it ended up being fractured. Resident #62 said she thought there were 2 CNAs at the time, but she could not remember for sure, but no gait belt was used while she was transferred. Resident #62 said since the incident, the CNAs used a - lift to transfer her. During an observation on 05/05/25 at 10:59 AM CNA L and CNA B transferred Resident #62 from her bed to her wheelchair. CNA L placed the r lift under the bed and failed to lock it in position prior to lifting Resident #62 in the air. CNA L locked the lift prior to sitting Resident #62 in the chair. During an interview on 05/05/25 at 11:16 AM CNA L said she realized that she did not lock the hoyer lift when she was placingResident #62 and began to lift her. CNA L said she didn't see a problem with not locking the hoyer lift because she was holding her, but she did understand that there were risks when you do not lock the hoyer lift prior to lifting the residents in the air. CNA L said she could not tell me a risk. During an interview on 05/06/25 at 12:32 PM LVN DD said she was floor nurse on 01/06/25 when Resident #62 had a transfer that resulted in the fracture of her left ankle. LVN DD said she remembered the CNA B which was the CNA that came and got her. She CNA B told her she was getting her up and she could stand and pivot, but Resident #62's body turned, and her left foot did not which caused it to fracture with exposed bone. LVN DD said CNA B was the only CNA in the room. LVN DD said Resident #62 was considered a one person assist because she could stand and pivot, but she needed guidance with a gait belt with transfers. During an interview on 05/06/25 at 12:41 PM CNA B said she was the only CNA in the room on 01/06/25. CNA B said Resident #62 was a one person assist for transfers prior to her fracture and she required a hoyer lift for transfers after the incident. She said Resident #62 did not move her feet during the transfer and she went down while she was trying to transfer her. CNA B said the only thing to do at that point was to brace Resident #62 and try to prevent the fall to the floor. CNA B pulled up the CNA Kardex (documentation kiosk to where it tells the CNA how residents are to be transferred) and Resident #62 had 1X person assist on her care plan for transfers. CNA B said the information was incorrect, but she knew that Resident #62 required 2 staffs to assist now. She said there was no other way for CNAs to find out how to transfer outside of that except word of mouth. CNA B said she did not use a gait belt, but she never used it with Resident #62. CNA B said she should have used a gait belt because it could have helped her and Resident #62 for situations like the incident with Resident #62 unable to move her feet. During an interview on 05/06/25 at 03:37 PM the DON said she expected them to use a gait belt with everyone unless they were totally independent. She said improper transfers placed residents at a higher risk for falls or injury. The DON said the nursing management nurses(DON, ADONs) were responsible for ensuring the CNAs were trained on using the hoyer lifts upon hire and annually. During an interview on 05/07/25 at 9:39 AM, the DON stated when residents had falls it was a collaborative effort between she, the ADONs and the MDS Coordinator. The DON stated with an unwitnessed fall, neuro checks should be performed unless they go out to the hospital, a fall risk assessment, head-toe assessment and the CP should be updated with new interventions after it's discussed during morning meetings. The DON said they the nursing management also completed rounding. The DON stated high risk falls should be CP and it should say potential for or at risk for falls. The DON stated the CP did not specify high risk or moderate. The DON stated the standard protocol for transferring someone without a hoyer was to use a gait belt unless it's an independent resident. The DON stated the same measures would be performed for a witnessed except neuros unless the resident was seen hitting their head. The DON said the ADONs and were responsible for ensuring the staff were trained on transfers for residents. During an interview on 05/08/25 at 12:54 PM the Administrator said her expectation was for the staff to utilize the tools that the facility was providing them and for them to provide safe transfers and be knowledgeable of the care plans for ways to prevent falls. The Administrator said she expected nurses and CNAs to complete task and assist residents to the best of their ability and if needed they could come to her or the therapy department and get assistance or training as needed to complete task. The Administrator said all nurses (floor nurses, MDS nurse, treatment nurse, DON, and ADONs) were responsible for ensuring the updated information for residents was accurate. The Administrator said the social worker also has a part in care planning. The Administrator said she expected the staff to notify the administrator when falls happen and notify the DON to ensure the process is completed correctly. She said she expected the nurses to assess the resident, call the doctors, and send to ER if needed. The Administrator said she expected incident reports to be completed, neurological checks to be started if needed, and then all the management staff to come behind and update changes accordingly so CNAs are aware of changes when they pull care plans and Kardex information. The Administrator said the failure of not updating the care plans and ADL assistance placed risks to the numerous. She said the resident's risk depended on which resident. The Administrator said some of the risks included risk of falls, risk for poor transfers, and injuries. Record review of the facility policy Fall Management System reviewed 02/28/2025 indicated: It is the policy of this facility that each resident will be assessed to determine his/her risk for falls, and a plan of care implemented based on resident's needs .
Inspection of August 18, 2023
1 findingBased on observation, interview, and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as possible and each resident receives adequate supervision to prevent accidents for 14 of 87 (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) residents reviewed for accidents/hazards. The facility failed to provide adequate supervision for Resident #1 when she left the facility with a stranger on [DATE]. Resident #1 was taken approximately 25 miles away from the facility to her former residence, where the stranger dropped her off. Resident #1 was gone from the facility for approximately 1 and ,d+[DATE] hours. The facility was not aware she had left the facility. The facility failed to complete an updated elopement assessment when Resident #1 displayed wandering/elopement behaviors. The facility failed to complete a quarterly elopement assessment for Resident #1 #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12 #13, and #14. These failures resulted in Resident #1's elopement from the facility and placed her and other residents at risk for serious injury, serious harm, serious impairment or death. An Immediate Jeopardy (IJ) was identified on [DATE] at 9:45 a.m. The IJ template was provided to the facility on [DATE] at 10:14 a.m. While the IJ was removed on [DATE] at 3:24 p.m., the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that is not immediate due to the facility's need to complete in-services and evaluate the effectiveness of the corrective systems. These failures could place residents with exit seeking behaviors at risk for injury or death. Findings included: 1.Record review of Resident #1's face sheet indicated she was [AGE] years old and admitted to the facility on [DATE] with diagnoses including, dementia, anxiety, depression, heart disease, type II diabetes, high blood pressure, muscle weakness and lack of coordination. Record review of the MDS dated [DATE] indicated Resident #1 had the behavior of wandering that occurred 1 to 3 days during the 7 days look back period. Record review of the MDS dated [DATE] indicated Resident #1 usually made herself understood and usually understood others. The MDS indicated she had severe cognitive impairment (BIMS of 5). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #1 had exhibited no behavior of wandering during the 7 days look back. The MDS indicated Resident #1 required extensive assistance with mobility and bathing. The MDS indicated Resident #1 required limited assistance with toilet use. The MDS indicated she required supervision with all other ADLs. The MDS indicated Resident #1 was not steady and was only able to stabilize with staff assistance when walking (with assistive device), turning around, and moving on and off the toilet. The MDS indicated she was frequently incontinent of bowel and bladder. Record review of Resident #1's care plan dated [DATE] indicated Resident #1 wandered related to cognitive impairment and was at [NAME] for injury. The care plan interventions were, attempt to determine any isolated or cause of wandering; weigh monthly; redirect resident if resident entered a restricted area; encourage social and activity attendance; use verbal clues for redirection to dissuade exit seeking behaviors; distract resident from wandering by offering pleasant diversions, structured activities, food, television, book, etc . There were no updated care plan interventions after the elopement incident on [DATE]. Record review of Resident #1's admission elopement assessment dated [DATE] indicated Resident #1 scored her as zero and stated, Not at risk to elope at this time . The elopement assessment stated, a combined score of 6 or more triggers possible elopement risk. The elopement assessment indicated the assessment was to be completed on initial (admission), re admit, quarterly, or significant change. The score of zero resulted from the following behavioral observation questions/responses: *Spends time on the first floor or wanders between floors or units? -Response: no; *Hangs around facility exits and/or stairways? -Response: no; *Verbalizes a serious/strong intent to leave the facility in the absence of an appropriate discharge plan? -Response: no; *Responds poorly to staff re-direction when roaming into areas that are off limits or unauthorized. -Response: no *Has the physical ability to leave the building? -Response: no *Becomes agitated, confused and/or disoriented or displays consistently poor judgement (i.e., would not be able to safely care for him/herself outside of the facility)? -Response: no; and *Engages in theme behavior(i.e., leaving for work, seeking his/her car, searching for children, seeking people/places from days/years gone by)? -Response: no This assessment was completed by LVN A. Record review of the nursing note for Resident #1 dated [DATE] at 10:49 p.m., Res. (Resident #1) up ambulating the facility with walker without distress or pain noted. Confused and forgetful. Wanders hallway without attempt to leave facility. Redirected easily . This note was written by LVN C. Record review of the nursing note for Resident #1 dated [DATE] at 9:40 p.m., stated Res. (Resident #1) up ambulating facility without distress or pain. Alert and responsive. Disoriented and wandering facility. Redirected easily . This note was written by LVN C. Record review of the nursing note for Resident #1 dated [DATE] at 2:00 p.m. stated Left facility with other family and did not sign out, family brought (Resident #1) back safely. This note was written by LVN A. Record review of the nursing notes for Resident #1 from [DATE] to [DATE] found no additional notes which referenced wandering or elopement behaviors. Record review of Resident #1's elopement assessment dated [DATE] indicated Resident #1 scored her as an 8 and stated, At risk for elopement . The elopement assessment stated, a combined score of 6 or more triggers possible elopement risk. The elopement assessment indicated the assessment was to be completed on initial (admission), re admit, quarterly, or significant change. The score of eight resulted from the following behavioral observation questions/responses: *Spends time on the first floor or wanders between floors or units? -Response: no; *Hangs around facility exits and/or stairways? -Response: no; *Verbalizes a serious/strong intent to leave the facility in the absence of an appropriate discharge plan? -Response: yes; *Responds poorly to staff re-direction when roaming into areas that are off limits or unauthorized. -Response: no *Has the physical ability to leave the building? -Response: yes *Becomes agitated, confused and/or disoriented or displays consistently poor judgement (i.e., would not be able to safely care for him/herself outside of the facility)? -Response: yes; and *Engages in theme behavior (i.e., leaving for work, seeking his/her car, searching for children, seeking people/places from days/years gone by)? -Response: Yes This assessment was completed by RN B. Record review of the elopement assessments completed for Resident #1 since her admission on [DATE] to [DATE] revealed Resident #1 had an elopement assessment completed upon her admission to the facility ([DATE]) and after her elopement incident ([DATE]). The elopement assessments revealed there were no additional elopement assessments between [DATE] and [DATE]. During an interview on [DATE] at 10:18 a.m., Resident #1's visitor said [DATE] she was at home with her family. Resident #1's visitor said a family member noticed a car pull up to Resident #1's former residence. Resident #1's visitor explained her home was adjacent to Resident #1's previous residence. Resident #1 said no one lived in Resident #1's previous home and they (Resident #1's visitor and family) maintained the property. Resident #1'svisitor said they (Resident #1's visitor and family) watched as car pulled up an older gentleman got out of the car and assisted an older woman out of the car (she explained the distance from which she was observing impeded her ability to initially identify the woman). Resident #1's visitor said they (Resident #1's visitor and family) watched as the car drove off. Resident #1's visitor said approximately 10 minutes or so had passed and they (Resident #1's visitor and family) decided to walk down and check on Resident #1's previous residence. Resident #1's visitor said as they (Resident #1's visitor and family) approached the home they found Resident #1 sitting in her carport. Resident #1's visitor said Resident #1 was confused and was looking for her house keys to get into the home to start laundry and cook dinner for her (Resident #1's) husband. Resident #1's visitor explained Resident #1's husband had been deceased for over a year. Resident #1's visitor said she asked Resident #1 who the man was that had brought her to the home, and she said she did not know him. Resident #1's visitor said they (Resident #1's visitor and family) then returned Resident #1 to the facility. Resident #1's visitor said the home was approximately 25 miles from the facility and estimated Resident #1 had been gone from the facility for ,d+[DATE] ,d+[DATE] hours. Resident #1's visitor said when they (Resident #1's visitor and family) returned to the facility with Resident #1 the facility was not aware she had left. Resident #1's visitor said she was very concerned over the incident. She said the family was thinking about leaving for the day and was so thankful they had not. She said Resident #1 would have been outside without water in the heat for who knows how long had they left the house. During an interview on [DATE] at 10:50 a.m., the Administrator said the front door was staffed by a receptionist on the day ([DATE]) Resident #1 left the facility with another resident's family member. The Administrator said she had spoken with the resident's family member that took Resident #1 from the facility on [DATE]. The Administrator said he (the resident's family member that took Resident #1 from the facility ) was very upset and felt awful, she explained he thought Resident #1 was a visitor who simply needed a ride home. The Administrator said it was possible Resident #1 left with the man while the receptionist had went to bathroom. The Administrator the facility receptionists were all in-serviced after the elopement and instructed that if they needed to leave the desk, even to use the restroom they were to notify/obtain supervision for the front door. The Administrator said the door was secured with an exit code at the time of the elopement, but the facility now ensured the code for exit was changed daily and only the receptionist and department heads knew the code. The Administrator said Resident #1's admission elopement assessment was negative. The Administrator said elopement assessments were to be completed upon admission and quarterly. The Administrator said she in-serviced staff to complete elopement assessments if residents displayed elopement behaviors even if it was not time for the quarterly elopement assessment. The Administrator said Resident #1 now has a wander guard device (bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time. When a resident with a bracelet approaches a monitored door, the system alarms and alerts caregivers) in place. During an interview and observation on [DATE] at 10:55 a.m., Resident #1 sat in a chair in the social area adjacent to the nurses' station. Resident #1 said I need to go home. Can you take me home? Resident #1 had a wander guard device on her left ankle. During an observation on [DATE] at 10:58 a.m., LVN A walked with Resident #1 to the front entrance of the building. When Resident #1 was within a few feet of the door, the wander guard system began to alarm. During an interview on [DATE] at 11:05 a.m., LVN A said she regularly took care of Resident #1 on the 6:00 a.m. to 6:00 p.m. shift. LVN A said Resident #1 wandered in the facility but had never been exit seeking before [DATE]. LVN A said Resident #1 would always approach staff and make statements like, 'I need to go home', 'Where is my son?', Do you know where (city of former residence) Texas is?'. LVN A said wandering and making those statements/asking those questions ('I need to go home', 'Where is my son?', Do you know where (city of former residence) Texas is?') were not new behaviors for Resident #1 and said she those behaviors were present since her admission. LVN A said Resident #1 was always easily redirected and reorientated. LVN A said she took care of Resident #1 on [DATE] and served he lunch in the dining room that day. LVN A said she had no idea that Resident #1 had left the facility until her (Resident #1's) family brought her back to the facility. LVN A said she would have to look at her nursing documentation to know what time Resident #1 had returned to the facility. LVN A said she believed Resident #1 was gone from the facility for approximately an hour. LVN A said elopement assessments should be completed on admission, readmission, quarterly and with any change of condition. During an interview on [DATE] at 11:15 a.m., CNA M said she regularly took care of Resident #1. said Resident #1 wandered in the facility but had never been exit seeking before [DATE]. CNA M said LVN A said Resident #1 would always approach staff and say things like, 'Where am I?', 'Where is my son?', 'I need to go home to my husband'. During an interview on [DATE] at 2:55 p.m., CNA N said she regularly took care of Resident #1. CNA N said she regularly took care of Resident #1. She said Resident #1 wandered in the facility but typically approached staff and say things like, 'Where am I?', 'I need to go home', 'Do you know where (city of former residence) Texas is?' CNA N said Resident #1 was not exit seeking before the [DATE]. During an interview on [DATE] at 3:00 p.m., LVN C said she regularly took care of Resident #1 on the 6:00 p.m.- to 6:00 a.m. shift. LVN C said elopement assessments should be completed on admission, readmission, quarterly and with any change of condition. LVN C regularly wandered the facility but not aimlessly. LVN C said she would sometimes be tearful and say she (Resident #1) needed to go home. LVN C said Resident #1 was always easily reoriented and reassured that she (Resident #1) lived in the facility. LVN C said elopement assessments should be completed on admission, readmission, quarterly and with any change of condition. During an interview on [DATE] at 3:14 p.m., LVN L said elopement assessments should be completed on admission, readmission, quarterly and with any change of condition. LVN L said she did not regularly care for Resident #1 as her primary nurse but was familiar with her. LVN L said Resident #1 wandered the facility in the area in front of the nurses station. LVN L said she would approach staff and say things like 'Where am I?', 'I need to go home', 'Do you know where (city of former residence) Texas is?' 'Do you know where my son is?'. LVN L said Resident #1 was not exit seeking and was easily reoriented. During an interview on [DATE] at 3:23 p.m., RN D said she regularly cared for Resident #1 on 6:00 a.m. to 6:00 p.m. shift. RN D said Resident #1 would always approach staff and make statements like, 'I need to go home', 'Where is my son?', and 'Do you know where (city of former residence) Texas is?' Rn D said Resident #1 was easily reoriented. RN D said Resident #1 was not exit seeking but always wandered the facility. RN D said elopement assessments should be completed on admission, readmission, quarterly and with any change of condition. During an interview on [DATE] at 10:20 a.m., LVN A said when she completed the admission elopement assessment on [DATE] for Resident #1, she (Resident #1) had been in the facility a few hours. LVN A said she based her answers on the observations she had at that time ([DATE]) and from speaking with the family. LVN A said Resident #1 did not receive another elopement assessment until after she left the faciity on [DATE]. LVN A said elopement assessments should be completed on admission, readmission, quarterly and with any change of condition. LVN A said nurses are alerted by the EMR system what assessments are due and when they need to be completed. LVN A said if the assessment does not appear on the work list, the nurse is not aware the assessment needs to be completed. LVN A said had she completed an assessment on Resident #1 at the end of April or beginning of [DATE] she would have answered the elopement assessment questions in the following manner: *Spends time on the first floor or wanders between floors or units? -Response: yes *Hangs around facility exits and/or stairways? -Response: no; *Verbalizes a serious/strong intent to leave the facility in the absence of an appropriate discharge plan? -Response: no; *Responds poorly to staff re-direction when roaming into areas that are off limits or unauthorized. -Response: no *Has the physical ability to leave the building? -Response: yes *Becomes agitated, confused and/or disoriented or displays consistently poor judgement (i.e., would not be able to safely care for him/herself outside of the facility)? -Response: yes; and *Engages in theme behavior (i.e., leaving for work, seeking his/her car, searching for children, seeking people/places from days/years gone by)? -Response: yes LVN A said her responses would have scored Resident #1 as a 6 and triggered her as a risk for elopement. During an interview on [DATE] at 11:41 receptionist F said she worked at the facility supervising the front entrance on [DATE]from 12:00 p.m., to 2:00 p.m. Receptionist F said she saw the family visitor Resident #1 was said to have left with. Receptionist F said she did not see Resident #1 leave the building with the family visitor. Receptionist F insisted she left her desk at no time between 12:00 p.m. to 2:00 p.m. An interview with the male visitor that took Resident #1 from the facility on [DATE] was attempted on [DATE] and [DATE] but was not completed. During an interview on [DATE] at 11:44 p.m., RN B said she was familiar with Resident #1. RN B said elopement assessments should be completed on admission, readmission, quarterly and with any change of condition. RN B said nurses know what residents need an elopement assessment because the EMR system would populate the assessments due to be completed. RN B said there was in issue when the EMR updated a few months ago that seemed to have affected the generation of the assessment lists due for residents. RN B said they discovered the issue because the EMR system was saying residents had assessments due that had already been completed. RN B said she believed this EMR issue was why Resident #1 did not trigger for a quarterly elopement assessment. RN B said had she completed an elopement assessment on Resident #1 at the end of April or beginning of [DATE] she would have answered the elopement assessment questions in the following manner: *Spends time on the first floor or wanders between floors or units? -Response: yes *Hangs around facility exits and/or stairways? -Response: no; *Verbalizes a serious/strong intent to leave the facility in the absence of an appropriate discharge plan? -Response: no; *Responds poorly to staff re-direction when roaming into areas that are off limits or unauthorized. -Response: no *Has the physical ability to leave the building? -Response: yes *Becomes agitated, confused and/or disoriented or displays consistently poor judgement (i.e., would not be able to safely care for him/herself outside of the facility)? -Response: yes; and *Engages in theme behavior (i.e., leaving for work, seeking his/her car, searching for children, seeking people/places from days/years gone by)? -Response: yes RN B said her responses would have scored Resident #1 as a 6 and triggered her as a risk for elopement risk. RN B said had the quarterly assessment been performed and triggered Resident #1 as an elopement risk, we (facility staff) would have spoke to the family and placed a wander guard system at that time. During an interview on [DATE] at 12:00 p.m., the Corporate RNC stated she was familiar with Resident #1. The Corporate RNC said had she completed an elopement assessment on Resident #1 at the end of April or beginning of [DATE] she would have answered the elopement assessment questions in the following manner: *Spends time on the first floor or wanders between floors or units? -Response: yes but she was always easily redirected.; *Hangs around facility exits and/or stairways? -Response: no; *Verbalizes a serious/strong intent to leave the facility in the absence of an appropriate discharge plan? -Response: no; *Responds poorly to staff re-direction when roaming into areas that are off limits or unauthorized. -Response: no; *Has the physical ability to leave the building? -Response: yes; *Becomes agitated, confused and/or disoriented or displays consistently poor judgement (i.e., would not be able to safely care for him/herself outside of the facility)? -Response: yes; and *Engages in theme behavior (i.e., leaving for work, seeking his/her car, searching for children, seeking people/places from days/years gone by)? -Response: yes The Corporate RNC said her responses would have scored Resident #1 as a 6 and triggered her as a risk for elopement risk. The Corporate RNC said had the quarterly assessment been performed and triggered Resident #1 as an elopement risk, she would have relied on the judgement of the nursing staff. The Corporate RNC said there was updated to the EMR system that effected the generation of the list of assessments nurses would be prompted to complete. The Corporate RNC said this EMR issue is what cause Resident #1 to miss her quarterly elopement assessment. The Corporate Nurse said the problem was recognized sometime in [DATE]. The Corporate RNC said she was working in her buildings to come up with a solution in May/June of 2023 and it was decide all assessments would be started on the next MDS that was due for each resident -instead of a needle in the haystack approach. 2.Record review of Resident #2's face sheet indicated she was [AGE] years old and readmitted to the facility on [DATE] with diagnoses including, dementia, history of right femur fracture, osteoporosis atrial fibrillation, heart failure, muscle weakness, repeated falls, and the presence of right artificial hip joint. Record review of the MDS dated [DATE] indicated Resident #2 made herself understood and understood others. The MDS indicated she had moderate cognitive impairment (BIMS of 11). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #2 had exhibited no behavior of wandering during the 7 days look back. The MDS indicated Resident #2 required extensive assistance with bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. The MDS indicated she required supervision with locomotion in her wheelchair and eating. The care plan revised on [DATE] indicated Resident #2 had impaired cognition and was at risk for further cognitive decline due to dementia. The care plan interventions included, monitor/document report to physician any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status changes. Record review of the elopement assessments on [DATE] completed for Resident #2 since [DATE] revealed Resident #2 had a quarterly elopement assessment completed [DATE] and no additional elopement assessments had been completed. 3.Record review of Resident #3's face sheet indicated she was [AGE] years old and admitted to the facility on [DATE] with diagnoses including, dementia, history of stroke, hemiplegia and hemiparesis affecting the right dominant side, heart disease, and heart failure. Record review of the MDS dated [DATE] indicated Resident #3 sometimes made herself understood and sometimes understood others. The MDS indicated she had severe cognitive impairment (BIMS of 1). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #3 had exhibited no behavior of wandering during the 7 days look back. The MDS indicated Resident #3 required extensive assistance with bed mobility, transfers, locomotion in her wheelchair on the unit, dressing, and personal hygiene. The MDS indicated she required limited assistance with locomotion off the unit in her wheelchair. The MDS indicated she required supervision with locomotion in her wheelchair and eating. The MDS indicated walking had not occurred during the 7 day look back period. The MDS indicated she was totally dependent on staff for toileting and bathing. The care plan revised on [DATE] indicated Resident #3 had impaired cognition and was at risk for further cognitive decline due to dementia. The care plan interventions included, provide a homelike environment, visible clocks, a calendar, low glare light, consistent care routines, and familiar objects. Record review of the elopement assessments on [DATE] completed for Resident #3 since [DATE] revealed Resident #3 had an admission elopement assessment completed [DATE] and no additional elopement assessments had been completed. 4. Record review of Resident #4's face sheet indicated she was [AGE] years old and readmitted to the facility on [DATE] with diagnoses including, dementia, Type II diabetes, heart disease, heart failure and COPD (chronic obstructive pulmonary disease). Record review of the MDS dated [DATE] indicated Resident #4 made herself understood and understood others. The MDS indicated she had intact cognition (BIMS of 13). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #4 had exhibited no behavior of wandering during the 7 days look back. The MDS indicated Resident #4 required supervision only with ADLS. The care plan revised on [DATE] indicated Resident #4 had impaired cognition and was at risk for further cognitive decline due to dementia. The care plan interventions included monitor/document report to physician any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status changes. Record review of the elopement assessments on [DATE] completed for Resident #4 since [DATE] revealed Resident #4 had an admission elopement assessment completed [DATE] and no additional elopement assessments had been completed. 5.Record review of Resident #5's face sheet indicated she was [AGE] years old and admitted to the facility on [DATE] with diagnoses including, history of hydrocephalus, high blood pressure, Type II diabetes, chronic migraine, seizures, muscle weakness and lack of coordination. Record review of the MDS dated [DATE] indicated Resident #5 made herself understood and understood others. The MDS indicated she had moderate cognitive impairment (BIMS of 11). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #5 had exhibited no behavior of wandering during the 7 days look back. The MDS indicated Resident #5 required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS indicated she required supervision with eating and locomotion in her wheelchair. The MDS indicated walking had not occurred during the 7 day look back period. The care plan revised on [DATE] indicated Resident #5 had impaired cognition and was at risk for further cognitive decline due to confused and forgetful at times. The care plan interventions included, monitor/document report to physician any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status changes. Record review of the elopement assessments on [DATE] completed for Resident #5 since [DATE] revealed Resident #5 had a quarterly elopement assessment completed [DATE] and no additional elopement assessments had been completed. 6. Record review of Resident #6's face sheet indicated she was [AGE] years old and admitted to the facility on [DATE] with diagnoses including, dementia, high blood pressure COPD, history of stroke, muscle weakness, lack of coordination and severe glaucoma. Record review of the MDS dated [DATE] indicated Resident #6 made herself understood and understood others. The MDS indicated she had moderate cognitive impairment (BIMS of 12). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #6 had exhibited no behavior of wandering during the 7 days look back. The MDS indicated Resident #6 required supervision only with ADLS. The care plan revised on [DATE] indicated Resident #6 had impaired cognition and was at risk for further cognitive decline related to dementia. The care plan interventions included, provide a homelike environment, visible clocks, a calendar, low glare light, consistent care routines, and familiar objects. Record review of the elopement assessments on [DATE] completed for Resident #6 since [DATE] revealed Resident #6 had an admission elopement assessment completed [DATE] and no additional elopement assessments had been completed. 7. Record review of Resident #7's face sheet indicated she was [AGE] years old and readmitted to the facility on [DATE] with diagnoses including, history of strokes, hemiplegia hemiparesis affecting the right dominant side, muscle weakness, lack of coordination, depression, anxiety and polyosteoarthritis (term used when at least five joints are affected with arthritis). Record review of the MDS dated [DATE] indicated Resident #7 made herself understood and understood others. The MDS indicated she had intact cognition (BIMS of 15). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #7 had exhibited no behavior of wandering during the 7 days look back. The MDS indicated Resident #7 was totally dependent on staff for transfers, dressing, and bathing. The MDS indicated she required extensive assistance with bed mobility, locomotion in her wheelchair, toilet use and personal hygiene. The MDS indicated she required supervision only with eating. The care plan revised on [DATE] indicated Resident #7 had impaired cognition and was at risk for further cognitive decline related to history of stroke, depression and anxiety. The care plan interventions included, the care plan interventions included, monitor/document report to physician any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status changes. Record review of the elopement assessments on [DATE] completed for Resident #7 since [DATE] revealed Resident #7 had a re-entry elopement assessment completed [DATE] and no additional elopement assessments had been completed. 8.Record review of Resident #8's face sheet indicated he was [AGE] years old and admitted to the facility on [DATE] with diagnoses including, Parkinson's disease, mild intellectual disabilities, high blood pressure, unsteadiness on feet, and muscle weakness. Record review of the MDS dated [DATE] indicated Resident #8 usually made himself understood and understood others. The MDS indicated he had moderate cognitive impair [TRUNCATED]
Inspection of July 11, 2023
2 findingsBased on observation, interview, and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 3 of 12 (Resident #1, Resident #2, Resident #3) residents reviewed for safe smoking. 1. The facility failed to have a system in place to ensure resident safety while residents were signed out of the facility when smoking and traveling by themselves. 2. Resident #3 was in his wheelchair, smoking in the parking lot and was almost struck by a car. 3. The facility failed to provide supervision for Resident #1, who was allowed to sign herself out and self-propel in a wheelchair to a local convenience store down the street (0.2 miles from facility), loiter in a neighboring medical parking lot, and smoked at the entrance of the facility's parking lot near a two-lane street with a posted speed limit of 30 mph. 4. The facility failed to follow their smoking policy by allowing multiple residents to sign themselves out and smoke and allowing Resident #1 and Resident #2 who required supervision while smoking to smoke unsupervised. There was no designated smoking area in the front of the facility where residents go smoke. 5. The facility had no policy to address resident signing themselves out. 6. The facility did not have a covered area or approved ash trays to fire extinguisher. An Immediate Jeopardy (IJ) situation was identified on 07/08/2023 at 5:00 p.m. The IJ template was provided to the facility on [DATE] at 5:00 p.m. While the IJ was removed on 07/11/2023 at 12:58 p.m., the facility remained out of compliance at a scope of pattern and severity level of no actual harm with the potential for more than minimal harm because all staff had not been trained on the smoking policy, sign out on pass, and incident/accident reporting. Theses failures could place residents at risk for harm, serious injuries, and death. Findings included: 1. Record review of a face sheet dated 07/08/23 indicated Resident #1 was a [AGE] year-old female, admitted on [DATE] with diagnoses including Parkinson's disease (is a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), heart failure (the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), cerebral infarction (stroke), contracture (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) to right hand, contracture of muscle, right upper arm, neuropathy (develops when nerves in the body's extremities - such as the hands, feet and arms - are damaged) and hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction affecting right dominant side. The face sheet indicated Resident #1 was her financial contact and a family member was an emergency contact. Unable to determine Resident #1's legal representative. Record review of an annual MDS assessment dated [DATE] indicated Resident #1 was understood and understood others. Resident #1 had minimal difficulty hearing (difficulty in some environment) with no hearing aid, clear speech, and impaired vision (sees large print, but not regular print in newspapers/books) with corrective lenses. Resident #1 had a BIMS score of 13 which indicated intact cognition and required limited assistance for bed mobility, dressing, toilet use, personal hygiene, and bathing but supervision for transfer. Resident #1 had functional limitation in range of motion (interfered with daily functions or placed resident at risk of injury) with impairment on one side, upper and lower extremities. Resident #1 used a walker and manual wheelchair for a mobility device. Resident #1 used tobacco. Resident #1 was administered an opioid (powerful pain-reducing medications). Record review of a care plan dated 10/22/2022 indicated Resident #1 was a smoker and was at risk for injury. Resident #1 was a safe smoker and did not require an apron. Intervention included educate resident on smoking policy, explain, and show resident and family where designated smoking areas are and repeat as necessary, and assist resident to and from smoking area as needed. Record review of a care plan dated 10/20/22 indicated Resident #1 had impaired visual function and was at risk for falls, injury, and a decline in functional ability. Intervention included involve in activities which do not require vision to participate. Record review of a care plan dated 10/20/22 indicated Resident #1 was in the facility for long-term care placement as a result of a continued need for the services of skilled nursing staff as evidence by an inability to provide self-care. Record review of a care plan dated 05/25/22 indicated Resident #1 had the potential for falls related to stroke/hemiplegia, meds, weakness, unsteady/poor balance, neuropathy, right ankle pain, contractures, and osteoporosis (is a disease that thins and weakens the bones). Intervention included wheelchair operation. Record review of a care plan dated 05/05/23 indicated Resident #1 had communication problems related to stroke, decreased hearing, and does not wear hearing aid. Intervention included anticipate and meet needs. Record review of a progress note for Resident #1, dated 06/15/23 at 4:27 p.m., completed by the ADM, indicated Discussed with Resident #1 today our smoking policy. Resident #1 was found in facility smoking area unsupervised actively smoking. When asked how Resident #1 got cigarette she said out of the smoke box, but nursing staff says they didn't provide the cigarettes or the box to her. Resident #1 was educated on smoking policy and need to turn in cigarettes and lighter to nurse's station. Record review of a progress note for Resident #1, dated 06/27/23 at 8:25 p.m., completed by LVN E, indicated up in wheelchair at nurse's station after sitting outside for hours . Record review of a smoking assessment dated [DATE], completed by RN A, indicated Resident #1 had visual deficit and needed supervision for adaptive equipment. Record review of a smoking assessment dated [DATE], completed by RN B, indicated Resident #1 had dexterity problem and needed supervision for adaptive equipment. Record review of a smoking assessment dated [DATE], completed by SW C, indicated Resident #1 had dexterity problem and needed supervision for adaptive equipment. Record review of a fall risk assessment dated [DATE], completed by LVN C, indicated Resident #1 was a moderate risk for falls. Record review of Release of Responsibility for Leave of Absence form of Resident #1, at the reception desk, dated 03/12/23-7/7/23 indicated, I, the undersigned, hereby accept complete responsibility for Resident #1 while away from the facility and absolve the management of said facility, its personnel and the attending physician of responsibility for any deterioration in condition, or accident that may happen while the resident/patient is away .Authorization must be signed by the resident/patient . date .time signing out .signature of person accepting responsibility for Resident/Patient . signing in .date .time . signature of facility representative .: *276 out of 279 entries (107 days) Resident #1 did not sign her own signature. *241 out of 279 entries (107 days) Resident #1's destination was not noted. *17 out of 279 entries (107 days) Resident #1 did not have a sign in signature after signing out. *3 out of 107 days Resident #1's sign in was noted 2 hours or more from when she signed out, with outside as the destination. * 18 out of 107 days Resident #1's sign in was noted 2 hours or more from when she signed, with no destination noted. * 3 of the 18 days Resident #1's sign in was noted 2 hours or more from when she signed, with no destination noted, a comment was noted wasn't here when I left. (5/25/23 signed out at 8:30 p.m., 6/19/23 signed out at 8:50 p.m., 6/22/23 signed out at 5:15 p.m., 7/7/23 signed out at 3:11 p.m.). Record review of Release of Responsibility for Leave of Absence form for Resident #1, at the nurse's station, dated 05/17/23- 07/08/23 indicated, I, the undersigned, hereby accept complete responsibility for Resident #1 while away from the facility and absolve the management of said facility, its personnel and the attending physician of responsibility for any deterioration in condition, or accident that may happen while the resident/patient is away .Authorization must be signed by the resident/patient . signing out .date .time . signature of person accepting responsibility for resident/patient .signing in . date .time .signature of facility representative .: * 7 out of 12 entries (9 days) Resident #1 did not sign her own signature. * 12 out of 12 entries (9 days) Resident #1's destination was not noted. * 11 out of 12 entries (9days) Resident #1 did not have a sign in signature after signing out. During an interview and observation on 07/08/23 at 2:45 p.m., Resident #1 was sitting in the front lobby in her wheelchair. Resident #1's right arm was contracted. She said she wanted to be interviewed in the front lobby. Resident #1 aggressively said, Are you here about smoking? Resident #1 said she did not keep her cigarettes on herself, but nursing staff gave her cigarettes from a lock box. She said she had not seen any other residents that smoked, with lighters or cigarettes on them while not on smoke break. Resident #1 said she had not seen other residents smoking in the front parking lot. Resident #1 said she was allowed to smoke at scheduled smoke breaks times but could also smoke alone at other times too. She said she had to sign out to smoke at nonscheduled times and had to go far away from the facility to smoke. Resident #1 said she liked to smoke at the end of the parking lot near the entrance and sometimes she went to the store at the corner. She said she had to wheel herself in the street because there was no sidewalk. Resident #1 said she could barely hold the things she bought at store to bring them back. 2. Record review of a face sheet dated 07/08/23 indicated Resident #2 was a [AGE] year-old female, admitted on [DATE] with diagnoses including dementia (is the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), congestive heart failure (is a serious condition in which the heart doesn't pump blood as efficiently as it should), nicotine dependence (involves physical and psychological factors that make it difficult to stop using tobacco, even if the person wants to quit), cigarettes, long term current use of anticoagulants (are medications that help stop your blood from thickening or clotting.) and chronic obstructive pulmonary disease (is a chronic inflammatory lung disease that causes obstructed airflow from the lungs). The face sheet indicated Resident #2 was her financial contact and a family member was an emergency contact. Unable to determine Resident #2s legal representative. Record review of an admission MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. Resident #2 had minimal difficulty hearing and no hearing aid. Resident #2 had clear speech and moderately impaired vision (limited vision) used corrective lenses. Resident #2 had a BIMS score of 08 which indicated moderate cognition impairment and required limited assistance for toilet use, extensive assistance for bed mobility, transfer, dressing, personal hygiene, and bathing. Resident #2 was not steady, only able to stabilize with staff assistance for walking and turning around and facing the opposite direction while walking. Resident #2 used a walker and wheelchair for mobility devices. The MDS indicated Resident #2 was not a current tobacco use. Resident #2 had a fall in the last 2-6 months prior to admission. Record review of a care plan dated 03/24/23 indicated Resident #2 had impaired cognition and was at risk for a further decline in cognitive and functional abilities related to confusion, forgetfulness, and age-related decline. Resident #2 takes an anticoagulant and was at risk for bleeding. Resident #2 had impaired visual function and was at risk for falls, injury, and decline in functional ability. Resident #2 had a communication problem related to impaired hearing/vision/cognition. Intervention ensure/provide a safe environment. Resident #2 had the potential for falls related to status post-surgery, weakness, decreased mobility, pain, meds, impaired cognition/vision, and history of falls. Resident #2 was a smoker and was at risk for injury. Resident is a smoker and does not require an apron. Interventions included educate on smoking policy and explain and show resident and family where designated smoking areas are and repeat as necessary and assist resident to and from smoking area as needed. Record review of a smoking assessment dated [DATE], completed by RN B, indicated Resident #2 needed supervision for adaptive equipment and supervised with each smoke break. Record review of a smoking assessment dated [DATE], completed by LVN D, indicated Resident #2 needed supervision for adaptive equipment. Record review of Release of Responsibility for Leave of Absence form for Resident #2, at the reception desk, dated 05/16/23-7/7/23 indicated, I, the undersigned, hereby accept complete responsibility for Resident #2 while away from the facility and absolve the management of said facility, its personnel and the attending physician of responsibility for any deterioration in condition, or accident that may happen while the resident/patient is away .Authorization must be signed by the resident/patient . signing out .date .time . signature of person accepting responsibility for resident/patient .signing in . date .time .signature of facility representative .: *32 out of 265 entries Resident #2 did not sign her own signature. *263 out of 265 entries Resident #2's destination was not noted. *9 out of 265 entries Resident #2 did not have a sign in signature after signing out. Record review of Release of Responsibility for Leave of Absence form for Resident #2, at the nurse's station, dated 05/16/23- 07/07/23 indicated, I, the undersigned, hereby accept complete responsibility for Resident #2 while away from the facility and absolve the management of said facility, its personnel and the attending physician of responsibility for any deterioration in condition, or accident that may happen while the resident/patient is away .Authorization must be signed by the resident/patient . signing out .date .time . signature of person accepting responsibility for resident/patient .signing in . date .time .signature of facility representative .: * 14 out of 14 entries Resident #2's destination was not noted. * 4 out of 14 entries Resident #2 did not have a sign in signature after signing out. During an observation on 07/07/23 at 3:35 p.m., Resident #2 was observed smoking in the designated smoking area of the facility with no safety concerns. Resident #2 was supervised by the Maintenance Supervisor. During an observation on 07/08/23 at 9:09 a.m., Resident #2 was observed smoking in the designated smoking area of the facility with no safety concerns. Resident #2 was supervised by the Maintenance Supervisor. During an interview on 07/08/23 at 3:00 p.m., Resident #2 said a couple months ago the facility started letting her check in and out to smoke unsupervised. She said she had to sign out at the nurse's station to get her cigarette and lighter and sign out at the receptionist desk. Resident #2 said she had to smoke 50 feet away from the building but still on the facility's premise. She said when she came back from smoking, she had to turn the cigarettes and lighters back to the nurse. Resident #2 said she put her cigarettes out then rolled it up in napkin or Kleenex in her hand the threw it away in a trash can when she got in the facility. She said she did not throw her cigarettes butts in the ground. Resident #2 said Resident #1 did not sign in or out nor return her cigarettes and lighter to the nurse. She said Resident #3 also smoked out in the front. Resident #2 said the facility instructed her when she smoked in front of the building to wear hat, sunscreen and sit in the shade. 3. Record review of a face sheet dated 07/08/23 indicated Resident #3 was a [AGE] year-old male, admitted [DATE] with diagnoses including cerebral infarction (stroke), vascular dementia (refers to changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction affecting left non-dominant side, lack of coordinator, seizures (is a medical condition where you have a temporary, unstoppable surge of electrical activity in your brain), contracture (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity), left foot, muscle weakness, Type 2 diabetes mellitus (is a disease that occurs when your blood glucose, also called blood sugar, is too high) with diabetic neuropathy (is a type of nerve damage that can occur if you have diabetes) and long term current use of anticoagulants (are medications that help stop your blood from thickening or clotting.). The face sheet indicated Resident #3's family member was his power of attorney for financial and care, emergency contact, and essential care worker. Unable to determine Resident #3's legal representative. Record review of an admission MDS assessment dated [DATE] indicated Resident #3 was understood and understood others. Resident #3 had adequate hearing and vision. Resident #3 had a BIMS of 14 which indicated intact cognition and required extensive assistance for bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. Resident #3 had functional limitation in range of motion on one side, upper and lower extremities. Resident #3 used a wheelchair as a mobility device. Resident #3 had one fall with no injury since admission. Resident #3 used tobacco. Resident #3 was administered an opioid (powerful pain-reducing medications). Record review of a care plan dated 04/25/23 indicated Resident #3 had potential for falls related to stroke history, hemiplegia/hemiparesis, pain meds, antihypertensive meds, contracture left foot, seizure disorder, restless legs syndrome, diabetes, poor balance, impaired mobility, incontinence, and insomnia. Intervention included educate the resident/family/caregivers about safety reminders. Record review of a care plan dated 04/25/23 indicated Resident #3 had a history of seizures and was taking anticonvulsant medication which places the resident at risk for falls and injury. Intervention included to remove objects that resident may strike during seizure activity. Record review of a care plan dated 04/25/23 indicated Resident #3 had alteration in musculoskeletal status related to contracture left foot. Intervention included educate resident, family/caregivers on safety measures that need to be taken in order to reduce risk of falls. Record review of a care plan dated 04/25/23 indicated Resident #3 was taking an anticoagulant and was at risk for bleeding. Record review of a care plan dated 07/07/23 indicated Resident #3 was a smoker and at risk for injury. Resident #3 does not require an apron. Intervention included educate resident on smoking policy, explain, and show resident and family where designated smoking areas are and repeat as necessary and assist resident to and from smoking area as needed. Resident was a safe smoker and did not require direct staff supervision during. Record review of a smoking assessment dated [DATE], completed by RN A, indicated Resident #3 was a safe smoker. Record review of a smoking assessment dated [DATE], completed by Business Development Specialist, indicated Resident #3 was a safe smoker. Record review of Release of Responsibility for Leave of Absence form for Resident #3, at the reception desk, dated 04/14/23-07/07/23 indicated, I, the undersigned, hereby accept complete responsibility for Resident #3 while away from the facility and absolve the management of said facility, its personnel and the attending physician of responsibility for any deterioration in condition, or accident that may happen while the resident/patient is away .Authorization must be signed by the resident/patient . signing out .date .time . signature of person accepting responsibility for resident/patient .signing in . date .time .signature of facility representative .: *169 out of 227 entries Resident #3 did not sign his own signature. *203 out of 227 entries Resident #3's destination was not noted. *4 out of 227 entries Resident #3 did not have a sign in signature after signing out. Record review of Release of Responsibility for Leave of Absence form for Resident #3, at the nurse's station, dated 04/14/23- 07/07/23 indicated, I, the undersigned, hereby accept complete responsibility for Resident #3 while away from the facility and absolve the management of said facility, its personnel and the attending physician of responsibility for any deterioration in condition, or accident that may happen while the resident/patient is away .Authorization must be signed by the resident/patient . signing out .date .time . signature of person accepting responsibility for resident/patient .signing in . date .time .signature of facility representative .: * 45 out of 45 entries Resident #3's destination was not noted. * 15 out of 45 entries Resident #3 did not have a sign in signature after signing out. Record review of the average weather conditions for 04/23, according to the National Weather Service, indicated the high average monthly temperature was 75.3 degrees and 52.9 degrees as the lowest. Record review of the average weather conditions for 05/23, according to the National Weather Service, indicated the high average monthly temperature was 81.7degrees and 60.7 degrees as the lowest. Record review of the average weather conditions for 06/23, according to the National Weather Service, indicated the high average monthly temperature was 89.6 degrees and 70.4 degrees as the lowest. Record review of the average crime rate on 07/13/23, according to the City-Data., indicated the city's crime rate was higher than in 68.2% of U.S. cities. Record review of a list of In-Services in April, May, June 2023, indicated the following .April topics .Life Safety, Abuse/Neglect, Reporting .May topic . who to contact, how to deal with aggressive behaviors .Abuse/ Neglect .June topics .Customer Service, Dining room service, Wasteful with supplies, Abuse/neglect . Record review of In-services in April 2023 indicated no topics on Smoking policy. Record review an undated facility Smoke Breaks list indicated the following, .Times .9:00 AM, 11:00 AM, 1:00 PM, 3:30 PM, 7:00 PM, 9 PM .Primary .Restorative (9:00 AM) .Receptionist (11:00 AM) . Medical Record (1:00 PM) . Maintenance (3:30 PM) . Hall 3 and 4 (7:00 PM) .Hall 1 and 2 (9:00 PM) . During an interview on 07/07/23 at 5:48 p.m., MA O said residents were not supposed to keep cigarettes and lighters on them. She said it was a safety issue to allow residents to smoke in the front area. She said the area was not safe because of people driving in and out of the parking lot. She said about a month ago, she saw a truck almost back into Resident #3. She said Resident #3 liked to sit in the middle of the parking lot. She said a truck was backing out of a parking space and Resident #3 was also wheeling himself backwards, so he was not looking where he was going. She said she had to frantically wave and yell at the visitor and Resident #3 to avoid an accident. She said she did not tell the ADM, DON, or a nurse about the incident. She said she probably should have told someone the next day. During an interview on 07/07/23 at 6:00 p.m., LVN P said residents who smoked in the front were supposed to be 50 ft away from the building and able to get themselves in and out of the building. She said there was no way for the front desk to know if the resident signed out with the nurse. She said unless a nurse was at the nurse's station, they could miss the resident coming back and some might leave the smoking material at the nurse's station when no staff were there. She said she heard the staffing coordinator almost ran into a resident in the front parking lot because the resident was smoking at 5 a.m. She said she told the ADM and DON, she did not think it was safe to allow residents to smoke in the front. She said the nursing staff cannot be around to make sure residents signed out and in or if the residents were smoking 50 ft away from the building. She said staff did not know if residents were keeping cigarettes and lighters in their pockets and were not allowed to search them. She said it was important for them to know if resident had smoking items because they did not want the residents to light something with a lot of oxygen in the building. She said there was also a risk of the residents giving their lighter to someone else. During an observation on 07/08/23 at 8:23 a.m., the facility's front entrance was perpendicular to a two lane, side street with a posted speed limit of 30 mph. On the left side of the street, when facing the main street, the facility was near, a building of medical offices was noted and a convenience store. On the right side of the street, was a local hospital. The side street did not have a sidewalk of either side. The facility's entrance driveway was narrow and was cut off by a metal fence. Near the metal fence, parallel parking spots were noted and regular parking spaces on the other side. The front door entrance was on slight incline with a circular driveway. The maintenance supervisor was picking up trash and used cigarettes. During an interview on 07/08/23 at 8:35 a.m., the ADM said Resident #3 was out on pass for the weekend. During an interview on 07/08/23 at 9:19 a.m., Receptionist F said she worked the front desk on the weekends, either 8am-5pm or 8am-8pm. She said residents could go to the front of the building to smoke. She said residents had to sign in and out in binder when they went out front. She said Resident #1, Resident #2, and Resident #3 were the main residents who smoked out front. She said Resident #3 was noncompliant with signing in and out with each smoke break. She said she had not been in-serviced on the updated Smoking Policy revised in April 2023. She said she had to sign the resident's name sometimes because they would not do it. She said she did not realize the signing out portion on the Release of Responsibility for Leave of Absence was only the signature of the person accepting responsibility for the resident. She said resident had to be 50 ft away from the front door to smoke in the front. She said sometimes the residents were not compliant. She said she would instruct the residents to go smoke in the area with the bench behind the therapy building. She said residents who smoked in the front, left cigarettes butts everywhere. She said there was a trash can by the door but not 50 ft away from the entrance door and no ashtrays. During an interview on 07/08/23 at 11:00 a.m., the payroll coordinator said she had been employed at the facility for 7 years. She said on the weekends she occasionally worked as a CNA. She said since she started 7 years ago, smokers smoked in the back of the facility and at the schedule smoke break times. She said about 90-120 days ago when the new administrator started, smokers were allowed to request their smoking box which held cigarettes and lighter, sign out and in at nurse's station then sign out and in at the receptionist desk and smoke wherever per the administrator. She said the residents did have to smoke at least 50 ft away from the entrance door. She said the residents were supposed to be cognitive enough to sign out and in and return smoking items to the nurse. She said the nurses were supposed to keep up with which resident was smoking out front and if they had turned in their smoking items or not. She said the problem with that situation was that they had to take care of other residents and were not stationed at the nurse's station and different residents were asking for their smoking items at different times. She said she did not know the facility had a revision to the smoking policy in April 2023. She said Resident #1, Resident #2, and Resident #3 did not follow the rules. She said Resident #3 did not routinely return his cigarettes and lighter back to the nurse's station after he smoked. She said he smoked a lot, and a family member brought him 2 packs of cigarettes a day. She said half the time the residents did not sign out and already had their smoking items because they did not turn them in from the previous smoke break. She said she normally arrived to work around 3 a.m.- 6a.m., and residents were outside smoking in the dark parking lot. She said the residents in the front smoked at the front door, in between cars near the metal fence, and at the entrance of the facility parking lot near the hospital. She said she did not think any of the residents who were allowed to smoke in the front were cognitive enough to be outside unsupervised. She said all of residents discarded their used cigarettes on the ground. She said staff from the nearby medical buildings had expressed concerns about the resident being in the front alone. She said Resident #3 had almost been hit by a car in the front parking lot because the visitor could not see him. She said the front area where the residents were allowed to smoke did not have ashtrays or metal receptacles. She said she did not feel like the front parking lot was a safe area to smoke in because it was a high traffic area and tight parking spaces. During an interview on 07/08/23 at 11:22 a.m., SW C said she had been employed for the facility for 2 weeks. She said she would be responsible of care plans and initial assessment. She said she was not fully oriented to the facility. She said she had not received training or in-service of the smoking policy. She said she only knew the resident's smoking material was stored behind the nurse's station. She said she knew all smokers had to be supervised and there was scheduled smoke breaks. She said she knew resident could not smoke within 50 feet of the building, in the front. She said if residents were non-compliant with the smoking policy, counseling was provided. She said she had seen ashtrays and metal receptacles in the back smoking area but not the front. She said she felt there was a gray area if the residents were safe smoking in the front. She said it depended on the resident cognition and physical ability. She said she did not know the residents well enough to determine which residents were safe and unsafe in the front smoking unsupervised. During an interview and observation on 07/08/23 at 11: 30 a.m., the staffing coordinator said she had been employed at the facility for [AGE] years. She said she did fill in and work the floor as a CNA when they were short staffed. She said she thought the ADON had given an in-service on the updated smoking policy but after looking thru in-service binder, she realized they had not done one. She said the smoking area was in the back of the facility and all the residents had to be supervised. She said about 3 weeks ago she noticed residents smoking in the front parking lot of the facility. She said the residents who smoked in the front were usually by the metal fence or by the benches behind the therapy office. She said the front area where the residents smoked did not have metal ashtrays or receptacles. She heard about a resident almost getting hit by a car in the front [TRUNCATED]
Based on observation, interview, and record review the facility failed to ensure a resident had the right to be free from neglect for 3 of 3 residents reviewed for neglect (Resident #1, Resident #2, Resident #3). 1. The facility failed to have a system in place to ensure resident safety while residents were signed out of the facility when smoking and traveling by themselves. 2. Resident #3 was in his wheelchair, smoking in the parking lot and was almost struck by a car. 3. The facility failed to provide supervision for Resident #1, who was allowed to sign herself out and self-propel in a wheelchair to a local convenience store down the street (0.2 miles from facility), loiter in a neighboring medical parking lot, and smoked at the entrance of the facility's parking lot near a two-lane street with a posted speed limit of 30 mph. 4. The facility failed to follow their smoking policy by allowing multiple residents to sign themselves out and smoke and allowing Resident #1 and Resident #2 who required supervision while smoking to smoke unsupervised. There was no designated smoking area in the front of the facility where residents go smoke. 5. The facility had no policy to address resident signing themselves out. 6. The facility did not have a covered area or approved ash trays to fire extinguisher. An Immediate Jeopardy (IJ) situation was identified on 07/10/2023 at 1:35 p.m. The IJ template was provided to the facility on [DATE] at 2:42 p.m. While the IJ was removed on 07/11/2023 at 12:58 p.m., the facility remained out of compliance at a scope of pattern and severity level of no actual harm with the potential for more than minimal harm because all staff had not been trained on the smoking policy, sign out on pass, and incident/accident reporting. Theses failures could place residents at risk for harm, serious injuries, and death. Findings included: 1. Record review of a face sheet dated 07/08/23 indicated Resident #1 was a [AGE] year-old female, admitted on [DATE] with diagnoses including Parkinson's disease (is a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), heart failure (the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), cerebral infarction (stroke), contracture (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) to right hand, contracture of muscle, right upper arm, neuropathy (develops when nerves in the body's extremities - such as the hands, feet and arms - are damaged) and hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction affecting right dominant side. The face sheet indicated Resident #1 was her financial contact and a family member was an emergency contact. Unable to determine Resident #1's legal representative. Record review of an annual MDS assessment dated [DATE] indicated Resident #1 was understood and understood others. Resident #1 had minimal difficulty hearing (difficulty in some environment) with no hearing aid, clear speech, and impaired vision (sees large print, but not regular print in newspapers/books) with corrective lenses. Resident #1 had a BIMS score of 13 which indicated intact cognition and required limited assistance for bed mobility, dressing, toilet use, personal hygiene, and bathing but supervision for transfer. Resident #1 had functional limitation in range of motion (interfered with daily functions or placed resident at risk of injury) with impairment on one side, upper and lower extremities. Resident #1 used a walker and manual wheelchair for a mobility device. Resident #1 used tobacco. Resident #1 was administered an opioid (powerful pain-reducing medications). Record review of a care plan dated 10/22/2022 indicated Resident #1 was a smoker and was at risk for injury. Resident #1 was a safe smoker and did not require an apron. Intervention included educate resident on smoking policy, explain, and show resident and family where designated smoking areas are and repeat as necessary, and assist resident to and from smoking area as needed. Record review of a care plan dated 10/20/22 indicated Resident #1 had impaired visual function and was at risk for falls, injury, and a decline in functional ability. Intervention included involve in activities which do not require vision to participate. Record review of a care plan dated 10/20/22 indicated Resident #1 was in the facility for long-term care placement as a result of a continued need for the services of skilled nursing staff as evidence by an inability to provide self-care. Record review of a care plan dated 05/25/22 indicated Resident #1 had the potential for falls related to stroke/hemiplegia, meds, weakness, unsteady/poor balance, neuropathy, right ankle pain, contractures, and osteoporosis (is a disease that thins and weakens the bones). Intervention included wheelchair operation. Record review of a care plan dated 05/05/23 indicated Resident #1 had communication problems related to stroke, decreased hearing, and does not wear hearing aid. Intervention included anticipate and meet needs. Record review of a progress note for Resident #1, dated 06/15/23 at 4:27 p.m., completed by the ADM, indicated Discussed with Resident #1 today our smoking policy. Resident #1 was found in facility smoking area unsupervised actively smoking. When asked how Resident #1 got cigarette she said out of the smoke box, but nursing staff says they didn't provide the cigarettes or the box to her. Resident #1 was educated on smoking policy and need to turn in cigarettes and lighter to nurse's station. Record review of a progress note for Resident #1, dated 06/27/23 at 8:25 p.m., completed by LVN E, indicated up in wheelchair at nurse's station after sitting outside for hours . Record review of a smoking assessment dated [DATE], completed by RN A, indicated Resident #1 had visual deficit and needed supervision for adaptive equipment. Record review of a smoking assessment dated [DATE], completed by RN B, indicated Resident #1 had dexterity problem and needed supervision for adaptive equipment. Record review of a smoking assessment dated [DATE], completed by SW C, indicated Resident #1 had dexterity problem and needed supervision for adaptive equipment. Record review of a fall risk assessment dated [DATE], completed by LVN C, indicated Resident #1 was a moderate risk for falls. Record review of Release of Responsibility for Leave of Absence form of Resident #1, at the reception desk, dated 03/12/23-7/7/23 indicated, I, the undersigned, hereby accept complete responsibility for Resident #1 while away from the facility and absolve the management of said facility, its personnel and the attending physician of responsibility for any deterioration in condition, or accident that may happen while the resident/patient is away .Authorization must be signed by the resident/patient . date .time signing out .signature of person accepting responsibility for Resident/Patient . signing in .date .time . signature of facility representative .: *276 out of 279 entries (107 days) Resident #1 did not sign her own signature. *241 out of 279 entries (107 days) Resident #1's destination was not noted. *17 out of 279 entries (107 days) Resident #1 did not have a sign in signature after signing out. *3 out of 107 days Resident #1's sign in was noted 2 hours or more from when she signed out, with outside as the destination. * 18 out of 107 days Resident #1's sign in was noted 2 hours or more from when she signed, with no destination noted. * 3 of the 18 days Resident #1's sign in was noted 2 hours or more from when she signed, with no destination noted, a comment was noted wasn't here when I left. (5/25/23 signed out at 8:30 p.m., 6/19/23 signed out at 8:50 p.m., 6/22/23 signed out at 5:15 p.m., 7/7/23 signed out at 3:11 p.m.). Record review of Release of Responsibility for Leave of Absence form for Resident #1, at the nurse's station, dated 05/17/23- 07/08/23 indicated, I, the undersigned, hereby accept complete responsibility for Resident #1 while away from the facility and absolve the management of said facility, its personnel and the attending physician of responsibility for any deterioration in condition, or accident that may happen while the resident/patient is away .Authorization must be signed by the resident/patient . signing out .date .time . signature of person accepting responsibility for resident/patient .signing in . date .time .signature of facility representative .: * 7 out of 12 entries (9 days) Resident #1 did not sign her own signature. * 12 out of 12 entries (9 days) Resident #1's destination was not noted. * 11 out of 12 entries (9days) Resident #1 did not have a sign in signature after signing out. During an interview and observation on 07/08/23 at 2:45 p.m., Resident #1 was sitting in the front lobby in her wheelchair. Resident #1's right arm was contracted. She said she wanted to be interviewed in the front lobby. Resident #1 aggressively said, Are you here about smoking? Resident #1 said she did not keep her cigarettes on herself, but nursing staff gave her cigarettes from a lock box. She said she had not seen any other residents that smoked, with lighters or cigarettes on them while not on smoke break. Resident #1 said she had not seen other residents smoking in the front parking lot. Resident #1 said she was allowed to smoke at scheduled smoke breaks times but could also smoke alone at other times too. She said she had to sign out to smoke at nonscheduled times and had to go far away from the facility to smoke. Resident #1 said she liked to smoke at the end of the parking lot near the entrance and sometimes she went to the store at the corner. She said she had to wheel herself in the street because there was no sidewalk. Resident #1 said she could barely hold the things she bought at store to bring them back. 2. Record review of a face sheet dated 07/08/23 indicated Resident #2 was a [AGE] year-old female, admitted on [DATE] with diagnoses including dementia (is the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), congestive heart failure (is a serious condition in which the heart doesn't pump blood as efficiently as it should), nicotine dependence (involves physical and psychological factors that make it difficult to stop using tobacco, even if the person wants to quit), cigarettes, long term current use of anticoagulants (are medications that help stop your blood from thickening or clotting.) and chronic obstructive pulmonary disease (is a chronic inflammatory lung disease that causes obstructed airflow from the lungs). The face sheet indicated Resident #2 was her financial contact and a family member was an emergency contact. Unable to determine Resident #2s legal representative. Record review of an admission MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. Resident #2 had minimal difficulty hearing and no hearing aid. Resident #2 had clear speech and moderately impaired vision (limited vision) used corrective lenses. Resident #2 had a BIMS score of 08 which indicated moderate cognition impairment and required limited assistance for toilet use, extensive assistance for bed mobility, transfer, dressing, personal hygiene, and bathing. Resident #2 was not steady, only able to stabilize with staff assistance for walking and turning around and facing the opposite direction while walking. Resident #2 used a walker and wheelchair for mobility devices. The MDS indicated Resident #2 was not a current tobacco use. Resident #2 had a fall in the last 2-6 months prior to admission. Record review of a care plan dated 03/24/23 indicated Resident #2 had impaired cognition and was at risk for a further decline in cognitive and functional abilities related to confusion, forgetfulness, and age-related decline. Resident #2 takes an anticoagulant and was at risk for bleeding. Resident #2 had impaired visual function and was at risk for falls, injury, and decline in functional ability. Resident #2 had a communication problem related to impaired hearing/vision/cognition. Intervention ensure/provide a safe environment. Resident #2 had the potential for falls related to status post-surgery, weakness, decreased mobility, pain, meds, impaired cognition/vision, and history of falls. Resident #2 was a smoker and was at risk for injury. Resident is a smoker and does not require an apron. Interventions included educate on smoking policy and explain and show resident and family where designated smoking areas are and repeat as necessary and assist resident to and from smoking area as needed. Record review of a smoking assessment dated [DATE], completed by RN B, indicated Resident #2 needed supervision for adaptive equipment and supervised with each smoke break. Record review of a smoking assessment dated [DATE], completed by LVN D, indicated Resident #2 needed supervision for adaptive equipment. Record review of Release of Responsibility for Leave of Absence form for Resident #2, at the reception desk, dated 05/16/23-7/7/23 indicated, I, the undersigned, hereby accept complete responsibility for Resident #2 while away from the facility and absolve the management of said facility, its personnel and the attending physician of responsibility for any deterioration in condition, or accident that may happen while the resident/patient is away .Authorization must be signed by the resident/patient . signing out .date .time . signature of person accepting responsibility for resident/patient .signing in . date .time .signature of facility representative .: *32 out of 265 entries Resident #2 did not sign her own signature. *263 out of 265 entries Resident #2's destination was not noted. *9 out of 265 entries Resident #2 did not have a sign in signature after signing out. Record review of Release of Responsibility for Leave of Absence form for Resident #2, at the nurse's station, dated 05/16/23- 07/07/23 indicated, I, the undersigned, hereby accept complete responsibility for Resident #2 while away from the facility and absolve the management of said facility, its personnel and the attending physician of responsibility for any deterioration in condition, or accident that may happen while the resident/patient is away .Authorization must be signed by the resident/patient . signing out .date .time . signature of person accepting responsibility for resident/patient .signing in . date .time .signature of facility representative .: * 14 out of 14 entries Resident #2's destination was not noted. * 4 out of 14 entries Resident #2 did not have a sign in signature after signing out. During an observation on 07/07/23 at 3:35 p.m., Resident #2 was observed smoking in the designated smoking area of the facility with no safety concerns. Resident #2 was supervised by the Maintenance Supervisor. During an observation on 07/08/23 at 9:09 a.m., Resident #2 was observed smoking in the designated smoking area of the facility with no safety concerns. Resident #2 was supervised by the Maintenance Supervisor. During an interview on 07/08/23 at 3:00 p.m., Resident #2 said a couple months ago the facility started letting her check in and out to smoke unsupervised. She said she had to sign out at the nurse's station to get her cigarette and lighter and sign out at the receptionist desk. Resident #2 said she had to smoke 50 feet away from the building but still on the facility's premise. She said when she came back from smoking, she had to turn the cigarettes and lighters back to the nurse. Resident #2 said she put her cigarettes out then rolled it up in napkin or Kleenex in her hand the threw it away in a trash can when she got in the facility. She said she did not throw her cigarettes butts in the ground. Resident #2 said Resident #1 did not sign in or out nor return her cigarettes and lighter to the nurse. She said Resident #3 also smoked out in the front. Resident #2 said the facility instructed her when she smoked in front of the building to wear hat, sunscreen and sit in the shade. 3. Record review of a face sheet dated 07/08/23 indicated Resident #3 was a [AGE] year-old male, admitted [DATE] with diagnoses including cerebral infarction (stroke), vascular dementia (refers to changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction affecting left non-dominant side, lack of coordinator, seizures (is a medical condition where you have a temporary, unstoppable surge of electrical activity in your brain), contracture (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity), left foot, muscle weakness, Type 2 diabetes mellitus (is a disease that occurs when your blood glucose, also called blood sugar, is too high) with diabetic neuropathy (is a type of nerve damage that can occur if you have diabetes) and long term current use of anticoagulants (are medications that help stop your blood from thickening or clotting.). The face sheet indicated Resident #3's family member was his power of attorney for financial and care, emergency contact, and essential care worker. Unable to determine Resident #3's legal representative. Record review of an admission MDS assessment dated [DATE] indicated Resident #3 was understood and understood others. Resident #3 had adequate hearing and vision. Resident #3 had a BIMS of 14 which indicated intact cognition and required extensive assistance for bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. Resident #3 had functional limitation in range of motion on one side, upper and lower extremities. Resident #3 used a wheelchair as a mobility device. Resident #3 had one fall with no injury since admission. Resident #3 used tobacco. Resident #3 was administered an opioid (powerful pain-reducing medications). Record review of a care plan dated 04/25/23 indicated Resident #3 had potential for falls related to stroke history, hemiplegia/hemiparesis, pain meds, antihypertensive meds, contracture left foot, seizure disorder, restless legs syndrome, diabetes, poor balance, impaired mobility, incontinence, and insomnia. Intervention included educate the resident/family/caregivers about safety reminders. Record review of a care plan dated 04/25/23 indicated Resident #3 had a history of seizures and was taking anticonvulsant medication which places the resident at risk for falls and injury. Intervention included to remove objects that resident may strike during seizure activity. Record review of a care plan dated 04/25/23 indicated Resident #3 had alteration in musculoskeletal status related to contracture left foot. Intervention included educate resident, family/caregivers on safety measures that need to be taken in order to reduce risk of falls. Record review of a care plan dated 04/25/23 indicated Resident #3 was taking an anticoagulant and was at risk for bleeding. Record review of a care plan dated 07/07/23 indicated Resident #3 was a smoker and at risk for injury. Resident #3 does not require an apron. Intervention included educate resident on smoking policy, explain, and show resident and family where designated smoking areas are and repeat as necessary and assist resident to and from smoking area as needed. Resident was a safe smoker and did not require direct staff supervision during. Record review of a smoking assessment dated [DATE], completed by RN A, indicated Resident #3 was a safe smoker. Record review of a smoking assessment dated [DATE], completed by Business Development Specialist, indicated Resident #3 was a safe smoker. Record review of Release of Responsibility for Leave of Absence form for Resident #3, at the reception desk, dated 04/14/23-07/07/23 indicated, I, the undersigned, hereby accept complete responsibility for Resident #3 while away from the facility and absolve the management of said facility, its personnel and the attending physician of responsibility for any deterioration in condition, or accident that may happen while the resident/patient is away .Authorization must be signed by the resident/patient . signing out .date .time . signature of person accepting responsibility for resident/patient .signing in . date .time .signature of facility representative .: *169 out of 227 entries Resident #3 did not sign his own signature. *203 out of 227 entries Resident #3's destination was not noted. *4 out of 227 entries Resident #3 did not have a sign in signature after signing out. Record review of Release of Responsibility for Leave of Absence form for Resident #3, at the nurse's station, dated 04/14/23- 07/07/23 indicated, I, the undersigned, hereby accept complete responsibility for Resident #3 while away from the facility and absolve the management of said facility, its personnel and the attending physician of responsibility for any deterioration in condition, or accident that may happen while the resident/patient is away .Authorization must be signed by the resident/patient . signing out .date .time . signature of person accepting responsibility for resident/patient .signing in . date .time .signature of facility representative .: * 45 out of 45 entries Resident #3's destination was not noted. * 15 out of 45 entries Resident #3 did not have a sign in signature after signing out. Record review of the average weather conditions for 04/23, according to the National Weather Service, indicated the high average monthly temperature was 75.3 degrees and 52.9 degrees as the lowest. Record review of the average weather conditions for 05/23, according to the National Weather Service, indicated the high average monthly temperature was 81.7degrees and 60.7 degrees as the lowest. Record review of the average weather conditions for 06/23, according to the National Weather Service, indicated the high average monthly temperature was 89.6 degrees and 70.4 degrees as the lowest. Record review of the average crime rate on 07/13/23, according to the City-Data., indicated the city's crime rate was higher than in 68.2% of U.S. cities. Record review of a list of In-Services in April, May, June 2023, indicated the following .April topics .Life Safety, Abuse/Neglect, Reporting .May topic . who to contact, how to deal with aggressive behaviors .Abuse/ Neglect .June topics .Customer Service, Dining room service, Wasteful with supplies, Abuse/neglect . Record review of In-services in April 2023 indicated no topics on Smoking policy. Record review an undated facility Smoke Breaks list indicated the following, .Times .9:00 AM, 11:00 AM, 1:00 PM, 3:30 PM, 7:00 PM, 9 PM .Primary .Restorative (9:00 AM) .Receptionist (11:00 AM) . Medical Record (1:00 PM) . Maintenance (3:30 PM) . Hall 3 and 4 (7:00 PM) .Hall 1 and 2 (9:00 PM) . During an interview on 07/07/23 at 5:48 p.m., MA O said residents were not supposed to keep cigarettes and lighters on them. She said it was a safety issue to allow residents to smoke in the front area. She said the area was not safe because of people driving in and out of the parking lot. She said about a month ago, she saw a truck almost back into Resident #3. She said Resident #3 liked to sit in the middle of the parking lot. She said a truck was backing out of a parking space and Resident #3 was also wheeling himself backwards, so he was not looking where he was going. She said she had to frantically wave and yell at the visitor and Resident #3 to avoid an accident. She said she did not tell the ADM, DON, or a nurse about the incident. She said she probably should have told someone the next day. During an interview on 07/07/23 at 6:00 p.m., LVN P said residents who smoked in the front were supposed to be 50 ft away from the building and able to get themselves in and out of the building. She said there was no way for the front desk to know if the resident signed out with the nurse. She said unless a nurse was at the nurse's station, they could miss the resident coming back and some might leave the smoking material at the nurse's station when no staff were there. She said she heard the staffing coordinator almost ran into a resident in the front parking lot because the resident was smoking at 5 a.m. She said she told the ADM and DON, she did not think it was safe to allow residents to smoke in the front. She said the nursing staff cannot be around to make sure residents signed out and in or if the residents were smoking 50 ft away from the building. She said staff did not know if residents were keeping cigarettes and lighters in their pockets and were not allowed to search them. She said it was important for them to know if resident had smoking items because they did not want the residents to light something with a lot of oxygen in the building. She said there was also a risk of the residents giving their lighter to someone else. During an observation on 07/08/23 at 8:23 a.m., the facility's front entrance was perpendicular to a two lane, side street with a posted speed limit of 30 mph. On the left side of the street, when facing the main street, the facility was near, a building of medical offices was noted and a convenience store. On the right side of the street, was a local hospital. The side street did not have a sidewalk of either side. The facility's entrance driveway was narrow and was cut off by a metal fence. Near the metal fence, parallel parking spots were noted and regular parking spaces on the other side. The front door entrance was on slight incline with a circular driveway. The maintenance supervisor was picking up trash and used cigarettes. During an interview on 07/08/23 at 8:35 a.m., the ADM said Resident #3 was out on pass for the weekend. During an interview on 07/08/23 at 9:19 a.m., Receptionist F said she worked the front desk on the weekends, either 8:00 am-5:00 pm or 8:00 am-8:00pm. She said residents could go to the front of the building to smoke. She said residents had to sign in and out in binder when they went out front. She said Resident #1, Resident #2, and Resident #3 were the main residents who smoked out front. She said Resident #3 was noncompliant with signing in and out with each smoke break. She said she had not been in-serviced on the updated Smoking Policy revised in April 2023. She said she had to sign the resident's name sometimes because they would not do it. She said she did not realize the signing out portion on the Release of Responsibility for Leave of Absence was only the signature of the person accepting responsibility for the resident. She said resident had to be 50 ft away from the front door to smoke in the front. She said sometimes the residents were not compliant. She said she would instruct the residents to go smoke in the area with the bench behind the therapy building. She said residents who smoked in the front, left cigarettes butts everywhere. She said there was a trash can by the door but not 50 ft away from the entrance door and no ashtrays. During an interview on 07/08/23 at 11:00 a.m., the Payroll Coordinator said she had been employed at the facility for 7 years. She said on the weekends she occasionally worked as a CNA. She said since she started 7 years ago, smokers smoked in the back of the facility and at the schedule smoke break times. She said about 90-120 days ago when the new administrator started, smokers were allowed to request their smoking box which held cigarettes and lighter, sign out and in at nurse's station then sign out and in at the receptionist desk and smoke wherever per the administrator. She said the residents did have to smoke at least 50 ft away from the entrance door. She said the residents were supposed to be cognitive enough to sign out and in and return smoking items to the nurse. She said the nurses were supposed to keep up with which resident was smoking out front and if they had turned in their smoking items or not. She said the problem with that situation was that they had to take care of other residents and were not stationed at the nurse's station and different residents were asking for their smoking items at different times. She said she did not know the facility had a revision to the smoking policy in April 2023. She said Resident #1, Resident #2, and Resident #3 did not follow the rules. She said Resident #3 did not routinely return his cigarettes and lighter back to the nurse's station after he smoked. She said he smoked a lot, and a family member brought him 2 packs of cigarettes a day. She said half the time the residents did not sign out and already had their smoking items because they did not turn them in from the previous smoke break. She said she normally arrived to work around 3 a.m.- 6a.m., and residents were outside smoking in the dark parking lot. She said the residents in the front smoked at the front door, in between cars near the metal fence, and at the entrance of the facility parking lot near the hospital. She said she did not think any of the residents who were allowed to smoke in the front were cognitive enough to be outside unsupervised. She said all of residents discarded their used cigarettes on the ground. She said staff from the nearby medical buildings had expressed concerns about the resident being in the front alone. She said Resident #3 had almost been hit by a car in the front parking lot because the visitor could not see him. She said the front area where the residents were allowed to smoke did not have ashtrays or metal receptacles. She said she did not feel like the front parking lot was a safe area to smoke in because it was a high traffic area and tight parking spaces. During an interview on 07/08/23 at 11:22 a.m., SW C said she had been employed for the facility for 2 weeks. She said she would be responsible of care plans and initial assessment. She said she was not fully oriented to the facility. She said she had not received training or in-service of the smoking policy. She said she only knew the resident's smoking material was stored behind the nurse's station. She said she knew all smokers had to be supervised and there was scheduled smoke breaks. She said she knew resident could not smoke within 50 feet of the building, in the front. She said if residents were non-compliant with the smoking policy, counseling was provided. She said she had seen ashtrays and metal receptacles in the back smoking area but not the front. She said she felt there was a gray area if the residents were safe smoking in the front. She said it depended on the resident cognition and physical ability. She said she did not know the residents well enough to determine which residents were safe and unsafe in the front smoking unsupervised. During an interview and observation on 07/08/23 at 11: 30 a.m., the staffing coordinator said she had been employed at the facility for [AGE] years. She said she did fill in and work the floor as a CNA when they were short staffed. She said she thought the ADON had given an in-service on the updated smoking policy but after looking thru in-service binder, she realized they had not done one. She said the smoking area was in the back of the facility and all the residents had to be supervised. She said about 3 weeks ago she noticed residents smoking in the front parking lot of the facility. She said the residents who smoked in the front were usually by the metal fence or by the benches behind the therapy office. She said the front area where the residents smoked did not have metal ashtrays or receptacles. She heard about a resident almost getting hit by a car in the front parking lot, but she did not witness the incident. She said she came to wo [TRUNCATED]
Inspection of December 11, 2015
5 findingsBased on observation, interview and record review the facility failed to be administered in a manner that enabled it to use its resources to effectively and efficiently attain and maintain the highest practicable physical, mental, and psychosocial well being for one (1) of four (4) residents reviewed for significant changes (Resident #4) when: 1) the DON failed to follow-up to ensure LVN A had called 911 immediately when Resident #4 had an altered mental and physical change of condition resulting in hospitalization on [DATE]. The DON was not aware LVN A had not called 911 immediately until surveyor informed the DON. 2) the Administrator failed to follow-up to make certain LVN A called 911 immediately when Resident #4 had an altered mental and physical change of condition resulting in hospitalization . On 12/06/15 at 2:50 AM, Charge Nurse LVN A waited 45 minutes before contacting 911 when Resident #4 experienced a change of condition. Upon arrival at the hospital via an ambulance, the initial [DIAGNOSES REDACTED]. Resident #4 discharged from the hospital to home with a discharge [DIAGNOSES REDACTED]. The delay in obtaining emergency medical care for Resident #4 placed her at risk of brain damage and potential complications. An IJ was identified on 12/10/2015. While the IJ was removed on 12/11/2015, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern due to the facility was still monitoring the effectiveness of the Plan of Removal. These failures placed 43 residents, who resided on Halls 1 and 2 where LVN A worked, at risk for delayed emergency services and delay in care which could lead to death or worsening of resident's condition. Findings Include: Interview on 12/10/2015 at 10:38 AM the DON stated LVN A had called her at 3:07 AM on 12/06/2015 about Resident #4 being unresponsive and pulse oxygen of 72% so the DON stated she told LVN A to immediately call 911 and sent Resident #4 out to the hospital. The DON stated she had thought LVN A had immediately called 911 and was not aware LVN A waited to get hold of the physician until after surveyor informed the DON. The DON stated in the morning meeting on 12/06/2015 it was mentioned Resident #4 went to the hospital and she assumed LVN A had called 911 immediately to send Resident #4 to the hospital. The DON stated LVN A and the other nurses had all recently been in-serviced about a resident's change of condition in November 2015 and were in-serviced when to call 911 instead of calling the physician first in emergency situations. Interview on 12/10/2015 at 11:20 AM the Administrator stated he expected the nurse to follow the DON instructions to call 911 immediately and not to wait to get hold of the physician. The Administrator stated he expected the nurse to call 911 first and send resident out when he or she was having a change of condition. The Administrator stated then the nurse should call the DON, physician, and the resident's responsible party once resident had been sent to the hospital via EMS. The Administrator stated he could have followed up more to ensure LVN A did call 911 immediately. Review of Resident #4's Face Sheet dated 11/30/2015 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's Admission MDS assessment dated [DATE] reflected she was cognitively intact. She required extensive assistance with two person physical assistance with bed mobility, transfers, dressing and hygiene. Review of Resident #4's Comprehensive Care Plan dated 11/30/2015 reflected she had an ADL self-care performance deficit related to musculoskeletal impairment, activity intolerance, limited mobility, impaired balance. Resident #4 was not transferred, was bedfast all or most of the time. Review of SBAR Communication Form dated 12/06/2015 signed by LVN A reflected Resident #4 had a pulse oxygen of 72%, Cyanotic Nail Beds, and unresponsive to verbal stimuli at 2:50 AM. Resident #4's vital signs were blood pressure 107/64, pulse 122, respiratory rate 24, and temperature was 97.6 degrees at 2:50 AM. The form reflected the doctor was called at 3:35 PM. The American National Red Cross noted the following regarding Oxygen Saturation: Pulse oximetry, using a pulse oximeter, is used to measure the percentage of oxygen saturation in the blood and appears as a percentage of hemoglobin saturated with oxygen (Figure). Pulse oximetry readings are recorded using the percentage and then SpO2 (e.g., 95 to 99 percent SpO2). The pulse oximeter reading never should be used to withhold oxygen from a victim who appears to be in respiratory distress or when it is the standard of care to apply oxygen despite good pulse oximetry readings, such as in a victim with chest pain. Normal: 95-100% SPO2 Mild [MEDICAL CONDITION] 91-94% SPO2 Moderate [MEDICAL CONDITION] 86-90% SPO2 Severe [MEDICAL CONDITION] <85% SPO2 To use a pulse oximeter, apply the probe to the victim ' s finger or any other measuring site, such as the earlobe or foot, according to the manufacturer ' s recommendation. Let the machine register the oxygen saturation level and verify the victim ' s pulse rate on the oximeter with the actual pulse of the victim. Monitor and record the victim ' s saturation levels while administering emergency oxygen. If the oxygen level reaches 100 percent and local protocols allow, you may decrease the flow rate of oxygen and change to a lower-flowing delivery device. This information was retrieved on 12/29/2015 from www.redcross.org Review of Nursing Home to Hospital Transfer Form dated transfer 12/06/2015 signed by LVN A reflected Resident #4 was sent to the local hospital. Interview on 12/10/2015 at 5:35 AM and 10:10 AM with LVN A revealed she was told by day shift nurse that Resident #4 had been sleeping a lot more than usual on 12/05/2015 during the day. LVN A, who worked 6 pm - 6 am shift, revealed she did a round to check on Resident #4 around midnight on 12/06/2015 and Resident #4 was responsive. She stated when she checked on Resident #4 at about 2:50 AM Resident #4 did not respond to verbal stimuli. LVN A revealed she assessed Resident #4 and took vitals. She stated her pulse oxygen saturation level was 72%. She stated she put Resident #4 on oxygen via face mask at 2 Liters per minute and monitored to see if Resident #4's pulse oxygen would increase for about 15 minutes. LVN A said she was in and out of Resident #4's room checking on her at least every 10 to 15 minutes. She revealed she did not get help from the other LVN or a CNA to stay with Resident #4 when she left the room. LVN A stated she called the DON at about 3:07 AM telling her Resident #4 was unresponsive and had pulse oxygen saturation level of 72%. She said the DON told her to call 911 and send the resident out. LVN A revealed she did not call 911 because she stated she needed to get hold of the physician prior to sending Resident #4 to the hospital. She continued to monitor Resident #4's pulse oxygen when she was in the room. LVN A stated the pulse oxygen saturation level was 78% when she checked on it again about 10 - 15 minutes later and she increased Resident #4's oxygen to 3 Liters per minute. She revealed she tried to contact Resident #4 ' s physician to get an order to send Resident #4 to the hospital. When she spoke with the physician at 3:35 PM she was told to call 911 and send Resident #4 out. LVN A stated then she called 911 immediately after getting off the phone with the doctor and EMS came out within minutes. LVN A revealed the most Resident #4 ' s pulse oxygen saturation level increased to was 80% prior to EMS. Interview on 12/11/2015 at 7:24 PM with LVN C revealed LVN A asked her for the physician's number to call so she asked LVN A what was going on. LVN C stated LVN A told her Resident #4 was unresponsive and she needed to call the physician. LVN C revealed she asked if she needed any assistance and LVN A said she did not need any help. LVN C stated she was not aware Resident #4 did not have a staff member with her and was not aware of Resident #4's vitals. LVN C revealed she did not know what specifically was going on with Resident #4 so LVN A made the 911 call since she knew specifically what was going on with Resident #4. LVN C revealed she was at the nurse's station at the same time. Further interview on 12/10/2015 at 12:48 PM with CNA I revealed she did not recall anything unusual going on with Resident #4 on the night of 12/05/2015 and recalled talking with Resident #4 at about 12:30 AM at 12/06/2015 when doing her rounds. CNA I was not aware Resident #4 was sent to the hospital until after Resident #4 was sent out via EMS. Interview on 12/10/2015 at 4:52 PM with CNA G revealed she recalled when doing rounds Resident #4 was unresponsive and she saw a pulse oxygen on Resident #4 which read 79% pulse oxygen saturation level and heart rate of 128. She stated no one was with Resident #4 and she knew if the pulse oxygen was on Resident #4 a nurse had already been in there. CNA G stated she immediately went to the nurse's station where both nurses were at the nurses' station and she asked them what was going on with Resident #4. She revealed LVN A stated EMS had already been called. CNA G stated LVN A seemed to have it handled so she continued checking on the other residents. CNA G revealed EMS came a few minutes later and took Resident #4 out to the hospital. Interview on 12/10/2015 at 12:20 PM the Medical Director stated he expected if a resident had a pulse oxygen rate of 72% and was unresponsive for the nurse to call 911 first and then get call the physician. The Medical Director stated from his visit on 11/18/2015 with Resident #4 she was oriented to person, place and time and on 12/06/2016 she did have a significant change of condition and expected the nurse to call 911 immediately. Review of Respiratory: Oxygen Administration policy dated 05/05/2014 reflected During a respiratory emergency or respiratory distress, it is appropriate for nursing to administer oxygen immediately (2-3 liters) and notify physician after resident is stabilized or transferred by EMS. Procedure included 7. Respiratory distress evaluation, assess breathing patterns, respirations and pulse oximeter reading if the pulse oximeter reading is less than 90% and there are other signs of respiratory distress including Cyanosis (blue coloring) contact EMS. The facility Administrator and DON were notified on 12/10/2015 at 1:32 PM that an IJ was identified and a plan of removal was requested at that time. The following Plan of Removal was submitted by the Administrator on 12/11/2015 at 2:38 PM. The following Plan of Removal (PoR) was accepted on 12/11/2015 at 2:38 PM. The PoR reflected LVN A received an in-service on 12/10/2015 by Regional Nurse Consultant on Emergency Response Management Guidelines and Guidelines on Oxygen Use. LVN A will take post test before she is allowed to return to work. LVN A was suspended pending Investigation on 12/10/2015. The PoR reflected that Immediately on 12-10-15 resident rounds were conducted by the DON and Regional Nurse Consultant to identify resident (s) with a rapid decline in condition or change in condition. Based on the findings 911 and or physician will be notified for further interventions. The resident rounds were completed on December10, 2015. The PoR reflected - All Staff will be educated by the DON or Regional Nurse Consultant on - 1. Emergency Response Management Guidelines 2. Guideline on Respiratory Oxygen Use 3. A Post Test will be provided The in-service started immediately on December 10, 2015 and completed 12-11-15. Any staff that has not been in-serviced will not be allowed to work until the in-service and post test is completed. The DON /Weekend Supervisor will track attendance with use of an employee roster. The PoR reflected that for QAA Monitoring - DON will conduct emergency response drills once a week on each shift for the next four weeks, then every month using mock scenarios such as a resident with rapid decline in change of condition, a resident with abnormal vital signs, choking resident or a resident with acute chest pain. Staff response will be documented on Emergency Drill Form DON will also provide a post test on Emergency Response The DON will monitor residents with change in condition or emergency situations using the Acute Patient Condition Change QAPI tool or Emergency Response Management Time. The DON will use the Acute Patient Condition Change QAPI tool 5 times a week and the Emergency Response Management Timeline when there is a resident emergency situation. If an issue is identified the DON will re-educate and/or follow the disciplinary policy. The PoR reflected the following System Changes - Emergency Response Drill and Post Test will be conducted weekly for four weeks. The DON or designee will validate thru emergency response drill observations how staff respond when there is resident emergency/ acute condition decline such as change in respiratory status. Emergency Response Management, dated 5-31-13, and Respiratory: Oxygen Administration dated 5-15-14. These systems are being reinforced through the plan of removal process. The PoR reflected the folllowing regarding the QAA Committee - DON will report findings to QAA Committee who will review and evaluate to make recommendations to sustain compliance. Medical Director was notified of the immediate jeopardy on December 10, 2015 Starting 12/10/15 the administrator will monitor the implementation of this plan by attending the daily clinical meeting with a review of any change of condition within the last 24 hours. The administrator will review in-service records, emergency response drills and post tests to validate staff knowledge of emergency response weekly during QAA Meeting. Minutes will be taken to document review and evaluation by the administrator for four weeks and then monthly. On 12/11/2015 from 2:38 PM until 7:32 PM the following obervtions, interviews and record reviews were conducted to verify the faciltiy implemented their Plan of Removal: Interviews of six (6) of six (6) nurses on different shifts (LVN C, LVN D, LVN E, LVN F, LVN N, and LVN O ) to verify their attendance at the in-services as well as to verify their comprehension of the subject matter. Interviews of eight (8) of nine (8) CNAs on different shifts (CNA J, CNA K, CNA L, CNA P, CNA Q, CNA R, CNA S, and CNA T) to verify their attendance at the in-services as well as to verify their comprehension of the subject manner. On 12/11/2015 at 7:32 PM the facility Administrator, DON, Regional Nurse Consultant, and the Regional Director of Operations were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. The facility provided a list on 12/10/2015 of 43 residents who resided on Hall 1 and Hall 2.
Based on observation, interview, and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (Resident #4) of four residents reviewed for a significant change of condition. Charge Nurse LVN A failed to immediately contact 911 when Resident #4 was found unresponsive with a low oxygen saturation level. Charge Nurse LVN A failed to remain with Resident #4 when she experienced a change of condition. On 12/06/15 at 2:50 AM, Charge Nurse LVN A waited 45 minutes before contacting 911 when Resident #4 experienced a change of condition. Upon arrival at the hospital via an ambulance, the initial [DIAGNOSES REDACTED]. Resident #4 discharged from the hospital to home with a discharge [DIAGNOSES REDACTED]. The delay in obtaining emergency medical care for Resident #4 placed her at risk of brain damage and potential complications. An IJ was identified on 12/10/2015. While the IJ was removed on 12/11/2015, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern due to the facility was still monitoring the effectiveness of the Plan of Removal. These failures placed 43 residents, who resided on Halls 1 and 2 where LVN A worked, at risk for delayed emergency services and delay in care which could lead a worsening of a resident's condition or death. Findings included: Review of Resident #4's Face Sheet, dated 11/30/2015, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's Admission MDS assessment dated [DATE] reflected she was cognitively intact. She required extensive assistance with two person physical assistance with bed mobility, transfers, dressing and hygiene. Review of Resident #4's Comprehensive Care Plan dated 11/30/2015 reflected she had an ADL self-care performance deficit related to musculoskeletal impairment, activity intolerance, limited mobility, impaired balance. Resident #4 was not transferred, was bedfast all or most of the time. Review of SBAR Communication Form dated 12/06/2015 signed by LVN A reflected Resident #4 had a pulse oxygen of 72%, Cyanotic Nail Beds, and unresponsive to verbal stimuli at 2:50 AM. Resident #4's vital signs were blood pressure 107/64, pulse 122, respiratory rate 24, and temperature was 97.6 degrees at 2:50 AM. The form reflected the doctor was called at 3:35 AM. The American National Red Cross noted the following regarding Oxygen Saturation: Pulse oximetry, using a pulse oximeter, is used to measure the percentage of oxygen saturation in the blood and appears as a percentage of hemoglobin saturated with oxygen (Figure). Pulse oximetry readings are recorded using the percentage and then SpO2 (e.g., 95 to 99 percent SpO2). The pulse oximeter reading never should be used to withhold oxygen from a victim who appears to be in respiratory distress or when it is the standard of care to apply oxygen despite good pulse oximetry readings, such as in a victim with chest pain. Normal: 95-100% SPO2 Mild [MEDICAL CONDITION] 91-94% SPO2 Moderate [MEDICAL CONDITION] 86-90% SPO2 Severe [MEDICAL CONDITION] <85% SPO2 To use a pulse oximeter, apply the probe to the victim ' s finger or any other measuring site, such as the earlobe or foot, according to the manufacturer ' s recommendation. Let the machine register the oxygen saturation level and verify the victim ' s pulse rate on the oximeter with the actual pulse of the victim. Monitor and record the victim ' s saturation levels while administering emergency oxygen. If the oxygen level reaches 100 percent and local protocols allow, you may decrease the flow rate of oxygen and change to a lower-flowing delivery device. This information was retrieved on 12/29/2015 from www.redcross.org. Review of Nursing Home to Hospital Transfer Form dated 12/06/2015 signed by LVN A reflected Resident #4 was sent to the local hospital. Interview on 12/10/2015 at 5:35 AM and 10:10 AM with LVN A revealed she was told by day shift nurse that Resident #4 had been sleeping a lot more than usual on 12/05/2015 during the day. LVN A, who was a Charge Nurse worked 6 pm - 6 am shift, revealed she did a round to check on Resident #4 around midnight on 12/06/2015 and Resident #4 was responsive. She stated when she checked on Resident #4 at about 2:50 AM Resident #4 did not respond to verbal stimuli. LVN A revealed she assessed Resident #4 and took vitals. She stated her pulse oxygen saturation level was 72%. She stated she put Resident #4 on oxygen via face mask at 2 Liters per minute and monitored to see if Resident #4's pulse oxygen would increase for about 15 minutes. LVN A said she was in and out of Resident #4's room checking on her at least every 10 to 15 minutes. She revealed she did not get help from the other LVN or a CNA to stay with Resident #4 when she left the room. LVN A stated she called the DON at about 3:07 AM telling her Resident #4 was unresponsive and had pulse oxygen saturation level of 72%. She said the DON told her to call 911 and send the resident out. LVN A revealed she did not call 911 because she stated she needed to get hold of the physician prior to sending Resident #4 to the hospital. She continued to monitor Resident #4's pulse oxygen when she was in the room. LVN A stated the pulse oxygen saturation level was 78% when she checked on it again about 10 - 15 minutes later and she increased Resident #4's oxygen to 3 Liters per minute. She revealed she tried to contact Resident #4 ' s physician to get an order to send Resident #4 to the hospital. When she spoke with the physician at 3:35 AM she was told to call 911 and send Resident #4 out. LVN A stated then she called 911 immediately after getting off the phone with the doctor and EMS came out within minutes. LVN A revealed the most Resident #4 ' s pulse oxygen saturation level increased to was 80% prior to EMS. Interview on 12/11/2015 at 7:24 PM with LVN C revealed LVN A asked her for the physician's number to call so she asked LVN A what was going on. LVN C stated LVN A told her Resident #4 was unresponsive and she needed to call the physician. LVN C revealed she asked if she needed any assistance and LVN A said she did not need any help. LVN C stated she was not aware Resident #4 did not have a staff member with her and was not aware of Resident #4's vitals. LVN C revealed she did not know what specifically was going on with Resident #4 so LVN A made the 911 call since she knew specifically what was going on with Resident #4. LVN C revealed she was at the nurse's station at the same time. Interview on 12/10/2015 at 5:50 AM with CNA U revealed he had worked on Resident #4's hall prior to the night she went to the hospital. CNA U stated Resident #4 was a light sleeper when he made his rounds and responded to verbal stimuli at night. Further interview on 12/10/2015 at 12:48 PM with CNA I revealed she did not recall anything unusual going on with Resident #4 on the night of 12/05/2015 and recalled talking with Resident #4 at about 12:30 AM at 12/06/2015 when doing her rounds. CNA I was not aware Resident #4 was sent to the hospital until after Resident #4 was sent out via EMS. Interview on 12/10/2015 at 4:52 PM with CNA G revealed she recalled when doing rounds Resident #4 was unresponsive and she saw a pulse oxygen on Resident #4 which read 79% pulse oxygen saturation level and heart rate of 128. She stated no one was with Resident #4 and she knew if the pulse oxygen was on Resident #4 a nurse had already been in there. CNA G stated she immediately went to the nurse's station where both nurses were at the nurses' station and she asked them what was going on with Resident #4. She revealed LVN A stated EMS had already been called. CNA G stated LVN A seemed to have it handled so she continued checking on the other residents. CNA G revealed EMS came a few minutes later and took Resident #4 out to the hospital. Interview on 12/10/2015 at 10:38 AM with the DON revealed LVN A had called her at 3:07 AM on 12/06/2015 about Resident #4 being unresponsive with a pulse oxygen saturation level of 72%. She stated she told LVN A to immediately call 911 and send Resident #4 out to the hospital. The DON stated she expected the nurse to call the 911 immediately and get assistance from the other nurse. She revealed she thought LVN A had immediately called 911 and was not aware LVN A waited to get hold of the physician to send Resident #4 out to the hospital until after surveyor informed her. The DON stated LVN A and the other nurses had recently been in-serviced about a resident's change of condition in November 2015 and were in-serviced when to call 911 instead of calling the physician first in emergency situations. She stated she expected the nurse to call for assistance or use the emergency call button to get assistance from the other nurse or another CNA. The DON revealed Resident #4 should not have been left alone and LVN A should have called for assistance staying with Resident #4 or have a CNA or the other nurse stay with Resident #4 while she called 911 and got the paperwork ready. Review of Resident #4's Hospital Records from 12/06/2015 through 12/08/2015 reflected on 12/06/2015 reflected she came to the emergency room by EMS due to altered mental status, decreased mentation, and resident was unresponsive. Resident #4 was only responsive to physical stimuli at the hospital and grimaced only to painful stimuli. Resident #4's vitals were blood pressure 105/88, heart rate 118, respiratory rate 26, oxygen saturation level of 95%, and temperature 102. The clinical impression [MEDICAL CONDITION], healthcare-related pneumonia, Urinary Tract Infection, Detectable Troponin, Dehydration, Azotemia, [MEDICAL CONDITION], and Altered Mental Status secondary to above with mostly metabolic factors [MEDICAL CONDITION]. Her lungs had decreased air entry bilaterally. Her electrocardiogram on 12/06/2015 showed sinus [MEDICAL CONDITION] 115 beats per minute, incomplete right bundle branch block, and no specific ST or T wave changes. Her chest x-ray showed infiltrate in the left lower lobe. Her complete blood count on 12/06/2015 at 4:27 AM showed white blood cell count of 29.2, Hemoglobin of 9.8, and platelet count 291. Her computerized tomography of the head was done without contrast, which showed 2.3 centimeter low density lesion in the right temporal lobe, may be due to acute infarct and she had magnetic resonance imaging which showed acute infarct in the medial left frontal lobe of 2.3 centimeters. Resident #4 was in the Intensive Care Unit during her stay in the hospital and was discharged to home with Hospice on 12/08/2015. Her final [DIAGNOSES REDACTED]. Review of facility inservice Notification of Changes dated 11/16/2015 reflected LVN A was inserviced on resident emergency response situations requiring EMS involvement. Interview on 12/10/2015 at 11:20 AM with the Administrator revealed the nurse should have followed the DON ' s instructions to call 911 immediately and not to wait until she contacted the physician. The Administrator stated he expected the nurse to call 911 first and send a resident out when he or she was having a change of condition. The Administrator revealed then the nurse should call the DON, physician, and the resident's responsible party once the resident had been sent to the hospital via EMS. Interview on 12/10/2015 at 12:20 PM with the Medical Director revealed he expected if a resident had a pulse oxygen saturation level of 72% and was unresponsive, the nurse to call 911 first and then call the physician. The Medical Director stated from his visit on 11/18/2015 with Resident #4 she was oriented to person, place and time and on 12/06/2016 she did have a significant change of condition and he expected the nurse to call 911 immediately. Review of the facility's policy Respiratory: Oxygen Administration dated 05/05/2014 reflected, During a respiratory emergency or respiratory distress, it is appropriate for nursing to administer oxygen immediately (2-3 liters) and notify physician after resident is stabilized or transferred by EMS . 7. Respiratory distress evaluation, assess breathing patterns, respirations and pulse oximeter reading if the pulse oximeter reading is less than 90% and there are other signs of respiratory distress including Cyanosis (blue coloring) contact EMS. The facility Administrator and DON were notified on 12/10/2015 at 1:32 PM that an IJ was identified and a plan of removal was requested at that time.- The following Plan of Removal (PoR) was accepted on 12/11/2015 at 2:38 PM. The PoR reflected LVN A received an in-service on 12/10/2015 by Regional Nurse Consultant on Emergency Response Management Guidelines and Guidelines on Oxygen Use. LVN A will take post test before she is allowed to return to work. LVN A was suspended pending Investigation on 12/10/2015. The PoR reflected that Immediately on 12-10-15 resident rounds were conducted by the DON and Regional Nurse Consultant to identify resident (s) with a rapid decline in condition or change in condition. Based on the findings 911 and or physician will be notified for further interventions. The resident rounds were completed on December 10, 2015. The PoR reflected - All Staff will be educated by the DON or Regional Nurse Consultant on - 1. Emergency Response Management Guidelines 2. Guideline on Respiratory Oxygen Use 3. A Post Test will be provided The in-service started immediately on December 10, 2015 and completed 12-11-15. Any staff that has not been in-serviced will not be allowed to work until the in-service and post test is completed. The DON /Weekend Supervisor will track attendance with use of an employee roster. The PoR reflected that for QAA Monitoring - DON will conduct emergency response drills once a week on each shift for the next four weeks, then every month using mock scenarios such as a resident with rapid decline in change of condition, a resident with abnormal vital signs, choking resident or a resident with acute chest pain. Staff response will be documented on Emergency Drill Form DON will also provide a post test on Emergency Response The DON will monitor residents with change in condition or emergency situations using the Acute Patient Condition Change QAPI tool or Emergency Response Management Time. The DON will use the Acute Patient Condition Change QAPI tool 5 times a week and the Emergency Response Management Timeline when there is a resident emergency situation. If an issue is identified the DON will re-educate and/or follow the disciplinary policy. The PoR reflected the following System Changes - Emergency Response Drill and Post Test will be conducted weekly for four weeks. The DON or designee will validate thru emergency response drill observations how staff respond when there is resident emergency/ acute condition decline such as change in respiratory status. Emergency Response Management, dated 5-31-13, and Respiratory: Oxygen Administration dated 5-15-14. These systems are being reinforced through the plan of removal process. The PoR reflected the folllowing regarding the QAA Committee - DON will report findings to QAA Committee who will review and evaluate to make recommendations to sustain compliance. Medical Director was notified of the immediate jeopardy on December 10, 2015 Starting 12/10/15 the administrator will monitor the implementation of this plan by attending the daily clinical meeting with a review of any change of condition within the last 24 hours. The administrator will review in-service records, emergency response drills and post tests to validate staff knowledge of emergency response weekly during QAA Meeting. Minutes will be taken to document review and evaluation by the administrator for four weeks and then monthly. On 12/11/2015 from 2:38 PM until 7:32 PM the following obervtions, interviews and record reviews were conducted to verify the faciltiy implemented their Plan of Removal: Interviews with nurses on different shifts (LVN C, LVN D, LVN E, LVN F, LVN N, and LVN O) to verify their attendance at the in-services as well as to verify their comprehension of the subject matter. All of the nurses were able to give examples of when he or she should call 911 immediately before calling the physician when a resident has a change of condition and pulse oxygen saturation is less than 90%. All nurses interviewed stated a resident should not be left alone when he or she is having a change of condition and would call out or use the call button to get assistance after another staff member. Attempts were made to contact LVN A (who was suspended pending facility investigation) via telephone, but surveyor was unable to interview LVN A. Interviews with CNAs on different shifts (CNA J, CNA K, CNA L, CNA P, CNA Q, CNA R, CNA S, and CNA T) to verify their attendance at the in-services as well as to verify their comprehension of the subject manner. CNAs were able to tell surveyor what he or she would do if a resident had a change of condition. The CNAs stated they would immediately call out or use the call button to get assistance from a nurse. Reviewed Additional Resident Records and Observations of staff on 12/11/2015 revealed staff took appropriate action to assist residents experiencing a change of condition. On 12/11/2015 at 7:32 PM, the facility Administrator, DON, Regional Nurse Consultant, and the Regional Director of Operations were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. The facility provided a list on 12/10/2015 of 43 residents who resided on Hall 1 and Hall 2.
Based on interview and record review, the facility failed to meet professional standards for one (1) LVN (LVN A) for one (Resident #4) of four residents reviewed for significant change when: LVN A failed to immediately contact 911 when Resident #4 was found unresponsive with a low oxygen saturation level. LVN A failed to remain with Resident #4 when she experienced a change of condition. On 12/06/15 at 2:50 AM, LVN A waited 45 minutes before contacting 911 when Resident #4 experienced a change of condition. Upon arrival at the hospital via an ambulance, the initial [DIAGNOSES REDACTED]. Resident #4 discharged from the hospital to home with a discharge [DIAGNOSES REDACTED]. The delay in obtaining emergency medical care for Resident #4 placed her at risk of brain damage and potential complications. An IJ was identified on 12/10/2015. While the IJ was removed on 12/11/2015, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy' and a scope of pattern due to the facility was still monitoring the effectiveness of the Plan of Removal. These failures placed 43 residents, who resided on Halls 1 and 2 where LVN A worked, at risk for delayed emergency services and delay in care which could lead to worsening of a resident's condition or death. Findings included: Review of Resident #4's Face Sheet, dated 11/30/2015, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's Admission MDS assessment dated [DATE] reflected she was cognitively intact. She required extensive assistance with two person physical assistance with bed mobility, transfers, dressing and hygiene. Review of Resident #4's Comprehensive Care Plan dated 11/30/2015 reflected she had an ADL self-care performance deficit related to musculoskeletal impairment, activity intolerance, limited mobility, impaired balance. Resident #4 was not transferred, was bedfast all or most of the time. Review of SBAR Communication Form dated 12/06/2015 signed by LVN A reflected Resident #4 had a pulse oxygen of 72%, Cyanotic Nail Beds, and unresponsive to verbal stimuli at 2:50 AM. Resident #4's vital signs were blood pressure 107/64, pulse 122, respiratory rate 24, and temperature was 97.6 degrees at 2:50 AM. The form reflected the doctor was called at 3:35 AM. The American National Red Cross noted the following regarding Oxygen Saturation: Pulse oximetry, using a pulse oximeter, is used to measure the percentage of oxygen saturation in the blood and appears as a percentage of hemoglobin saturated with oxygen (Figure). Pulse oximetry readings are recorded using the percentage and then SpO2 (e.g., 95 to 99 percent SpO2). The pulse oximeter reading never should be used to withhold oxygen from a victim who appears to be in respiratory distress or when it is the standard of care to apply oxygen despite good pulse oximetry readings, such as in a victim with chest pain. Normal: 95-100% SPO2 Mild [MEDICAL CONDITION] 91-94% SPO2 Moderate [MEDICAL CONDITION] 86-90% SPO2 Severe [MEDICAL CONDITION] <85% SPO2 To use a pulse oximeter, apply the probe to the victim ' s finger or any other measuring site, such as the earlobe or foot, according to the manufacturer ' s recommendation. Let the machine register the oxygen saturation level and verify the victim ' s pulse rate on the oximeter with the actual pulse of the victim. Monitor and record the victim ' s saturation levels while administering emergency oxygen. If the oxygen level reaches 100 percent and local protocols allow, you may decrease the flow rate of oxygen and change to a lower-flowing delivery device. This information was retrieved on 12/29/2015 from www.redcross.org> Review of Nursing Home to Hospital Transfer Form dated 12/06/2015 signed by LVN A reflected Resident #4 was sent to the local hospital. Interview on 12/10/2015 at 5:35 AM and 10:10 AM with LVN A revealed she was told by day shift nurse that Resident #4 had been sleeping a lot more than usual on 12/05/2015 during the day. LVN A, who was a Charge Nurse worked 6 pm - 6 am shift, revealed she did a round to check on Resident #4 around midnight on 12/06/2015 and Resident #4 was responsive. She stated when she checked on Resident #4 at about 2:50 AM Resident #4 did not respond to verbal stimuli. LVN A revealed she assessed Resident #4 and took vitals. She stated her pulse oxygen saturation level was 72%. She stated she put Resident #4 on oxygen via face mask at 2 Liters per minute and monitored to see if Resident #4's pulse oxygen would increase for about 15 minutes. LVN A said she was in and out of Resident #4's room checking on her at least every 10 to 15 minutes. She revealed she did not get help from the other LVN or a CNA to stay with Resident #4 when she left the room. LVN A stated she called the DON at about 3:07 AM telling her Resident #4 was unresponsive and had pulse oxygen saturation level of 72%. She said the DON told her to call 911 and send the resident out. LVN A revealed she did not call 911 because she stated she needed to get hold of the physician prior to sending Resident #4 to the hospital. She continued to monitor Resident #4's pulse oxygen when she was in the room. LVN A stated the pulse oxygen saturation level was 78% when she checked on it again about 10 - 15 minutes later and she increased Resident #4's oxygen to 3 Liters per minute. She revealed she tried to contact Resident #4 ' s physician to get an order to send Resident #4 to the hospital. When she spoke with the physician at 3:35 PM she was told to call 911 and send Resident #4 out. LVN A stated then she called 911 immediately after getting off the phone with the doctor and EMS came out within minutes. LVN A revealed the most Resident #4 ' s pulse oxygen saturation level increased to was 80% prior to EMS. Interview on 12/11/2015 at 7:24 PM with LVN C revealed LVN A asked her for the physician's number to call so she asked LVN A what was going on. LVN C stated LVN A told her Resident #4 was unresponsive and she needed to call the physician. LVN C revealed she asked if she needed any assistance and LVN A said she did not need any help. LVN C stated she was not aware Resident #4 did not have a staff member with her and was not aware of Resident #4's vitals. LVN C revealed she did not know what specifically was going on with Resident #4 so LVN A made the 911 call since she knew specifically what was going on with Resident #4. LVN C revealed she was at the nurse's station at the same time. Interview on 12/10/2015 at 5:50 AM with CNA U revealed he had worked on Resident #4's hall prior to the night she went to the hospital. CNA U stated Resident #4 was a light sleeper when he made his rounds and responded to verbal stimuli at night. Interview on 12/10/2015 at 12:48 PM with CNA I revealed she did not recall anything unusual going on with Resident #4 on the night of 12/05/2015 and recalled talking with Resident #4 at about 12:30 AM at 12/06/2015 when doing her rounds. CNA I was not aware Resident #4 was sent to the hospital until after Resident #4 was sent out via EMS. Interview on 12/10/2015 at 4:52 PM with CNA G revealed she recalled when doing rounds Resident #4 was unresponsive and she saw a pulse oxygen on Resident #4 which read 79% pulse oxygen saturation level and heart rate of 128. She stated no one was with Resident #4 and she knew if the pulse oxygen was on Resident #4 a nurse had already been in there. CNA G stated she immediately went to the nurse's station where both nurses were at the nurses' station and she asked them what was going on with Resident #4. She revealed LVN A stated EMS had already been called. CNA G stated LVN A seemed to have it handled so she continued checking on the other residents. CNA G revealed EMS came a few minutes later and took Resident #4 out to the hospital. Interview on 12/10/2015 at 10:38 AM with the DON revealed LVN A had called her at 3:07 AM on 12/06/2015 about Resident #4 being unresponsive with a pulse oxygen saturation level of 72%. She stated she told LVN A to immediately call 911 and send Resident #4 out to the hospital. The DON stated she expected the nurse to call the 911 immediately and get assistance from the other nurse. She revealed she thought LVN A had immediately called 911 and was not aware LVN A waited to get hold of the physician to send Resident #4 out to the hospital until after surveyor informed her. The DON stated LVN A and the other nurses had recently been in-serviced about a resident's change of condition in November 2015 and were in-serviced when to call 911 instead of calling the physician first in emergency situations. She stated she expected the nurse to call for assistance or use the emergency call button to get assistance from the other nurse or another CNA. The DON revealed Resident #4 should not have been left alone and LVN A should have called for assistance staying with Resident #4 or have a CNA or the other nurse stay with Resident #4 while she called 911 and got the paperwork ready. Review of Resident #4's Hospital Records from 12/06/2015 through 12/08/2015 reflected on 12/06/2015 reflected she came to the emergency room by EMS due to altered mental status, decreased mentation, and resident was unresponsive. Resident #4 was only responsive to physical stimuli at the hospital and grimaced only to painful stimuli. Resident #4's vitals were blood pressure 105/88, heart rate 118, respiratory rate 26, oxygen saturation level of 95%, and temperature 102. The clinical impression [MEDICAL CONDITION], healthcare-related pneumonia, Urinary Tract Infection, Detectable Troponin, Dehydration, Azotemia, [MEDICAL CONDITION], and Altered Mental Status secondary to above with mostly metabolic factors [MEDICAL CONDITION]. Her lungs had decreased air entry bilaterally. Her electrocardiogram on 12/06/2015 showed sinus [MEDICAL CONDITION] 115 beats per minute, incomplete right bundle branch block, and no specific ST or T wave changes. Her chest x-ray showed infiltrate in the left lower lobe. Her complete blood count on 12/06/2015 at 4:27 AM showed white blood cell count of 29.2, Hemoglobin of 9.8, and platelet count 291. Her computerized tomography of the head was done without contrast, which showed 2.3 centimeter low density lesion in the right temporal lobe, may be due to acute infarct and she had magnetic resonance imaging which showed acute infarct in the medial left frontal lobe of 2.3 centimeters. Resident #4 was in the Intensive Care Unit during her stay in the hospital and was discharged to home with Hospice on 12/08/2015. Her final [DIAGNOSES REDACTED]. Review of facility inservice Notification of Changes dated 11/16/2015 reflected LVN A was inserviced on resident emergency response situations requiring EMS involvement. Interview on 12/10/2015 at 11:20 AM with the Administrator revealed the nurse should have followed the DON ' s instructions to call 911 immediately and not to wait until she contacted the physician. The Administrator stated he expected the nurse to call 911 first and send a resident out when he or she was having a change of condition. The Administrator revealed then the nurse should call the DON, physician, and the resident's responsible party once the resident had been sent to the hospital via EMS. Interview on 12/10/2015 at 12:20 PM with the Medical Director revealed he expected if a resident had a pulse oxygen saturation level of 72% and was unresponsive, the nurse to call 911 first and then call the physician. The Medical Director stated from his visit on 11/18/2015 with Resident #4 she was oriented to person, place and time and on 12/06/2016 she did have a significant change of condition and he expected the nurse to call 911 immediately. Review of the facility's policy Respiratory: Oxygen Administration dated 05/05/2014 reflected, During a respiratory emergency or respiratory distress, it is appropriate for nursing to administer oxygen immediately (2-3 liters) and notify physician after resident is stabilized or transferred by EMS . 7. Respiratory distress evaluation, assess breathing patterns, respirations and pulse oximeter reading if the pulse oximeter reading is less than 90% and there are other signs of respiratory distress including Cyanosis (blue coloring) contact EMS. The facility Administrator and DON were notified on 12/10/2015 at 1:32 PM that an IJ was identified and a plan of removal was requested at that time.- The following Plan of Removal (PoR) was accepted on 12/11/2015 at 2:38 PM. The PoR reflected LVN A received an in-service on 12/10/2015 by Regional Nurse Consultant on Emergency Response Management Guidelines and Guidelines on Oxygen Use. LVN A will take post test before she is allowed to return to work. LVN A was suspended pending Investigation on 12/10/2015. The PoR reflected that Immediately on 12-10-15 resident rounds were conducted by the DON and Regional Nurse Consultant to identify resident (s) with a rapid decline in condition or change in condition. Based on the findings 911 and or physician will be notified for further interventions. The resident rounds were completed on December 10, 2015. The PoR reflected - All Staff will be educated by the DON or Regional Nurse Consultant on - 1. Emergency Response Management Guidelines 2. Guideline on Respiratory Oxygen Use 3. A Post Test will be provided The in-service started immediately on December 10, 2015 and completed 12-11-15. Any staff that has not been in-serviced will not be allowed to work until the in-service and post test is completed. The DON /Weekend Supervisor will track attendance with use of an employee roster. The PoR reflected that for QAA Monitoring - DON will conduct emergency response drills once a week on each shift for the next four weeks, then every month using mock scenarios such as a resident with rapid decline in change of condition, a resident with abnormal vital signs, choking resident or a resident with acute chest pain. Staff response will be documented on Emergency Drill Form DON will also provide a post test on Emergency Response The DON will monitor residents with change in condition or emergency situations using the Acute Patient Condition Change QAPI tool or Emergency Response Management Time. The DON will use the Acute Patient Condition Change QAPI tool 5 times a week and the Emergency Response Management Timeline when there is a resident emergency situation. If an issue is identified the DON will re-educate and/or follow the disciplinary policy. The PoR reflected the following System Changes - Emergency Response Drill and Post Test will be conducted weekly for four weeks. The DON or designee will validate thru emergency response drill observations how staff respond when there is resident emergency/ acute condition decline such as change in respiratory status. Emergency Response Management, dated 5-31-13, and Respiratory: Oxygen Administration dated 5-15-14. These systems are being reinforced through the plan of removal process. The PoR reflected the folllowing regarding the QAA Committee - DON will report findings to QAA Committee who will review and evaluate to make recommendations to sustain compliance. Medical Director was notified of the immediate jeopardy on December 10, 2015 Starting 12/10/15 the administrator will monitor the implementation of this plan by attending the daily clinical meeting with a review of any change of condition within the last 24 hours. The administrator will review in-service records, emergency response drills and post tests to validate staff knowledge of emergency response weekly during QAA Meeting. Minutes will be taken to document review and evaluation by the administrator for four weeks and then monthly. On 12/11/2015 from 2:38 PM until 7:32 PM the following obervtions, interviews and record reviews were conducted to verify the faciltiy implemented their Plan of Removal: Interviews with nurses on different shifts (LVN C, LVN D, LVN E, LVN F, LVN N, and LVN O) to verify their attendance at the in-services as well as to verify their comprehension of the subject matter. All of the nurses were able to give examples of when he or she should call 911 immediately before calling the physician when a resident has a change of condition and pulse oxygen saturation is less than 90%. All nurses interviewed stated a resident should not be left alone when he or she is having a change of condition and would call out or use the call button to get assistance after another staff member. Attempts were made to contact LVN A (who was suspended pending facility investigation) via telephone, but surveyor was unable to interview LVN A. Interviews with CNAs on different shifts (CNA J, CNA K, CNA L, CNA P, CNA Q, CNA R, CNA S, and CNA T) to verify their attendance at the in-services as well as to verify their comprehension of the subject manner. CNAs were able to tell surveyor what he or she would do if a resident had a change of condition. The CNAs stated they would immediately call out or use the call button to get assistance from a nurse. Reviewed Additional Resident Records and Observations of staff on 12/11/2015 revealed staff took appropriate action to assist residents experiencing a change of condition. On 12/11/2015 at 7:32 PM, the facility Administrator, DON, Regional Nurse Consultant, and the Regional Director of Operations were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. The facility provided a list on 12/10/2015 of 43 residents who resided on Hall 1 and Hall 2.
Based on interview and record review, the facility failed to implement written policies and procedures that prohibit neglect for one (Resident #4) of four residents reviewed for significant change of condition. LVN A failed to immediately contact 911 when Resident #4 was found unresponsive with a low oxygen saturation level. LVN A failed to remain with Resident #4 when she experienced a change of condition. On 12/06/15 at 2:50 AM, LVN A waited 45 minutes before contacting 911 when Resident #4 experienced a change of condition. Upon arrival at the hospital via an ambulance, the initial [DIAGNOSES REDACTED]. Resident #4 discharged from the hospital to home with a discharge [DIAGNOSES REDACTED]. The delay in obtaining emergency medical care for Resident #4 placed her at risk of brain damage and potential complications. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/10/15. While the IJ was removed on 12/11/15, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. This deficient practice could place 43 residents at risk for delayed emergency services and delay in care which could lead to worsening of a resident's condition or death. Findings Include: Review of the facility's policy Resident Protection revised 01/29/2015 reflected residents had the right to be free from neglect. The policy defined neglect as a deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental anguish/illness or physical injury, or harm or death to the resident. Review of Resident #4's Face Sheet, dated 11/30/2015, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's Admission MDS assessment dated [DATE] reflected she was cognitively intact. She required extensive assistance with two person physical assistance with bed mobility, transfers, dressing and hygiene. Review of Resident #4's Comprehensive Care Plan dated 11/30/2015 reflected she had an ADL self-care performance deficit related to musculoskeletal impairment, activity intolerance, limited mobility, impaired balance. Resident #4 was not transferred, was bedfast all or most of the time. Review of SBAR Communication Form dated 12/06/2015 signed by LVN A reflected Resident #4 had a pulse oxygen of 72%, Cyanotic Nail Beds, and unresponsive to verbal stimuli at 2:50 AM. Resident #4's vital signs were blood pressure 107/64, pulse 122, respiratory rate 24, and temperature was 97.6 degrees at 2:50 AM. The form reflected the doctor was called at 3:35 AM. The American National Red Cross noted the following regarding Oxygen Saturation: Pulse oximetry, using a pulse oximeter, is used to measure the percentage of oxygen saturation in the blood and appears as a percentage of hemoglobin saturated with oxygen (Figure). Pulse oximetry readings are recorded using the percentage and then SpO2 (e.g., 95 to 99 percent SpO2). The pulse oximeter reading never should be used to withhold oxygen from a victim who appears to be in respiratory distress or when it is the standard of care to apply oxygen despite good pulse oximetry readings, such as in a victim with chest pain. Normal: 95-100% SPO2 Mild [MEDICAL CONDITION] 91-94% SPO2 Moderate [MEDICAL CONDITION] 86-90% SPO2 Severe [MEDICAL CONDITION] <85% SPO2 To use a pulse oximeter, apply the probe to the victim ' s finger or any other measuring site, such as the earlobe or foot, according to the manufacturer ' s recommendation. Let the machine register the oxygen saturation level and verify the victim ' s pulse rate on the oximeter with the actual pulse of the victim. Monitor and record the victim ' s saturation levels while administering emergency oxygen. If the oxygen level reaches 100 percent and local protocols allow, you may decrease the flow rate of oxygen and change to a lower-flowing delivery device. This information was retrieved on 12/29/2015 from www.redcross.org> Review of Nursing Home to Hospital Transfer Form dated 12/06/2015 signed by LVN A reflected Resident #4 was sent to the local hospital. Interview on 12/10/2015 at 5:35 AM and 10:10 AM with LVN A revealed she was told by day shift nurse that Resident #4 had been sleeping a lot more than usual on 12/05/2015 during the day. LVN A, who was a Charge Nurse worked 6 pm - 6 am shift, revealed she did a round to check on Resident #4 around midnight on 12/06/2015 and Resident #4 was responsive. She stated when she checked on Resident #4 at about 2:50 AM Resident #4 did not respond to verbal stimuli. LVN A revealed she assessed Resident #4 and took vitals. She stated her pulse oxygen saturation level was 72%. She stated she put Resident #4 on oxygen via face mask at 2 Liters per minute and monitored to see if Resident #4's pulse oxygen would increase for about 15 minutes. LVN A said she was in and out of Resident #4's room checking on her at least every 10 to 15 minutes. She revealed she did not get help from the other LVN or a CNA to stay with Resident #4 when she left the room. LVN A stated she called the DON at about 3:07 AM telling her Resident #4 was unresponsive and had pulse oxygen saturation level of 72%. She said the DON told her to call 911 and send the resident out. LVN A revealed she did not call 911 because she stated she needed to get hold of the physician prior to sending Resident #4 to the hospital. She continued to monitor Resident #4's pulse oxygen when she was in the room. LVN A stated the pulse oxygen saturation level was 78% when she checked on it again about 10 - 15 minutes later and she increased Resident #4's oxygen to 3 Liters per minute. She revealed she tried to contact Resident #4 ' s physician to get an order to send Resident #4 to the hospital. When she spoke with the physician at 3:35 PM she was told to call 911 and send Resident #4 out. LVN A stated then she called 911 immediately after getting off the phone with the doctor and EMS came out within minutes. LVN A revealed the most Resident #4 ' s pulse oxygen saturation level increased to was 80% prior to EMS. Interview on 12/11/2015 at 7:24 PM with LVN C revealed LVN A asked her for the physician's number to call so she asked LVN A what was going on. LVN C stated LVN A told her Resident #4 was unresponsive and she needed to call the physician. LVN C revealed she asked if she needed any assistance and LVN A said she did not need any help. LVN C stated she was not aware Resident #4 did not have a staff member with her and was not aware of Resident #4's vitals. LVN C revealed she did not know what specifically was going on with Resident #4 so LVN A made the 911 call since she knew specifically what was going on with Resident #4. LVN C revealed she was at the nurse's station at the same time. Further interview on 12/10/2015 at 12:48 PM with CNA I revealed she did not recall anything unusual going on with Resident #4 on the night of 12/05/2015 and recalled talking with Resident #4 at about 12:30 AM at 12/06/2015 when doing her rounds. CNA I was not aware Resident #4 was sent to the hospital until after Resident #4 was sent out via EMS. Interview on 12/10/2015 at 4:52 PM with CNA G revealed she recalled when doing rounds Resident #4 was unresponsive and she saw a pulse oxygen on Resident #4 which read 79% pulse oxygen saturation level and heart rate of 128. She stated no one was with Resident #4 and she knew if the pulse oxygen was on Resident #4 a nurse had already been in there. CNA G stated she immediately went to the nurse's station where both nurses were at the nurses' station and she asked them what was going on with Resident #4. She revealed LVN A stated EMS had already been called. CNA G stated LVN A seemed to have it handled so she continued checking on the other residents. CNA G revealed EMS came a few minutes later and took Resident #4 out to the hospital. Interview on 12/10/2015 at 10:38 AM with the DON revealed LVN A had called her at 3:07 AM on 12/06/2015 about Resident #4 being unresponsive with a pulse oxygen saturation level of 72%. She stated she told LVN A to immediately call 911 and send Resident #4 out to the hospital. The DON stated she expected the nurse to call the 911 immediately and get assistance from the other nurse. She revealed she thought LVN A had immediately called 911 and was not aware LVN A waited to get hold of the physician to send Resident #4 out to the hospital until after surveyor informed her. The DON stated LVN A and the other nurses had recently been in-serviced about a resident's change of condition in November 2015 and were in-serviced when to call 911 instead of calling the physician first in emergency situations. She stated she expected the nurse to call for assistance or use the emergency call button to get assistance from the other nurse or another CNA. The DON revealed Resident #4 should not have been left alone and LVN A should have called for assistance staying with Resident #4 or have a CNA or the other nurse stay with Resident #4 while she called 911 and got the paperwork ready. Review of Resident #4's Hospital Records from 12/06/2015 through 12/08/2015 reflected on 12/06/2015 reflected she came to the emergency room by EMS due to altered mental status, decreased mentation, and resident was unresponsive. Resident #4 was only responsive to physical stimuli at the hospital and grimaced only to painful stimuli. Resident #4's vitals were blood pressure 105/88, heart rate 118, respiratory rate 26, oxygen saturation level of 95%, and temperature 102. The clinical impression [MEDICAL CONDITION], healthcare-related pneumonia, Urinary Tract Infection, Detectable Troponin, Dehydration, Azotemia, [MEDICAL CONDITION], and Altered Mental Status secondary to above with mostly metabolic factors [MEDICAL CONDITION]. Her lungs had decreased air entry bilaterally. Her electrocardiogram on 12/06/2015 showed sinus [MEDICAL CONDITION] 115 beats per minute, incomplete right bundle branch block, and no specific ST or T wave changes. Her chest x-ray showed infiltrate in the left lower lobe. Her complete blood count on 12/06/2015 at 4:27 AM showed white blood cell count of 29.2, Hemoglobin of 9.8, and platelet count 291. Her computerized tomography of the head was done without contrast, which showed 2.3 centimeter low density lesion in the right temporal lobe, may be due to acute infarct and she had magnetic resonance imaging which showed acute infarct in the medial left frontal lobe of 2.3 centimeters. Resident #4 was in the Intensive Care Unit during her stay in the hospital and was discharged to home with Hospice on 12/08/2015. Her final [DIAGNOSES REDACTED]. Review of facility inservice Notification of Changes dated 11/16/2015 reflected LVN A was inserviced on resident emergency response situations requiring EMS involvement. Interview on 12/10/2015 at 11:20 AM with the Administrator revealed the nurse should have followed the DON ' s instructions to call 911 immediately and not to wait until she contacted the physician. The Administrator stated he expected the nurse to call 911 first and send a resident out when he or she was having a change of condition. The Administrator revealed then the nurse should call the DON, physician, and the resident's responsible party once the resident had been sent to the hospital via EMS. Interview on 12/10/2015 at 12:20 PM with the Medical Director revealed he expected if a resident had a pulse oxygen saturation level of 72% and was unresponsive, the nurse to call 911 first and then call the physician. The Medical Director stated from his visit on 11/18/2015 with Resident #4 she was oriented to person, place and time and on 12/06/2016 she did have a significant change of condition and he expected the nurse to call 911 immediately. Review of the facility's policy Respiratory: Oxygen Administration dated 05/05/2014 reflected, During a respiratory emergency or respiratory distress, it is appropriate for nursing to administer oxygen immediately (2-3 liters) and notify physician after resident is stabilized or transferred by EMS . 7. Respiratory distress evaluation, assess breathing patterns, respirations and pulse oximeter reading if the pulse oximeter reading is less than 90% and there are other signs of respiratory distress including Cyanosis (blue coloring) contact EMS. The facility Administrator and DON were notified on 12/10/2015 at 1:32 PM that an IJ was identified and a plan of removal was requested at that time.- The following Plan of Removal (PoR) was accepted on 12/11/2015 at 2:38 PM. The PoR reflected LVN A received an in-service on 12/10/2015 by Regional Nurse Consultant on Emergency Response Management Guidelines and Guidelines on Oxygen Use. LVN A will take post test before she is allowed to return to work. LVN A was suspended pending Investigation on 12/10/2015. The PoR reflected that Immediately on 12-10-15 resident rounds were conducted by the DON and Regional Nurse Consultant to identify resident (s) with a rapid decline in condition or change in condition. Based on the findings 911 and or physician will be notified for further interventions. The resident rounds were completed on December 10, 2015. The PoR reflected - All Staff will be educated by the DON or Regional Nurse Consultant on - 1. Emergency Response Management Guidelines 2. Guideline on Respiratory Oxygen Use 3. A Post Test will be provided The in-service started immediately on December 10, 2015 and completed 12-11-15. Any staff that has not been in-serviced will not be allowed to work until the in-service and post test is completed. The DON /Weekend Supervisor will track attendance with use of an employee roster. The PoR reflected that for QAA Monitoring - DON will conduct emergency response drills once a week on each shift for the next four weeks, then every month using mock scenarios such as a resident with rapid decline in change of condition, a resident with abnormal vital signs, choking resident or a resident with acute chest pain. Staff response will be documented on Emergency Drill Form DON will also provide a post test on Emergency Response The DON will monitor residents with change in condition or emergency situations using the Acute Patient Condition Change QAPI tool or Emergency Response Management Time. The DON will use the Acute Patient Condition Change QAPI tool 5 times a week and the Emergency Response Management Timeline when there is a resident emergency situation. If an issue is identified the DON will re-educate and/or follow the disciplinary policy. The PoR reflected the following System Changes - Emergency Response Drill and Post Test will be conducted weekly for four weeks. The DON or designee will validate thru emergency response drill observations how staff respond when there is resident emergency/ acute condition decline such as change in respiratory status. Emergency Response Management, dated 5-31-13, and Respiratory: Oxygen Administration dated 5-15-14. These systems are being reinforced through the plan of removal process. The PoR reflected the folllowing regarding the QAA Committee - DON will report findings to QAA Committee who will review and evaluate to make recommendations to sustain compliance. Medical Director was notified of the immediate jeopardy on December 10, 2015 Starting 12/10/15 the administrator will monitor the implementation of this plan by attending the daily clinical meeting with a review of any change of condition within the last 24 hours. The administrator will review in-service records, emergency response drills and post tests to validate staff knowledge of emergency response weekly during QAA Meeting. Minutes will be taken to document review and evaluation by the administrator for four weeks and then monthly. On 12/11/2015 from 2:38 PM until 7:32 PM the following obervtions, interviews and record reviews were conducted to verify the faciltiy implemented their Plan of Removal: Interviews with nurses on different shifts (LVN C, LVN D, LVN E, LVN F, LVN N, and LVN O) to verify their attendance at the in-services as well as to verify their comprehension of the subject matter. All of the nurses were able to give examples of when he or she should call 911 immediately before calling the physician when a resident has a change of condition and pulse oxygen saturation is less than 90%. All nurses interviewed stated a resident should not be left alone when he or she is having a change of condition and would call out or use the call button to get assistance after another staff member. Attempts were made to contact LVN A (who was suspended pending facility investigation) via telephone, but surveyor was unable to interview LVN A. Interviews with CNAs on different shifts (CNA J, CNA K, CNA L, CNA P, CNA Q, CNA R, CNA S, and CNA T) to verify their attendance at the in-services as well as to verify their comprehension of the subject manner. CNAs were able to tell surveyor what he or she would do if a resident had a change of condition. The CNAs stated they would immediately call out or use the call button to get assistance from a nurse. Reviewed Additional Resident Records and Observations of staff on 12/11/2015 revealed staff took appropriate action to assist residents experiencing a change of condition. On 12/11/2015 at 7:32 PM, the facility Administrator, DON, Regional Nurse Consultant, and the Regional Director of Operations were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. The facility provided a list on 12/10/2015 of 43 residents who resided on Hall 1 and Hall 2.
Based on interview, and record review, the facility failed to implement policies and procedures to prevent neglect for one (Resident #4) of four residents reviewed for significant change of condition. LVN A failed to immediately contact 911 when Resident #4 was found unresponsive with a low oxygen saturation level. LVN A failed to remain with Resident #4 when she experienced a change of condition. On 12/06/15 at 2:50 AM, LVN A waited 45 minutes before contacting 911 when Resident #4 experienced a change of condition. Upon arrival at the hospital via an ambulance, the initial [DIAGNOSES REDACTED]. Resident #4 discharged from the hospital to home with a discharge [DIAGNOSES REDACTED]. The delay in obtaining emergency medical care for Resident #4 placed her at risk of brain damage and potential complications. An IJ was identified on 12/10/2015. While the IJ was removed on 12/11/2015, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern due to the facility was still monitoring the effectiveness of the Plan of Removal. These failures placed 43 residents, who resided on Halls 1 and 2 where LVN A worked, at risk for delayed emergency services and delay in care which could lead to worsening of a resident's condition or death. Findings included: Review of Resident #4's Face Sheet, dated 11/30/2015, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's Admission MDS assessment dated [DATE] reflected she was cognitively intact. She required extensive assistance with two person physical assistance with bed mobility, transfers, dressing and hygiene. Review of Resident #4's Comprehensive Care Plan dated 11/30/2015 reflected she had an ADL self-care performance deficit related to musculoskeletal impairment, activity intolerance, limited mobility, impaired balance. Resident #4 was not transferred, was bedfast all or most of the time. Review of SBAR Communication Form dated 12/06/2015 signed by LVN A reflected Resident #4 had a pulse oxygen of 72%, Cyanotic Nail Beds, and unresponsive to verbal stimuli at 2:50 AM. Resident #4's vital signs were blood pressure 107/64, pulse 122, respiratory rate 24, and temperature was 97.6 degrees at 2:50 AM. The form reflected the doctor was called at 3:35 AM. The American National Red Cross noted the following regarding Oxygen Saturation: Pulse oximetry, using a pulse oximeter, is used to measure the percentage of oxygen saturation in the blood and appears as a percentage of hemoglobin saturated with oxygen (Figure). Pulse oximetry readings are recorded using the percentage and then SpO2 (e.g., 95 to 99 percent SpO2). The pulse oximeter reading never should be used to withhold oxygen from a victim who appears to be in respiratory distress or when it is the standard of care to apply oxygen despite good pulse oximetry readings, such as in a victim with chest pain. Normal: 95-100% SPO2 Mild [MEDICAL CONDITION] 91-94% SPO2 Moderate [MEDICAL CONDITION] 86-90% SPO2 Severe [MEDICAL CONDITION] <85% SPO2 To use a pulse oximeter, apply the probe to the victim ' s finger or any other measuring site, such as the earlobe or foot, according to the manufacturer ' s recommendation. Let the machine register the oxygen saturation level and verify the victim ' s pulse rate on the oximeter with the actual pulse of the victim. Monitor and record the victim ' s saturation levels while administering emergency oxygen. If the oxygen level reaches 100 percent and local protocols allow, you may decrease the flow rate of oxygen and change to a lower-flowing delivery device. This information was retrieved on 12/29/2015 from www.redcross.org Review of Nursing Home to Hospital Transfer Form dated 12/06/2015 signed by LVN A reflected Resident #4 was sent to the local hospital. Interview on 12/10/2015 at 5:35 AM and 10:10 AM with LVN A revealed she was told by day shift nurse that Resident #4 had been sleeping a lot more than usual on 12/05/2015 during the day. LVN A, who was a Charge Nurse worked 6 pm - 6 am shift, revealed she did a round to check on Resident #4 around midnight on 12/06/2015 and Resident #4 was responsive. She stated when she checked on Resident #4 at about 2:50 AM Resident #4 did not respond to verbal stimuli. LVN A revealed she assessed Resident #4 and took vitals. She stated her pulse oxygen saturation level was 72%. She stated she put Resident #4 on oxygen via face mask at 2 Liters per minute and monitored to see if Resident #4's pulse oxygen would increase for about 15 minutes. LVN A said she was in and out of Resident #4's room checking on her at least every 10 to 15 minutes. She revealed she did not get help from the other LVN or a CNA to stay with Resident #4 when she left the room. LVN A stated she called the DON at about 3:07 AM telling her Resident #4 was unresponsive and had pulse oxygen saturation level of 72%. She said the DON told her to call 911 and send the resident out. LVN A revealed she did not call 911 because she stated she needed to get hold of the physician prior to sending Resident #4 to the hospital. She continued to monitor Resident #4's pulse oxygen when she was in the room. LVN A stated the pulse oxygen saturation level was 78% when she checked on it again about 10 - 15 minutes later and she increased Resident #4's oxygen to 3 Liters per minute. She revealed she tried to contact Resident #4 ' s physician to get an order to send Resident #4 to the hospital. When she spoke with the physician at 3:35 PM she was told to call 911 and send Resident #4 out. LVN A stated then she called 911 immediately after getting off the phone with the doctor and EMS came out within minutes. LVN A revealed the most Resident #4 ' s pulse oxygen saturation level increased to was 80% prior to EMS. Interview on 12/11/2015 at 7:24 PM with LVN C revealed LVN A asked her for the physician's number to call so she asked LVN A what was going on. LVN C stated LVN A told her Resident #4 was unresponsive and she needed to call the physician. LVN C revealed she asked if she needed any assistance and LVN A said she did not need any help. LVN C stated she was not aware Resident #4 did not have a staff member with her and was not aware of Resident #4's vitals. LVN C revealed she did not know what specifically was going on with Resident #4 so LVN A made the 911 call since she knew specifically what was going on with Resident #4. LVN C revealed she was at the nurse's station at the same time. Interview on 12/10/2015 at 5:50 AM with CNA U revealed he had worked on Resident #4's hall prior to the night she went to the hospital. CNA U stated Resident #4 was a light sleeper when he made his rounds and responded to verbal stimuli at night. Interview on 12/10/2015 at 12:48 PM with CNA I revealed she did not recall anything unusual going on with Resident #4 on the night of 12/05/2015 and recalled talking with Resident #4 at about 12:30 AM at 12/06/2015 when doing her rounds. CNA I was not aware Resident #4 was sent to the hospital until after Resident #4 was sent out via EMS. Interview on 12/10/2015 at 4:52 PM with CNA G revealed she recalled when doing rounds Resident #4 was unresponsive and she saw a pulse oxygen on Resident #4 which read 79% pulse oxygen saturation level and heart rate of 128. She stated no one was with Resident #4 and she knew if the pulse oxygen was on Resident #4 a nurse had already been in there. CNA G stated she immediately went to the nurse's station where both nurses were at the nurses' station and she asked them what was going on with Resident #4. She revealed LVN A stated EMS had already been called. CNA G stated LVN A seemed to have it handled so she continued checking on the other residents. CNA G revealed EMS came a few minutes later and took Resident #4 out to the hospital. Interview on 12/10/2015 at 10:38 AM with the DON revealed LVN A had called her at 3:07 AM on 12/06/2015 about Resident #4 being unresponsive with a pulse oxygen saturation level of 72%. She stated she told LVN A to immediately call 911 and send Resident #4 out to the hospital. The DON stated she expected the nurse to call the 911 immediately and get assistance from the other nurse. She revealed she thought LVN A had immediately called 911 and was not aware LVN A waited to get hold of the physician to send Resident #4 out to the hospital until after surveyor informed her. The DON stated LVN A and the other nurses had recently been in-serviced about a resident's change of condition in November 2015 and were in-serviced when to call 911 instead of calling the physician first in emergency situations. She stated she expected the nurse to call for assistance or use the emergency call button to get assistance from the other nurse or another CNA. The DON revealed Resident #4 should not have been left alone and LVN A should have called for assistance staying with Resident #4 or have a CNA or the other nurse stay with Resident #4 while she called 911 and got the paperwork ready. Review of Resident #4's Hospital Records from 12/06/2015 through 12/08/2015 reflected on 12/06/2015 reflected she came to the emergency room by EMS due to altered mental status, decreased mentation, and resident was unresponsive. Resident #4 was only responsive to physical stimuli at the hospital and grimaced only to painful stimuli. Resident #4's vitals were blood pressure 105/88, heart rate 118, respiratory rate 26, oxygen saturation level of 95%, and temperature 102. The clinical impression [MEDICAL CONDITION], healthcare-related pneumonia, Urinary Tract Infection, Detectable Troponin, Dehydration, Azotemia, [MEDICAL CONDITION], and Altered Mental Status secondary to above with mostly metabolic factors [MEDICAL CONDITION]. Her lungs had decreased air entry bilaterally. Her electrocardiogram on 12/06/2015 showed sinus [MEDICAL CONDITION] 115 beats per minute, incomplete right bundle branch block, and no specific ST or T wave changes. Her chest x-ray showed infiltrate in the left lower lobe. Her complete blood count on 12/06/2015 at 4:27 AM showed white blood cell count of 29.2, Hemoglobin of 9.8, and platelet count 291. Her computerized tomography of the head was done without contrast, which showed 2.3 centimeter low density lesion in the right temporal lobe, may be due to acute infarct and she had magnetic resonance imaging which showed acute infarct in the medial left frontal lobe of 2.3 centimeters. Resident #4 was in the Intensive Care Unit during her stay in the hospital and was discharged to home with Hospice on 12/08/2015. Her final [DIAGNOSES REDACTED]. Review of facility inservice Notification of Changes dated 11/16/2015 reflected LVN A was inserviced on resident emergency response situations requiring EMS involvement. Interview on 12/10/2015 at 11:20 AM with the Administrator revealed the nurse should have followed the DON ' s instructions to call 911 immediately and not to wait until she contacted the physician. The Administrator stated he expected the nurse to call 911 first and send a resident out when he or she was having a change of condition. The Administrator revealed then the nurse should call the DON, physician, and the resident's responsible party once the resident had been sent to the hospital via EMS. Interview on 12/10/2015 at 12:20 PM with the Medical Director revealed he expected if a resident had a pulse oxygen saturation level of 72% and was unresponsive, the nurse to call 911 first and then call the physician. The Medical Director stated from his visit on 11/18/2015 with Resident #4 she was oriented to person, place and time and on 12/06/2016 she did have a significant change of condition and he expected the nurse to call 911 immediately. Review of the facility's policy Respiratory: Oxygen Administration dated 05/05/2014 reflected, During a respiratory emergency or respiratory distress, it is appropriate for nursing to administer oxygen immediately (2-3 liters) and notify physician after resident is stabilized or transferred by EMS . 7. Respiratory distress evaluation, assess breathing patterns, respirations and pulse oximeter reading if the pulse oximeter reading is less than 90% and there are other signs of respiratory distress including Cyanosis (blue coloring) contact EMS. The facility Administrator and DON were notified on 12/10/2015 at 1:32 PM that an IJ was identified and a plan of removal was requested at that time.- The following Plan of Removal (PoR) was accepted on 12/11/2015 at 2:38 PM. The PoR reflected LVN A received an in-service on 12/10/2015 by Regional Nurse Consultant on Emergency Response Management Guidelines and Guidelines on Oxygen Use. LVN A will take post test before she is allowed to return to work. LVN A was suspended pending Investigation on 12/10/2015. The PoR reflected that Immediately on 12-10-15 resident rounds were conducted by the DON and Regional Nurse Consultant to identify resident (s) with a rapid decline in condition or change in condition. Based on the findings 911 and or physician will be notified for further interventions. The resident rounds were completed on December 10, 2015. The PoR reflected - All Staff will be educated by the DON or Regional Nurse Consultant on - 1. Emergency Response Management Guidelines 2. Guideline on Respiratory Oxygen Use 3. A Post Test will be provided The in-service started immediately on December 10, 2015 and completed 12-11-15. Any staff that has not been in-serviced will not be allowed to work until the in-service and post test is completed. The DON /Weekend Supervisor will track attendance with use of an employee roster. The PoR reflected that for QAA Monitoring - DON will conduct emergency response drills once a week on each shift for the next four weeks, then every month using mock scenarios such as a resident with rapid decline in change of condition, a resident with abnormal vital signs, choking resident or a resident with acute chest pain. Staff response will be documented on Emergency Drill Form DON will also provide a post test on Emergency Response The DON will monitor residents with change in condition or emergency situations using the Acute Patient Condition Change QAPI tool or Emergency Response Management Time. The DON will use the Acute Patient Condition Change QAPI tool 5 times a week and the Emergency Response Management Timeline when there is a resident emergency situation. If an issue is identified the DON will re-educate and/or follow the disciplinary policy. The PoR reflected the following System Changes - Emergency Response Drill and Post Test will be conducted weekly for four weeks. The DON or designee will validate thru emergency response drill observations how staff respond when there is resident emergency/ acute condition decline such as change in respiratory status. Emergency Response Management, dated 5-31-13, and Respiratory: Oxygen Administration dated 5-15-14. These systems are being reinforced through the plan of removal process. The PoR reflected the folllowing regarding the QAA Committee - DON will report findings to QAA Committee who will review and evaluate to make recommendations to sustain compliance. Medical Director was notified of the immediate jeopardy on December 10, 2015 Starting 12/10/15 the administrator will monitor the implementation of this plan by attending the daily clinical meeting with a review of any change of condition within the last 24 hours. The administrator will review in-service records, emergency response drills and post tests to validate staff knowledge of emergency response weekly during QAA Meeting. Minutes will be taken to document review and evaluation by the administrator for four weeks and then monthly. On 12/11/2015 from 2:38 PM until 7:32 PM the following obervtions, interviews and record reviews were conducted to verify the faciltiy implemented their Plan of Removal: Interviews with nurses on different shifts (LVN C, LVN D, LVN E, LVN F, LVN N, and LVN O) to verify their attendance at the in-services as well as to verify their comprehension of the subject matter. All of the nurses were able to give examples of when he or she should call 911 immediately before calling the physician when a resident has a change of condition and pulse oxygen saturation is less than 90%. All nurses interviewed stated a resident should not be left alone when he or she is having a change of condition and would call out or use the call button to get assistance after another staff member. Attempts were made to contact LVN A (who was suspended pending facility investigation) via telephone, but surveyor was unable to interview LVN A. Interviews with CNAs on different shifts (CNA J, CNA K, CNA L, CNA P, CNA Q, CNA R, CNA S, and CNA T) to verify their attendance at the in-services as well as to verify their comprehension of the subject manner. CNAs were able to tell surveyor what he or she would do if a resident had a change of condition. The CNAs stated they would immediately call out or use the call button to get assistance from a nurse. Reviewed Additional Resident Records and Observations of staff on 12/11/2015 revealed staff took appropriate action to assist residents experiencing a change of condition. On 12/11/2015 at 7:32 PM, the facility Administrator, DON, Regional Nurse Consultant, and the Regional Director of Operations were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. The facility provided a list on 12/10/2015 of 43 residents who resided on Hall 1 and Hall 2.
Inspection of February 9, 2014
3 findingsBased on observation, interview and record review, the facility failed to implement the facility's policies and procedures, which prohibit neglect for one (Resident #1) of five residents reviewed for neglect. The facility failed to put a plan in place to prevent Resident #1's elopement on 02/04/14 sometime after 7:00 PM and before 9:45 PM, while the Wander Guard system was not working. The facility failed to continue Resident #1's increased supervision of every 15 minute checks, after his return from the emergency roiagnom on [DATE], while the Wander Guard system continued to still not work. Resident #1 eloped and was missing for at least 3.5 hours during the night hours of 02/04/14, and the early morning hours of 02/05/14. The resident was found by the police and transported to the emergency room due to his altered mental status. While in the emergency room , his temperature was 94 degrees F and warming blankets were used to increase temperature. An Immediate Jeopardy (IJ) was identified on 02/07/14. While the IJ was removed on 02/09/14, the facility remained out of compliance at a severity level of "no actual harm with the potential for more than minimal harm that is not immediate jeopardy," and a scope of "pattern" because the facility was still in-servicing staff and implementing the Plan of Removal. These failures could affect the five residents, including Resident #1, who were at high risk for elopement, by placing them at risk for being able to elope from the facility, which could result in a resident being lost, falls, injuries, other serious mental/physical harm and/or death. Findings included: Resident #1's MDS assessment, dated 12/31/13, reflected he was a [AGE] year-old male, who was admitted to the facility on [DATE]. The MDS assessment also reflected Resident #1 had [DIAGNOSES REDACTED]. The MDS assessment further reflected Resident #1 was able to understand and be understood by others. He was severely cognitively impaired and had disorganized thinking, which was continuously present. He did not wander. The MDS assessment also reflected he required set-up assistance with bed mobility, transfers, walking in his room, walking in the corridor, locomotion on the unit, locomotion off the unit, and with eating. He needed the assistance of one person with dressing and toilet use, and the assistance of two or more persons with personal hygiene and bathing. Resident #1's balance during transitions and walking was not steady, but he was able to stabilize without staff assistance, and he did not use any mobility devices. Resident #1's Elopement/Wandering Assessment Tool, dated 03/14/13, reflected a score of five, which indicated he was at high risk for elopement. There was a handwritten note on the tool, which reflected a Wander Guard was in place. Resident #1's Elopement/Wandering Assessment Tool, dated 05/24/13, reflected a score of six, which indicated he was at high risk of elopement. Resident #1's Care Plan, dated 06/30/13, reflected, "Resident at risk for elopement, requires use of a wander guard (sic) for safety, unaware of safety issues D/T (due to) confusion." The goal was, "Resident will have fewer episodes of attempt to elope with use of wanderguard (sic) X3 (times 3) months." The approaches were the following: "Assess res (resident) for risk of elopement quarterly, monitor wanderguard (sic) for functional working order by testing freq (frequently), redirect res when attempting to leave facility, social service intervention as needed, follow facility protocol in event elopement occurs, notify family, physician of any coc (change of condition)." The Care Plan was stamped on 09/26/13, 12/12/13, and 02/07/14 as "continue." Resident #1's Elopement/Wandering Assessment Tool, dated 08/23/13 and 11/22/13, reflected scores of three, which indicated the resident was a moderate risk for elopement. There was a handwritten note on the tool, which reflected a Wander Guard was in place. The note was not dated. Resident #1's February 2014 MAR indicated [REDACTED]. Check q shift Start Date: 5/25/2013 Day and Evening." The MAR indicated [REDACTED]. Resident #1's Nurse's Notes, dated 02/04/14 and timed at 9:45 PM, reflected the MA asked Resident #1's nurse, if she had seen him. The MA told the nurse the last time she saw the resident was at 8:30. The Notes reflected they looked for Resident #1 in his favorites spots, but could not locate him. Then they initiated a "head count face to face." When they could not locate him in the facility, the DON, ADON, and Administrator were notified. The Notes reflected staff was interviewed to determined the last time he was seen, and the police were notified. The search continued outside and the family and physician were also notified. Nurse's Notes, dated 02/04/14 (date should be 02/05/14) and timed at 12:40 AM, reflected the facility was notified the resident was at the hospital with no injuries, but he was cold. http://www.weather.com/weather/monthly/ ?month=0 reflected the high temperature on 02/04/14 was 43 degrees F and the low temperature was 37 degrees F. The high temperature on 02/05/14 was 37 degrees F and the low temperature was 25 degrees F. The facility's Incident/Accident Report, dated 02/04/14, reflected Resident #1 was not found in the building, and the Missing Resident protocol was initiated. The resident was found and taken to the emergency room by EMS. The Investigation Follow-Up, dated 02/04/14 and attached to the Incident Report, reflected the investigation was started on 02/04/14. The Summary of Investigation section, of the Investigation Follow-Up, reflected, "Res had a plan & voiced it upon locating him 'was going to (city) to a movie.'" Past Interventions Attempted section, of the Investigation Follow-Up, reflected, "Wanderguard (sic) in place, device monitored daily." Recommendations/New Interventions section, of the Investigation Follow-Up, reflected, "Resident is to be assessed for a locked unit. Social Services to seek for placement. Resident to be monitored closely. Resident followed visitors out the door...." The Incident/Accident Report was signed by the DON, but not by the Administrator. An interview with LVN F on 02/09/14 at 6:10 PM revealed she was assigned to care for Resident #1 on 02/04/14. She stated she saw him watching TV when she arrived for duty at around 6:00 PM, and that was the last time she could remember seeing him. LVN F revealed he was discovered missing around 9:45 PM. She stated she did not know if the resident was at the 7:00 PM smoke break. LVN F revealed she notified the Administrator and the police and the Missing Resident protocol was initiated. An interview with LVN C on 02/07/14 at 3:00 PM revealed Resident #1 was at the smoke break at 7:00 PM on Tuesday, 02/04/14. Interview with the DON on 02/07/2014 at 11:10 AM revealed she received a call from the facility about 10:00 PM on 02/04/14 and was told they could not find Resident #1. She stated a head count was initiated, and she asked when was the last time he was seen. She revealed he was a smoker, and he was not seen at the 9:00 PM smoking time. The DON said the MA also could not find him to give him his 9:00 PM medications. She stated she arrived at the facility at 10:05 PM, and the head count was repeated. She revealed all the areas outside were searched and the family, police, and physician were notified. She stated the facility received a call from the local police department at about 12:40 AM, and they said they found Resident #1 and he was at the emergency room . The DON revealed she went to the emergency room and identified the resident. She stated she also interviewed him. The DON revealed he said he was going to another city to watch a movie when asked where he was going. She stated she estimated he was missing for 3.5 hours. She said he had a Wander Guard. The DON stated, "Feels like he followed someone out." She revealed maybe through the 100 Hall door. The DON revealed she did not know what happened that resulted in Resident #1 eloping. She stated there was nothing in place to prevent Resident #1's elopement, when the Wander Guard system was down after construction. Interview with the Administrator on 02/07/2014 at 11:34 AM revealed she received a call around 10:00 to 10:30 PM on 02/04/14 from the facility, and they could not find Resident #1. She stated the police, family, and physician were called, and the searches continued. The Administrator revealed the police found him and called at 12:30 AM to inform them. She stated the resident was in the emergency room for several hours. She stated he went out the door with people. The Administrator revealed she was still waiting on statements from some staff, who worked that day. She stated the front door was broken, and Resident #1 could have gone through it. She revealed Resident #1 said he went out with other people. The Administrator stated, "Door is totally lockdown." She revealed, "Before you could use the code." She stated now it would not open. The Administrator revealed Resident #1 said he went out the front door, where the renovation was going on. She stated only Maintenance could open that door. She said, "All staff keeping eye on him." Interview with the Maintenance Director on 02/07/14 at approximately 12:15 PM, revealed he thought the resident exited the facility with a visitor. He stated, "Wander Guard system not working at this time." He revealed the Wander Guard on the old door could not work on the new door. The Maintenance Director stated the parts were ordered and would be there on Monday, 02/10/14. He revealed the temporary entrance had a code, but no Wander Guard system in place. The Maintenance Director stated they "were not required to have a Wander Guard." Further interview with the Administrator on 02/08/14 at 12:45 PM revealed the expansion of the facility started in May 2013 and the wall that had been there was opened in the middle of January. She stated the Wander Guard system should have been there. She revealed the contractor failed to have the Wander Guard on the door. The Administrator stated, "It is ultimately our responsibility." Further interview with the DON on 02/08/14 at 12:30 PM revealed she did not think the front door had the Wander Guard system on it. She stated the area opened up from the construction in January 2014. The DON revealed that should have not gone undetected. Resident #1's Triage emergency room Notes, dated 02/05/14 and timed at 12:17 AM, reflected he was found walking along Highway 34 by Farm to Market Road 1903, and the police sent EMS to pick him up due to his altered mental status. Resident #1 was assessed with [REDACTED]. Patient was covered with warm blankets for "warming measures." The Notes reflected his temperature at 2:11 AM was 97.5 F, which was his baseline. Resident #1's Nurse's Notes, dated 02/04/14 (should be dated 02/05/14) and timed at 6:00 AM, reflected he arrived at the facility and was oriented to his name. The Notes also reflected he was not in pain or discomfort, his respirations were even and unlabored, and he was happy. An interview with LVN C on 02/07/14 at 3:00 PM revealed she learned of Resident #1's elopement during report. She stated the night nurse told her they were doing every 15 minute checks on the resident, but it ended on the night shift because they were not doing them that day. An observation on 02/07/14 at 2:50 PM revealed Resident #1 watching TV in the living area opposite the Nurse's Station. An interview with LVN D on 02/07/14 at 2:55 PM revealed Resident #1 was not on any special monitoring. He stated he knew the resident was an elopement risk, but he had a Wander Guard, so they would hear the door alarm if he or any of the residents, who were at high risk for elopement and had Wander Guards, tried to go out the door. LVN D revealed Resident #1 and two other residents, who were high risk for elopement, were close to the Nurse's Station. The facility's current policy, "Elopement/Missing Resident-Mag Lock Doors," revised October 2012, reflected, "...If the resident is assessed as moderate to high risk the monitoring procedure will be implemented...5. The magnetic door lock system will be checked weekly by maintenance...9...If there are circumstances that place the residents health, safety, and/or welfare at risk the report will be made to the regulatory agency as soon as the facility is aware that the resident is missing and cannot be located...." The facility's current Abuse Prohibition Policy and Procedure, revised July 2012, reflected, "...VII. Reporting and Response to Alleged Incidents: A. Incidents of alleged abuse, neglect or misappropriation of resident property must be reported to the appropriate local, state, and federal agencies...Neglect - A deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental anguish/illness or physical injury, or harm or death to a resident...." An IJ was identified on 02/07/14. On 02/07/14 at 3:20 PM, the Administrator and DON were notified of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal, accepted on 02/08/14, reflected the following: The facility has 6 doors. Three of the six doors have mag lock delayed egress alarms with a key pad. The key pad code is used to exit three of the six doors which are as follows: 1. Front main door 2. D.R. door that goes to the smoke patio 3. Hall I door The remaining 3 exit doors alarm immediately when opened, a key is required to stop the alarm: 1. Hall 2 door 2. Hall 3 door 3. Hall 4 door On 02/07/14, the facility implemented the following Action Plan that affected Resident #1 and had the potential to affect four other residents:: 1) The following residents were placed on 1:1 observations at 4:00 PM till 5:00 PM by the DON and were monitored: Residents #1, #5, #4, #3, and #2. 2) The elopement risk assessment was used to re assess these residents for elopement using the Elopement Risk assessment tool 02/07/14. 3) At 5:00 PM staff members were stationed at the main front entrance, hall I door, and dining room door that led to the smoke patio. 4) For all residents in the center, the elopement risk assessment will be reviewed and evaluated for change in status on 02/08/14. 6) A staff member schedule was developed by the Administrator for continuous door monitoring for the main front door, hall I, and D/R door leading to smoke patio 24 hours a day, 7 days a week until a Wander Guard system is installed on the main front door, Hall I door and the D/R door leading to smoke patio and this door monitoring and schedule will continue from 02/07/14 and ending no later than 02/13/14. 7) All facility doors would be checked including the functioning of the Wander Guard system daily for two weeks by the Maintenance Supervisor beginning on 02/08/14 and ending 02/22/14. 8) All Staff will be in serviced annually on missing person guidelines by DON 9) A missing resident drill would be conducted monthly by the Administrator. 10) All staff were provided education by the DON, beginning 02/07/14 and would be completed by 02/08/14. 11) All assigned to door monitoring would receive education regarding the door monitoring procedure by the DON and ADON beginning 02/07/14 and would continue until 02/10/14. 12) Each staff member would have access to a walkie talkie or cell phone to enable them to notify the Charge Nurse in case of a needed break, so staff member on the monitoring schedule could be assigned to the door. Each staff member would have understanding they could not leave the exit door they were monitoring until replacement was in place. 13) Wander Guard Company was notified on 02/07/14 and would be installing the Wander Guard System on the Main front door on 02/08/14 by 1:00 PM; Hall I door on 02/10/14 by 2:00 PM; and the Dining Room door that led to the smoke patio on 02/13/14 or sooner. Interviews with CNA H, CNA I, the Dietary Manager, Laundry Aide J, and CNA K on 02/09/14 from 5:49 PM through 6:02 PM revealed they were in-serviced and understood their training. They knew what to do if a resident was missing. The IJ was removed on 02/09/14. On 02/09/14 at 8:30 PM, the Administrator and the DON were notified the IJ was removed. While the IJ was removed on 02/09/14, the facility remained out of compliance at a severity level of "no actual harm with the potential for more than minimal harm that is not immediate jeopardy," and a scope of "pattern" because the facility was still in-servicing staff and implementing the Plan of Removal. A document, "Wander Residents," dated 02/14/14, reflected five residents, who wandered in the facility, including Resident #1.
Based on observation, interview and record review, the facility failed to implement the facility's policies and procedures, which prohibit neglect for one (Resident #1) of five residents reviewed for neglect. The facility failed to put a plan in place to prevent Resident #1's elopement on 02/04/14 sometime after 7:00 PM and before 9:45 PM, while the Wander Guard system was not working. The facility failed to continue Resident #1's increased supervision of every 15 minute checks, after his return from the emergency roiagnom on [DATE], while the Wander Guard system continued to still not work. Resident #1 eloped and was missing for at least 3.5 hours during the night hours of 02/04/14, and the early morning hours of 02/05/14. The resident was found by the police and transported to the emergency room due to his altered mental status. While in the emergency room , his temperature was 94 degrees F and warming blankets were used to increase temperature. An Immediate Jeopardy (IJ) was identified on 02/07/14. While the IJ was removed on 02/09/14, the facility remained out of compliance at a severity level of "no actual harm with the potential for more than minimal harm that is not immediate jeopardy," and a scope of "pattern" because the facility was still in-servicing staff and implementing the Plan of Removal. These failures could affect the five residents, including Resident #1, who were at high risk for elopement, by placing them at risk for being able to elope from the facility, which could result in a resident being lost, falls, injuries, other serious mental/physical harm and/or death. Findings included: 1) Resident #1's MDS assessment, dated 12/31/13, reflected he was a [AGE] year-old male, who was admitted to the facility on [DATE]. The MDS assessment also reflected Resident #1 had [DIAGNOSES REDACTED]. The MDS assessment further reflected Resident #1 was able to understand and be understood by others. He was severely cognitively impaired and had disorganized thinking, which was continuously present. He did not wander. The MDS assessment also reflected he required set-up assistance with bed mobility, transfers, walking in his room, walking in the corridor, locomotion on the unit, locomotion off the unit, and with eating. He needed the assistance of one person with dressing and toilet use, and the assistance of two or more persons with personal hygiene and bathing. Resident #1's balance during transitions and walking was not steady, but he was able to stabilize without staff assistance, and he did not use any mobility devices. Resident #1's Elopement/Wandering Assessment Tool, dated 03/14/13, reflected a score of five, which indicated he was at high risk for elopement. There was a handwritten note on the tool, which reflected a Wander Guard was in place. Resident #1's Elopement/Wandering Assessment Tool, dated 05/24/13, reflected a score of six, which indicated he was at high risk of elopement. Resident #1's Care Plan, dated 06/30/13, reflected, "Resident at risk for elopement, requires use of a wander guard (sic) for safety, unaware of safety issues D/T (due to) confusion." The goal was, "Resident will have fewer episodes of attempt to elope with use of wanderguard (sic) X3 (times 3) months." The approaches were the following: "Assess res (resident) for risk of elopement quarterly, monitor wanderguard (sic) for functional working order by testing freq (frequently), redirect res when attempting to leave facility, social service intervention as needed, follow facility protocol in event elopement occurs, notify family, physician of any coc (change of condition)." The Care Plan was stamped on 09/26/13, 12/12/13, and 02/07/14 as "continue." Resident #1's Elopement/Wandering Assessment Tool, dated 08/23/13 and 11/22/13, reflected scores of three, which indicated the resident was a moderate risk for elopement. There was a handwritten note on the tool, which reflected a Wander Guard was in place. The note was not dated. Resident #1's February 2014 MAR reflected the following entries: "ASSESS WANDERGUARD (sic) MONITORING DEVICE FOR FUNCTIONING QDAY Start Date: 5/25/2013 Day Shift...PERFORM WANDERGUARD (sic) SYSTEM CHECK Q WEEK ON THRUSDAY (sic) Start Date: 5/25/2013 Day Shift Wanderguard (sic) in place for safety and prevent elopement. Check q shift Start Date: 5/25/2013 Day and Evening." The MAR was initialed as completed on 02/01/14, 02/02/14, 02/03/14, 02/04/14 for everything except checking the system once a week. Resident #1's Nurse's Notes, dated 02/04/14 and timed at 9:45 PM, reflected the MA asked Resident #1's nurse, if she had seen him. The MA told the nurse the last time she saw the resident was at 8:30. The Notes reflected they looked for Resident #1 in his favorites spots, but could not locate him. Then they initiated a "head count face to face." When they could not locate him in the facility, the DON, ADON, and Administrator were notified. The Notes reflected staff was interviewed to determined the last time he was seen, and the police were notified. The search continued outside and the family and physician were also notified. Nurse's Notes, dated 02/04/14 (date should be 02/05/14) and timed at 12:40 AM, reflected the facility was notified the resident was at the hospital with no injuries, but he was cold. http://www.weather.com/weather/monthly/ ?month=0 reflected the high temperature on 02/04/14 was 43 degrees F and the low temperature was 37 degrees F. The high temperature on 02/05/14 was 37 degrees F and the low temperature was 25 degrees F. The facility's Incident/Accident Report, dated 02/04/14, reflected Resident #1 was not found in the building, and the Missing Resident protocol was initiated. The resident was found and taken to the emergency room by EMS. The Investigation Follow-Up, dated 02/04/14 and attached to the Incident Report, reflected the investigation was started on 02/04/14. The Summary of Investigation section, of the Investigation Follow-Up, reflected, "Res had a plan & voiced it upon locating him 'was going to (city) to a movie.'" Past Interventions Attempted section, of the Investigation Follow-Up, reflected, "Wanderguard (sic) in place, device monitored daily." Recommendations/New Interventions section, of the Investigation Follow-Up, reflected, "Resident is to be assessed for a locked unit. Social Services to seek for placement. Resident to be monitored closely. Resident followed visitors out the door...." The Incident/Accident Report was signed by the DON, but not by the Administrator. An interview with LVN F on 02/09/14 at 6:10 PM revealed she was assigned to care for Resident #1 on 02/04/14. She stated she saw him watching TV when she arrived for duty at around 6:00 PM, and that was the last time she could remember seeing him. LVN F revealed he was discovered missing around 9:45 PM. She stated she did not know if the resident was at the 7:00 PM smoke break. LVN F revealed she notified the Administrator and the police and the Missing Resident protocol was initiated. An interview with LVN C on 02/07/14 at 3:00 PM revealed Resident #1 was at the smoke break at 7:00 PM on Tuesday, 02/04/14. Interview with the DON on 02/07/2014 at 11:10 AM revealed she received a call from the facility about 10:00 PM on 02/04/14 and was told they could not find Resident #1. She stated a head count was initiated, and she asked when was the last time he was seen. She revealed he was a smoker, and he was not seen at the 9:00 PM smoking time. The DON said the MA also could not find him to give him his 9:00 PM medications. She stated she arrived at the facility at 10:05 PM, and the head count was repeated. She revealed all the areas outside were searched and the family, police, and physician were notified. She stated the facility received a call from the local police department at about 12:40 AM, and they said they found Resident #1 and he was at the emergency room . The DON revealed she went to the emergency room and identified the resident. She stated she also interviewed him. The DON revealed he said he was going to another city to watch a movie when asked where he was going. She stated she estimated he was missing for 3.5 hours. She said he had a Wander Guard. The DON stated, "Feels like he followed someone out." She revealed maybe through the 100 Hall door. The DON revealed she did not know what happened that resulted in Resident #1 eloping. She stated there was nothing in place to prevent Resident #1's elopement, when the Wander Guard system was down after construction. Interview with the Administrator on 02/07/2014 at 11:34 AM revealed she received a call around 10:00 to 10:30 PM on 02/04/14 from the facility, and they could not find Resident #1. She stated the police, family, and physician were called, and the searches continued. The Administrator revealed the police found him and called at 12:30 AM to inform them. She stated the resident was in the emergency room for several hours. She stated he went out the door with people. The Administrator revealed she was still waiting on statements from some staff, who worked that day. She stated the front door was broken, and Resident #1 could have gone through it. She revealed Resident #1 said he went out with other people. The Administrator stated, "Door is totally lockdown." She revealed, "Before you could use the code." She stated now it would not open. The Administrator revealed Resident #1 said he went out the front door, where the renovation was going on. She stated only Maintenance could open that door. She said, "All staff keeping eye on him." Interview with the Maintenance Director on 02/07/14 at approximately 12:15 PM, revealed he thought the resident exited the facility with a visitor. He stated, "Wander Guard system not working at this time." He revealed the Wander Guard on the old door could not work on the new door. The Maintenance Director stated the parts were ordered and would be there on Monday, 02/10/14. He revealed the temporary entrance had a code, but no Wander Guard system in place. The Maintenance Director stated they "were not required to have a Wander Guard." Further interview with the Administrator on 02/08/14 at 12:45 PM revealed the expansion of the facility started in May 2013 and the wall that had been there was opened in the middle of January. She stated the Wander Guard system should have been there. She revealed the contractor failed to have the Wander Guard on the door. The Administrator stated, "It is ultimately our responsibility." Further interview with the DON on 02/08/14 at 12:30 PM revealed she did not think the front door had the Wander Guard system on it. She stated the area opened up from the construction in January 2014. The DON revealed that should have not gone undetected. Resident #1's Triage emergency room Notes, dated 02/05/14 and timed at 12:17 AM, reflected he was found walking along Highway 34 by Farm to Market Road 1903, and the police sent EMS to pick him up due to his altered mental status. Resident #1 was assessed with [REDACTED]. Patient was covered with warm blankets for "warming measures." The Notes reflected his temperature at 2:11 AM was 97.5 F, which was his baseline. Resident #1's Nurse's Notes, dated 02/04/14 (should be dated 02/05/14) and timed at 6:00 AM, reflected he arrived at the facility and was oriented to his name. The Notes also reflected he was not in pain or discomfort, his respirations were even and unlabored, and he was happy. An interview with LVN C on 02/07/14 at 3:00 PM revealed she learned of Resident #1's elopement during report. She stated the night nurse told her they were doing every 15 minute checks on the resident, but it ended on the night shift because they were not doing them that day. An observation on 02/07/14 at 2:50 PM revealed Resident #1 watching TV in the living area opposite the Nurse's Station. An interview with LVN D on 02/07/14 at 2:55 PM revealed Resident #1 was not on any special monitoring. He stated he knew the resident was an elopement risk, but he had a Wander Guard, so they would hear the door alarm if he or any of the residents, who were at high risk for elopement and had Wander Guards, tried to go out the door. LVN D revealed Resident #1 and two other residents, who were high risk for elopement, were close to the Nurse's Station. The facility's current policy, "Elopement/Missing Resident-Mag Lock Doors," revised October 2012, reflected, "...If the resident is assessed as moderate to high risk the monitoring procedure will be implemented...5. The magnetic door lock system will be checked weekly by maintenance...9...If there are circumstances that place the residents health, safety, and/or welfare at risk the report will be made to the regulatory agency as soon as the facility is aware that the resident is missing and cannot be located...." An IJ was identified on 02/07/14. On 02/07/14 at 3:20 PM, the Administrator and DON were notified of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal, accepted on 02/08/14, reflected the following: The facility has 6 doors. Three of the six doors have mag lock delayed egress alarms with a key pad. The key pad code is used to exit three of the six doors which are as follows: 1. Front main door 2. D.R. door that goes to the smoke patio 3. Hall I door The remaining 3 exit doors alarm immediately when opened, a key is required to stop the alarm: 1. Hall 2 door 2. Hall 3 door 3. Hall 4 door On 02/07/14, the facility implemented the following Action Plan that affected Resident #1 and had the potential to affect four other residents:: 1) The following residents were placed on 1:1 observations at 4:00 PM till 5:00 PM by the DON and were monitored: Residents #1, #5, #4, #3, and #2. 2) The elopement risk assessment was used to re assess these residents for elopement using the Elopement Risk assessment tool 02/07/14. 3) At 5:00 PM staff members were stationed at the main front entrance, hall I door, and dining room door that led to the smoke patio. 4) For all residents in the center, the elopement risk assessment will be reviewed and evaluated for change in status on 02/08/14. 6) A staff member schedule was developed by the Administrator for continuous door monitoring for the main front door, hall I, and D/R door leading to smoke patio 24 hours a day, 7 days a week until a Wander Guard system is installed on the main front door, Hall I door and the D/R door leading to smoke patio and this door monitoring and schedule will continue from 02/07/14 and ending no later than 02/13/14. 7) All facility doors would be checked including the functioning of the Wander Guard system daily for two weeks by the Maintenance Supervisor beginning on 02/08/14 and ending 02/22/14. 8) All Staff will be in serviced annually on missing person guidelines by DON 9) A missing resident drill would be conducted monthly by the Administrator. 10) All staff were provided education by the DON, beginning 02/07/14 and would be completed by 02/08/14. 11) All assigned to door monitoring would receive education regarding the door monitoring procedure by the DON and ADON beginning 02/07/14 and would continue until 02/10/14. 12) Each staff member would have access to a walkie talkie or cell phone to enable them to notify the Charge Nurse in case of a needed break, so staff member on the monitoring schedule could be assigned to the door. Each staff member would have understanding they could not leave the exit door they were monitoring until replacement was in place. 13) Wander Guard Company was notified on 02/07/14 and would be installing the Wander Guard System on the Main front door on 02/08/14 by 1:00 PM; Hall I door on 02/10/14 by 2:00 PM; and the Dining Room door that led to the smoke patio on 02/13/14 or sooner. Interviews with CNA H, CNA I, the Dietary Manager, Laundry Aide J, and CNA K on 02/09/14 from 5:49 PM through 6:02 PM revealed they were in-serviced and understood their training. They knew what to do if a resident was missing. The IJ was removed on 02/09/14. On 02/09/14 at 8:30 PM, the Administrator and the DON were notified the IJ was removed. While the IJ was removed on 02/09/14, the facility remained out of compliance at a severity level of "no actual harm with the potential for more than minimal harm that is not immediate jeopardy," and a scope of "pattern" because the facility was still in-servicing staff and implementing the Plan of Removal. A document, "Wander Residents," dated 02/07/14, reflected five residents, who wandered in the facility, including Resident #1.
Based on observation, interview and record review, the facility failed to implement the facility's written policies and procedures, which prohibit neglect for one (Resident #1) of five residents reviewed for neglect. The facility failed to put a plan in place to prevent Resident #1's elopement on 02/04/14 sometime after 7:00 PM and before 9:45 PM, while the Wander Guard system was not working. The facility failed to continue Resident #1's increased supervision of every 15 minute checks, after his return from the emergency roiagnom on [DATE], while the Wander Guard system continued to still not work. The facility failed to report Resident #1's elopement to the State survey and certification agency. Resident #1 eloped and was missing for at least 3.5 hours during the night hours of 02/04/14, and the early morning hours of 02/05/14. The resident was found by the police and transported to the emergency room due to his altered mental status. While in the emergency room , his temperature was 94 degrees F and warming blankets were used to increase temperature. An Immediate Jeopardy (IJ) was identified on 02/07/14. While the IJ was removed on 02/09/14, the facility remained out of compliance at a severity level of "no actual harm with the potential for more than actual harm that is not immediate jeopardy," and a scope of "pattern" because the facility was still in-servicing staff and implementing the Plan of Removal. These failures could affect the five residents, including Resident #1, who were at high risk for elopement, by placing them at risk for being able to elope from the facility, which could result in a resident being lost, falls, injuries, other serious mental/physical harm and/or death. Findings included: The facility's current Abuse Prohibition Policy and Procedure, revised July 2012, reflected, "...VII. Reporting and Response to Alleged Incidents: A. Incidents of alleged abuse, neglect or misappropriation of resident property must be reported to the appropriate local, state, and federal agencies...Neglect - A deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental anguish/illness or physical injury, or harm or death to a resident...." The facility's current policy, "Elopement/Missing Resident-Mag Lock Doors," revised October 2012, reflected, "...If the resident is assessed as moderate to high risk the monitoring procedure will be implemented...5. The magnetic door lock system will be checked weekly by maintenance...9...If there are circumstances that place the residents health, safety, and/or welfare at risk the report will be made to the regulatory agency as soon as the facility is aware that the resident is missing and cannot be located...." Resident #1's MDS assessment, dated 12/31/13, reflected he was a [AGE] year-old male, who was admitted to the facility on [DATE]. The MDS assessment also reflected Resident #1 had [DIAGNOSES REDACTED]. The MDS assessment further reflected Resident #1 was able to understand and be understood by others. He was severely cognitively impaired and had disorganized thinking, which was continuously present. He did not wander. The MDS assessment also reflected he required set-up assistance with bed mobility, transfers, walking in his room, walking in the corridor, locomotion on the unit, locomotion off the unit, and with eating. He needed the assistance of one person with dressing and toilet use, and the assistance of two or more persons with personal hygiene and bathing. Resident #1's balance during transitions and walking was not steady, but he was able to stabilize without staff assistance, and he did not use any mobility devices. Resident #1's Elopement/Wandering Assessment Tool, dated 03/14/13, reflected a score of five, which indicated he was at high risk for elopement. There was a handwritten note on the tool, which reflected a Wander Guard was in place. Resident #1's Elopement/Wandering Assessment Tool, dated 05/24/13, reflected a score of six, which indicated he was at high risk of elopement. Resident #1's Care Plan, dated 06/30/13, reflected, "Resident at risk for elopement, requires use of a wander guard (sic) for safety, unaware of safety issues D/T (due to) confusion." The goal was, "Resident will have fewer episodes of attempt to elope with use of wanderguard (sic) X3 (times 3) months." The approaches were the following: "Assess res (resident) for risk of elopement quarterly, monitor wanderguard (sic) for functional working order by testing freq (frequently), redirect res when attempting to leave facility, social service intervention as needed, follow facility protocol in event elopement occurs, notify family, physician of any coc (change of condition)." The Care Plan was stamped on 09/26/13, 12/12/13, and 02/07/14 as "continue." Resident #1's Elopement/Wandering Assessment Tool, dated 08/23/13 and 11/22/13, reflected scores of three, which indicated the resident was a moderate risk for elopement. There was a handwritten note on the tool, which reflected a Wander Guard was in place. The note was not dated. Resident #1's February 2014 MAR indicated [REDACTED]. Check q shift Start Date: 5/25/2013 Day and Evening." The MAR indicated [REDACTED]. Resident #1's Nurse's Notes, dated 02/04/14 and timed at 9:45 PM, reflected the MA asked Resident #1's nurse, if she had seen him. The MA told the nurse the last time she saw the resident was at 8:30. The Notes reflected they looked for Resident #1 in his favorites spots, but could not locate him. Then they initiated a "head count face to face." When they could not locate him in the facility, the DON, ADON, and Administrator were notified. The Notes reflected staff was interviewed to determined the last time he was seen, and the police were notified. The search continued outside and the family and physician were also notified. Nurse's Notes, dated 02/04/14 (date should be 02/05/14) and timed at 12:40 AM, reflected the facility was notified the resident was at the hospital with no injuries, but he was cold. http://www.weather.com/weather/monthly/ ?month=0 reflected the high temperature on 02/04/14 was 43 degrees F and the low temperature was 37 degrees F. The high temperature on 02/05/14 was 37 degrees F and the low temperature was 25 degrees F. The facility's Incident/Accident Report, dated 02/04/14, reflected Resident #1 was not found in the building, and the Missing Resident protocol was initiated. The resident was found and taken to the emergency room by EMS. The Investigation Follow-Up, dated 02/04/14 and attached to the Incident Report, reflected the investigation was started on 02/04/14. The Summary of Investigation section, of the Investigation Follow-Up, reflected, "Res had a plan & voiced it upon locating him 'was going to (city) to a movie.'" Past Interventions Attempted section, of the Investigation Follow-Up, reflected, "Wanderguard (sic) in place, device monitored daily." Recommendations/New Interventions section, of the Investigation Follow-Up, reflected, "Resident is to be assessed for a locked unit. Social Services to seek for placement. Resident to be monitored closely. Resident followed visitors out the door...." The Incident/Accident Report was signed by the DON, but not by the Administrator. An interview with LVN F on 02/09/14 at 6:10 PM revealed she was assigned to care for Resident #1 on 02/04/14. She stated she saw him watching TV when she arrived for duty at around 6:00 PM, and that was the last time she could remember seeing him. LVN F revealed he was discovered missing around 9:45 PM. She stated she did not know if the resident was at the 7:00 PM smoke break. LVN F revealed she notified the Administrator and the police and the Missing Resident protocol was initiated. An interview with LVN C on 02/07/14 at 3:00 PM revealed Resident #1 was at the smoke break at 7:00 PM on Tuesday, 02/04/14. Interview with the DON on 02/07/2014 at 11:10 AM revealed she received a call from the facility about 10:00 PM on 02/04/14 and was told they could not find Resident #1. She stated a head count was initiated, and she asked when was the last time he was seen. She revealed he was a smoker, and he was not seen at the 9:00 PM smoking time. The DON said the MA also could not find him to give him his 9:00 PM medications. She stated she arrived at the facility at 10:05 PM, and the head count was repeated. She revealed all the areas outside were searched and the family, police, and physician were notified. She stated the facility received a call from the local police department at about 12:40 AM, and they said they found Resident #1 and he was at the emergency room . The DON revealed she went to the emergency room and identified the resident. She stated she also interviewed him. The DON revealed he said he was going to another city to watch a movie when asked where he was going. She stated she estimated he was missing for 3.5 hours. She said he had a Wander Guard. The DON stated, "Feels like he followed someone out." She revealed maybe through the 100 Hall door. The DON revealed she did not know what happened that resulted in Resident #1 eloping. She stated there was nothing in place to prevent Resident #1's elopement, when the Wander Guard system was down after construction. The DON revealed the Administrator did not report Resident #1's elopement to DADS because the situation did not meet the guideline of the resident being gone for four or more hours. Interview with the Administrator on 02/07/2014 at 11:34 AM revealed she received a call around 10:00 to 10:30 PM on 02/04/14 from the facility, and they could not find Resident #1. She stated the police, family, and physician were called, and the searches continued. The Administrator revealed the police found him and called at 12:30 AM to inform them. She stated the resident was in the emergency room for several hours. She stated he went out the door with people. The Administrator revealed she was still waiting on statements from some staff, who worked that day. She stated the front door was broken, and Resident #1 could have gone through it. She revealed Resident #1 said he went out with other people. The Administrator stated, "Door is totally lockdown." She revealed, "Before you could use the code." She stated now it would not open. The Administrator revealed Resident #1 said he went out the front door, where the renovation was going on. She stated only Maintenance could open that door. She said, "All staff keeping eye on him." The Administrator revealed she did not report Resident #1's elopement because she thought the resident had to be gone for four to eight hours or longer. She stated she estimated he was gone for about two hours. Interview with the Maintenance Director on 02/07/14 at approximately 12:15 PM, revealed he thought the resident exited the facility with a visitor. He stated, "Wander Guard system not working at this time." He revealed the Wander Guard on the old door could not work on the new door. The Maintenance Director stated the parts were ordered and would be there on Monday, 02/10/14. He revealed the temporary entrance had a code, but no Wander Guard system in place. The Maintenance Director stated they "were not required to have a Wander Guard." Further interview with the Administrator on 02/08/14 at 12:45 PM revealed the expansion of the facility started in May 2013 and the wall that had been there was opened in the middle of January. She stated the Wander Guard system should have been there. She revealed the contractor failed to have the Wander Guard on the door. The Administrator stated, "It is ultimately our responsibility." Further interview with the DON on 02/08/14 at 12:30 PM revealed she did not think the front door had the Wander Guard system on it. She stated the area opened up from the construction in January 2014. The DON revealed that should have not gone undetected. Resident #1's Triage emergency room Notes, dated 02/05/14 and timed at 12:17 AM, reflected he was found walking along Highway 34 by Farm to Market Road 1903, and the police sent EMS to pick him up due to his altered mental status. Resident #1 was assessed with [REDACTED]. Patient was covered with warm blankets for "warming measures." The Notes reflected his temperature at 2:11 AM was 97.5 F, which was his baseline. Resident #1's Nurse's Notes, dated 02/04/14 (should be dated 02/05/14) and timed at 6:00 AM, reflected he arrived at the facility and was oriented to his name. The Notes also reflected he was not in pain or discomfort, his respirations were even and unlabored, and he was happy. An interview with LVN C on 02/07/14 at 3:00 PM revealed she learned of Resident #1's elopement during report. She stated the night nurse told her they were doing every 15 minute checks on the resident, but it ended on the night shift because they were not doing them that day. An observation on 02/07/14 at 2:50 PM revealed Resident #1 watching TV in the living area opposite the Nurse's Station. An interview with LVN D on 02/07/14 at 2:55 PM revealed Resident #1 was not on any special monitoring. He stated he knew the resident was an elopement risk, but he had a Wander Guard, so they would hear the door alarm if he or any of the residents, who were at high risk for elopement and had Wander Guards, tried to go out the door. LVN D revealed Resident #1 and two other residents, who were high risk for elopement, were close to the Nurse's Station. An IJ was identified on 02/07/14. On 02/07/14 at 3:20 PM, the Administrator and DON were notified of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal, accepted on 02/08/14, reflected the following: The facility has 6 doors. Three of the six doors have mag lock delayed egress alarms with a key pad. The key pad code is used to exit three of the six doors which are as follows: 1. Front main door 2. D.R. door that goes to the smoke patio 3. Hall I door The remaining 3 exit doors alarm immediately when opened, a key is required to stop the alarm: 1. Hall 2 door 2. Hall 3 door 3. Hall 4 door On 02/07/14, the facility implemented the following Action Plan that affected Resident #1 and had the potential to affect four other residents:: 1) The following residents were placed on 1:1 observations at 4:00 PM till 5:00 PM by the DON and were monitored: Residents #1, #5, #4, #3, and #2. 2) The elopement risk assessment was used to re assess these residents for elopement using the Elopement Risk assessment tool 02/07/14. 3) At 5:00 PM staff members were stationed at the main front entrance, hall I door, and dining room door that led to the smoke patio. 4) For all residents in the center, the elopement risk assessment will be reviewed and evaluated for change in status on 02/08/14. 6) A staff member schedule was developed by the Administrator for continuous door monitoring for the main front door, hall I, and D/R door leading to smoke patio 24 hours a day, 7 days a week until a Wander Guard system is installed on the main front door, Hall I door and the D/R door leading to smoke patio and this door monitoring and schedule will continue from 02/07/14 and ending no later than 02/13/14. 7) All facility doors would be checked including the functioning of the Wander Guard system daily for two weeks by the Maintenance Supervisor beginning on 02/08/14 and ending 02/22/14. 8) All Staff will be in serviced annually on missing person guidelines by DON 9) A missing resident drill would be conducted monthly by the Administrator. 10) All staff were provided education by the DON, beginning 02/07/14 and would be completed by 02/08/14. 11) All assigned to door monitoring would receive education regarding the door monitoring procedure by the DON and ADON beginning 02/07/14 and would continue until 02/10/14. 12) Each staff member would have access to a walkie talkie or cell phone to enable them to notify the Charge Nurse in case of a needed break, so staff member on the monitoring schedule could be assigned to the door. Each staff member would have understanding they could not leave the exit door they were monitoring until replacement was in place. 13) Wander Guard Company was notified on 02/07/14 and would be installing the Wander Guard System on the Main front door on 02/08/14 by 1:00 PM; Hall I door on 02/10/14 by 2:00 PM; and the Dining Room door that led to the smoke patio on 02/13/14 or sooner. Interviews with CNA H, CNA I, the Dietary Manager, Laundry Aide J, and CNA K on 02/09/14 from 5:49 PM through 6:02 PM revealed they were in-serviced and understood their training. They knew what to do if a resident was missing. The IJ was removed on 02/09/14. On 02/09/14 at 8:30 PM, the Administrator and the DON were notified the IJ was removed. While the IJ was removed on 02/09/14, the facility remained out of compliance at a severity level of "no actual harm with the potential for more than minimal harm that is not immediate jeopardy," and a scope of "pattern" because the facility was still in-servicing staff and implementing the Plan of Removal. A document, "Wander Residents," dated 02/07/14, reflected five residents, who wandered in the facility, including Resident #1.
Inspection of May 31, 2012
2 findingsBased on interview and record review, it was determined the facility failed to provide care and services to maintain the highest practicable physical well-being for one (Resident #1) of six residents receiving anticoagulation therapy. Resident #1 was receiving anticoagulation therapy ([MEDICATION NAME]) for PE and [MEDICAL CONDITION] with unstable PT/INRs (measured in seconds). Adjustments in the [MEDICATION NAME] doses were made daily to every three days based on the PT/INRs from the time of admission, 03/31/12, until 04/17/12. At that time an adjustment was made in the [MEDICATION NAME], but no order was given to monitor the lab. On 05/04/12 at 6:30 PM, the facility identified Resident #1 was experiencing a change in condition with a decline in her level of consciousness and increased respiratory rate. The physician was not notified. On 05/05/12 at 6:30 AM, the facility nurse assessed the resident with an elevated heart rate (114) and respiratory rate (40). The nurse did not notify the doctor but called hospice for intervention. At 9:45 AM on 05/05/12, the hospice nurse revisited and notified the physician of the resident's decline and lab test were ordered. The resident was discharged to the hospital on [DATE] at 2:15 PM, after family insistence. Upon arrival to the hospital, Resident #1's PT/INR was >240/21.5 and the resident was diagnosed with [REDACTED]. These failures placed Resident #1 in the hospital for 5 days and placed 5 other residents at risk for not receiving necessary medical interventions that could cause a serious medical problem, a decline in health and possible death. Findings included: 1) Resident #1, an [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed Resident #1 received Anticoagulant Medication. Review of Resident #1's facility "History and Physical" dated 04/04/12 revealed the resident had current [DIAGNOSES REDACTED]. Further review of this form revealed the resident's rehab potential was "fair." Review of an undated facility "Interim Plan of Care" for Resident #1 revealed "[MEDICATION NAME] precautions." Review of an undated facility care plan revealed Resident #1 received [MEDICATION NAME] for a recent [MEDICAL CONDITION] Embolism. The "Goals" reflected Resident #1 would have therapeutic INR levels. "Interventions" included: PT/INRs would be done as ordered and reported to the physician; [MEDICATION NAME] would be administered as ordered; the resident would have no leafy green vegetables; and the resident would be observed for bruising and bleeding. 2) Review of Resident #1's "admission orders [REDACTED]. "The PT and INR are used to monitor the effectiveness of the anticoagulant [MEDICATION NAME] ([MEDICATION NAME]?). This drug affects the function of the coagulation cascade and helps inhibit the formation of blood clots...The goal with [MEDICATION NAME] therapy is to maintain a balance between preventing clots and causing excessive bleeding. This balance requires careful monitoring, typically by PT/INR...There is no set frequency for doing the test. A doctor will order them often enough to make sure that the drug is producing the desired effect - that it is increasing the person's clotting time to a therapeutic level without causing excessive bleeding or bruising...A prolonged PT means that the blood is taking too long to form a clot." (Retrieved on 06/14/12 at http://labtestsonline.org/understanding/analytes/pt/tab/test.) Lexi-Comp's "Drug Information Handbook for Advanced Practice Nursing," 9th Edition, Copyright 2008, pages 1738-1740, reflected [MEDICATION NAME] was an anticoagulant. "The Institute for Safe Medication Practices (ISMP) includes this medication among the list of drugs which have a heightened risk of causing significant patient harm when used in error ...(U.S. Boxed Warning): May cause major or fatal bleeding...Risk factors for bleedings include high intensity anticoagulation (INR >4), Age (>65), Variable INRs, history of GI Bleeding, hypertension, [MEDICAL CONDITION] disease, serious [MEDICAL CONDITIONS], malignancy, trauma ...The elderly may be more sensitive to anticoagulant therapy ...." Review of a physician's orders [REDACTED]. Resident #1's lab results dated 04/03/12 reflected the PT/INR results were 19.3/2.3. Review of a physician's orders [REDACTED]. Resident #1's lab results dated 04/09/12 reflected the PT/INR results were 42.8/8.5. Review of a physician's orders [REDACTED]. Resident #1's lab results dated 04/12/12 reflected the PT/INR results were 39.5/7.5. Review of a physician's orders [REDACTED]. Resident #1's lab results dated 04/13/12 revealed the PT/INR results were 20.7/2.6. Review of a physician's orders [REDACTED]. Resident #1's lab results dated 04/16/12 reflected the PT/INR results were 12.3/1.1. Review of Resident #1's "Nurse's Notes" dated 04/17/12 at 4:00 PM revealed the PT/INR results were received and PA B, Dr. A's PA, was notified. The [MEDICATION NAME] was increased to 3.5 mg daily. Review of a physician's orders [REDACTED]. (Note no further PT/INR orders.) Further review of Resident #1's physician's orders [REDACTED]. 3) Review of Resident #1's "Nurse's Notes" dated 04/14/12 at 3:00 PM revealed LVN C was called to the shower room by an unidentified CNA. Resident #1 was noted to have a large purple/black bruised area on her right hip that measured 12 inches by 3 inches. Further review of this note revealed the physician was not notified. Review of Resident #1's "Nurse's Notes" dated 04/15/12 at 3:00 PM revealed the bruise to the resident's right hip had increased in size to 22 inches by 3 inches. Further review of this note revealed the physician was not notified. During a telephone interview on 05/31/12 at 9:47 AM LVN C stated she saw Resident #1's bruise. She stated, "I didn't know if she (Resident #1) fell . I was the first one who noticed the bruise and it was quite large. I think I notified the doctor and family. I normally document in the nurse's notes." LVN C stated she knew Resident #1 was on [MEDICATION NAME]. The surveyor queried LVN C regarding responsibilities to residents on [MEDICATION NAME]. LVN C responded, "Look for bruising and monitor PT/INR's." LVN C was queried if she notified Resident #1's physician on 04/15/12 when she documented the bruise had increased in size to 22 inches. LVN C stated, " No, because I notified him the day before and I didn't need to call the doctor again." Review of a facility physician's progress note dated 04/18/12 revealed Resident #1 fell with a bruise to her right leg. Further review of the progress note revealed Resident #1's INR was elevated. Review of a facility "Falls Management - Plan of Care" dated 04/19/12 revealed a hand written star and "pt (patient) on [MEDICATION NAME] - PT/INR unstable." Review of Resident #1's MAR's dated 04/17/12 through 05/04/12 revealed the resident received [MEDICATION NAME] 3.5 mg daily. 4) During an interview on 05/30/12 at 9:54 AM, ADON G stated "Triage Nursing Assessments" were completed by facility staff when a resident had a change in condition and the nurse's charted on the assessment sheets every shift or until the issue resolved. Review of the facility "Triage Nursing Assessments" dated 05/04/12 revealed: At 7:20 AM - Resident #1's temperature was 99.1?, blood pressure was 120/88, pulse was 109, respirations were 28. Hospice was notified. At 6:30 PM - Resident #1's temperature was 99.7?, blood pressure was 140/62, pulse was 82, respirations were 29 and the resident was hard to arouse. "Resident appears sedated, but will arouse slightly to tactile stimulus." At 10:00 PM - the resident's temperature was 100? axillary, blood pressure was 164/76, pulse was 109 and irregular and respirations were 28. The resident was "hard to arouse." Review of a hospice nurse's notes dated 05/05/12 at 6:23 AM revealed Resident #1 had a change in her level of consciousness. Further review of this note revealed the resident was diaphoretic, confused, lethargic and disoriented. The resident's functional status was "deteriorating." Review of the facility "Triage Nursing Assessment" dated 05/05/12 at 6:40 AM revealed Resident #1's temperature was 97.6?, blood pressure was 124/76, pulse was 114 and respirations were 40. The resident was slightly diaphoretic and "more difficult to arouse than previous assessment. Call placed to ________ Hospice d/t (due to) change from previous visit (6:23 AM)." At 7:30 AM - the facility nurse notified the physician and the resident's family member. The note reflected the Hospice nurse revisited at 9:45 AM and ordered a comfort kit, CBC and UA for the resident. At 1:00 PM - the resident's family member was at the facility demanding that Resident #1 be sent to the hospital because he/she felt (Resident #1) was having a stroke. The nurse told the resident's family member she (nurse) had to go through proper procedures. At 1:30 PM the family member continued to insist the resident be sent to the hospital and the nurse placed a call to the Hospice nurse. The Hospice nurse reported if the family wanted the resident to go to the ER, then the facility should send her. A call was then placed to the physician. At 2:00 PM the nurse spoke with the physician and he gave the order to send the resident to the ER. At 2:15 PM the ambulance was at the facility to transport the resident. 5) Review of "emergency room RN Notes" dated 05/05/12 revealed, "The patient (Resident #1) is disoriented to person, place and time. (PT (patient) JUST STARES AND DOES NOT MAKE FACIAL EXPRESSIONS)...." Review of the hospital "history and physical examination [REDACTED]. Further review of this form revealed Resident #1 had a history of [REDACTED]. "The patient was on [MEDICATION NAME] before, but it (Resident #1) is not on current medication at the nursing home. We will restart [MEDICATION NAME] and monitor [MEDICATION NAME] time (PT) /international normalized ratio (INR)." Review of the hospital lab report dated 05/05/12 at 4:03 PM revealed Resident #1's PT/INR results were >240 /21.5. Resident #1's Hgb was 8.2 and Hct was 26.5. The lab reports reflected the normal values were: PT/INR 9.0-12.0/2.0-3.0, Hgb 12.0-17.0 and Hct 36-46. Review of the hospital physician's progress note dated 05/06/12 at 12:33 PM revealed, "[MEDICATION NAME] toxicity." Review of the hospital physician orders [REDACTED].#1 received one dose of Vitamin K 5 mg, three units of PRBCs, and 3 units of FFP. Review of the hospital lab reports from 05/05/12 - 05/10/12 revealed Resident #1's PT/INR went from >240/21.5 on admission to 37.0/3.3 at the time of discharge. The resident's HCT was 23.2 and rose to 30.4 by the day of discharge Review of the hospital "Discharge Medications" dated 05/10/12 revealed [MEDICATION NAME] 2 mg daily if INR was less than 3. Further review of the discharge medications revealed "the patient might need to have [MEDICATION NAME] time and international normalized ration checked frequently." 6) During an interview on 05/29/12 at 10:52 AM, the DON stated Resident #1's PT/INR's were up and down. She stated, "They (facility) could never get them ([MEDICATION NAME]) adjusted, frequent changes." The DON further stated she was not aware Resident #1 did not have PT/INR orders after 04/16/12. She stated, "I would expect the nurses to ask for PT/INR labs if not written." During an interview on 05/29/12 at 11:20 AM, LVN D stated when a resident was on [MEDICATION NAME], PT/INRs were usually drawn weekly as a routine order. She further stated if there were not routine orders, she would have to call the doctor to get it started. LVN D stated she was aware Resident #1 had a PE when she was first admitted (03/31/12). The surveyor showed LVN D Resident #1's telephone physician order [REDACTED]. (Note: LVN D wrote the verbal order) LVN D stated, "That's odd." The surveyor queried LVN D if she asked the PA for PT/INR lab orders and LVN D stated, "Apparently not. I don't know why. Maybe I was thinking hers (Resident #1's) were routine ...The only thing I can say is it got missed." During an interview on 05/30/12 at 10:07 AM, ADON E stated Resident #1 was on [MEDICATION NAME] and her PT/INRs were unstable and needed to be "monitored more frequently than you normally do." The surveyor showed ADON E Resident #1's telephone order dated 04/17/12 to increase the [MEDICATION NAME] to 3.5 mg. ADON E revealed she saw the order and stated, "It's a good order." When queried about an a PT/INR, ADON E stated she did not remember if she asked about when the next PT/INR would be drawn. During an interview on 05/30/12 at 10:20 AM, Dr. A (Resident #1's physician) stated when a resident was on [MEDICATION NAME], he would have standing orders for INRs; once a week until stable then every two weeks. He wanted the resident's INR to be between 2 and 3 (therapeutic range). He further stated if there was a change in the [MEDICATION NAME] dose, he would write an addition PT/INR order as well as keep the routine order. Dr. A was made aware Resident #1 had a verbal order written on 04/17/12 to increase the resident's [MEDICATION NAME] to 3.5 mg daily and there were no further PT/INR's order. He was also informed his PA signed the order. Dr. A stated, "I can't tell you why he didn't catch it." When Dr. A was told Resident #1 was admitted to the hospital with [REDACTED]. A stated "I bet she did." Dr. A stated he was scared [AGE] years ago when a resident "fell through the cracks" by not having her [MEDICATION NAME] monitored. Dr. A stated he put standing orders in place for medications that required lab monitoring a few years ago, but when management changed at the facility he was not sure what happened to standing orders. On 05/30/12 at 11:35 AM, the DON brought a list of standing orders to the surveyors which were written by Dr. A and dated 05/30/12. The DON stated as long as she had been at the facility (January 2012) she had not seen any standing orders. During an interview on 05/30/12 at 1:25 PM, Hospice Nurse F stated she was called to see Resident #1 on 05/05/12 for a change in condition. Hospice Nurse F stated she had never seen the resident before. She stated the resident was lethargic, clammy, had increased respirations, was short of breath, was using her accessory muscles to breath and was running a temperature. She stated, "I questioned whether it was the beginning of death and dying." Hospice Nurse F called Dr. A and received orders for a CBC, U/A with C & S and a comfort kit (medications for comfort). During an interview on 05/31/12 at 8:23 AM, the surveyors reviewed Resident #1's [MEDICATION NAME] situation with the Pharmacy Consultant. The Pharmacy Consultant stated the "Dr. didn't have orders? " The surveyor revealed there were no orders for a PT/INR after 04/17/12. The Pharmacy Consultant stated there "should've been a fallback. They're supposed to do an (anticoagulant) monitor sheet for anyone on anticoagulants, it's a company policy." Review of Resident #1's facility chart revealed there was not an anticoagulant monitor sheet in her chart. During an interview on 05/31/12 at 9:35 AM, PA B (Dr. A's PA) stated when a resident was on [MEDICATION NAME] he ordered a PT/INR at least weekly. "If I can get four (PT/INRs) in a row in a therapeutic range, I will go to every two weeks (PT/INR). The surveyor told PA B that he signed the order on 04/17/12 that reflected to increase the [MEDICATION NAME] to 3.5 mg daily with no future PT/INRs. PA B stated, "I sign all the orders whether I gave the order or not. Whenever I do an adjustment of the [MEDICATION NAME], I order a PT/INR. I don't know how the order wasn't written." PA B stated when he visited the facility he looked at the lab slips that were left for him. "So if there isn't a lab result I wouldn't be looking." The surveyor told PA B that Resident #1 was admitted to the hospital on [DATE] with an INR of 21.5 and PA B stated, "That is a catastrophic error. Something clearly went wrong." 7) Review of a list provided by the DON on 05/29/12 revealed there were five residents in the facility that were receiving [MEDICATION NAME].
Based on interview and record review the facility failed to ensure medication regimens were monitored to help promote or maintain resident's highest practicable mental, physical and psychosocial well-being of one (Resident #1) of six residents who were reviewed for monitoring of anticoagulant (blood thinning) medications. Resident #1 was receiving anticoagulation therapy ([MEDICATION NAME]) for PE and [MEDICAL CONDITION] and had unstable PT/INRs (lab used to determine effectiveness of anticoagulation therapy). Adjustments in the [MEDICATION NAME] doses were made daily to every three days based on the PT/INRs from the time of admission, 03/31/12, until 04/17/12. At that time an adjustment was made in the [MEDICATION NAME], but no order was given to continue to monitor the lab. The resident continued to received the [MEDICATION NAME] 3.5 mg daily from 04/17/12 until 05/05/12 without the PT/INRs rechecked. On 05/05/12, the resident was sent to the hospital where the PT/INR was >240/21.5. The resident was diagnosed with [REDACTED]. These failures placed six residents, including Resident #1, at risk for not receiving necessary lab required when receiving [MEDICATION NAME] which could cause a serious medical problem, a decline in health and possible death. Findings included: 1) Resident #1, an [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed Resident #1 received Anticoagulant Medication. Review of Resident #1's facility "History and Physical" dated 04/04/12 revealed the resident had current [DIAGNOSES REDACTED]. Further review of this form revealed the resident's rehab potential was "fair." Review of an undated facility "Interim Plan of Care" for Resident #1 revealed "[MEDICATION NAME] precautions." Review of an undated facility care plan revealed Resident #1 received [MEDICATION NAME] for a recent [MEDICAL CONDITION] Embolism. The "Goals" reflected Resident #1 would have therapeutic INR levels. "Interventions" included: PT/INRs would be done as ordered and reported to the physician; [MEDICATION NAME] would be administered as ordered; the resident would have no leafy green vegetables; and the resident would be observed for bruising and bleeding. 2) Review of Resident #1's "admission orders [REDACTED]. Lexi-Comp's "Drug Information Handbook for Advanced Practice Nursing," 9th Edition, Copyright 2008, pages 1738-1740, reflected [MEDICATION NAME] was an anticoagulant. "The Institute for Safe Medication Practices (ISMP) includes this medication among the list of drugs which have a heightened risk of causing significant patient harm when used in error ...(U.S. Boxed Warning): May cause major or fatal bleeding...Risk factors for bleedings include high intensity anticoagulation (INR >4), Age (>65), Variable INRs, history of GI Bleeding, hypertension, [MEDICAL CONDITION] disease, serious [MEDICAL CONDITIONS], malignancy, trauma ...The elderly may be more sensitive to anticoagulant therapy ...." Review of a physician's orders [REDACTED]. Resident #1's lab results dated 04/03/12 reflected the PT/INR results were 19.3/2.3. Review of a physician's orders [REDACTED]. Resident #1's lab results dated 04/09/12 reflected the PT/INR results were 42.8/8.5. Review of a physician's orders [REDACTED]. Resident #1's lab results dated 04/12/12 reflected the PT/INR results were 39.5/7.5. Review of a physician's orders [REDACTED]. Resident #1's lab results dated 04/13/12 revealed the PT/INR results were 20.7/2.6. Review of a physician's orders [REDACTED]. Resident #1's lab results dated 04/16/12 reflected the PT/INR results were 12.3/1.1. Review of Resident #1's "Nurse's Notes" dated 04/17/12 at 4:00 PM revealed the PT/INR results were received and PA B was notified for Dr. A. The [MEDICATION NAME] was increased to 3.5 mg daily. Review of a physician's orders [REDACTED]. (Note no further PT/INR orders.) Further review of Resident #1's physician's orders [REDACTED]. 3) Review of Resident #1's "Nurse's Notes" dated 04/14/12 at 3:00 PM revealed LVN C was called to the shower room by an unidentified CNA. Resident #1 was noted to have a large purple/black bruised area on her right hip that measured 12 inches by 3 inches. Further review of this note revealed the physician was not notified. Review of Resident #1's "Nurse's Notes" dated 04/15/12 at 3:00 PM revealed the bruise to the resident's right hip had increased in size to 22 inches by 3 inches. Further review of this note revealed the physician was not notified. During a telephone interview on 05/31/12 at 9:47 AM LVN C stated she saw Resident #1's bruise. She stated, "I didn't know if she (Resident #1) fell . I was the first one who noticed the bruise and it was quite large. I think I notified the doctor and family. I normally document in the nurse's notes." LVN C stated she knew Resident #1 was on [MEDICATION NAME]. The surveyor queried LVN C regarding responsibilities to residents on [MEDICATION NAME]. LVN C responded, "Look for bruising and monitor PT/INR's." LVN C was queried if she notified Resident #1's physician on 04/15/12 when she documented the bruise had increased in size to 22 inches. LVN C stated, " No, because I notified him the day before and I didn't need to call the doctor again." Review of a facility physician's progress note dated 04/18/12 revealed Resident #1 fell with a bruise to her right leg. Further review of the progress note revealed Resident #1's INR was elevated. Review of a facility "Falls Management - Plan of Care" dated 04/19/12 revealed a hand written star and "pt (patient) on [MEDICATION NAME] - PT/INR unstable." Review of Resident #1's MAR's dated 04/17/12 through 05/04/12 revealed the resident received [MEDICATION NAME] 3.5 mg daily. 4) During an interview on 05/30/12 at 9:54 AM, ADON G stated "Triage Nursing Assessments" were completed when a resident had a change in condition and the nurse's charted on the assessment sheets every shift or until the issue resolved. Review of the facility "Triage Nursing Assessments" dated 05/04/12 revealed: At 7:20 AM - Resident #1's temperature was 99.1?, blood pressure was 120/88, pulse was 109, respirations were 28. Hospice was notified. At 6:30 PM - Resident #1's temperature was 99.7?, blood pressure was 140/62, pulse was 82, respirations were 29 and the resident was hard to arouse. "Resident appears sedated, but will arouse slightly to tactile stimulus." At 10:00 PM - the resident's temperature was 100? axillary, blood pressure was 164/76, pulse was 109 and irregular and respirations were 28. The resident was "hard to arouse." Review of a hospice nurse's notes dated 05/05/12 at 6:23 AM revealed Resident #1 had a change in her level of consciousness. Further review of this note revealed the resident was diaphoretic, confused, lethargic and disoriented. The resident's functional status was "deteriorating." Review of the facility "Triage Nursing Assessment" dated 05/05/12 at 6:40 AM revealed Resident #1's temperature was 97.6?, blood pressure was 124/76, pulse was 114 and respirations were 40. The resident was slightly diaphoretic and "more difficult to arouse than previous assessment. Call placed to ________ Hospice d/t (due to) change from previous visit." At 7:30 AM - the nurse notified the physician and the resident's family member. The note reflected the Hospice nurse revisited at 9:45 AM and ordered a comfort kit, CBC and UA for the resident. At 1:00 PM - the resident's family member was at the facility demanding that Resident #1 be sent to the hospital because he/she felt (Resident #1) was having a stroke. The nurse told the resident's family member she (nurse) had to go through proper procedures. At 1:30 PM - the family member continued to insist the resident be sent to the hospital and the nurse placed a call to the hospice nurse. The hospice nurse reported if the family wanted the resident to go to the ER, then to send her. A call was then placed to the physician. At 2:00 PM the nurse spoke with the physician and he gave the order to send the resident to the ER. At 2:15 PM the ambulance was at the facility to transport the resident. 5) Review of "emergency room RN Notes" dated 05/05/12 revealed, "The patient (Resident #1) is disoriented to person, place and time. (PT (patient) JUST STARES AND DOES NOT MAKE FACIAL EXPRESSIONS)...." Review of the hospital "history and physical examination [REDACTED]. Further review of this form revealed Resident #1 had a history of [REDACTED]. "The patient was on [MEDICATION NAME] before, but it (Resident #1) is not on current medication at the nursing home. We will restart [MEDICATION NAME] and monitor [MEDICATION NAME] time (PT) /international normalized ratio (INR)." Review of the hospital lab report dated 05/05/12 at 4:03 PM revealed Resident #1's PT/INR results were >240 /21.5. Resident #1's Hgb was 8.2 and Hct was 26.5. Further review of this lab report revealed the normal values were: PT/INR 9.0-12.0/2.0-3.0 (standard therapy range), Hgb 12.0-17.0 and Hct 36-46. Review of the hospital physician's progress note dated 05/06/12 at 12:33 PM revealed, "[MEDICATION NAME] toxicity." Review of the hospital physician orders [REDACTED].#1 received one dose of Vitamin K 5 mg, three units of PRBCs, and three units of FFP. Review of the hospital lab reports from 05/05/12 - 05/10/12 revealed Resident #1's PT/INR went from >240/21.5 on admission to 37.0/3.3 at the time of discharge. The resident's HCT was 23.2 and rose to 30.4 by the day of discharge Review of the hospital "Discharge Medications" dated 05/10/12 revealed [MEDICATION NAME] 2 mg daily if INR was less than 3. Further review of the discharge medications revealed "the patient might need to have [MEDICATION NAME] time and international normalized ration checked frequently." 6) During an interview on 05/29/12 at 10:52 AM, the DON stated Resident #1's PT/INR's were up and down. She stated, "They (facility) could never get them ([MEDICATION NAME]) adjusted, frequent changes." The DON further stated she was not aware Resident #1 did not have PT/INR orders after 04/16/12. She stated, "I would expect the nurses to ask for PT/INR labs if not written." During an interview on 05/29/12 at 11:20 AM, LVN D stated when a resident was on [MEDICATION NAME], PT/INRs were usually drawn weekly as a routine order. She further stated if there were not routine orders, she would have to call the doctor to get it started. LVN D stated she was aware Resident #1 had a PE when she was first admitted (03/31/12). The surveyor showed LVN D Resident #1's telephone physician order [REDACTED]. (Note: LVN D wrote the verbal order) LVN D stated, "That's odd." The surveyor queried LVN D if she asked the PA for PT/INR lab orders and LVN D stated, "Apparently not. I don't know why. Maybe I was thinking hers (Resident #1's) were routine ...The only thing I can say is it got missed." During an interview on 05/30/12 at 10:07 AM, ADON E stated Resident #1 was on [MEDICATION NAME] and her PT/INRs were unstable and needed to be "monitored more frequently than you normally do." The surveyor showed ADON E Resident #1's telephone order dated 04/17/12 to increase the [MEDICATION NAME] to 3.5 mg. ADON E revealed she saw the order and stated, "It's a good order." When queried about an PT/INR, ADON E stated she did not remember if she asked about when the next PT/INR would be drawn. During an interview on 05/30/12 at 10:20 AM, Dr. A (Resident #1's physician) stated when a resident was on [MEDICATION NAME], he would have standing orders for INRs; once a week until stable then every two weeks. He wanted the resident's INR to be between 2 and 3 (therapeutic range). He further stated if there was a change in the [MEDICATION NAME] dose, he would write an addition PT/INR order as well as keep the routine order. Dr. A was made aware Resident #1 had a verbal order written on 04/17/12 to increase the resident's [MEDICATION NAME] to 3.5 mg daily and there were no further PT/INR's order. He was also informed his PA signed the order. Dr. A stated, "I can't tell you why he didn't catch it." When Dr. A was told Resident #1 was admitted to the hospital with [REDACTED]. A stated "I bet she did." Dr. A stated he was scared [AGE] years ago when a resident "fell through the cracks" by not having her [MEDICATION NAME] monitored. Dr. A stated he put standing orders in place for medications that required lab monitoring a few years ago, but when management changed at the facility he was not sure what happened to standing orders. On 05/30/12 at 11:35 AM, the DON brought a list of standing orders to the surveyors which were written by Dr. A and dated 05/30/12. The DON stated as long as she had been at the facility (January 2012) she had not seen any standing orders. During an interview on 05/30/12 at 1:25 PM, Hospice Nurse F stated she was called to see Resident #1 on 05/05/12 for a change in condition. Hospice Nurse F stated she had never seen the resident before. She stated the resident was lethargic, clammy, had increased respirations, was short of breath, was using her accessory muscles to breath and was running a temperature. She stated, "I questioned whether it was the beginning of death and dying." Hospice Nurse F called Dr. A and received orders for a CBC, U/A with C & S and a comfort kit (medications for comfort). During an interview on 05/31/12 at 8:23 AM, the surveyors reviewed Resident #1's [MEDICATION NAME] situation with the Pharmacy Consultant. The Pharmacy Consultant stated the "Dr. didn't have orders? " The surveyor revealed there was no order to check the PT/INR after 04/17/12. The Pharmacy Consultant stated there "should've been a fallback. They're supposed to do an (anticoagulant) monitor sheet for anyone on anticoagulants, it's a company policy." Review of Resident #1's facility chart revealed there was not an anticoagulant monitor sheet in her chart. During an interview on 05/31/12 at 9:35 AM, PA B (Dr. A's PA) stated when a resident was on [MEDICATION NAME] he ordered a PT/INR at least weekly. "If I can get four (PT/INR's) in a row in a therapeutic range, I will go to every two weeks (PT/INR). The surveyor told PA B that he signed the order on 04/17/12 that reflected to increase the [MEDICATION NAME] to 3.5 mg daily with no future PT/INRs. PA B stated, "I sign all the orders whether I gave the order or not. Whenever I do an adjustment of the [MEDICATION NAME], I order a PT/INR. I don't know how the order wasn't written." PA B stated when he visited the facility he looked at the lab slips that were left for him. "So if there isn't a lab result I wouldn't be looking." The surveyor told PA B that Resident #1 was admitted to the hospital on [DATE] with an INR of 21.5 and PA B stated, "That is a catastrophic error. Something clearly went wrong." 7) Review of a list provided by the DON on 05/29/12 revealed there were five residents in the facility that were receiving [MEDICATION NAME].
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