Every finding on record at Heritage Gardens Rehabilitation and Healthcare

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 3 of 4 hallways (200 Hall, 300 Hall, and 400 Hall) reviewed for accidents and hazards.The facility failed to ensure 3 of 3 mechanical lifts on 3 Halls (200 Hall, 300 Hall and 400 Hall) were locked and secured when not in use.This failure could place residents, at risk of falls and/or injuriesFindings include:Observation of the 200 Hall on 04/14/26 at 1:13 PM revealed 1 unlocked and unsecured mechanical lift parked on the 200 Hall parked in between room [ROOM NUMBER] and room [ROOM NUMBER].Observation of the 400 Hall on 04/14/26 at 1:27 PM revealed 1 unlocked and unsecured mechanical lift parked on the 400 Hall parked outside of room [ROOM NUMBER].An email was sent to the Administrator on 04/14/26 at 1:59 PM, requested the facility's policy on accidents and hazards and mechanical lifts.Observation of the 300 Hall on 04/14/26 at 2:03 PM revealed 1 unlocked and unsecured mechanical lift parked on the 300 Hall parked outside of room [ROOM NUMBER].Observation on 04/14/26 at 2:10 PM revealed 3 staff members (which included LVN A and CNA B) were standing at the Nurses Station in the center of the 100-400 Halls.Observation on 04/14/26 at 3:46 PM on the 500 Hall revealed all empty rooms. The rooms included several mechanical lifts that were locked and secured, were plugged into the wall socket and were being recharged .In an interview on 04/14/26 at 2:14 PM with LVN A, she stated she had been employed at the facility for 29 years. LVN A stated on 04/14/26, she was assigned to the 100 Hall. She stated she was unaware the 1 mechanical lift on the hallways of 3 Halls (200 Hall, 300 Hall and 400 Hall) were parked and were unlocked and unsecured. LVN A stated she had taken In-Service Trainings on mechanical lift safety and storage. LVN A stated she could not recall when she had previously taken In-Service Trainings on mechanical lift usage, safety and storage. LVN A stated the In-Service Trainings she had taken stated all mechanical lifts were to be always locked when they were not in use. LVN A stated the 3 mechanical lifts were observed on the 3 Halls (200 Hall, 300 Hall and 400 Hall) should have been placed in the storage room on the 500 Hall. LVN A stated the 500 Hall was empty and did not have any residents on the hall and therefore that was the reason why the mechanical lifts were stored in rooms on the 500 Hall. LVN A stated the mechanical lifts were charged in the empty rooms on the 500 Hall when they were not in use. LVN A stated sometimes the staff from the dialysis center housed inside of the facility would leave the mechanical lifts outside of the dialysis center so they had easy access to use it when needed. LVN A stated if she observed an unlocked mechanical lift, she would immediately lock and secure the mechanical lift and then tell the DON there was an unlocked mechanical lift on the hall and the location where the mechanical lift was unlocked and unsecured. LVN A stated harm could be caused to anyone when a mechanical lift was unlocked, when and if someone bumped up against the unlocked mechanical lift, which would cause the mechanical lift to easily move and cause accidents and falls. She stated someone could be harmed by using the unlocked and unsecured mechanical lift and hurting themselves having a serious fall with injuries, such as broken bones fractures when a mechanical lift was unlocked and not safely secured when parked. In an interview on 04/14/26 at 2:28 PM with CNA C, she stated she had been employed at the facility for 36 years. CNA C stated on 04/14/26, she had been assigned to the 200 Hall. She stated she was unaware the 1 mechanical lift on the hallways of 3 Halls (200 Hall, 300 Hall and 400 Hall) were parked and were unlocked and unsecured. CNA C stated she had taken In-Service Trainings on mechanical lift usage, safety and storage. CNA C stated she did not remember when she had previously taken In-Service Trainings on mechanical lift usage, safety, and storage. CNA C stated on previous occasions she observed mechanical lifts on the 300 Hall and 400 Hall but did not check to see if they were securely locked and secured while they were parked on the halls. CNA C stated the mechanical lift that was unlocked and unsecured on the 200 Hall was most likely placed in the hall by someone who worked in the dialysis center who was housed inside the facility on the 200 Hall. CNA C stated she was busy in and out of the patients rooms today and did not observe the unlocked and unsecured mechanical lift on the 200 Hall that was observed by the state surveyor. CNA C stated if she observed a mechanical lift on her hall, she would immediately remove it and place it in an empty room on the 500 Hall where the other mechanical lifts were located. CNA C stated mechanical lifts should always be locked and secured when they were not in use. CNA C stated in the future, she would check the mechanical lifts every time she observed them on the hall to ensure they were locked and secured when they were parked. CNA C stated she would immediately notify her Nurse that an unlocked and unsecured mechanical lift was on the hall and most likely every staff member would receive In-Service Training by the ADON or DON about the proper storage for mechanical lifts. CNA C stated if she observed a staff member store the mechanical lift, she would ask them if they ensured the parked mechanical lifts were always locked when they were parked. CNA C stated if a mechanical lift was unlocked, there was a risk of the mechanical lift moving or someone hitting the mechanical lift. She stated another risk of having an unlocked and unsecured mechanical lift on the hall was someone could hit their limbs (ie: arm or leg), or wheelchair on the mechanical lift. CNA C stated someone could be harmed by an unlocked mechanical lift and may have some injuries such as bruises, broken bones, and fractures. In an interview on 04/14/26 at 2:52 PM with the DON, she stated she had been employed at the facility for 13 years. The DON stated she was unaware the 1 mechanical lift on the hallways of 3 Halls (200 Hall, 300 Hall and 400 Hall) that were parked and were unlocked and unsecured. The DON stated her expectation was all mechanical lifts in the building were to be always locked and secured when they were not in use. She stated all mechanical lifts should never be stored on the hallways when they were not in use and should be stored on the 500 Hall, which was the location of the stored mechanical lifts. The DON stated all staff were educated and trained on the proper usage, safety, and storage of mechanical lifts, which included always ensuring they were locked and always secured. The DON stated she could not recall when the staff received their last In-Service Training on mechanical lifts. She stated she would reeducate and retrain all staff with In-Service Trainings on mechanical lifts safety, usage, and storage. The DON stated the In-Service Training for all staff would include reeducation on performing routine checks/audits of all the mechanical lifts in the building. The DON stated there was a risk to anyone to be injured due to unlocked and unsecured mechanical lifts in the building. The DON stated there was potential for harm to anyone who attempted to lift themselves with the unlocked and unsecured mechanical lift, which could cause physical injuries, such as bruises, scrapes, broken bones, and fractures. The DON stated an unlocked and unsecured mechanical lift could also fall over on anyone if it was bumped into. The DON stated the facility did not have any policies related to mechanical lift safety, storage, accidents and hazards.Record review of facility's, undated, policy for Mechanical Lift, did not provide any information regarding accidents and hazards relating to mechanical lift safety and storage.Record review of facility's policy for Incident Reporting, revised 05/2025, did not provide any information regarding accidents and hazards relating to mechanical lift safety and storage .

Based on observation, interview and record review, the facility failed to secure the resident had the right to personal privacy and confidentiality of his or her personal and medical records for two staff reviewed for privacy and confidentiality of records.The facility failed to ensure LVN A locked and secured her laptop which contained private healthcare and confidential information for residents on the 100 Hall on 04/14/26. This failure could place residents at risk of exposure of their personal and medical information disclosed to unauthorized individuals including visitors and other residents, causing embarrassment, frustration, loss of dignity, decreased privacy and psycho-social well-being.Findings include: In an observation on 04/14/26 at 1:31 PM revealed the laptop on the medication cart was unlocked and unattended which displayed residents ' medications that needed to be passed. The laptop on the medication cart was unattended in between 2 resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) with the laptop facing the 100 Hallway. Two staff members (LVN A and CNA B) and two residents passed the unlocked and unsecured laptop on the 100 Hall. A female staff member later identified as LVN A stated the laptop on the medication cart belonged to her. LVN A stated she thought she locked the laptop prior to leaving it on the medication cart. LVN A stated she was assisting a resident in their room and was using the outlet in the hallway to charge her laptop . In an interview with LVN A on 04/14/26 at 1:46 PM, she stated she had been employed at the facility for 29 years. LVN A apologized to the State Surveyor for leaving the laptop unlocked on the Medication Cart on the 100 Hall. LVN A stated the state surveyor's observation was the first and only time in 29 years she had been employed at the facility that she left her laptop unlocked on any halls. LVN A stated she was unaware on 04/14/26 at 9:48 AM, the State Surveyor observed the laptop on the medication cart unlocked and unattended. LVN A stated during her employment at the facility, she had taken several In-Service Trainings on HIPPA, PHI and ensuring all patient information was protected, and always locked the laptops, computers and medication carts when they were not in use. LVN A stated HIPAA In-Service Training was conducted annually but was unable to recall the last In-Service Training she had taken on HIPPA and PHI. LVN A stated the risk of having the unlocked and unsecured laptop on the medication cart being left in the hallway outside of an occupied residents room was that it violated HIPAA because the laptop had confidential information regarding health records. LVN A stated leaving the computer unlocked, with residents' information, could give other residents, staff and visitors unauthorized access to residents' medical information. LVN A stated harm could be caused to a resident if unauthorized person(s) viewed their medical records and used the confidential information against them to bully and emotionally hurt them.In an interview with CNA B on 04/14/26 at 1:55 PM, she stated she had been employed at the facility for 2 years. She stated she and LVN worked the 6a-6p shift on 04/14/26 and both were assigned to the 100 Hall. CNA B stated she was unaware on 04/16/26 at 1:31 PM, that the State Surveyor observed the unlocked laptop on top of the medication cart on the 100 Hall in between 2 resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]). CNA B stated when she walked past the unlocked laptop on the Medication Cart on the 100 Hall in between 2 resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]), she did not notice that the laptop was unlocked. CNA B stated she did not know what staff member last used the unlocked laptop on the medication cart. CNA B stated the unlocked laptop on the medication cart would have contained patient records which included medical records that should be confidential and should not be seen by unauthorized individuals because it contained several residents personal and confidential information. CNA B stated if she noticed a laptop or computer was unlocked, she would immediately notify her Charge Nurse. CNA B stated the risk of patient confidential information being available to unauthorized people might cause a resident to feel embarrassed that others would know about their health issues, which violated the HIPAA guidelines. CNA B stated during her employment at the facility, she had taken several In-Service Trainings on securing patient information and HIPAA. In an interview with the DON on 04/14/26 at 2:52 PM, she stated she had been employed at the facility for 9 years. The DON stated she was unaware of the unlocked and unattended laptop on the medication cart on the 100 Hall. The DON stated computers and laptops should always be locked when unattended. The DON stated this was the responsibility of any nursing staff member who utilized the computer or laptop to access resident information. The DON stated all employees were expected to provide full privacy and confidentiality of all patient information for all residents. The DON stated it was her expectation residents' health information was to always remain private to prevent HIPPA violations. The DON stated she would begin In-Service Training to all staff on privacy and confidentiality of the residents' information and HIPAA protection for residents. The DON stated she would conduct random checks to ensure computers on the hallways were locked and secured when unattended. The DON stated the facility did not have a policy related to HIPAA policies, procedures, and guidelines regarding patient medical records. She stated the facility followed the HIPAA Guidelines in relation to the Health Insurance Portability and Accountability Act of 1966. The DON stated the failure to not protect the resident information may result in there being identity theft. She stated there was a potential of harm if someone who was not authorized to view the patient health records gained access to the records and used the information and caused poor self-esteem and embarrassment for residents. The DON stated personal and medical information about a resident should never be exposed on anything which included a laptop, computer or paper for everybody to see. During an interview with the Operations Manager and the DON on 4/14/26 at 4:37 PM, the Operations Manager and the DON stated the nursing staff should be logging off or closing the computer screen or laptop with resident information when they were walking away from them. Record review of the facility's Staff Schedule for 04/14/25 reflected LVN A and CNA B were assigned various shifts 6a-6p on the 100 Hall. Record review of the facility's In-Service Training records, from 01/01/26 to 04/01/26, reflected there were no In-Service Trainings conducted on residents' privacy during this period.Record review revealed the facility did not have a policy for HIPPA, Protected Health Information (PHI), and/or Safeguarding Electronic Records.Record review of the facility's policy, Resident Rights, revised 01/2022, did not provide any information regarding HIPPA, Protected Health Information (PHI), and/or Safeguarding Electronic Records.Record review of the facility's policy, Content of Medical Record, revised 08/2007, reflected the following:Policy:It is the policy of this facility that a separate medical record shall be maintained for each residentadmitted to the facility and the resident's name will be placed on all medical record forms.Procedures:The resident's medical record shall contain at least the following information:A. Identification Data2. Pertinent identification data to meet the facility's needs and accurately identify the resident is recorded on admission, updated periodically, and includes, but is not limited to, the following items: Resident's name, address and telephone number date of birth Date of admission Physician's name and telephone number Name, address and telephone number of legal representative or interested family member.4. Consents/Authorizations/Acknowledgments. Appropriate consent forms, authorizations and acknowledgments are signed by the resident or legal representative and entered in the medical record, items 1 and 3 may be kept in the financial file. These include, but are not limited to, the following: Consents for care and treatment Consents for generic drug use Authorization to release information for reimbursement purposes Acknowledgement of receipt of advance directive information Restraint usage informed consent and notification waiver, if applicable5. Authentication of Diagnoses.6. List of contents of the medical record: admission Record admission Agreement (May be kept in the financial record) Consent Forms (not included in the admission Consent) Advance Directive Acknowledgment Patients Decision making Capacity Transfer Record (admission and Transfer) History and Physical Current Diagnosis Statement that the patient was informed of his/her medical condition Rehabilitation Potential Physician's Orders Physician's Progress Notes TB Screening Laboratory, X-Ray/EKG-EEG Readings Minimum Data Set RAP Summary Care Plan Nursing admission Assessment Dietary Assessment and Progress Notes Activities Assessment and Progress Notes Social Services Assessment and Progress Notes Discharge Planning and Progress Notes Licensed Nurse's Notes Nursing Assistants ADL Flow Sheets Medication and Treatment Records Weight Record Vital Signs Inventory List Discharge Summary Post Discharge Plan of Care Notice of Transfer/DischargeOther miscellaneous records, which may be included in the medical records are: Therapy Evaluations and Progress Notes (P.T., O.T., Speech, Respiratory) Intake and Output Record Pressure Ulcer and Wound Record Other Assessments (Contracture, Physical Restraint, Psychotherapeutic Drug, Bowel and Bladder, Skin, etc .) Restorative Nursing Medicare Certification and Re-certification Consultation Reports IV Record Mortician's Receipt Advance Directive Copies Legal (Conservator /Guardianship Record).Record review of the CMS website reflected, Health Insurance Portability and Accountability Act of 1996. The Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) establishes national standards to protect individuals' medical records and other personal health information. The HIPAA Privacy Rule also gives individuals rights over their health information, like getting a copy of their records and seeking correction. The Rule applies to 3 types of HIPAA covered entities, like health plans, health care clearinghouses, and health care providers that conduct certain health care transactions electronically to safeguard protected health information (PHI) entrusted to them.

Based on interview and record review, the facility failed to ensure that an alleged violation involving abuse was investigated for 1 (Resident #1) of 6 residents reviewed. The facility's Abuse Coordinator failed to investigate Resident #1's sexual abuse allegation that occurred on 01/25/2026. This failure could place residents at risk of abuse, neglect, and/or exploitation.Findings included: Review of Resident #1 MDS assessment, dated 12/23/2025, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. The resident's cognitive status was severely impaired. Her diagnoses included Cerebral Infarction (the blood supply to part of the brain is blocked or reduced), Bipolar Disorder (mental condition marked by alternating periods of elation and depression), and Memory Deficit (a condition where individuals experience difficulties in forming, storing, and recalling memories). Review of Resident #1's Care Plan, dated 10/27/2022, reflected:Resident had an ADL self-care performance deficit related to left side paralysis, CVA (a loss of blood flow to the brain).Resident at risk for impaired cognitive function or impaired thought processes r/t cerebral infarct, bipolar, TIA (a brief blockage of blood flow to the brain), depression.Resident a risk for falls r/t TIA, cerebral infarct, left side paralysis has had an actual fall with minor injury related to poor balanceResident had potential for a psychosocial well-being problem r/t dependent behavior, social isolation. Record Review on 03/09/2026 of Resident #2 MDS assessment, dated 01/27/2026, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. The resident's cognitive status was severely impaired. His diagnoses included Vascular Dementia with Mood Disturbance (conditions that damage blood vessels and block blood flow to brain), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Cerebral Infarction (the blood supply to part of the brain is blocked or reduced), and Cognitive Communication Deficit (a condition where a person's ability to communicate effectively is compromised by an underlying impairment in mental processes). Record Review on 03/09/2026 of Resident #2's Care Plan, dated 12/11/2025, reflected:Resident has an ADL self-care performance deficit related to cerebral infarction (the blood supply to part of the brain is blocked or reduced)Resident is at risk for Altered Neurological Status r/t CVA (a loss of blood flow to the brain).Resident is at risk for Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest)Resident is at risk for impaired cognitive function or impaired thought processes r/t vascular Dementia (a group of symptoms affecting memory, thinking and social abilities, Agnosia (a neurological disorder characterized by the inability to recognize familiar objects, people, or sounds, despite having intact sensory functions). An interview on 03/09/2026 at 12:40 PM with the DON revealed an investigation was completed by the Administrator. Surveyor informed the DON that there were no documents regarding the abuse or investigation noted in Resident # 1 or Resident #2 chart, DON stated the Administrator should have a copy of the investigation. An interview on 03/09/2026 at 1:03 PM with the Administrator, the abuse coordinator, revealed that he was informed by a staff (could not recall which staff) that Resident #1 and Resident #2 were in the dining and that Resident #2 touched Resident #1 in her private area. Administrator stated Resident #1 and Resident #2 were separated immediately and Resident #2 was put on 1:1. Administrator stated Resident #2 was discharged and transferred to another facility the following day. Administrator stated that he completed a facility investigation of the incident and would provide a copy to surveyor. An interview on 03/09/2026 at 1:18 PM with Resident #1 revealed, Resident #1 in her room watching television. Resident was observed to be well-groomed and in appropriate clean and fitting clothing. Resident was alert and willing to speak to surveyor. Surveyor asked resident if anyone had touched her or hurt her, Resident stated no and was not able to recall the incident. An interview on 03/09/2026 at 2:40 PM with the Administrator Clinical Lead (corporate Administrator) revealed that an investigation was not completed and she and Clinical Cluster Lead (corporate DON) would begin working on the investigation regarding abuse. Record Review on 03/09/2026 of Resident #1 EMR did not reveal any reports of abuse being investigated. Record Review on 03/09/2026 of Resident#2 EMR did not reveal reports of 1:1 monitoring or reports of abuse being investigated. Review of the facility policy Abuse: Prevention of and Prohibition Against, dated 11.2017 and revised 4.2025 reflected: Investigation1. All identified events are reported to the Administrator immediately. 2. After receiving the allegation, and during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm (See, Protection, below).3. A licensed nurse will immediately examine the resident upon receiving reports of alleged physical or sexual abuse. The findings of the examination shall be recorded in the resident's medical record. 4. All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the Administrator or his/her designee.

Based on observation, 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 cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to 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 1 of 3 resident (Resident #1) reviewed for abuse reporting. The facility failed to report an allegation of abuse to the State Agency when Resident #1 was sexually abused by another resident. This failure could place residents at risk for not having allegations of abuse reported which could lead to injury or worsening of condition. Findings included: Review of Resident #1 MDS assessment, dated 12/23/2025, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. The resident's cognitive status was severely impaired. Her diagnoses included Cerebral Infarction (the blood supply to part of the brain is blocked or reduced), Bipolar Disorder (mental condition marked by alternating periods of elation and depression), and Memory Deficit (a condition where individuals experience difficulties in forming, storing, and recalling memories). Review of Resident #1's Care Plan, dated 10/27/2022, reflected:Resident has an ADL self-care performance deficit related to left side paralysis, CVA (a loss of blood flow to the brain).Resident at risk for impaired cognitive function or impaired thought processes r/t cerebral infarct, bipolar, TIA (a brief blockage of blood flow to the brain), depression.Resident is a risk for falls r/t TIA, cerebral infarct, left side paralysis has had an actual fall with minor injury related to poor balanceResident has potential for a psychosocial well-being problem r/t dependent behavior, social isolation.An entry dated 03/09/2026 reflected resident at Risk for Re-traumatization r/t history of trauma from other resident violence. Record Review on 03/09/2026 of Resident #2 MDS assessment, dated 01/27/2026, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. The resident's cognitive status was severely impaired. His diagnoses included Vascular Dementia with Mood Disturbance (conditions that damage blood vessels and block blood flow to brain), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Cerebral Infarction (the blood supply to part of the brain is blocked or reduced), and Cognitive Communication Deficit (a condition where a person's ability to communicate effectively is compromised by an underlying impairment in mental processes). Record Review on 03/09/2026 of Resident #2's Care Plan, dated 12/11/2025, reflected:Resident has an ADL self-care performance deficit related to cerebral infarction (the blood supply to part of the brain is blocked or reduced)Resident is at risk for Altered Neurological Status r/t CVA (a loss of blood flow to the brain).Resident is at risk for Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest)Resident is at risk for impaired cognitive function or impaired thought processes r/t vascular Dementia (a group of symptoms affecting memory, thinking and social abilities, Agnosia (a neurological disorder characterized by the inability to recognize familiar objects, people, or sounds, despite having intact sensory functions). An interview on 03/09/2026 at 9:30 AM with Resident #3 revealed he was in the dining room and witnessed Resident #2 placing his hand between Resident #1 legs and touching her private area. Resident #3 stated no staff were present at the time of incident. An interview on 03/09/2026 at 12:40 PM with the DON revealed she was informed towards the end of January 2026 that Resident #2 attempted to touch Resident #1 while they were sitting together in the dining room. DON stated Resident #2 was friendly and liked to hug and tell everyone he loves them. DON stated the incident was reported by a staff but unable to recall who the staff was. DON stated if an allegation is validated as abuse, then it is reported to the state. DON stated the allegation was not valid because both residents denied the incident and she did not report to the state. An interview on 03/09/2026 at 1:03 PM with the Administrator, the abuse coordinator, revealed that he was informed by a staff (could not recall which staff) that Resident #1 and Resident #2 were in the dining and that Resident #2 touched Resident #1 in her private area. Administrator stated Resident #1 and Resident #2 were separated immediately and Resident #2 was put on 1:1. Administrator stated Resident #2 was discharged and transferred to another facility the following day. Administrator stated he did not report the incident because both residents had a low BIMS, were confused, and Resident #2 was in the process of being transferred to another facility. An interview on 03/09/2026 at 1:18 PM with Resident #1 revealed, Resident#1 in her room watching television. Resident was observed to be well-groomed and in appropriate clean and fitting clothing. Resident was alert and willing to speak to surveyor. Surveyor asked resident if anyone had touched her or hurt her, Resident stated no and was not able to recall anyone touching her inappropriately. An interview on 03/09/2026 at 2:00 PM with the Administrator Clinical Lead (corporate Administrator) revealed that the Administrator and DON were just suspended for not reporting the abuse incident between Resident #1 and Resident #2. Administrator Clinical Lead stated she and Clinical Cluster Lead (corporate DON) would begin working on the abuse investigation and reported it to the state. Record Review on 03/09/2026 of Resident #1 EMR did not reveal any progress notes, incident reports, or witness statements regarding the allegation of abuse. Review of the facility policy Abuse: Prevention of and Prohibition Against, dated 11/2017 and revised 04/2025 reflected: Reporting / Response 1.All allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator. 2.Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations.5.The Facility will report to the State Nurse Aide Registry or the appropriate licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 6 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from abuse on 01/25/2026 when Resident #2 touched Resident #1 between her legs over her pants. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: Record Review on 03/09/2026 of Resident #1 MDS assessment, dated 12/23/2025, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. The resident's cognitive status was severely impaired. Her diagnoses included Cerebral Infarction (the blood supply to part of the brain is blocked or reduced), Bipolar Disorder (mental condition marked by alternating periods of elation and depression), and Memory Deficit (a condition where individuals experience difficulties in forming, storing, and recalling memories). Record Review on 03/09/2026 of Resident #1's Care Plan, dated 10/27/2022, reflected:Resident has an ADL self-care performance deficit related to left side paralysis, CVA (a loss of blood flow to the brain).Resident at risk for impaired cognitive function or impaired thought processes r/t cerebral infarct, Bipolar, TIA (a brief blockage of blood flow to the brain), and depression.Resident is a risk for falls r/t TIA, cerebral infarct, left side paralysis has had an actual fall with minor injury related to poor balance.Resident has potential for a psychosocial well-being problem r/t dependent behavior, social isolation.An entry dated 03/09/2026 reflected resident at Risk for Re-traumatization r/t history of trauma from other resident violence. Record Review on 03/09/2026 of Resident #2 MDS assessment, dated 01/27/2026, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. The resident's cognitive status was severely impaired. His diagnoses included Vascular Dementia with Mood Disturbance (conditions that damage blood vessels and block blood flow to brain), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Cerebral Infarction (the blood supply to part of the brain is blocked or reduced), and Cognitive Communication Deficit (a condition where a person's ability to communicate effectively is compromised by an underlying impairment in mental processes). Record Review on 03/09/2026 of Resident #2s Care Plan, dated 12/11/2025, reflected:Resident has an ADL self-care performance deficit related to cerebral infarction (the blood supply to part of the brain is blocked or reduced)Resident is at risk for Altered Neurological Status r/t CVA (a loss of blood flow to the brain).Resident is at risk for Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest)Resident is at risk for impaired cognitive function or impaired thought processes r/t vascular Dementia (a group of symptoms affecting memory, thinking and social abilities, Agnosia (a neurological disorder characterized by the inability to recognize familiar objects, people, or sounds, despite having intact sensory functions) Record Review on 03/09/2026 of Resident #1 EMR did not reveal any progress notes, incident reports, or witness statements regarding the allegation of abuse.An interview on 03/09/2026 at 9:30 AM with Resident #3 revealed he was sitting in the dining room and witnessed Resident #2 placing his hand between Resident #1 legs and touching her private area. Resident #3 stated no staff were present at the time of incident. Resident # 3 stated he informed Administrator of the incident. An interview on 03/09/2026 at 12:40 PM with the DON revealed she was informed around the end of January 2026 that Resident #2 attempted to touch Resident #1 while they were sitting together in the dining room. DON stated Resident #2 was friendly and liked to hug and tell everyone he loves them. DON stated the incident was reported by a staff but did not recall who the staff was. An interview on 03/09/2026 at 1:03 PM with the Administrator, the abuse coordinator, revealed he was informed by a staff (not able to recall staff) of an incident involving Resident #1 and Resident #2 in the dining room. Administrator stated it was alleged that Resident #2 touched Resident #1 in her private area. An interview on 03/09/2026 at 1:18 PM with Resident #1 revealed, resident in her room watching television. Resident was observed to be well-groomed and in appropriate clean and fitting clothing. Resident was alert and willing to speak to surveyor. Surveyor asked resident if anyone had touched her or hurt her, Resident stated no and was not able to recall anyone touching her inappropriately. Observation on 03/09/2026 of a video recording dated 01/25/2026, reveled Resident #2 putting his hand between Resident #1 legs and touching her private area.

Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program to the maximum extent practicable for one of five residents (Resident #25) reviewed for PASARR requirements.The facility failed to identify and screen Resident #25 as having a serious mental illness and failed to complete a new PASRR Level I screening and referral for further evaluation when there was evidence of mental illness.This failure placed residents at risk of not being appropriately identified, screened, and referred for PASRR evaluation and determination of the need for specialized services.Findings included: Review of Resident #25's MDS, dated [DATE], reflected he was a [AGE] year-old male who admitted to the facility on [DATE], with a BIMS score of 12, which indicated moderate cognitive impairment. Diagnoses included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and adjustment disorder (a mental health condition characterized by excessive emotional or behavioral responses to identifiable stressors, leading to significant distress and functional impairment). A resident mood interview showed Resident #25 was experiencing little interest or pleasure in doing things at a frequency of 2-6 days of the week. Review of Resident #25's PASRR Level I Screening, dated 06/19/25, reflected there was no evidence that Resident #25 had indicators of a mental illness. During an interview with the MDS Coordinator on 01/14/26 at 12:03PM, she stated Resident #25's PASRR Level I was completed at the hospital prior to his admission and indicated he did not have a mental illness; therefore, he did not qualify for a PASRR Level II evaluation. The MDS Coordinator stated upon a resident's admission to the facility; she verified a PASRR Level I screening had been completed and reviewed the resident's diagnoses to ensure they were appropriately captured on the PASRR Level I screening. She stated if a discrepancy was found on the PASRR Level I, she would contact the hospital to verify its accuracy. She stated that if the Level I was inaccurate, a new Level I would need to be completed by her. She stated because of these diagnoses, Resident #25 should have received a PASRR Level II evaluation. She reported if a resident had an inaccurate PASRR Level I evaluation, they could not receive additional mental health services such as medication management. She stated a resident could become more depressed. Review of the facility's policy PASRR Revised 5/2021 reflected the following: POLICY: It is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the State. PURPOSE: Mental disorder as defined in paragraph (k)(3)(1), of the SOM unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority prior to admission: That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility and; If the individual requires such level of services, whether the individual requires specialized services; or Intellectual disability, as defined in paragraph (k) (3) (2) of the SOM, unless the State intellectual disability or developmental disability authority has determined prior to admission - That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and If the individual requires such a level of services, whether the individual requires specialized services for the intellectual disability.

Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of one Resident (Resident #44) of four Resident reviewed for medication administration. The facility failed to ensure proper storage and disposal of Resident #44's Albuterol Sulfate HFA (expired on 1/10/2026). This failures could place residents at risk of medication error, reduced therapeutic effectiveness, and potential adverse and administration of expired medication.Review of Resident #44's Quarterly MDS Assessment, dated 12/26/25, reflected Resident #44 is a [AGE] year-old female admitted on [DATE], she had a BIMs score of 8 indicated moderate cognitive impairment. The resident had diagnoses which included Asthma, Chronic Obstructive Pulmonary Disease (COPD), chronic lung conditions causing breathing difficulty) heart failure (a condition when the heart muscle does not pump blood as well as it should), hypertension (high blood). Review of Resident #44's Comprehensive Care Plan, Date Initiated: 03/01/2025 reflected [NAME] is at risk for resp. complications r/t COPD (Chronic Obstructive Pulmonary Disease). Interventions included Give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness.Review of Resident #44's active physician orders Dated: [DATE], reflected the resident had active orders for Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT 2 puff inhale orally every 4 hours a needed for cough, wheezing.An observation on 01/13/2026 at 11:45 AM, of the 300 Hall Nurses Cart revealed Resident #44's Albuterol Sulfate HFA expired 01/10/2025 was stored and available for administration.In an interview on 01/13/2026 at 11:55 AM, LVN A stated she was unaware Resident #44's Albuterol Sulfate HFA was expired. She stated the risk to the resident was administration of expired medication She stated that she had been in serviced on medication labeling and storage. In an interview on 01/14/26 at 1:04 PM, the DON stated nurses were responsible for ensuring medication was within date and all expired medication are removed from the cart immediately. She stated the ADON and DON audit the medication carts weekly, then the pharmacy consultant checks the medication room, and the medication cart every month. She stated all expired medications should be taken off carts immediately. She stated the risk of having expired medication on the medication cart was the medication may not be effective and could lead to medication errors. She stated that the nurses and a medication aides' had been in-serviced on medication storage.In an interview on 01/14/26 at 3:29 PM, the ADON revealed the DON and ADON audit medication carts weekly. She stated nurses was responsible for ensuring all medication was within date and all expired medication were removed from the cart immediately. She stated the risk of having expired medication in the cart could lead to medication errors. She stated that the nurses and a medication aides' had been in-serviced on medication storage . Review of the facility's policy Medication Access and Storage / Drug Destruction Revised 7/2024 reflected the following: POLICY:It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications:PROCEDURES: Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications (e.g., medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. Medications requiring refrigeration or temperatures between 2 C (36 F) and 8 C (46 F) are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exists.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for 2 medication carts (hall 300 Nurses cart and 100 hall medication Aide cart) of 4 medication carts reviewed for pharmacy services. The facility failed to ensure proper storage and disposal Resident #83's Albuterol Sulfate HFA (Resident discharged [DATE]), acidophilus 1 billion which required refrigeration per manufacturer's guidelines was observed stored unrefrigerated. These failures could place residents at risk of medication error, reduced therapeutic effectiveness, and potential adverse outcome due to improper storage.Review of Resident #83's Quarterly MDS Assessment, dated 12/12/25, reflected the resident is a [AGE] year-old male admitted on [DATE], and had a BIMs score of 13 considered intact or normal. The resident had diagnoses which included hypertension (high blood), Anemia (a condition marked by a deficiency of red blood cells or of hemoglobin in the blood, resulting in pallor and weariness), heart failure (a condition when the heart muscle doesn't pump blood as well as it should), renal insufficiency (means the kidneys aren't working at full capacity, filtering waste and fluids less effectively), hemiplegia (is paralysis that affects only one side of your body), cerebral vascular Accident (a serious medical event where blood flow to part of the brain is suddenly interrupted, causing brain cells to die from lack of oxygen and nutrients, potentially leading to permanent disability or death). Review of Resident #83's Comprehensive Care Plan, Date Initiated: 09/19/2025 with Cancelled Date: 11/14/2025: [NAME] Has altered respiratory status/Difficulty Breathing r/t COPD, anxiety. Facility interventions included: Administer medication/puffers as ordered. Monitor for effectiveness and side effects. The interventions were cancelled 11/14/2025.Review of Resident #83's progress notes dated 11/6/2025 at 9:05 AM reflected Resident discharged to [FACILITY NAME] will all meds and discharge instructions, resident transported by facility van with facility driver. Complete Hospice nurse [NAME] notified. this entry was written by RN F.An observation on 01/13/2026 at 11:45 AM, of the 300 Hall Nurses Cart revealed medication labelled for Resident #83 who had been discharged [DATE] was found stored in the medication cart. An observation on 01/14/2026 at 11:45 AM, of 100 hall medication aide cart revealed acidophilus that required refrigeration was stored unrefrigerated in the medication cart. In an interview on 01/13/2026 at 11:55 AM, LVN A stated she was unaware Albuterol Sulfate HFA labelled for Resident #83 who was discharged on 11/6/2025 was still in the cart. She stated the nurses were responsible for ensuring all medication in the cart were within date and discharged residents' medication should have been removed as soon as the resident discharged . She stated the risk to the resident was medication error because a discharged resident medication can be accidentally administered to another resident. She stated that she had been in serviced on medication labeling and storage. In an interview on 01/14/2026 at 11:45 AM, MA C stated she was unaware the acidophilus was supposed to be refrigerated. She stated the risk of not storing medication in the fridge that requires refrigeration was the medication would be less effective.In an interview on 01/14/26 at 1:04 PM, the DON stated nurses was responsible for ensuring medication was within date and all discharged residents medication should be removed from the cart immediately. She stated the ADON and DON audit the medication carts weekly, then the pharmacy consultant checks the medication room, and the medication cart every month. She stated that when a resident was discharged that resident's medication should be removed from the cart immediately. She stated if medication were supposed to be refrigerated it should be refrigerated because the medication could lose its effectiveness. She stated the risk of having discharged residents' medication in the medication cart could lead to medication errors. She stated that the nurses and a medication aides' had been in-serviced on medication storage .In an interview on 01/14/26 at 3:29 PM, the ADON revealed the DON and ADON audit medication carts weekly. She stated that all medication that require refrigeration should be in the fridge because the medication loses its potency. She stated that discharged residents' medication should be removed from the cart immediately could lead to medication errors. Review of the facility's policy Medication Access and Storage / Drug Destruction Revised 7/2024 reflected the following: POLICY:It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications:PROCEDURES: Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications (e.g., medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. Medications requiring refrigeration or temperatures between 2 C (36 F) and 8 C (46 F) are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exists.

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident (Resident #17) of three residents, reviewed for infection control. The facility failed to ensure CNA C changed gloves and performed hand hygiene during incontinence care for Resident #17. This failure placed residents at risk for healthcare associated cross contamination and infections.Review of Resident #17's Quarterly MDS Assessment, dated 01/03/26, reflected the resident was [AGE] year-old male admitted [DATE] who had a BIMs score of 00 indicated severe cognitive impairment. The resident had diagnoses which included Atrial Fibrillation (a common, irregular heart rhythm where the heart's upper chambers quiver instead of beating effectively, potentially causing palpitations, fatigue, and dizziness, and significantly increasing the risk of stroke and heart failure), Heart failure (the heart can't pump enough oxygen-rich blood to meet the body's needs, often due to weakness or stiffness, causing symptoms like shortness of breath, fatigue, and leg swelling), Hypertension (high blood pressure)Coronary Artery .Section H - Bladder and Bowel of MDS the resident was frequently incontinent of bladder and always incontinent of bowel. Review of Resident #17's Comprehensive Care Plan, dated 12/30/26, reflected [NAME] is at risk for skin breakdown r/t bowel incontinence. Facility interventions included: Provide peri care after each incontinent episode. An observation on 01/14/2026 at 1:43 PM, revealed Resident #17 was in bed. He was awake, and alert. CNA C and CNA D introduced themselves and explained to the resident that they were going to provide incontinence care. CNA C and CNA D performed hand hygiene donned clean gloves. CNA C removed Resident #17's dirty brief, Resident #17 had a small bowel movement. CNA C cleaned the resident from front to back. CNA C put dirty diapers in trash can. CNA C did not change gloves or perform hand hygiene after cleaning the resident. CNA C applied barrier cream to the residents' buttocks rolled resident to the right then fastened the clean diaper. CNA C and CNA D repositioned Resident #17. CNA C touched the residents call light, CNA C arranged items on Resident#17's bedside table to include his water pitcher then removed gloves. An interview on 01/14/2026 at 1:48 PM, revealed CNA C knew that he was supposed to change gloves and perform hand hygiene. He stated he was nervous and forgot to change gloves and performed hand hygiene. He stated the risk to the resident was the risk of contaminating personal property that increased chances of infection. He stated he had been in serviced on infection control.An interview on 01/14/2026 at 1:49 PM, CNA D revealed that when providing incontinence, the practice was to change gloves and perform hand hygiene every time when going from dirty to clean. She stated CNA C should have changed gloves after cleaning the resident. She stated that he always changed gloves, and he must have been nervous because the surveyor was watching him. She stated she had been in serviced on incontinence care. She stated the risk to the resident was risk of contamination and infection. An interview on 01/14/2026 at 1:53 PM, with the ADON also the Infection Preventionist revealed staff was supposed to clean the resident, change gloves, perform hand hygiene, and then put a clean brief on the resident. The Infection Preventionist said failure to change gloves and perform hand hygiene could cause issues with infection control. She stated that staff had been in serviced on infection control and incontinence care.An interview with the DON on 01/14/2026 at 2:53 PM, revealed staff was supposed to change their gloves and perform hand hygiene after cleaning a resident. The DON said failure to do so could cause infection. She stated that staff had been in serviced on infection control and incontinence care.This facility policy titled Infection Prevent and Control Program revised 10/2022 Reflected:PolicyThe program will be carried out by the facility infection preventionist. It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards.Goals Decrease the risk of infection to residents and personnel. Recognize infection control practices while providing care. Identify and correct problems relating to infection control. Ensure compliance with state and federal regulations related to infection control Promote individual residents' rights and well-being while trying to prevent and control the spread of infection. facility personnel will wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice.

Based on observations, interviews, and record review, the facility failed to ensure residents were free from abuse for 1 of 5 residents (Resident #2) reviewed for abuse.The facility failed to ensure Resident #2 was free from abuse when Resident #1 punched him on 06/21/25, causing Resident #2 to have a laceration to his top lip.This failure could place residents at risk for severe and long-lasting impact for physical, psychological and emotional wellbeing. Findings included: Record review of Resident #2's MDS Assessment, dated 05/26/25, reflected the Resident#2 was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted [DATE]. He had no BIMS score recorded. His MDS indicated he had no behaviors. His diagnoses included Autistic Disorder (is a developmental disability caused by differences in the brain), Gastrostomy Status (a feeding tube inserted through the abdominal wall into the stomach ), Anxiety Disorder (a group of mental health conditions characterized by excessive, persistent fear and worry that can significantly interfere with daily life ), Cerebrovascular Accident (a medical term for a condition where there's a sudden interruption of blood flow to the brain, causing damage to brain tissue). Record review of Resident #2's care plan, revised 08/15/2022, reflected the following: Focus: [Resident#2] has actual mood/behavior problem r/t Autistic Disorder AEB/ crying out loud/ compulsive behavior (will repeatedly ask or call for something)/ yelling out/ disrobes, takes clothes off and throws them on the floor. Interventions: Assist to identify strengths, positive coping skills and reinforce these, Monitor/record/report to MD risk of increased anger, labile mood or agitation threatened by others or thoughts of harming someone, possession of objects that could be used as weapons Review of Resident #2's Progress Notes reflected the following: 06/21/25 4:30 AM - This nurse was notified by the nurse staff on the floor that to come to the resident and check on the resident with urgency. Rushed to the resident's room and observed the resident sitting on the wheelchair with visible bleeding from his mouth on his upper lip. The [CNA A] stated that she observed the resident being hit by the [Resident#1] and separated them and supported the resident back to his room. Assessed the resident bleeding noted from the resident's upper lip, pressure applied, cleaned gauze, an open area noted measuring 2cm and about 0.5 cm deep. V/S BP 122/78, P 74, R 18, TEMP 98.4, OXY SAT 97% RA. Resident denies pain/discomfort. Administrator notified, [NP E] notified new order to transfer resident to ER for further evaluation and treatment. 911 called and [Resident#2] transferred to [local hospital] via on stretcher DON notified, RP notified. This entry was written by RN C. 06/21/2025 09:14AM [Resident#2] returned from ER and 4 stitches noted to upper lips, with dry blood and mild swelling noted. After care instruction noted: to keep the area clean and dry and not to pick at stitches. Monitor surgical wound daily and if bleeding persist sent to er. Wound care consults for stitches care. Resident denies pain or discomfort at this time. Call light in reach and bed in lowest position. This entry was written by LVN D.Record review of Resident #2's hospital records, dated 06/21/25, reflected that Resident #2 was treated in the ER after being hit in the mouth which caused a deep cut on his upper lip. The wound was cleaned and closed with stitches both inside and outside the lip, to help it heal well. Observation and interview on 07/08/25 at 1:57 PM with Resident #2 revealed he was sitting in a wheelchair in his room writing on a piece of paper with a black sharpie . Resident #2 said he was not in pain, laceration to top lip healed. He did not recall the incident, and stated that everyone was good to him and he just wanted to write his sister a letter. Record review of Resident #1's MDS Assessment, dated 05/15/25, reflected the Resident #1 was a [AGE] year-old male who originally admitted to the facility on [DATE]. He had a BIMS score of 09, indicating moderate cognitive impairment. His MDS indicated he had no behaviors. His diagnoses included Traumatic Brain Injury (TBI), Anxiety Disorder, and Non-Alzheimer's Dementia. Record review of Resident #1's care plan, revised 06/21/25, reflected the following: Focus: 6/21/25- [Resident #1] Potential to demonstrate physical behaviors r/t Anger, Dementia 6/21/25 resident to resident incident: Interventions [Resident#1] should remain on 1:1 observation and recommended for him to be transferred to [local hospital] ER for further psych evaluation. Record review of Resident #1's Progress Notes reflected the following: 06/21/25 4:30 AM - This nurse was notified by the nurse staff on the floor to come [Resident#2] room and check on the resident with urgency. Rushed to the resident's room and observed [Resident#2] sitting on the wheelchair with visible bleeding from his mouth on his upper lip. The [CNA A] stated that she observed [Resident#2] being hit by the [Resident#1] and separated them and supported [Resident#2] back to his room [Resident #1] sent back to his room and placed on one-on-one monitoring. On assessment no visible injuries noted. [Resident#1] is alert and oriented x3 verbalizes needs. Denies pain/discomfort. V/S 145/89. P 76, R 18, temperature 97.6, oxy sat 97% RA. Administrator notified, NP E notified, DON notified. The resident is self-representative. [Resident#1 contact] called, and a message was left. This entry was written by RN C. Record review of clinical note by the psychologist dated 06/21/2025 at 1:33PM by the psychologist reflected that [Resident#1] was seen after a reported altercation with another resident. Law enforcements were notified, and report filed with state per regulations. [Resident#1] presented as quite angry throughout session. When therapist entered the room, he asked Did you hear about what happened with the nut job this morning? [Resident#1] He expressed agitation about patient in question and reported that patient had been bothering him. [Resident#1] elaborated that patient he felt targeted by patient and that the patient had been going into his room and bothering him. [Resident#1] was unable to elaborate specifically the other resident was doing that was causing such concern to him. [Resident#1] did complain about him wandering around the facility and bothering everybody. When therapist attempted to challenge [Resident#1]'s thoughts about the patients' cognitive impairments, [Resident#1] was adamant that the resident in question was quite aware of his actions, and he further blamed facility staff for letting him get away with it. [Resident#1] reported that he was aware that the patient reportedly lost a tooth and [Resident#1]'s response was good. [Resident#1] continued to fixate about the patient in question. [Resident#1] denied being remorseful about his actions and indicated that he would not change what he did if faced with a similar situation. [Resident#1] also generalized his anger from the patient in question to anybody who bothered him or came in his room. Therapist attempted to intervene and encourage [Resident#1] to use calming strategies to improve his outcomes given the relationship between anger and negative physiological reactions including increases in high blood pressure, muscle tension etc. [Resident#1] presented as resistant to therapist attempts to reframe and redirect his attention to other activities or calming strategies. [Resident#1] reported that he did not care if he was removed from the facility. [Resident#1] further presented as quite incredulous at the prospect of law enforcement intervention other consequences of his actions as he feels justified in his actions. This entry was written by the psychologist. Record review of Psychiatric Subsequent assessment dated [DATE] at reflected Patient is a [AGE] year-old White/Caucasian Male admitted to the facility on [DATE] for Long Term Care. On 6/22, pt punched another resident. The other resident sustained a laceration on his lip which required ER transfer. Pt states he was tired of the other resident bothering him and constantly entering his room. PCP added Xanax PRN and buspirone. Pt was also sent to the ER for evaluation. Returned to facility with no new orders. Pt is now calm. Pt is not expressing remorse but states he does not want to harm anyone. Pt lacks understanding of the other resident's behaviors. Pt believed the other resident was bothering him intentionally. Currently calm and remorseful that he hit the other resident. No SI, HI, or delusions at this time. No significant mood changes. This entry was entered by NP F Record review of hospital records dated 6/21/2025 at 20:27 Department of behavioral Health, Social work progress note reflected that Resident #1 was psych cleared stating that the aggression was not due a psychiatric issue and that resident #1 was a volunteer patient, and he wanted to leave and return back to the nursing home and he cannot he held against his will. An interview on 07/08/2025 at 10:09 AM with Resident #1 revealed that around 4:00 AM, Resident #2 was yelling and making noise outside Resident #1's room that woke Resident #1 up. Resident #1 stated that he got up and went to the nurse station to complain about Resident #2 waking him up. Resident #1 stated that Resident #2 liked to spit all the time, and it looked like Resident #2 was spiting at Resident #1. Resident #1 stated that he was upset so he punched Resident #2 in the mouth, and he was going to do it again, but the staff separated them and took Resident #2 away. Resident #1 stated that Resident #2 was always in places where he was not supposed to be, and that Resident #2 spit all over the place. Resident #1 stated that it was not his responsibility to worry about Resident #2's medical problems because it was obvious that Resident #2 had issues. Resident #1 stated that he did not look for trouble; he minded his own business and had no problem with other residents. He stated that he felt safe, but did not like anyone coming to make noise at his door at night and waking him up. An interview on 7.08.2025 at 11:18AM with CNA A revealed that while doing rounds on the 300 hall Resident#2 requested for a pen and paper. She gave him the paper and pen, but he wanted a sharpie marker that she did not have at the time. CNA A stated finished her rounds on the 300 hall. She stated she passed by Resident#2's room, and Resident#2 was in his room. She stated he told her he was writing a letter to his sister. CNA A stated she went to hall 200 ;where she was assigned two rooms. She stated that after providing care to the residents on 200 hall, she saw Resident #1 wheeling himself to the nurse station, he appeared upset and was using curse words. She asked him what was wrong, he stated that he was upset because Resident#2 was making noise and woke him up. She stated that then she saw Resident#2 at the nurse's station next to the trash can, with his cup that he spits in. CNA A stated that Resident #1 punched Resident #2 in the face, and she got in between Resident#1 and Resident#2 to separate them. CNA A stated she turned Resident #2 around and stood between them. She stated Resident #1 was threatening to hit Resident #2 again. She re-directed Resident #1 to go to his room. CNA A stated took Resident #2 back to his room, she then notified LVN B who went and assessed Resident #2. CNA A stated that LVN B notified the supervisor RN C, DON and Administrator, and they sent Resident #2 to the hospital. CNA A stated that the laceration on Residengt#2 looked like it needed stiches, so the nurses sent Resident #2 to the ER. She stated that she had been in-serviced on abuse and neglect, and had received training and resident-to-resident altercation. She stated that if she witnessed resident to resident, she would separate the residents to ensure they were safe, then report to the charge nurse, abuse coordinator, and DON. An interview on 07.08.2025 at 11:42 AM with Resident #2's FM revealed that Resident #2 was her brother who had autism with developmental delays and was always writing her a letter. She stated that he also produced a lot of saliva and spat in a cup, but never spat on anyone. She stated that she got a call from LVN B at 5 am that Resident #2 was attacked by another resident and had been sent to the ER. She stated that she went to the emergency room, and she was met by the police. She stated that Resident #2 had a huge laceration and got sutures to close it up. She stated that the police gave her a police report number, but no charges were filed. She stated that the Administrator told her that the facility would ensure that Resident #2 was safe and would not have interactions with Resident #1. The FM stated that she had found a group home for Resident #2 that would cater to his needs and as adult with autism. She stated that she had a meeting scheduled with a local behavioral clinic, the group home provider, and the social worker to begin the transitioning Resident #2 to the group home. Attempted on 07.08.2025 at 12:24 PM to interview RN C via telephone. There was no answer voicemail left with call back number. Attempted on 07.08.2025 at 12:30 PM to interview LVN B via telephone. There was no answer voicemail left with call back number. Interview on 07.08.2025 at 1:30PM with the DON revealed that she was notified by the Administrator and LVN B that Resident #2 and Resident#1 had an altercation. Resident#2 was wheeling himself around looking and calling for the nurse to get him a sharpie. Resident#1 was upset that he was woken up by Resident#2's noise. Resident#2 had a behavior that made him spit in a cup and Resident#1 thought he was spitting at him. CNA A was coming from providing care and was headed to the nurse station she saw Resident#1 wheeling himself towards Resident#2, then punched Resident#2 in the face. CNA A separated the residents then she called the LVN B. RN C assessed and evaluated Resident#2 and Resident#1; Resident#2 had laceration to his upper lip. they notified the NP, and got new orders to send Resident#2 to the ER. Resident#2 returned to the facility the same day with sutures to his top lip. DON stated that immediately after the incident, Resident#1 and Resident#2 were placed on one-on-one monitoring. Psyche evaluated Resident#2 and gave orders to discontinue one on one monitoring because he was not a risk to himself or any other resident. The DON stated that the psych NP gave orders to send Resident#1 to Hospital for evaluation for inpatient psyche services. Resident#1 was evaluated at and sent back to the facility because per the hospital evaluation, Resident#1 was not exhibiting any aggressive behavior. The DON stated that psych and the physician gave orders to continue one on one on Resident#1 until he got him to inpatient psych. The DON stated that the facility had sent referrals to inpatient psych hospitals, but he did not qualify him for inpatient psych services. The facility continued one on one monitoring on Resident#1 for three days then psyche discontinued the one-on-one monitoring stating he had calm down, and he was not exhibiting any aggressive behavior. The DON stated that Resident#1 had not exhibited aggression towards other residents that was an isolated issue with Resident#2. An interview on 07.08.2025 at 1:43 PM with NP E revealed that he was notified by LVN B that Resident#1 punched Resident#2 in the face causing Resident #2 to have a laceration to his upper lip. NP E stated that he gave orders to send Resident#2 to the ER for sutures. Resident#2 returned to the facility the same day. NP E stated that Resident#1 had previously mentioned that Resident#2 spat all the time but never mentioned wanting to hurt him. NP E stated that Resident#2 continuously spat in a cup, a behavior that was caused by his developmental issues. He stated that Resident#1 was calm most of the time, and that Resident#1 told NP E that he was annoyed with the noise by Resident #2, at 4 o'clock in the morning and that was what ticked him off. NP E stated that it was possible that another altercation could happen again if the two residents came across each other. He stated that Resident#2's family had been looking for a group home and even before this happened. He stated he that he told the DON that one of the residents had to move out. He stated that he gave a referral for the psych team to evaluate and treat . An interview on 07.08.2025 at 3:48 pm with Social Worker revealed that she was not at the facility when the incident happened. She stated that she was notified in the morning meeting that Resident#2 was wheeling himself around following the nurse looking for a sharpie so he could write. Resident#1 woke up, and he tried telling Resident#2 to be quiet. then Resident#1 punched Resident#2 in the face. She stated that Resident#1 and Resident#2's families were notified. The facility made sure Resident#1 and Resident#2 did not have contact with each other by placing them on one-on-one monitoring. She stated that the facility sent out referrals to six inpatient psychiatric hospitals, but he was denied admission due to his medical acuity. The provider psych services evaluated Resident#2 and Resident#1. Resident#2 was discharged from one-on-one monitoring the same day. Resident#1 continued one on one monitoring while the facility tried to get him inpatient psych services but was later cleared by practitioners after few days. Resident#1 used to have outbursts, but he has not had any outbursts in a while. Resident#2 had autism with developmental delays, but he did not have behaviors. She stated that she was not aware of any other incident between Resident#1 and any other resident, and no residents had voiced that they did not feel safe. She stated that Resident#2's family had been trying to find him a group home that would be more appropriate for Resident#2's needs. Stated that Resident#2's sister had found him a group home and the behavioral health clinic had started the process to transition him to the group home. She stated that Resident#2 denied any psychosocial injury; all he wanted was to go to a group home. An interview on 07.08.2025 at 4:00pm with the Administrator revealed that LVN B called him early morning on 06/21/2025 and told him that Resident#1 hit Resident#2. He stated that LVN B reported that Resident#2 had gone down the hallway looking for a nurse to give him a sharpie marker. The noise of resident#2 calling for the nurse woke resident#1. Resident#1 got up headed to the nurse's station, Resident#1 asked Resident#2 why he woke him up, and then punched Resident#2 in the face. CNA A witnessed the incident and immediately separated Resident#1 and Resident#2. LVN B took Resident#2 to the room and assessed Resident#2s injuries then called the NP and sent Resident#2 to the ER. Administrator stated Resident#1 confirmed that he punched Resident#2 in the face because he woke him up. The administrator stated that Resident#1 was placed on one-on-one monitoring immediately, and Resident#2 was sent to the ER. The administrator called the police, they came to the facility, and tried to interview Resident#1. then the police went and interviewed Resident#2 but no charges we filed. Resident#1 was on one-on-one from Saturday 6/21/2025 until Wednesday 6/25/25. Resident#1 was seen by psyche on Saturday 06/21/2025 and the following Tuesday 06/24/2025.The Administrator stated that Psych reevaluated Resident#1 on 6/25/2025, and per psyche assessment he was calm with no intentions to hurt anyone psych discontinued One on One monitoring . He stated that prior to the incident on 06/21/2025, Resident#2's FM was already looking for places to move Resident#2 to a group home that specialized in adults with autism. The behavioral clinic suggested s group home setting for Resident#2, but most group homes could not admit Resident#2 because he had a gastronomy tube (a feeding tube inserted through the abdominal wall into the stomach). She found a place and was waiting for paperwork so that she can move him. Since the incident, the facility had sent out referral for in patient psych for Resident#1 to six hospital, and they all declined him due to Resident#1's medical acuity, and because he had dementia; some of their programs did not admit patients with dementia. He stated that the facility educated all the staff to make sure the Resident#1 and Resident#2 did not have contact with each other. Because Resident#1 was legally blind, he thought that Resident#2 was spitting at him. Resident#2 had a medical condition that caused him to over produce saliva. The Administrator stated that after the incident the staff was in serviced on abuse and resident to resident altercation. The Administrator stated that safe surveys conducted and all the residents in the facility stated that the felt safe in the facility. Record review of the facility's incidents/accidents report from 1/25/25 to 06/25/25 reflected there were no other incidents that involved Resident #1 or Resident #2. Record review of the facility's policy, revised April 2025, and titled Abuse: Prevention of and Prohibition Against reflected: 1. Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 2.If the allegation of abuse, neglect, misappropriation of resident property, or exploitation involves another resident, the Facility will: Separate the residents so they do not interact with each other until circumstances of the reported incident can be determined. If a room change is appropriate, advise the residents and/or resident representatives of reason for the change in writing. Continue to assess, monitor, and intervene as necessary to maximize resident health and safety.

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of three residents, reviewed for infection control. 1. The facility failed to ensure CNA A changed gloves and performed hand hygiene during incontinence care for Resident #1. This failure placed residents at risk for healthcare associated cross contamination and infections. Findings included: 1. Review of Resident #1's Quarterly MDS Assessment, dated 02/25/25, reflected the resident had a BIMs score of 1 and was severely cognitively impaired. The resident had diagnoses which included stroke and non-Alzheimer's dementia. The resident was occasionally incontinent of bowel and bladder. The functional abilities of the resident was not documented. Review of Resident #1's Comprehensive Care Plan, dated 11/01/24, reflected the resident had an activities of daily living selfcare performance deficit related to dementia and decreased mobility. Facility interventions included: Encourage resident to participate to the fullest extent possible. An observation on 04/09/25 at 3:05 PM revealed Resident #1 was in bed. She was awake, alert, and confused. CNA A prepared to perform incontinence care for the resident. The resident's brief was wet. CNA A performed peri-care and cleaned the buttocks. CNA A did not change her gloves or perform hand hygiene. CNA A put a clean brief on the resident and covered her with the linens. An interview on 04/09/25 at 3:15 PM revealed CNA A knew that she was supposed to change gloves and perform hand hygiene but did not want to because the resident played with the water in the sink. An interview on 04/09/25 at 4:10 PM with the Infection Preventionist revealed staff were supposed to clean a resident, change gloves, perform hand hygiene, and then put a clean brief on the resident. The Infection Preventionist said failure to change gloves and perform hand hygiene could cause issues with infection control. An interview with the DON on 04/09/25 at 5:20 PM revealed staff were supposed to change their gloves and perform hand hygiene after cleaning a resident. The DON said failure to do so could cause infection. Review of the facility policy, Handwashing, dated July 2021, reflected: It is the policy of this facility to cleanse hands to prevent transmission of possible infectious material and to provide clean, healthy environment for residents and staff.

Based on interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 2 Nurse Aides (NA A and NA B) of four nurse aides reviewed for proficiency of nurse aides. The facility failed to ensure NA A and NA B were CNAs after four months of being hired 06/03/24. This failure could place residents at risk of not being provided care by qualified staff, which could cause inadequate care and injury resulting in decreased health and psycho-social well-being. Findings include: 1. Record review of NA A's employee record revealed she was hired 06/03/24 as a Nurse Aide trainee. Her Texas Performance Nurse Aide Program training was completed on 06/24/24. and she completed skills checkoffs on resident care and services. There was no proof of her being a Certified Nurse Assistant. Record review of the [State Portal] website, dated 03/13/25, revealed NA A's certification status was Prospective. Record review of NA A's Timesheet at [This Facility] revealed her date of hire was 06/03/24. She was in orientation from 06/03//24 - 07/05/24 and she started working regular hours on 07/13/24. The last day she worked was 03/08/25. 2. Record review of NA B's employee record revealed she was hired on 06/03/24 as a Nurse Aide trainee. Her Texas Performance Nurse Aide Program training was completed on 06/24/24 and she completed skills checkoffs on resident care and services. There was no proof of her being a Certified Nurse Assistant. Record review of the [State Portal] website, dated 03/13/25, revealed NA B's certification status was Prospective. Record review of NA B's Timesheet at [This Facility] revealed she was hired on 06/03/24. She was in orientation from 06/03/24 - 07/05/24 and she started working regular hours on 07/13/24. The last day she worked was 03/07/25. Interview on 03/13/25 at 10:23 AM, NA A stated she worked at the facility since 06/03/24 in the NA training program. She completed the training on 06/24/24. She stated she tried to do the written portion of the test but the camera on her computer was not working properly to register for the test. She stated she had not taken the CNA written test and was told by the DON, she needed to take the test by 03/24/25. She stated she used to work PRN but as of this year, she worked full time taking care of the residents. She stated she was trained by a few nurses and CNA's. She was trained on how to bathe and change the residents, transferring to and from the bed, Hoyer lift transfer with a 2nd person and the nurses did everything else. She stated the DON said she exceeded her time and they wanted her to take the NA test before 03/24/25. She stated she was not sure what the timeframe was to get her CNA license but she kept having problems with her computer and she was finally able to get her paperwork to go through last month. She stated she was working on completing the written test on 03/24/25 . Interviews were attempted and messages left for NA B to return calls on 03/12/25 at 1:55 PM and 4:54 PM and 03/13/25 at 10:47 AM, but she did not call the HHSC State Surveyor. Interview on 03/13/25 at 11:51 AM, Staffing Coordinator E stated the facility had a CNA training program and they had three or four NA's in training, but they were not on the schedule yet. She stated when they worked they worked with somebody alongside another CNA. She stated the NA were not working independently. She stated she was not sure who was responsible for ensuring they got certified and the NA's had to work 120 hours as a Nurse aide then they could take the CNA test. Interview on 03/13/25 at 1:00 PM, the DON stated they had NA's who provided care to the residents but as of today NA A and NA B were not going to work until they passed the CNA test. She stated NA C was still within his 120 days and in the process of taking his CNA test this month and NA D just recently passed her certification test this week. She stated she did not have a date on when NA A and NA B were going to take their CNA test. She stated she received clarification today (03/13/25) about the timeframe the NA's needed to get certified. She stated she thought the NA's had a year to get certified. She stated she spoke to her Clinical Resource Consultant and he told her the NA's had within 120 days to take the test and get certified. She stated from the times NA A and NA B took the class, they were pushing them to take the test but they had problems with uploading the information to register. She stated the instructor had already approved their trainings and they just needed to register for the written test. She was not sure why they did not ask to use a computer at the facility. She stated NA A and NA B were PRN's initially and then they were assigned rooms and provided care to the residents. She stated they changed briefs, showers, feeding assistance, setting up meal trays, grooming and Hoyer lift transfers with a 2nd person. She stated her plan to prevent NA's from going over their 120 days was to make sure they got certified. She stated the NA's worked independently and nurse management checked the resident's Plan Of Care and the nurses assisted them with documentation and care. She stated she would be responsible for ensuring the CNA tests were completed in 120 days. Interview on 03/13/25 at 2:01 PM, the Operations Manager stated they had a few NA' and NA A had not obtained her certification because of an issue with her computer and had since taken her off the schedule until she passes her test. He stated he was not sure why NA B had not obtained her certification. He stated he found out this morning (03/13/25) from their Clinical Resource Consultant that the NA's had 120 days from the date of hire to get certified. He stated after they completed the class part, the NA's were able to work for a short period of time with CNA's to care for the residents. He stated the NA's gave their resident reports to the CNA they worked with, to document in the system. He stated NA A and NA B should have already become CNA's. He stated the HR Director G and the DON were responsible for tracking the NA's 120 days and keeping track of their certifications stayed active. He stated NA's caring for the residents may result in the residents not getting taken care of properly or may cause them frustration. He stated the NA could do anything a CNA could do, but document. He stated he was not sure why the NA's could not document and after reviewing the job descriptions for the NA and CNA, he said they were different but the CNA's were able to provide care without supervision. He stated the NA's had temporary licensures that prohibited them from being able to document but not the care they provided the residents. He stated he was not aware the NA's days were not being tracked to take their CNA testings. He stated that was why they reached out to their Corporate HR resource person to do employee audits to ensure there were no other issues with the employees certification deadlines. Interview on 03/13/25 at 3:11 PM, the Administrator stated the facility had four NA's and there was an ongoing effort to address the issue with the CNA certifications. He stated HR Director G was responsible for ensuring the NA's were certified and, he had spoken to their Corporate CNA Trainer F and they were going to do a full audit. He stated the NA's were not going to work until they were certified. He stated management needed to re-educate the DON and HR Director G on making sure the NA's were certified in 120 days. He did not want to say how it could affect a resident if a NA provided care to the residents. He stated the residents could potentially not get the care they needed. He stated they were going to have one of their Corporate HR people do an audit of all employees records to make sure there were no issues with other staff certifications. Interview by phone on 03/13/25 at 3:49 pm, the HR Director G stated the Corporate CNA Trainer F was the instructor for the training program and showed the NA's how to apply and get Certified. He stated he thought CNA trainer F was supposed to be checking to ensure the NA were certified in the 120 days. He stated the NA's were not supposed to do documentation but were able to provide care as long as a nurse or cna was watching over them. He stated he planned to get with the DON and Corporate to prevent this from happening again. Interview on 03/13/25 at 5:01 PM, Corporate CNA trainer F stated the NA's did three weeks of training with her. She stated she tracked when they started the NA trainings and that was it. She stated the facility was responsible for keeping up with getting NA's certified before the 120 days. She stated she told the NA's and the DON about the dates and timeframes to get certified. She stated telling the NA's and the DON the NA's had to choose the date and time to take the test and they needed to tell the DON and Administrator once it was scheduled. She stated the 120 days included the training, she had to call her counterpart because she was not sure. She stated once the NA's completed their training they needed to upload their information into the [State Portal] registration website so she could approve it. She stated then the NA could choose a date to take the test. She stated last year she approved NA A and NA B registrations in the [State Portal] to take the test because they went through the CNA training and was not sure why they had not taken the test yet. She stated she was going to speak to the facility management to ensure the oversight was over the NA's and to ensure the tracking of the 120 days were being done. She stated the difference between the NA and CNA was one was certified and the other was not. Interview on 03/13/25 at 5:33 PM, the DON stated after she reviewed the job descriptions for the Nurse Aides and CNA's, they were pretty much the same. She stated the NA's did what the CNA's did but the NA's could not document and needed a nurse or CNA to assist with their documentation. She stated she was not sure why the NA's could not do their own documentation and thought they should be able to. She stated she was not able to say what could happen if an uncertified NA provided care to a resident. Record review of the facility's, undated, Human Resources Employee Handbook page 14 revealed, You are responsible for: Maintaining current/valid license and credentials Record review of the facility's Job Description for Nurse Aide policy, dated 12/17/21, revealed Position Summary: The primary purpose of your job position as a full-time staff member is to acquire the knowledge, skills and certification as a Certified Nursing Assistant by participation in the facility's planned educational program consisting of classroom instructions, clinical practice, and on the job, supervised training, and to perform certain services for which you have been trained and found to be competent during the training period. Essential Duties and Responsibilities: Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not excluded them from the position if the work is similar, related, or is an essential function of the position.

Based on observations, interviews, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 or 2 meals (lunch) reviewed for food meeting residents' needs. The facility failed to prepare and serve pureed rosemary roast pork and pureed corn as a pudding consistency for residents who required pureed diets. This deficient practice could affect residents who received pureed meals from the kitchen by contributing to dissatisfaction, poor intake, choking, and/or weight loss. The findings included: Record review of Week 4 Tuesday menu revealed the menu for the lunch service was [NAME] Roast Post, corn pudding . Observation on 11/05/24 at 11:49 AM of [NAME] A pureed corn with a hand blender, then proceeded to place it on the steam table. Then [NAME] A pureed the rosemary roasted pork with the hand blender then placed it on the steam table. [NAME] A did not check the consistency or ensure it was all blended to have a pudding consistency. Observation of test tray on 11/05/24 beginning at 1:00 PM, the test tray included the regular textured menu items and the pureed menu items. Pureed roasted pork and corn did not have a smooth/pudding consistency. The roasted pork had pieces of the pork and the corn had pieces of the corn and corn skin. Interview on 11/05/24 at 1:11 PM with [NAME] A revealed pureed food should be a pudding consistency. She stated she used the hand blender to blend the puree food, she stated she always used it. She stated depending on the meat she would also use the robot blender. She stated the facility had 5 residents who were on a pureed diet. She stated she normally tried the food to ensure it had a smooth consistency; however, today (11/05/24) she tried the food after trays were served. She stated when she tried it, she did not get any pieces of food. She stated it was her responsibility to cook and prepare resident food. She stated the risk if everything was not completely pureed, was the resident could choke. Interview on 11/05/24 at 1:24 PM with Dietary Manager revealed his expectation was for pureed food to have a smooth/ pudding consistency. He stated it was the responsibility of the cooks to puree food and it was his responsibility to ensure it was completed correctly. He stated [NAME] A informed him that she made a mistake, she grabbed the gravy from the regular texture, and placed it on top of the puree food. He stated that was how the chunks of pork were in the pureed meal. He stated the potential harm to residents was the possibility of chocking or aspirating. Record review of facility Pureed Diet policy, revised July 2022, reflected: Need to follow a pureed diet if [you] have trouble chewing, swallowing, or fully breaking down (digesting) solid foods. Pureed means that all food has a been ground, pressed, and/or strained to a soft, smooth consistency, like a pudding. Pureed Foods do not need chewing. They are completely smooth with no lumps, skins, strings or seeds.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 residents (Residents #41 and #46) reviewed for infection control. 1. The facility failed to ensure LVN L put on appropriate PPE (gown) before entering Resident #46's room to administer medications via gastronomy tube to Resident #46, who was on enhanced barrier precautions. 2. The facility failed to ensure LVN D changed soiled gloves and performed hand hygiene during wound care for Resident #41. These failures placed residents at risk of cross contamination and the spread of infection. Findings included: 1. Record review of Resident #46's Quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male, who admitted to the facility on [DATE]. The resident had moderate cognitive impairment with a BIMS score of 12, and his diagnoses included gastrostomy tube (a feeding tube placed through the skin and stomach wall), and the MDS reflected he had a feeding tube for nutrition. Record review of Resident #46's care plan dated 01/19/24 reflected: Focus: [Resident #46] requires tube feeding. Goal: [Resident #46] will remain adequate nutritional and hydration status through the next review date. Interventions: Enhanced barrier precaution: PPE required for high resident contact care activities. Indication wounds and gastronomy tube. Record review of Resident #46's physician order dated 04/14/24 reflected: Enhanced barrier precautions: PPE required for high contact care activities. Indication: wounds, indwelling medical device, infection, and MDRO status every shift. Observation on 11/05/24 at 12:16 PM revealed LVN L was preparing to provide Resident #46 medications. Resident #46's door had the following sign: Stop, enhanced barrier precautions -providers and staff must also wear Gown and Gloves. There was PPE inside the room. LVN L performed hand hygiene and donned a pair of gloves. Without donning a gown, LVN L then provided Resident #46 medication Norco 10/325mgs 1 tablet via his gastrostomy tube and then administered Jevity 237mls. Interview on 11/05/24 at 12:36 PM, LVN L stated she was the nurse assigned to Resident #46. LVN L stated she saw the PPE post at the door, but she was not aware Resident #46 was on enhanced barrier precautions. She stated she was not aware that PPE was supposed to be worn during care for Resident#46. She stated the risk of not donning PPE was that it could lead to the spread of infection. She stated she had done training on enhanced barrier precautions during COVID time, and she knew only those on isolation that required PPE she did not know about those on gastronomy tube. She stated she has not been using the gown on residents with a g-tube. 2. Record review of Resident #41's Entry MDS assessment dated [DATE] reflected the resident was [AGE] year-old female who admitted to the facility on [DATE]. The resident's cognition was moderately impaired. She had BIMS score of 11, and she had diagnoses of hypertension (high blood pressure) and a pressure ulcer. Record review of Resident #41's care plan dated 09/13/24 reflected: Focus: Resident#46 has pressure ulcer on sacrum rule out immobility. Goal: Pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions: Administer treatments as ordered and monitor for effectiveness. Record review of Resident #41's wound care orders, dated 09/18/24, reflected: Cleanse sacrum wound with normal saline or wound cleanser. Dry, apply collagen powder, apply calcium alginate, and cover with dry dressing daily and as needed if soiled or dislodged every day and as needed. Observation on 11/06/24 at 12:00 PM revealed LVN D did not change her gloves after removing the old dressing on Resident #41's wound. She went directly from removing the old dressing on the wound to cleansing the wound with clean gauze soaked with normal [NAME]. She then applied collagen and applied calcium alginate without changing the gloves or performing hand hygiene. She removed the gloves and the gown, she did not wash hands, put on new gloves, labeled the dressing, and then removed the gloves and the gown and washed her hands. Interview on 11/06/24 at 12:20 PM with LVN D revealed she did not change gloves and perform hand hygiene after removing the old dressing, and after cleansing the wound. LVN D stated she was not directed to perform hand hygiene between the procedure but before and after the procedure. LVN D stated she knew it was best standard of practice to remove dirty gloves and wash hands after removing the old dressing, but she forgot she, was nervous. LVN D stated changing gloves and performing hand hygiene during wound care would prevent contamination of the wound which could cause infection. She stated she had done training on infection control but not on wound care. Interview on 11/06/24 at 12:25 PM with the ADON who was helping LVN D perform wound care on Resident #41 revealed her expectation was for the nurse to remove gloves and perform hand hygiene after the removal of an old dressing and with contamination. The ADON stated the nurse was supposed to wash her hands after removing the old dressing and her gloves, and then again after cleansing the wound, the nurse was supposed to change her gloves and perform hand hygiene. The ADON stated LVN D failed to change gloves and wash hands. The risk of not changing gloves and performing hand hygiene during the wound care was that it would lead to cross contamination of the wound and then infection. She stated she had done trainings on wound care, and she will be doing training again with LVN D. Interview on 11/06/24 at 12:30 PM, the DON stated she expected staff to put on PPE when providing care to a resident who had a wound, catheter, or a g-tube. She stated residents who were on enhanced barrier precautions had signs on their doors to indicate the resident was on enhanced barrier precautions. The DON stated Resident #46 was on enhanced barrier precautions due to having a g-tube, and staff should put on PPE before providing any type of care. She stated the potential risk of not putting on PPE would be spread of infection. She stated the facility had done trainings on infection control and enhanced barrier precautions. Interview on 11/06/24 at 4:00 PM with the DON revealed her expectation was for the nurses to perform hand hygiene after removal of an old dressing and with contamination. The DON stated the nurse was supposed to wash her hands after removing the old dressing and her gloves, and then again between the procedure because she did not want the nurse to move from dirty to clean. The DON stated it was her responsibility to ensure staff were observing infection control protocols. The risk of not changing gloves and performing hand hygiene during the wound care was that it would lead to cross contamination of the wound and then infection. She stated she had done trainings on wound care and LVN D was assessed on skills, but no documentation was presented. The DON stated the person that did the skills assessment with LVN D was the resource personnel. Record review of training on enhanced barrier precautions, dated 04/24/24, reflected LVN L attended. Record review of Training on wound care, dated 06/06/24, reflected LVN D was in attendance. Record review of the facility's Infection Control policy, revised March 2024, reflected: .b. Personal protective equipment: 1. Wear gown and gloves for all interactions that may involve contact with the patient or the patient's environment. .3. Enhanced barrier precautions (EBP) are used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves and gloves during high contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident to resident.(e.g., resident with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs (multi-drug resistant organism). Record review of the facility's Dressing Change, Clean Technique policy, dated. September 2007, reflected: .1. Wash hands .5. [NAME] gloves 6. Use normal saline to soak dried dressings prior to removal 7. Remove old dry dressing and discards according to facility policy 8. Removes gloves and washes hands .11. clean wound according to physician's order moving from cleanest to dirtiest area .13. Apply dressings.

Based on interview and record review, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for 5 of 8 residents (5 confidential residents) reviewed for medically related social services. The facility failed to obtain needed services from outside entities, including absentee ballots, to ensure 5 confidential residents had the right to be able to vote in the current election cycle. This deficient practice could place residents at risk for their mental and psychosocial needs not being met and a decreased quality of life. Findings included: In a confidential group interview on 11/05/24 at 2:33 PM with five residents, they revealed they were never asked if they wanted to vote or informed on how they could vote in the upcoming Presidential election, while living in the facility. The five residents said they wanted to vote and knew that today was the last day to be able to do that for this election cycle but that no one had mentioned anything to them about their rights and ability or options to vote. The five residents expressed how important it was for them to be able to use their voice in the election cycle and it did not make them feel good to not be able to participate. Interview on 11/05/24 at 2:55 PM with the Activity Director revealed he had tried to get mail in ballots for the residents in the facility to use to be able to vote during this election cycle. The Activity Director said he also tried to find information on the resident's right to vote during this election cycle. The Activity Director said this was the first year he was responsible for ensuring residents were able to use their right to vote. The Activity Director said he had communicated once in October during a bingo activity with residents about the mail in ballots he had received. The Activity Director said he had no documentation as to how many residents, who the residents were that he talked to, or what date it was that he brought up voting during the bingo activity. The Activity Director said he did not want to hinder anyone from not being able to vote but he just was not sure on how exactly to assist the residents with their ballots. The Activity Director said he did mention voting by mail in ballot one other time to a resident who had asked and was able to mail their ballot off, but that was it. The Activity Director said he brought up the concern to the Operations Manager but he never followed-up with him about it . Interview on 11/05/24 at 3:16 PM with the Operations Manager revealed the Activity Director was responsible for ensuring residents used their right to vote in the election cycle this year. The Operations Manager said he went to each resident to ask if they were interested in voting and would have provided them a mail in ballot. The Operations Manager said he did not have a date or documentation of how many residents he spoke with regarding using their right to vote during this election cycle. The Operations Manager said he had only 2 residents who wanted to use the mail in ballot to vote from the conversations he had that day, though. The Operations Manager said yesterday (11/04/24) another resident had asked about being able to vote via mail in ballot, but he told the resident that window had closed to be able to vote that way. The Operations Manager said the facility made no plans to offer residents the right to vote in person at a polling location and only relied on the mail in ballots they had. The Operations Manager said he recognized he should have done a better job of helping the residents be able to vote during this election cycle. The Operations Manager said looking back he and the Activity Director only made initial attempts at providing the right to vote to the residents and did not have any follow-up. The Operations Manager said he wanted the residents to be able to exercise their right to vote. The Operations Manager said if residents did not have the right to vote that could lead to a lack of self-worth and not contributing to society as a whole and could have numerous repercussions. Record review of the facility's Resident Rights and Responsibilities policy, dated January 2022, reflected it did not address what rights a resident had.

Based on interviews and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 7 of 61 days (11/05/23, 11/11/23, 11/12/23, 11/19/23, 12/10/23, 12/24/23, and 12/31/23) reviewed for staffing. The facility failed to have an RN for at least 8 consecutive hours for the following 7 days: 11/05/23, 11/11/23, 11/12/23, 11/19/23, 12/10/23, 12/24/23, and 12/31/23. This failure placed all residents at risk of not receiving adequate medical care and supervision of an RN. Findings included: The facility was unable to provide proof they had RN coverage for the following dates: 11/05/23, 11/11/23, 11/12/23, 11/19/23, 12/10/23, 12/24/23, and 12/31/23. Record review of the facility's CMS PBJ Staffing Data report for FY Quarter 1 2024 (October 1- December 31) reflected No RN Hours were triggered. Further review reflected Infraction Dates of: 11/05 (SU); 11/11 (SA); 11/12 (SU); 11/19 (SU); 12/10 (SU); 12/24 (SU); 12/31 (SU). Interview on 11/06/24 at 10:47 AM with the DON revealed the facility did not have an RN working for the 7 dates the state surveyor had requested (11/05/23, 11/11/23, 11/12/23, 11/19/23, 12/10/23, 12/24/23, and 12/31/23). The DON said she checked the dates and saw that there was not an RN working in the building on those dates. The DON said usually she confirmed with the staffing coordinator that an RN had been scheduled for those dates, but she was not sure what happened. The DON said something must have been missed on those dates because only LVN's were working on those dates. The DON said usually an RN worked each day for at least 8 hours. The DON said if an RN was not in the building for 8 hours each day there could not be enough staff to complete a proper assessment that required an RN. Record review of the facility's current, undated Procedure and Guidance .483.35(b) reflected: .Facilities are responsible for ensuring they have an RN providing services at least 8 consecutive hours a day, 7 days a week.

Based on interview and record review, the facility failed to ensure the resident had the right to exercise his or her rights as a resident of the facility and a citizen or resident of the United States for 5 of 8 residents (5 confidential residents) reviewed for resident rights. The facility failed to ensure the five confidential residents had the right to be able to vote in the current election cycle. This deficient practice could affect dependent residents and their families and contribute to feelings of shame and loss of dignity. Findings included: In a confidential group interview on 11/05/24 at 2:33 PM with five residents, they revealed they were never asked if they wanted to vote or informed on how they could vote in the upcoming Presidential election, while living in the facility. The five residents said they wanted to vote and knew that today was the last day to be able to do that for this election cycle but that no one had mentioned anything to them about their rights and ability or options to vote. The five residents expressed how important it was for them to be able to use their voice in the election cycle and it did not make them feel good to not be able to participate. Interview on 11/05/24 at 2:55 PM with the Activity Director revealed he had tried to get mail in ballots for the residents in the facility to use to be able to vote during this election cycle. The Activity Director said he also tried to find information on the resident's right to vote during this election cycle. The Activity Director said this was the first year he was responsible for ensuring residents were able to use their right to vote. The Activity Director said he had communicated once in October during a bingo activity with residents about the mail in ballots he had received. The Activity Director said he had no documentation as to how many residents, who the residents were that he talked to, or what date it was that he brought up voting during the bingo activity. The Activity Director said he did not want to hinder anyone from not being able to vote but he just was not sure on how exactly to assist the residents with their ballots. The Activity Director said he did mention voting by mail in ballot one other time to a resident who had asked and was able to mail their ballot off, but that was it. The Activity Director said he brought up the concern to the Operations Manager but he never followed-up with him about it . Interview on 11/05/24 at 3:16 PM with the Operations Manager revealed the Activity Director was responsible for ensuring residents used their right to vote in the election cycle this year. The Operations Manager said he went to each resident to ask if they were interested in voting and would have provided them a mail in ballot. The Operations Manager said he did not have a date or documentation of how many residents he spoke with regarding using their right to vote during this election cycle. The Operations Manager said he had only 2 residents who wanted to use the mail in ballot to vote from the conversations he had that day, though. The Operations Manager said yesterday (11/04/24) another resident had asked about being able to vote via mail in ballot, but he told the resident that window had closed to be able to vote that way. The Operations Manager said the facility made no plans to offer residents the right to vote in person at a polling location and only relied on the mail in ballots they had. The Operations Manager said he recognized he should have done a better job of helping the residents be able to vote during this election cycle. The Operations Manager said looking back he and the Activity Director only made initial attempts at providing the right to vote to the residents and did not have any follow-up. The Operations Manager said he wanted the residents to be able to exercise their right to vote. The Operations Manager said if residents did not have the right to vote that could lead to a lack of self-worth and not contributing to society as a whole and could have numerous repercussions. Review of the facility's Resident Rights and Responsibilities policy, dated January 2022, reflected it did not address what rights a resident had.

Based on observations, interviews, and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for 1 (Residents #1) of 4 residents reviewed for tube feeding management. The facility failed to ensure Resident #1's Piston syringe for G tube flushing was changed daily. (A piston syringe is a small, cylindrical piece that fits inside the barrel of a syringe. It is typically made of plastic or metal and moves back and forth within the barrel to draw in or expel fluids for tube feedings.) These failures could place residents at risk un-sanitized treatment and infections. Findings included : Record review of Resident #1's face sheet dated 03/08/24 reflected a [AGE] year-old male admitted on [DATE] with dx dysphagia, oropharyngeal phase dysphagia (the inability to empty material from the esophagus i.e. stomach) following cerebral infarction. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 3 indicating he was severely impaired cognitively. Section K enteral feeding list. Record review of Resident #1's Care plan dated 01/12/24 reflected Will remain free of side effects or complications related to tube feeding through review date . Flush g-tube with 30-50 ml of water before and after medication administration flush tubing with 5ml-10ml water between each medication administration. Record review of Resident #1's Physician orders report dated 03/08/24 reflected, .Enteral Feed every shift rinse syringe after each use Enteral Feed .Enteral feed every shift change syringe. An observation on 03/07/24 at 08:45 AM revealed a piston syringe on the bed side table dated 03/05/24. Resident #1 was not interviewable. In an interview with DON on 03/07/24 at 9:31 AM she stated the piston syringe should be changed every shift. The nurses were expected to check the date and condition of the resident's Piston syringe during rounds to assure equipment for treatment was performed. In the event the syringe was not changed and dated, she expected the nurse to change and date the new one. The residents could get infections when syringes aren't changed daily or as needed. In an interview with the ADM on 03/07/24 at 9:45 AM he revealed he expected the nursing staff to follow policy and procedure for resident care . ADM stated that he expects the DON and ADON to monitor all nursing task to ensure no complications with the resident. In an interview with LVN S on 03/08/24 at 1:00 PM she revealed she was not the assigned nurse on 03/07/24. LVN S said resident tubing was changed on 03/07/24, but she did not know what time. The nurses should change piston syringe daily, and the change occurred during the 10PM to 6 AM shift. LVN S tubing was checked during rounds by nursing staff. LVN S stated if a piston syringe was observed undated, the nurse would change immediately. LVN S stated that all nurses were responsible for checking resident devices and equipment during rounds. S stated that failing to change the piston syringe daily or as needed could lead to bacterial infection. In an interview with the ADON on 03/08/24 at 2:06 PM she revealed the piston syringes should be dated to assure that the tubing was changed. The ADON said nurses were expected to change piston syringe daily during the night shift, as needed, and when observed with dates that are more than 24 hours. The ADON stated that the nurses should be monitoring tube supplies in the resident's room during rounds, upon arrival to shift . ADON stated that failing to change piston tube could lead to infection. Record review of facility Inservice dated 03/08/24 reflected policy listed below for all nursing staff. Record review of the facility's Policy titled, Gastronomy Tube Care Management, dated January 2022, reflected, Syringe Storage and Replacement: Syringes used for gastrostomy care will be stored at the bedside; the plunger will be removed after use and stored separately. b. The syringe will be discarded and replaced on a daily basis .

Based on interview and record review, the facility failed to ensure residents who require dialysis services, receive services consistent with professional standards of practice, the person-centered care plan and the resident's goals and preferences for one (Resident #1) of three residents, reviewed for in-house dialysis. The facility failed to ensure that Resident #1 was dialyzed Monday-Friday as ordered by the physician. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Review of Resident #1's Face Sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnoses included: peripheral vascular disease (narrowed blood vessels which reduce blood flow to the limbs), hyperlipidemia (high levels of fat particles in the blood), depression (depressed mood), diabetes mellitus (too much sugar in the blood) and end stage renal disease (kidneys cease functioning on a permanent basis). Review of Resident #1's physician orders dated 02/01/24 revealed Hemodialysis 5x/week every Monday-Friday at Provider A at Facility B. Review of nursing progress note dated 02/02/24 written by unknown staff member read Resident #1 was admitted from Hospital E to Facility B at 2250 PM . Review of text message provided by Administrator revealed on 02/01/24 the Administrator had received the following admission alert for Resident #1 from Case Manager D, 6:30 PM pick up from Hospital E and 7:00 PM estimated time of arrival to Facility B. Review of Hospital E progress note dated 01/31/24 for Resident #1 revealed hospital course .on hemodialysis Monday, Wednesday and Friday . Review of Facility's Leaving Facility Against Medical Advice Form revealed Resident #1 was signed out on 02/03/24 by her responsible party. Interview on 02/08/24 at 11:54 AM with the DON she stated Resident #1 was supposed to received dialysis from our in-house Provider A on Monday-Friday. The DON stated Resident #1 admitted to the facility on Thursday (02/01/24) very late that evening. The DON stated that Resident #1 admitted after hours on the 02/01/24, therefore Resident #1 was not on Provider A's schedule for dialysis on 02/02/24 and missed dialysis on Friday 02/02/24. The DON stated she had reviewed Resident #1's hospital paperwork and there was nothing stating when Resident #1 was last dialyzed however it read that Resident #1 had been receiving dialysis on Monday, Wednesday, and Friday in the hospital. The DON stated her expectation was for all residents who required dialysis to complete their dialysis as ordered by their physician. The DON stated the adverse effects of a resident not receiving dialysis as ordered could jeopardize their health or care. Interview on 02/08/24 at 12:42 PM with the ADON, she stated Resident #1 admitted to the facility on Thursday (02/01/24) late in the evening. The ADON stated on Friday morning (02/02/24) she was the nurse assigned to Resident #1. The ADON stated she was given report by the night shift LVN B and was told Resident #1 had dialysis at the hospital on 02/01/24 prior to her admission to Facility B . Interview on 02/08/24 at 12:50 PM with Provider A RN F, he stated that Resident #1 was not on the schedule for dialysis on 02/02/24. Interview on 02/08/24 at 1:17 PM with the Administrator, he stated he was aware that Resident #1 had missed her dialysis on Friday according to physician orders, but there was miscommunication with Facility B and Provider A to ensure her in-house dialysis was started on Friday 02/02/24 as ordered regardless of the time of her admission. The Administrator stated his expectation was for the facility to ensure residents received dialysis according to the physician orders. The Administrator stated that the communication the facility had received from Case Manager D with Hospital E was that Resident #1 was going to be picked up from Hospital E at 6:30 PM and arrive at the facility around 7:00 PM. She stated Resident #1 did not arrive until after 10:00 PM, around 11:00 PM. The Administrator stated that LVN C had been given report from Hospital E that Resident #1 had received dialysis on 02/01/24 prior to arrival at Facility B. The Administrator stated the late admission and the communication about Resident #1's last dialysis treatment resulted in the resident missing her dialysis treatment on 02/02/24. The Administrator stated that the hospital paperwork revealed Resident #1 was receiving dialysis Monday, Wednesday, and Friday while hospitalized . Interview on 02/08/24 at 7:15 PM with LVN C revealed he stated that he received report for Resident #1 on 02/01/24. LVN C stated that Hospital E stated, Resident #1 had received dialysis on 02/01/24 prior to discharge from Hospital E . Review of the facility's policy titled Dialysis (Renal), Pre-and Post-care dated December 2023, revealed It is the policy of this facility to: Assist resident in maintaining homeostasis per-and post-renal dialysis; .Participate in ongoing communication and collaboration with the dialysis facility regarding dialysis care and services .

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for one (Resident #1) of three residents reviewed for baseline care plan. Resident #1s baseline care plan was missing information related to dialysis. This failure could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met. Findings included: Review of Resident #1's Face Sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnoses included: peripheral vascular disease (narrowed blood vessels which reduce blood flow to the limbs), hyperlipidemia (high levels of fat particles in the blood), depression (depressed mood), diabetes mellitus (too much sugar in the blood) and end stage renal disease (kidneys cease functioning on a permanent basis). Review of Resident #1's Baseline Care Plan, dated 02/02/2024, revealed no focus area for dialysis. Further review of an initial care plan date initiated 02/03/24, revealed no focus area for dialysis. Review of Resident #1's physician orders dated 02/01/24 revealed Hemodialysis 5x/week every Monday-Friday at Provider A at Facility B. Observation and interview with the DON on 02/08/24 at 11:54 AM, the DON confirmed dialysis was not included in the baseline care plan. The DON revealed a care plan worksheet utilized by the facility as a baseline care plan. The DON further revealed the information from the worksheet carried over to the care plan to create the comprehensive care plan. The DON stated the worksheet does not have a dialysis option and does not allow for additional information to be added. The DON stated she was responsible for the completion of the baseline care plan and as the resident's admission continued it was expanded on. The DON acknowledged the importance of care service, such as dialysis, should be included on the baseline care plan. The DON stated it was important for a resident's specialized services to be included on the care plan as a true reflection of the care and services the resident requires, and it provided both . Record review of the facility's policy titled, Comprehensive Person-Centered Care Planning, revised December 2023, revealed, .The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care . 2.The baseline care plan will include minimum healthcare information necessary to properly care for a resident including, but not limited to: a) initial goals based on admission orders, b) physician orders, c) dietary orders, d) therapy services, 3 social services: and f) PASARR recommendations, if applicable.

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of seven residents reviewed for accidents and supervision. The facility failed to supervise Resident # 1 who had exit seeking behavior as a result he eloped from the facility on 06/11/17 at 04:30 AM. He was found in a busy highway by police department and returned on 06/11/17 at 5:25 AM. Upon entry on 06/27/17 at 10:15 AM, the squealer alarm ( device installed on the door, that makes loud squealing sound when triggered) was observed turned off. An Immediate Jeopardy was identified on 07/11/17 at 10:00 AM. While the IJ was removed on 07/12/17, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm and a scope of pattern because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. This failure placed seven residents identified as being at risk for elopement and utilizing the Wander Guard system at risk for elopement, serious injuries, and/or death. Findings included: Review of Face Sheet for Resident #1, dated 07/11/17, reflected he was a [AGE] year-old male originally admitted on [DATE] with [DIAGNOSES REDACTED]. Review of hospital admission record dated 06/29/17 revealed Resident #1 was admited to Hospital emergency record from the facility on 06/19/17 at 12:31 PM. Review of Elopement /Wandering evaluation completed on admission and signed and dated by the DON on 06/12/17 indicated resident #1 had an exit seeking/ wandering behavior and had been categorized as a high Risk with a score of 16. Review of Resident #1's Care Plan's revealed a care plan with initiation date of 06/09/17 that indicated Resident #1 was an elopement risk/wanderer related to impaired safety awareness. Resident wanders aimlessly, history of exit seeking at home. No goal(s) were identified. Review of Resident# 1's Medication Review Report, dated 06/27/17, indicated an active order to check wander guard placement and function was given on 06/14/17. Review of the Provider Self-Reporting of Incident Report, dated 06/11/17, and signed by the Administrator in Training revealed the following: Resident #1 was independently ambulatory, non-interviewable, and incapable of making informed decisions, had a history of [REDACTED]. The Provider Report dated 06/11/17, revealed the following: 3:00 AM - (LVN A) notices Resident #1wandering on the hallway and redirect him back to his room. 4:28 AM - (LVN A) observes resident # 1 in his room. He had made his bed and already dressed up. 4:30 AM - (LVN A) returns to Resident #1 room, and finds him missing. 5:02 AM - Police were notified of the missing resident. 5:25 AM - Police find Resident #1 (one half mile away) and return him to the facility. Provider Action Taken Post-Investigation: All wander guards/alarm doors are being checked daily by administrator/designee. Placed all elopement risks on 15 minute checks for three days. Head count initiated on every shift change. Interview with LVN A on 06/27/17 at 11:45 AM revealed she worked on 06/11/17 the morning Resident #1eloped from the facility. She reported that she had gone to the resident's room at about 4:20 AM where she found him up and dressing. She reported that she informed Resident #1 that it was early for breakfast. She reported that again at around 4:30 AM she went to check on the resident but found him missing. She reported she had gone to check on Resident #1 after hearing a low beep sound on Hall 200 exit door. When she looked at the exit, it appeared like somebody had just gone out through that exit door. She reported that resident #1 might have pushed the push bar and gone out. She immediately looked outside and summoned the other staff members about the missing resident. When they failed to locate the resident, she immediately informed the DON and Director of Operations. Police was also notified. She said the squealer alarm was OFF position but she had not realized before the incident. She reported that the facility has put up measures to prevent elopement that was not in place before. She reported that staff members are supposed to physically check whether the squealer alarm is ON during their shift ( a device installed on the exit doors that produces a loud squealing noise. It alerts caregivers when a resident with exit seeking behavior tries to exit a premise). Interview with the DON on 06/27/17 at 11:00 AM revealed that the squealer alarm should be reset for the safety of the residents on elopement risk. She reported that she was not aware the squealer alarm on Hall 200 was on OFF settings. She said the nurse with the alarm key should know better not to turn it off . She reported that squealer alarm alerted staff members when residents tried to exit Hall 200 exit door. She reported that Hall 200 exit door did not have a wander guard locking system. Interview with the Director of Operations on 06/27/17 at 10:05 AM revealed that he first learned the Resident #1 was missing on 06/11/17 at 5:15 AM. He reported that the resident left the building through the exit door on Hall 200. He stated the nurse reported that the squealer alarm may not have triggered and the push bar alarm had low sound. He reported that after the incident, he had put up measures to prevent another resident eloping. He said the staff members were in-serviced on Guideline on Out of Pass, Elopement Flow record on resident's location checklist, door usage and procedure, new door alarm codes, daily door checks and wander guards monitoring. He reported that prior to the elopement incident; no one had been assigned the responsibility for checking the exit door alarms or testing the wander guards daily. He said residents risked eloping or injury when the door alarm was off. He reported that he had assigned fewer staff members with the door keys for safety and supervision. He stated that some staff member assigned the squealer alarm key might have set the alarm to an OFF position. He reported that the resident might have gotten off the facility by pushing on the push bar alarm on Hall 200 exit door. Observation of the facility Hall 200 exit door on 06/27/17 at 10:10 AM revealed the door squealer alarm had been set to an OFF position. The door push bar alarm sound was very low and could not be heard at the nurse station. Interview with CNA B on 06/27/17 at 10:20 AM revealed that she worked on Hall 200 and had taken care of Resident #1 on different occasions. She reported that Resident #1 was a wanderer and had exit seeking behavior. She reported that she had noticed the exit door squealer alarm was set at OFF position and the push bar volume was low after a resident tried to exit the facility that morning. She said she had not reported to the nurse. She said residents could elope or get injured. Interview with LVN C on 06/27/17 at 11:43 AM revealed she was the nurse on Hall 200. She reported that she was taking care of residents who were elopement risks. She said that she had forgotten to reset the squealer alarm on Hall 200 exit door, after assisting a resident who was trying to exit that morning. She reported that the Hall 200 exit door did not have a wander guard locking system. She reported that the squealer alarm on Hall 200 should have been set to the On position, so that alarm sound could alert the staff members when a resident tried to exit. She reported that she was not aware the exit door squealer alarm had been turned OFF. LVN C reported that the action put residents at risk of eloping or injury. Interview with Director of Operations on 06/27/17 at 11:16 AM revealed the staff members with squealer alarm keys were to make sure the squealer alarms were reset to ON position He reported facility staff members were in-serviced on resident's elopement prevention. He reported the action could put the residents at risk of elopement or injury. He said the squealer alarm triggered when a resident tried to exit, and the staff members with the keys were responsible to reset it. Interview with the DON on 06/27/17 at 12:00 PM revealed during the elopement investigation that the push bar alarm sound on Hall 200 exit door was very low. They also found out the squealer alarm was left at an OFF position after assisting the resident back to the facility. She stated Resident #1 was out of the facility for about 30 minutes and was found by police and returned to facility. She said a full head-to-toe assessment was performed when he returned to the facility and he was found to have a skin tear to right elbow and right knee. Treatment was initiated. She reported that the resident was put on 1:1 observation. In-service was initiated on elopement prevention. She reported that the resident was later sent to the hospital for a full evaluation. The DON reported that the exit door squealer alarm must always be turned on to alert staff members when residents try to exit. She reported that LVN A forgot to set the squealer alarm on 06/27/17 at around 9:00 AM. She reported that the nurse had silenced it after a resident tried to exit and the action had put residents at risk of eloping or injury. She reported that staff members had been in-serviced on elopement prevention. She said, I don't understand why she should do that (turned the alarm off). Record review of the facility Policy and Procedure on Elopement provided by the DON and dated October 2007 read in part, Reset the door alarm after it is determined by visual check that no residents has exited the facility inappropriately, or is returned to the facility. An Immediate Jeopardy was identified on 07/11/17 at 10:00 AM. The Director of Operations and interim DON were notified, and a Plan of Removal was requested at that time. The Plan of Removal reflected: A. All doors and alarms were checked by the Director of Operations. All doors were found to be locked and alarms were appropriately engaged. The medical Director was notified and participated in the Plan of Removal. B. Elopement/Wander evaluations were completed on residents Interim DON. C. Actions taken to prevent re-occurrence were: Additional education was provided to staff, elopement process and evaluation, Wander guard process, responding to door alarms and use of alarm keys. The education was incorporated into facility orientation and annual competency review. Door alarms to be checked on every shift and documented on a log. D. Monitoring to ensure ongoing compliance: Alarm system logs. The Director of Operations to be responsible for all areas related to alarm system and function. Interim DON to be responsible for all aspects related to in servicing and resident care practice. On 07/11/17 at 9:15 AM, a list was provided by the DON reflecting all staff had been in-serviced on what to look for on squealer alarms. Return demonstration post-tests were also provided. She stated all staff would be in-serviced prior to being allowed to return to work. Review of In-service records submitted by the ADON on 07/11/17 revealed staff members in nursing, dietary, housekeeping and other managers were in serviced on elopement prevention, reporting and documentation. Interview with the ADON on 07/11/17 at 9:30 AM revealed he supervised staff by return demonstration and randomly questioning to validate understanding. He stated he did not believe there was a system in place to check the doors squealer alarms for functionality prior to the incident. The ADON reported that all staff members were in serviced on elopement process and evaluation. He reported that all staff was to check on the position of the squealer alarms at all time Interview with Staff members on 07/11/17 during the IJ at between 10:00 AM and 3:00 PM revealed Staff was asked to explain how the doors of the facility were checked, how often they were checked, where the documentation was maintained, and what they were to do if any of the items were not functioning and who to report. The following employees interviewed were able to correctly answer questions. The employees were as follows: - Day Shift (6:00 AM to 6:00 PM): LVN C, , LVN D,LVN H and CNA B - Day/Evening Shift (8:30 AM to 5:30 PM): LVN E, LVN G, CNA I, Speech Therapist, PTA, SW, and ADON - Night Shift (10:00 PM to 6:00 AM): LVN A, CNA F Observation on 7/12/17 at 10: AM on all the exit doors revealed the squealer alarms were functional and operating as required. While the IJ was removed on 07/12/17, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm and at a scope of pattern because the facility was continuing to in-service staff and monitor the effectiveness of the Plan of Removal. Facility resident's elopement list signed and dated 06/27/17 provided by the DON identified 7 of 66 residents who were elopement risk in the facility.

Based on observation, interview, and record review, the facility failed to be administered in a manner to enable it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being for 17 (Residents #1 - #17) of 18 residents reviewed for infection control. The Operational Manager and the DON failed to implement the facility's Infection Control Policy to prevent the spread of infections. Resident #1 was diagnosed with [REDACTED]. Within 24 hours, Residents #4 and #3 tested positive for Influenza, and Resident #4 was hospitalized . On [DATE], Residents #6, #5, and #2 tested positive for Influenza. From [DATE] through [DATE], the following residents tested positive for Influenza: Residents #8, #9, #11, #7, #12 (was hospitalized ), #10, #14, #15, #16, #17 and #13. On [DATE], an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy," and a scope of "pattern" as the facility was continuing to monitor the implementation of their plan of removal. This failure placed the other 56 residents at risk of developing influenza with the potential for complications, hospitalization and death. Findings included: 1. Resident #1's face sheet, dated [DATE], reflected the resident admitted to the facility on [DATE] at the age of 87. Resident #1's [DATE] physician's orders [REDACTED]. A Physician's progress note, dated [DATE], reflected Resident #1 "was not doing well," and added that the resident had increased shortness of breath, wheezing , fever, chills, and lethargy. A laboratory report, dated [DATE], revealed Resident #1 was positive for influenza. A nursing progress note, dated [DATE] at 9:10 AM, revealed Resident #1's family member requested Resident #1 be sent to the hospital. Resident #1's hospital discharge summary, dated [DATE], reflected her principal [DIAGNOSES REDACTED]. She expired on [DATE] (8 days after admission). 2. Resident #4's Admission Record, dated [DATE], reflected the resident admitted to the facility on [DATE] and his current age was 56. Resident #4's Nurse's Note, dated [DATE], reflected he was sent to a local hospital that same date. Resident #4's hospital laboratory test, dated [DATE], reflected he tested positive for influenza. 3. Review of a facility computer-generated spreadsheet, undated and not titled, revealed Resident #6 tested positive for influenza on [DATE]. 4. Resident #3's Admission Record, dated [DATE], reflected the resident was a [AGE] year-old female admitted to the facility [DATE] with [DIAGNOSES REDACTED]. The facility computer-generated spreadsheet, undated and not titled, revealed Resident #3 had a rapid flu test on [DATE] and was positive for influenza. Resident #3's Nurse's Note, dated [DATE], reflected a fever of 103.1 degrees F. The CDC's online Interim Guidance for Influenza Outbreak Management in Long-Term Care Facilities, last updated [DATE], available at <http://www.cdc.gov/flu>, reflected fever was a symptom of influenza. Resident #3's lab report, dated [DATE], reflected she was positive for the influenza. 5. Resident #2's Admission Record, dated [DATE], reflected, the resident was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's lab report, dated [DATE], reflected she was positive for influenza. 6. Resident #5's Admission Record, dated [DATE], reflected the resident was an [AGE] year-old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #5's lab report, dated [DATE], reflected she was positive for influenza. The nurses' notes, dated [DATE] at 10:25 a.m., reflected Resident #55 had a temperature of 102.1 degree F, O2 SATS (oxygen saturation level) of 88 percent on room air, an unproductive cough and crackling sounds in her both lungs. They imitated oxygen via a nasal cannula at 2 liters per minute and her oxygen level went up to 95 percent. 7. Resident #8's Admission Record, dated [DATE], reflected the resident was an [AGE] year-old male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #8's lab report, dated [DATE], reflected he tested positive for influenza. 8. Resident #9's Admission Record, dated [DATE], reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9's lab report, dated [DATE], reflected she tested positive for influenza. 9. Resident #11's Admission Record, dated [DATE], reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #11's lab report, dated [DATE], reflected she tested positive for influenza. 10. Resident #7's Admission Record, dated [DATE], reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #7's lab report, dated [DATE], reflected she tested positive for influenza. 11. Review of a facility computer-generated spreadsheet, undated and not titled, revealed Resident #12 tested positive for influenza on [DATE] and was hospitalized . 12. During an interview with the Operations Manager (OM) and DON on [DATE] at 11:00 AM, the OM said he was "sitting in" for the Administrator while he was out-of-town. The DON said the facility notified the local health department ([DATE]) that Residents #1, #4, #5 and #12 tested positive for the flu. The DON stated they were informed by the local health department that the number of residents affected was consistent with an outbreak. The DON stated the local health department informed the facility to follow the CDC guidelines which included [MEDICATION NAME] (the administration of a medication for the purpose of preventing disease) treatment of [REDACTED]. The OM acknowledged they were informed by local health department to follow the CDC guidelines including providing [MEDICATION NAME] treatment for [REDACTED]." 13. During an interview with two physicians with the Texas Department of Health on [DATE] at 11 AM, MD F and MD G both said that upon learning of the initial flu illness at the facility on [DATE], they informed OM that all residents and staff would need [MEDICATION NAME] treatment. 14. Resident #10's undated Admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #10's lab report, dated [DATE], reflected she tested positive for influenza. 15. Resident #14's lab report, dated [DATE], reflected the resident was a [AGE] year-old male who tested positive for influenza. 16. Review of a facility computer-generated spreadsheet, undated and not titled, revealed on [DATE], Residents #15, #16 and #17 tested positive for influenza and on [DATE], Resident #13 tested positive for influenza. 17. During an interview on [DATE] at 11:00 AM, the DON provided no explanation as to why the facility had not implemented their policy for infection control prevention and the CDC guidelines for providing [MEDICATION NAME] treatment. The DON said she had in-serviced all staff regarding influenza. The in-service sign-in sheet titled "Flu", dated [DATE], only included the signatures of 10 employees as having participated in the training. 18. An interview with RNC D on [DATE] at 10:00 AM revealed she became aware on [DATE] that the facility did not administer the [MEDICATION NAME] treatment. 19. Review of the facility's Infection Control Policy/Procedure, revised ,[DATE], reflected the following: -- Section I: Goals - A. . . . to decrease the risk of infection to patients . . . -- Section II: Infection Control Program - It noted the infection control program was comprehensive in that it addressed detection, prevention and control of infections among patients and personnel. It noted the major activities of the program were . . . B. Implementation of Control Measures - Prevention of spread of infections is accomplished by use of Universal Precautions and other barriers, appropriate treatment and follow-up. -- Section III. Division of Responsibilities for Infection Control Activities. It noted the Director of Nursing (DON), or designee was ultimately responsible for the infection control program. 20. The CDC's online Interim Guidance for Influenza Outbreak Management in Long-Term Care Facilities, last updated [DATE], available at <http://www.cdc.gov/flu>, reflected the following: -- Long-term care facilities may be defined as institutions such as nursing homes and skilled nursing facilities. -- Residents of a long-term care facilities can experience severe and fatal illness during influenza outbreaks. -- When at least two patients are ill within 72 hours of each other and at least one resident has laboratory-confirmed influenza, the facility should promptly initiate [MEDICAL CONDITION] to all non-ill residents, regardless of whether they received influenza vaccination during the previous fall. -- CDC recommends [MEDICAL CONDITION] for a minimum of two weeks and continuing for at least seven days after the last known case was identified. 21. On [DATE] at 2:00 PM, the Operations Manager and DON were notified an Immediate Jeopardy (IJ) was identified. 22. On [DATE], at 10:30 AM, the Operations Manager, Administrator, DON, and the RN Clinician, were notified the facility's Plan of Removal (PoR) was accepted. 23. The PoR reflected the facility had created a spreadsheet template that will be used to capture all the above requested information and will be emailed daily to the local health department. The PoR reflected the immediate action taken included the following: -- All residents were provided prescription [MEDICATION NAME] per Primary Care Physician or facility Medical Director. In addition, [MEDICATION NAME] has also been ordered and given to all facility employees. -- [DATE] - Notifications were posted warning ill visitors and all children not to enter because of flu in the facility. -- [DATE] - In-service given to staff on infection control (CDC recommendations for flu in long term care) -- [DATE] - All residents swabbed and started on [MEDICATION NAME] -- [MEDICATION NAME] dosage and duration would adhere to the recommended CDC guidelines and the local county health department which are the following: The POR reflected the following for residents positive or symptomatic for influenza: - 75mg of [MEDICATION NAME] twice daily for 14 days and continuing for at least 7 days after the last known case was identified. The PoR reflected that for residents negative for influenza and without symptoms of influenza, the resident would receive 75mg of [MEDICATION NAME] once daily for a minimum of 2 weeks and continuing for at least 7 days after the last known case was identified. The PoR reflected that as of [DATE] all new admissions stopped. The PoR reflected that on [DATE], the DON provided in-service to staff on infection control (CDC recommendations for flu in long term care). It noted the DON and RN I will follow up with conducting required in-services of all new hires, staff on leave, and staff on vacation, prior to them working their assigned shift. It noted the DON and RN I performed competencies of hand washing, linen removal from residents' rooms to laundry, Personal Protective Equipment (PPE). The PoR reflected that on [DATE], the Medical Director was notified of the IJ. The PoR reflected the Administrator was responsible for implementation of the above plan. The PoR also reflected the following systematic change to prevent recurrence: -- Four RNs conducted in-service training regarding Hand Hygiene with the following discussion points: proper use of regular or antimicrobial hand soap, pushing uniform sleeves above wrist, proper hand inspection for visible soiling, and proper hand washing duration for ,[DATE] seconds. -- The nurses also conducted in-service training regarding Caring for Patients Under Isolation Precautions with the following discussion points: appropriate use and disposal of Personal Protective Equipment (PPE), proper handling and transportation of soiled linens, and procedures for disinfecting re-usable equipment when removed from room. -- The nurses also conducted in-service training regarding Signs and Symptoms of the Flu with the following discussion points: how to recognized signs and symptoms of flu for both a resident and an employee; how to properly report signs and symptoms of the flu to the Director of Nursing; and staff notified of the CDC Guidelines for prevention of influenza and informed of the postings placed at all facility entry points. The PoR reflected that to evaluate staff competency, each staff member was given a return demonstration competency check-off after each in-service. The PoR reflected as part of flu education for staff, residents and family members, signs and pamphlets on Influenza Prevention have been distributed and posted at all facility entrances. The facility will use an Infection Control Preventionist (ICP), and the Director of Nursing, to continue daily active surveillance for respiratory illness among residents, health care personnel, and visitors to the facility. The PoR reflected the following for monitoring to ensure on-going compliance: (1) Clinical Resource (RNC D), will continue to maintain daily communication with the local health department on status of Influenza outbreak including new cases, resolution of active cases, and surveillance activities. Due to the size of the spreadsheet, the facility is unable to embed the content of the daily communication tool, which is being sent as a daily report via email to Epidemiologist (MD F), with the local health department. Please see the attachment titled, " Influenza List, " which will accompany this Plan or Removal email. (2) Facility will continue to prohibit employees and visitors with signs and symptoms of respiratory illness from direct contact with residents through ongoing surveillance activities. (3) Clinical Resource (RNC D) will provide summary of outbreak and activities to QA and A committee for review and recommendations. The PoR concluded noting that residents with positive symptoms for influenza would be placed on droplet precaution isolation with notification of Medical Director and the residents would continue to follow Medical Director orders. 24. To verify the facility implemented their Plan of Removal the following was conducted: On [DATE], review of the list of the physician's orders [REDACTED]. Interviews conducted on [DATE] and [DATE] with: LVN L, LVN M, LVN N, LVN P, CNA O, CNA and CNA K revealed they received the flu, handwashing and infection control in-services and were able to accurately verbalize understanding of above in-services. 25. On [DATE] at 2:15 PM the Operations Manager, RN Clinician, and Administrator, were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern," as the facility was continuing to monitor the implementation of their plan of removal. 26. The facility's Census, dated [DATE], reflected a census of 73 residents.

Based on interview, and record review, the facility failed to maintain an Infection Control Program designed to provide a safe environment and to help prevent the development and transmission of disease and infection for 17 (Residents #1 - #17) of 18 residents reviewed for infection control. The facility failed to promptly initiate antiviral [MEDICATION NAME] (use of [MEDICATION NAME]) for all non-ill residents to control an influenza outbreak. Resident #1 was diagnosed with [REDACTED]. Within 24 hours, Residents #4 and #3 tested positive for Influenza, and Resident #4 was hospitalized . On [DATE], Residents #6, #5, and #2 tested positive for Influenza. From [DATE] through [DATE], the following residents tested positive for Influenza: Residents #8, #9, #11, #7, #12 (was hospitalized ), #10, #14, #15, #16, #17 and #13. On [DATE], an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy," and a scope of "pattern" as the facility was continuing to monitor the implementation of their plan of removal. This failure placed the other 56 residents at risk of developing influenza with the potential for complications, hospitalization and death. Findings included: 1. Resident #1's face sheet, dated [DATE], reflected the resident admitted to the facility on [DATE] at the age of 87. Resident #1's [DATE] physician's orders [REDACTED]. A Physician's progress note, dated [DATE], reflected Resident #1 "was not doing well," and added that the resident had increased shortness of breath, wheezing , fever, chills, and lethargy. A laboratory report, dated [DATE], revealed Resident #1 was positive for influenza. A nursing progress note, dated [DATE] at 9:10 AM, revealed Resident #1's family member requested Resident #1 be sent to the hospital. Resident #1's hospital discharge summary, dated [DATE], reflected her principal [DIAGNOSES REDACTED]. She expired on [DATE] (8 days after admission). 2. Resident #4's Admission Record, dated [DATE], reflected the resident admitted to the facility on [DATE] and his current age was 56. Resident #4's Nurse's Note, dated [DATE], reflected he was sent to a local hospital that same date. Resident #4's hospital laboratory test, dated [DATE], reflected he tested positive for influenza. 3. Review of a facility computer-generated spreadsheet, undated and not titled, revealed Resident #6 tested positive for influenza on [DATE]. 4. Resident #3's Admission Record, dated [DATE], reflected the resident was a [AGE] year-old female admitted to the facility [DATE] with [DIAGNOSES REDACTED]. The facility computer-generated spreadsheet, undated and not titled, revealed Resident #3 had a rapid flu test on [DATE] and was positive for influenza. Resident #3's Nurse's Note, dated [DATE], reflected a fever of 103.1 degrees F. The CDC's online Interim Guidance for Influenza Outbreak Management in Long-Term Care Facilities, last updated [DATE], available at <http://www.cdc.gov/flu>, reflected fever was a symptom of influenza. Resident #3's lab report, dated [DATE], reflected she was positive for the influenza. 5. Resident #2's Admission Record, dated [DATE], reflected, the resident was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's lab report, dated [DATE], reflected she was positive for influenza. 6. Resident #5's Admission Record, dated [DATE], reflected the resident was an [AGE] year-old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #5's lab report, dated [DATE], reflected she was positive for influenza. The nurses' notes, dated [DATE] at 10:25 a.m., reflected Resident #55 had a temperature of 102.1 degree F, O2 SATS (oxygen saturation level) of 88 percent on room air, an unproductive cough and crackling sounds in her both lungs. They imitated oxygen via a nasal cannula at 2 liters per minute and her oxygen level went up to 95 percent. 7. Resident #8's Admission Record, dated [DATE], reflected the resident was an [AGE] year-old male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #8's lab report, dated [DATE], reflected he tested positive for influenza. 8. Resident #9's Admission Record, dated [DATE], reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9's lab report, dated [DATE], reflected she tested positive for influenza. 9. Resident #11's Admission Record, dated [DATE], reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #11's lab report, dated [DATE], reflected she tested positive for influenza. 10. Resident #7's Admission Record, dated [DATE], reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #7's lab report, dated [DATE], reflected she tested positive for influenza. 11. Review of a facility computer-generated spreadsheet, undated and not titled, revealed Resident #12 tested positive for influenza on [DATE] and was hospitalized . 12. During an interview with the Operations Manager (OM) and DON on [DATE] at 11:00 AM, the OM said he was "sitting in" for the Administrator while he was out-of-town. The DON said the facility notified the local health department ([DATE]) that Residents #1, #4, #5 and #12 tested positive for the flu. The DON stated they were informed by the local health department that the number of residents affected was consistent with an outbreak. The DON stated the local health department informed the facility to follow the CDC guidelines which included [MEDICATION NAME] (the administration of a medication for the purpose of preventing disease) treatment of [REDACTED]. The OM acknowledged they were informed by local health department to follow the CDC guidelines including providing [MEDICATION NAME] treatment for [REDACTED]." 13. During an interview with two physicians with the Texas Department of Health on [DATE] at 11 AM, MD F and MD G both said that upon learning of the initial flu illness at the facility on [DATE], they informed OM that all residents and staff would need [MEDICATION NAME] treatment. 14. Resident #10's undated Admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #10's lab report, dated [DATE], reflected she tested positive for influenza. 15. Resident #14's lab report, dated [DATE], reflected the resident was a [AGE] year-old male who tested positive for influenza. 16. Review of a facility computer-generated spreadsheet, undated and not titled, revealed on [DATE], Residents #15, #16 and #17 tested positive for influenza and on [DATE], Resident #13 tested positive for influenza. 17. During an interview on [DATE] at 11:00 AM, the DON provided no explanation as to why the facility had not implemented their policy for infection control prevention and the CDC guidelines for providing [MEDICATION NAME] treatment. The DON said she had in-serviced all staff regarding influenza. The in-service sign-in sheet titled "Flu", dated [DATE], only included the signatures of 10 employees as having participated in the training. 18. An interview with RNC D on [DATE] at 10:00 AM revealed she became aware on [DATE] that the facility did not administer the [MEDICATION NAME] treatment. 19. Review of the facility's Infection Control Policy/Procedure, revised ,[DATE], reflected the following: -- Section I: Goals - A. . . . to decrease the risk of infection to patients . . . -- Section II: Infection Control Program - It noted the infection control program was comprehensive in that it addressed detection, prevention and control of infections among patients and personnel. It noted the major activities of the program were . . . B. Implementation of Control Measures - Prevention of spread of infections is accomplished by use of Universal Precautions and other barriers, appropriate treatment and follow-up. -- Section III. Division of Responsibilities for Infection Control Activities. It noted the Director of Nursing (DON), or designee was ultimately responsible for the infection control program. 20. The CDC's online Interim Guidance for Influenza Outbreak Management in Long-Term Care Facilities, last updated [DATE], available at <http://www.cdc.gov/flu>, reflected the following: -- Long-term care facilities may be defined as institutions such as nursing homes and skilled nursing facilities. -- Residents of a long-term care facilities can experience severe and fatal illness during influenza outbreaks. -- When at least two patients are ill within 72 hours of each other and at least one resident has laboratory-confirmed influenza, the facility should promptly initiate antiviral [MEDICATION NAME] to all non-ill residents, regardless of whether they received influenza vaccination during the previous fall. -- CDC recommends antiviral [MEDICATION NAME] for a minimum of two weeks and continuing for at least seven days after the last known case was identified. 21. On [DATE] at 2:00 PM, the Operations Manager and DON were notified an Immediate Jeopardy (IJ) was identified. 22. On [DATE], at 10:30 AM, the Operations Manager, Administrator, DON, and the RN Clinician, were notified the facility's Plan of Removal (PoR) was accepted. 23. The PoR reflected the facility had created a spreadsheet template that will be used to capture all the above requested information and will be emailed daily to the local health department. The PoR reflected the immediate action taken included the following: -- All residents were provided prescription [MEDICATION NAME] per Primary Care Physician or facility Medical Director. In addition, [MEDICATION NAME] has also been ordered and given to all facility employees. -- [DATE] - Notifications were posted warning ill visitors and all children not to enter because of flu in the facility. -- [DATE] - In-service given to staff on infection control (CDC recommendations for flu in long term care) -- [DATE] - All residents swabbed and started on [MEDICATION NAME] -- [MEDICATION NAME] dosage and duration would adhere to the recommended CDC guidelines and the local county health department which are the following: The POR reflected the following for residents positive or symptomatic for influenza: - 75mg of [MEDICATION NAME] twice daily for 14 days and continuing for at least 7 days after the last known case was identified. The PoR reflected that for residents negative for influenza and without symptoms of influenza, the resident would receive 75mg of [MEDICATION NAME] once daily for a minimum of 2 weeks and continuing for at least 7 days after the last known case was identified. The PoR reflected that as of [DATE] all new admissions stopped. The PoR reflected that on [DATE], the DON provided in-service to staff on infection control (CDC recommendations for flu in long term care). It noted the DON and RN I will follow up with conducting required in-services of all new hires, staff on leave, and staff on vacation, prior to them working their assigned shift. It noted the DON and RN I performed competencies of hand washing, linen removal from residents' rooms to laundry, Personal Protective Equipment (PPE). The PoR reflected that on [DATE], the Medical Director was notified of the IJ. The PoR reflected the Administrator was responsible for implementation of the above plan. The PoR also reflected the following systematic change to prevent recurrence: -- Four RNs conducted in-service training regarding Hand Hygiene with the following discussion points: proper use of regular or antimicrobial hand soap, pushing uniform sleeves above wrist, proper hand inspection for visible soiling, and proper hand washing duration for ,[DATE] seconds. -- The nurses also conducted in-service training regarding Caring for Patients Under Isolation Precautions with the following discussion points: appropriate use and disposal of Personal Protective Equipment (PPE), proper handling and transportation of soiled linens, and procedures for disinfecting re-usable equipment when removed from room. -- The nurses also conducted in-service training regarding Signs and Symptoms of the Flu with the following discussion points: how to recognized signs and symptoms of flu for both a resident and an employee; how to properly report signs and symptoms of the flu to the Director of Nursing; and staff notified of the CDC Guidelines for prevention of influenza and informed of the postings placed at all facility entry points. The PoR reflected that to evaluate staff competency, each staff member was given a return demonstration competency check-off after each in-service. The PoR reflected as part of flu education for staff, residents and family members, signs and pamphlets on Influenza Prevention have been distributed and posted at all facility entrances. The facility will use an Infection Control Preventionist (ICP), and the Director of Nursing, to continue daily active surveillance for respiratory illness among residents, health care personnel, and visitors to the facility. The PoR reflected the following for monitoring to ensure on-going compliance: (1) Clinical Resource (RNC D), will continue to maintain daily communication with the local health department on status of Influenza outbreak including new cases, resolution of active cases, and surveillance activities. Due to the size of the spreadsheet, the facility is unable to embed the content of the daily communication tool, which is being sent as a daily report via email to Epidemiologist (MD F), with the local health department. Please see the attachment titled, " Influenza List, " which will accompany this Plan or Removal email. (2) Facility will continue to prohibit employees and visitors with signs and symptoms of respiratory illness from direct contact with residents through ongoing surveillance activities. (3) Clinical Resource (RNC D) will provide summary of outbreak and activities to QA and A committee for review and recommendations. The PoR concluded noting that residents with positive symptoms for influenza would be placed on droplet precaution isolation with notification of Medical Director and the residents would continue to follow Medical Director orders. 24. To verify the facility implemented their Plan of Removal the following was conducted: On [DATE], review of the list of the physician's orders [REDACTED]. Review of the list of physicians orders verified 61 residents received 75 mg of [MEDICATION NAME] every day for seven days. Interviews conducted on [DATE] and [DATE] with: LVN L, LVN M, LVN N, LVN P, CNA O, CNA and CNA K revealed they received the flu, handwashing and infection control in-services and were able to accurately verbalize understanding of above in-services. 25. On [DATE] at 2:15 PM the Operations Manager, RN Clinician, and Administrator, were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern," as the facility was continuing to monitor the implementation of their plan of removal. 26. The facility's Census, dated [DATE], reflected a census of 73 residents.

Based on observation, interview and record review, it was determined the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for two (Residents #1 and #3) of four residents reviewed for quality of care. 1) On 02/22/13 Resident #1 complained of a "pop" and subsequent pain during an attempted transfer with OT from the bed to the scooter. The resident required an increase of PRN pain medication from 02/22/13 to 02/28/13. Nursing assessments were not completed when the resident experienced pain to an area not previously identified. The NP and pain management physician first learned of the "pop" and the resident's complaints of pain to her hip during their routinely scheduled visits on 02/27/13. X-rays were ordered on [DATE] and the results on 02/28/13 indicated a Fractured Right Femur. These failures resulted in the resident's decreased participation in OT, delay in treatment and the prolonging of the resident's pain, which resulted in a very poor quality of life for the resident. These failures could affect the facility's nine residents receiving OT who resided on Hall 400, and placed them at risk for inadequate assessments, ineffective pain management, hopelessness and fear, having a negative impact on their health and well-being. 2) Staff failed to monitor Resident #3 for safety, when she verbalized threats of suicide from 02/04/13 until her discharge to the hospital on [DATE]. The staff also failed to notify Resident #3's physician and her Clinical Psychologist of suicide threats. These failures resulted in an attempt to send Resident #3 to a geriatric psychiatric hospital, but the resident was diverted to an acute care hospital, while in route due to chest pain. 3) Staff failed to obtain a Psychiatric Consult for Resident #1, which was ordered by the discharging physician. Staff also failed to assess the resident for the need of sitter services which were also recommended by the discharging physician. These failures could affect Resident #1 and the other 75 residents, by placing them at risk for suicide attempts, exacerbation of psychological symptoms, and decreased quality of life. Findings included: 1) Resident #1, an [AGE] year-old female, was admitted to the facility on [DATE], per the Admission Record Resident Information document dated 02/08/13. Resident #1's Resident-Data Collection form dated 01/23/13 reflected she had severe pain to her legs daily, but not constantly. The pain was described as aching. Resident #1 was assessed as having [MEDICAL CONDITION] to her feet and legs. The Resident-Data Collection form also reflected the resident was non-weight bearing and required the assistance of two persons for transfers. Resident #1 was described as alert, cooperative, oriented and comprehension was quick. Resident #1's MDS assessment dated [DATE] reflected she was admitted from a hospital, her hearing was adequate, her ability to make ideas and wants understood by others was intact, she had clear comprehension of others, her short and long-term memory were impaired, and she was moderately impaired with cognitive skills for daily decision-making. The MDS assessment also reflected she required extensive assistance of one person for bed mobility; transfers between surfaces including to or from the bed, chair, wheelchair and standing position occurred only once or twice and the assistance of two persons was required; ambulation did not occur; required extensive assistance of one person for dressing and personal hygiene and the extensive assistance of two persons for toileting; required limited assistance of one person with eating; and was dependent one person for bathing. The MDS assessment further reflected Resident #1 was not steady and required staff support for stabilization to complete a surface to surface transfer; moving from a seated to standing position, walking, turning around and moving on and off the toilet were activities, which did not occur; used a wheelchair for mobility; was incontinent of bowel and had a indwelling catheter; and [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed Resident #1 reported the presence of pain almost constantly and on a scale of one to ten (with ten being the worst), the resident indicated her pain was an eight. Review of the Initial History and Physical, dated 01/30/13 and completed by the pain management physician revealed Resident #1's chief complaints included Acute [MEDICAL CONDITIONS] and Bilateral [MEDICAL CONDITION] of the Lower Extremities. The assessment reflected the resident was admitted to the facility to receive rehabilitation following a [DIAGNOSES REDACTED]. The Initial History and Physical reflected, "lower leg & foot pain severe.." Resident #1 reported sharp pain down from knees. The resident reported her pain was three on a scale from one to ten with pain medication and without pain medication it was eight out of ten. Review of the Active/Discontinued/Completed physician's orders [REDACTED]. Review of the Pain Management Flow Sheets dated 01/24/13 through 02/28/13 and the narcotic control records for 02/20/13 through 02/28/13 revealed the following: From 01/24/13 through 02/21/13 Resident #1 received multiple doses of [MEDICATION NAME] 50 mg and eight doses of [MEDICATION NAME] 10/325 mg and from 02/22/13 to 02/28/13 Resident #1 received six doses of [MEDICATION NAME] 50 mg and 23 doses of [MEDICATION NAME] 10/325 mg. Resident #3's Comprehensive Plan of Care, dated 02/04/13, reflected the resident complained of increased joint pain/discomfort and was at risk for injury from decrease in ADLs and the goal was the resident would maintain current ADLs and pain/discomfort would be relieved with in one hour after intervention over next 90 days. The approaches included monitoring for signs/symptoms of increased pain/discomfort, assessing resident for possible causes, giving medications/treatments, physical and relaxation modalities, assessing relief, providing pressure relieving and positioning devices as needed; assisting with ADLs and comfort measures as needed; allowing resident to verbalize feelings of pain and discomfort; encouraging socialization and activity attendance as tolerated; monitoring for constipating effects of pain medication; encouraging increase fluid intake within dietary limits; therapy referral as needed; and assessing and documenting pain. Interview on 03/11/13 at 9:00 AM with the Director of Rehabilitation revealed newly admitted residents were routinely evaluated for PT, OT and ST in accordance with physician's orders [REDACTED]. During the interview, the Director of Rehabilitation provided a list of all residents who received PT, OT and ST from 02/01/13 to 03/11/13. The computer-generated list reflected the names of the residents, their admitted s, the start of service dates and the end of service dates for PT, OT and ST services. The list reflected Resident #1 received PT from 01/24/13 to 02/04/13 and OT from 01/24/13 to 02/28/13. Interview on 03/11/13 at 12:00 PM with OT A revealed Resident #1 received OT for strengthening and mobility so she could achieve her prior level of functioning which included being able to transfer herself into her electric scooter. OT A stated Resident #1's primary goal was to return to her home in the community where she lived with her spouse. OT A revealed the resident was weak and her activity tolerance was low. She stated a mechanical sling-type lift was used to transfer Resident #1 from the bed to the scooter in order to increase the resident's tolerance for sitting before attempting transfer training. OT A revealed the mechanical sling-type lift was determined to be the safest mode of transferring the resident. OT A stated on 02/05/13, during a care plan meeting Resident #1's family member expressed concerns about using the mechanical lift for transfers. OT A also stated she informed the family member that Resident #1 required maximum assistance for bed mobility and repositioning. OT A revealed Resident #1 was not yet safe to sit on the edge of the bed. OT A revealed on 02/21/13 Resident #1 demonstrated an improvement with trunk control, pulling herself up in bed, turning from side to side in bed and she was able to scoot to the edge of the bed. OT A stated on 02/22/13 an attempt was made to transfer Resident #1 from the bed to the electric scooter without using the mechanical lift. Resident #1 reached for the arm of the scooter and yelled out in pain stating, "Oh. I felt it pop. What have I done?" OT A revealed she went to get LVN B when Resident #1 pointed to her groin area and complained of pain. OT A stated LVN B examined the resident and administered two pain pills. Interview on 03/11/13 at 2:25 PM with LVN B revealed on 02/22/13 she was summoned to Resident #1's room by OT A. LVN B stated OT A told her Resident #1 heard a pop and her right groin area was hurting. LVN B stated she removed the resident's adult brief and examined the resident. She stated there was no discoloration, swelling or bruising and she thought it was a muscle spasm. LVN B revealed she did not believe the resident could have fractured anything or that the resident may need to have an x-ray because Resident #1 had not fallen, been dropped or been lifted. LVN B stated she did not notify the physician or initiate an incident report. Resident #1's OT daily treatment notes, dated 02/22/13 and electronically signed by OT A, reflected, "Narrative Comments: While pt (patient) was sitting on side of bed, pt reached for wc arm, feet were not touching the floor, then yelled out in pain. Procedure to set up transfer from bed to wc was stopped. Pt assisted to lie back down on bed. Pt said she heard a pop, and said 'what have I done now, Oh dear.' Once pt was secured in bed, therapist went to report to nurse. Nurse came and checked. Pt did not want to attempt getting into wc again this date. Therapist called daughter and reported event....Tx (Treatment) for transfers and sitting in wc discontinued." Resident #1's Nurse's Note, dated 02/22/13, authored by LVN B and timed at 11:30 AM reflected, "OT reported that resident c/o pain at rt (right) groin when OT approached her to get her up in w/c. [MEDICATION NAME] 10/325 mg 1 tab given for pain. @ (at) 1200 verbalized pain relief but resident refused to get up in w/c. Notified family." The facility's 24 Hour Report/Change of Condition Report dated 02/22/13 did not reflect the incident. The 24 Hour Report/Change of Condition Report dated 02/23/13 reflected PRN [MEDICATION NAME] was administered at 11:53 AM and at bedtime for complaints of hip pain. Telephone interview on 03/11/13 at 1:55 PM with OTA I revealed she provided OT to Resident #1 two or three times after 02/22/13. OTA I stated Resident #1 complained of pain to her right hip upon movement and of pain to her lower legs prior to 02/22/13, but after 02/22/13 the resident began complaining of pain to her lower back and hip. Resident #1's Nurse's Notes, dated 02/24/13, authored by LVN C and timed 11:11 AM, reflected she was alert and oriented times three and complained of pain to her right hip. The Note reflected LVN C administered [MEDICATION NAME] at 9:20 AM and at 11:00 AM the resident reported the pain was a three on a scale of one to ten. The facility's 24 Hour Report/Change of Condition Report dated 02/24/13 reflected PRN [MEDICATION NAME] was administered at 9:20 AM, 1:20 PM and 5:00 PM and [MEDICATION NAME] was administered at 2:00 AM and Tylenol was administered at 5:00 AM. The facility's 24 Hour Report/Change of Condition Report dated 02/25/13 reflected [MEDICATION NAME] was administered at bedtime and [MEDICATION NAME] was administered at 4:00 AM for complaints of pain around the hip/waist area. Resident #1's Nurse's Note, dated 02/26/13, authored by RN F and timed 12:24 AM reflected she complained of hip pain and [MEDICATION NAME] was administered at 7:45 PM and [MEDICATION NAME] was administered at 12:00 AM. The Note also reflected, "Will cont to assess and monitor for effectiveness." Resident #1's OT Daily Treatment Note, dated 02/26/13 and electronically signed by OTA I, reflected, "Pt in bed with c/o R (right) hhip (sic) pain and subjective report that x-ray pending. Therapy provided in bed pending results. Therapeutic Activities: balloon volleyball to increase dynamic balance during sitting in bed, incorporating use of B (Both) arms and crossing midline w/subjective report of hip pain. Activity stopped and moved to static sitting activity to help prevent R hip pain." Interview on 03/12/13 at 10:05 AM with OTA I revealed she provided OT to Resident #1 on 02/26/13, 02/27/13 and 02/28/13. She stated OTA J worked with the resident on 02/25/13. OTA I revealed on 02/26/13 the primary focus of OT was to work on getting Resident #1 out of bed and into the chair. During one of the OT sessions with Resident #1, the resident told OTA I she could not get out bed and stated she was waiting on the results of an x-ray. OTA I stated on 02/26/13 the resident complained of lower back and right hip pain. She revealed Resident #1 told her she heard a popping sound during an attempted transfer. OTA I stated she first heard about the popping noise from the resident. OTA I revealed she did not know what the popping noise was about and the resident was complaining of pain during their OT sessions, so OTA I began focusing on the resident's upper body so as not to compromise her hip. Interview on 03/12/13 at 10:25 AM with OTA J revealed she provided OT to Resident #1 on 02/25/13. OTA J stated on 02/25/13 OT A instructed her (OTA J) to be careful with the resident during treatment because on 02/22/13 during an attempted transfer Resident #1's hip popped. OTA J stated she decided not to get Resident #1 out of bed on 02/25/13 and instead focused on fine motor skills. OTA J stated when she asked Resident #1 how she was feeling the resident told her that her hip was hurting. Interview on 03/12/13 at 10:20 AM OT A revealed Resident #1 transferred from the bed to the scooter a total of three times for the OT certification period of 01/24/13 to 02/28/13. On 02/06/13 Resident #1 sat in her scooter for one hour. On 02/20/13 and 02/21/13 Resident #1 sat in her scooter for two hours each day. OT A revealed after the attempted transfer on 02/22/13, Resident #1 did not sit in her scooter. Interview on 03/12/13 at 11:00 AM with the DON revealed she first learned of the popping noise during the attempted transfer on 02/22/13 of Resident #1 on 02/28/13 at approximately 4:00 PM from OT A. The DON stated at that time she interviewed LVN B, who denied being told by OT A and Resident #1 there had been a popping noise during an attempted transfer on 02/22/13. The DON revealed NP H made visits to the facility a minimum of one time weekly. She stated the pain management physician made visits to the facility on ce a week to evaluate residents, including all residents receiving PT and OT therapy, residents who were not achieving therapy goals due to pain and residents who were being administered pain medication more frequently. The DON stated NP H and the pain management physician were at the facility on 02/27/13 for routine visits. She revealed Resident #1 described the "pop" to NP H on 02/27/13. The DON stated NP H ordered an x-ray for Resident #1's back on 02/27/13 due to the resident's complaints of pain and the increase in the amount of PRN pain medications being administered. The DON revealed when the pain management physician evaluated Resident #1, the resident complained to him about hip pain. The DON stated the pain management physician utilized Lidocain injections for pain management when indicated. She revealed as a standard of practice the pain management physician ordered x-rays prior to giving the injections to rule out other causes of the pain. The pain management physician ordered an x-ray on 02/27/13 of Resident #1's hip. The DON also revealed she expected the nurses to conduct a thorough assessment and notify the physician when there was an increase in the frequency of pain medication being administered. She stated when PRN pain medications were being used on a routine basis, the physician should be notified NP H's assessment of Resident #1 dated 02/27/13 reflected, "3 - 4 days ago while transfer from bed to w/c heard a 'pop' in (right) lower back. Since then been having severe LBP (lower back pain) can't sleep." Resident #1's Physician's Telephone Order, dated 02/27/13, reflected, "x-ray of Lumbar Spine." Resident #1' pain management physician's follow-up progress note, dated 02/27/13, reflected she reported complaints of right hip pain, and exams related to the complaint included, "...tenderness (right) GTB (Greater Trochanteric Bursitis)...." The plan for "Therapy" reflected, "Continue therapy." Resident #1's Physician's Telephone Order dated 02/27/13 reflected, "x-ray (right) hip R/O (Rule Out) dislocation or Fx" Resident #1's Nurse's Note, dated 02/27/13, authored by LVN E and timed at 7:24 PM reflected a new order was received to x-ray her right hip to rule out dislocation or fracture. The Note also reflected, "X-ray of lumbar spine, increase [MEDICATION NAME] 19 mg 1 PO QID X 1 wk then 10 mg PO TID, [MEDICATION NAME] 40 mg per 1cc vial, lidocain 1% for joint injection. All orders notified to family. X-ray scheduled. Medicine orders faxed to pharmacy." Resident #1's Radiology Report dated 02/28/13 reflected the results were "Suspected subcapital [MEDICAL CONDITION] femur." Resident #1's Nurse's Note, dated 02/28/13, authored by LVN C and timed at 4:05 PM, reflected she complained of pain in left hip area, the pain was a seven on a scale of one to ten, and [MEDICATION NAME] was administered. An interview with LVN C on 03/11/13 at 3:25 PM revealed Resident #1 complained of pain to her right hip on 02/28/13 and not her left hip. When asked why he documented the pain was to her left hip, he replied it was an error. When asked if he notified the physician about Resident #1's pain, LVN C responded the resident had not fallen, so he administered pain medication which was effective and did not contact the physician. Resident #1's OT Daily Treatment Note, dated 02/27/13 and electronically signed by OTA I, reflected treatment was provided at bed level due to continuing verbalizations made by the resident of pain, and the resident's right hip pain increased with movement in bed. A telephone interview on 03/12/13 at 11:35 AM with the Radiology Services Director revealed on 02/28/13 Resident #1 had x-rays for Lumbar Spine and Bilateral Hips taken at the facility prior to 10:15 AM. The Director stated the results of the x-rays were dictated at 11:36 AM, were transcribed at 11:57 AM, and LVN C was notified of the results via a telephone call by the x-ray provider at 12:38 PM. The Radiology Services Director further stated, "Anyone (facility staff) can look in computer system for results once dictated." Interview on 03/12/13 at 1:30 PM with the facility's only ADON revealed sometime after 5:00 PM on 02/28/13 she "just happened to see" the radiology report for Resident #1 at the Nurse's Station. The ADON stated LVN C was documenting on another resident and the radiology report was laying on the nurse's desk. The ADON revealed she asked LVN C what action had been taken regarding the results of the radiology report, and LVN C told her he left a message for the physician regarding the results of the x-ray and was awaiting a return call from the physician. Resident #1's Nurse's Notes, dated 02/28/13, authored by LVN C and timed at 4:27 PM, reflected the results of the x-rays were "..probable subcapital [MEDICAL CONDITION] femur with mild displacement...Dr called at 1520 (3:20 PM) message left waiting on response. Called Dr at 1635 (4:35 PM) office assistant asked if labs could be faxed. Results faxed...." Interview on 03/12/13 at 11:45 AM with LVN C revealed radiology reports were available on the computer. LVN C stated if the results were critical or reflected a fracture, the radiology provider called the facility and faxed the report. LVN C stated he received a call from the radiology provider regarding Resident #1's x-ray results, and he did not intend to wait so long to notify the physician of the x-ray results. Resident #1's Nurse's Notes, dated 02/28/13, authored by LVN C and timed 5:44 PM revealed orders were received from the resident's physician to send her to the emergency room for further evaluation. Resident #1's OT Discharge Summary electronically signed by OT A and dated 03/11/13 reflected, "Pt will transfer from bed to wc with Max A (Maximum Assist) without mechanical lift daily" was discontinued on 02/28/13. The documentation reflected, "Previous (02/23/13) Pt sat on side of bed and used mechanical lift to transfer from bed to wc 2/6 days this reporting period. Discharge (02/28/13) Pt did not sit on side of bed or transfer from bed to wc days this reporting period." The report further reflected Resident #1 did not transition due to pain and discomfort. Short term goal #5.0 reflected, "Pt will sit in wc for 2-3 hours daily. Baseline (02/14/13) Pt would sit in wc for hours daily. Previous (02/23/13) Pt is not sitting in wc this past week due to discomfort. Discharge (02/28/13) Pt did not sit in wc this past week due to discomfort during transitions." Resident #1's OT Progress Note electronically signed by OT A and dated 03/08/13 reflected, "Pt incurred pain on 2-22-13 and did not attempt sitting on side of bed and refused mechanical lift transfer due to left hip discomfort." Interview on 03/12/13 at 1:05 PM with the DON revealed an incident report was completed for Resident #1. 2) Resident #3, a [AGE] year-old female, was initially admitted to the facility on [DATE] and was re-admitted on [DATE], per the Admission Record Resident Information document dated 12/24/12. Review of the quarterly MDS assessment dated [DATE] revealed the following: Resident #3 was most recently admitted to the facility on [DATE] from an acute hospitalization , as reflected in Section A Identification Information. Section B included assessments of Resident #3's hearing, speech and her ability to understand others and to make herself understood by others. It was reflected Resident #3 was not comatose and her hearing was adequate without difficulty in normal conversation and social interaction. Resident #3 usually understood others and she usually made herself understood by others. Section C - Cognitive Patterns reflected the Brief Interview for Mental Status was not conducted. Resident #3 was assessed as having both short and long-term memory deficits and was moderately impaired with cognitive skills for daily decision-making. Sections D and E - Resident #3's assessments for mood and behavioral symptoms reflected little interest or pleasure in doing things, feeling down, depressed or hopeless, feeling tired or having little energy, poor appetite or overeating and being short-tempered and easily annoyed. All of these symptoms occurred nearly everyday (12 to 14 days). Resident #3 experienced hallucinations and [MEDICAL CONDITION]. She was assessed as exhibiting verbal behavior symptoms directed toward others one to three days. Section G - Functional Status reflected Resident #3 received the extensive assistance of two persons for bed mobility and transfers between surfaces. Resident #3 required the limited assistance of one person with locomotion off the unit. She required extensive assistance of one person for dressing and eating and total dependence of one person for hygiene and toileting. It was reflected Resident #3 was assessed as being totally dependent on one person for bathing. A wheelchair was the mobility device identified in Section G, as normally used by Resident #3. Section I - Active [DIAGNOSES REDACTED]. All care plans located in the current clinical record were reviewed and revealed a computer-generated care plan dated 02/25/13 reflecting Resident #3 was cognitively impaired, was impaired with her ability to understand other and was impaired with daily decision-making. Care plans dated 02/25/13 included alteration in continence, risk for falls, nutrition, risks for the development pressure ulcers and [MEDICAL CONDITION] medications. Review of nursing progress notes dated 01/28/13 revealed Resident #3 was starting to "hear voices again." Nursing progress notes dated 01/29/13 reflected a care plan meeting was held on 01/29/13 and the resident was in attendance. The documentation reflected the resident continued to exhibit behavioral issues including yelling and anxiety. The nurse's notes reflected, "..staff try to redirect as able with psych services following." Social Services progress notes dated 02/04/13, authored by the Director of Social Services and timed 10:57 AM reflected, "Resident states very depressed, hearing voices to harm self. She states suicidal ideation, wants to overdose on pills. She states wants to cry all the time, is tearful at this time. She states is lonely...Resident called 911 last night, high anxiety, however was not taken to hospital...." The documentation reflected Resident #3 asked to be sent to a specific geriatric psychiatric facility and the Director of Social Services faxed the resident's records to the requested facility. Nursing progress notes dated 02/04/13, authored by LVN K and timed 12:19 PM reflected, "As resident was passing in WC she yelled help. I asked her what she needed and if everything was fine. She said she was hearing voices and they were telling her to do it. When I asked her to clarify what she meant she said to take pills. I asked to take pills for what and she said to die. I asked her if she had a plan to do that and she denied it. I asked her to promise me that she wouldn't act on her voices that she was hearing and she agreed. Spoke to SW (Director of Social Services) about episode. will cont to monitor." Review of the Psychological Solutions session note dated 02/05/13 revealed Resident #3 was alert and oriented to person, place and time. The word "Questionable" was hand-written in the space indicating if the resident was suicidal. The documentation reflected Resident #3's thought processes were illogical and she had poor judgment. The plan/recommendation section reflected, "Pt. awake, repeats she is hearing voices and seeing monsters. Pt. very much wants to go to inpatient (sign for treatment). States she is being told to hurt herself...." The documentation reflected the psychological services provider recommended to the Director of Social Services placement for psychological services and treatment. Social Services progress notes dated 02/05/13, authored by the Director of Social Services, timed 4:00 AM and identified as a late entry reflected Resident #3 was seen by psychological services "today." The documentation reflected the resident and psychological services agreed the resident required in-patient treatment. The Director of Social Services documented her contact with possible facility's in which to admit the resident. It was reflected, "Resident continues to be agitated, suicidal ideation, distressed, staff try to provide support. Nursing progress notes dated 02/05/13, authored by LVN K and timed 7:20 PM reflected, "Resident complained of not wanting to live throughout the day and complained of wanting to take pills to die, also to slit her wrists to die. SW notified and she is working on getting her into a psych facility. Resident not at danger to herself currently but being monitored closely..." Review of a Resident Transfer Form dated 02/05/13 revealed Resident #3 was transported by non-emergent transportation to a psychiatric facility. The reason for transfer reflected, "psych - suicidal." During the transport, Resident #3 complained of chest pain and was taken to a local hospital's emergency room for evaluation and treatment. Interview on 03/12/13 at 3:05 PM with the Director of Social Services revealed Resident #3 ambulated independently via the wheelchair. She stated the resident was being seen on a regular basis by psychological services. The Director of Social Services revealed she did not contact the resident's physician or the psychological services for Resident #3 following the residents verbalizations of suicide on 02/04/13. The Director of Social Services stated Resident #3 was seen by psychological services at the facility on 02/05/13 for a routine visit. She stated it was difficult to find in-patient care for the resident because she required so much physical assistance with ADLs. When asked how she monitored Resident #3 to ensure her safety while attempting to locate an in-patient facility, the Director of Social Services stated the resident was in her office frequently and she (Director of Social Services) and LVN K could see her in the hallway. She stated she was unaware if the resident had attempted suicide in the past. Interview on 03/13/13 at 12:15 PM with the Director of Social Services revealed she was unaware of the facility's policy for Suicidal Precautions. Interview on 03/12/13 at 3:30 PM with LVN K revealed she determined Resident #3 was not a threat to herself or anyone else and would not act on her threats to harm herself because she did not have a plan and she (Resident #3) promised LVN K she would not hurt herself. When asked how she was monitoring Resident #3, LVN K stated she could see the resident in the hallway and she asked the resident if she was okay. She stated she was unaware if the resident had attempted suicide in the past. When asked if the resident's physician was contacted on 02/04/13 regarding the suicidal verbalizations, LVN K stated she did not notify the physician, but did not document it. Interview on 03/13/13 at 11:05 AM with LVN K revealed she was unaware of the facility's policy for Suicidal Precautions. Interview on 03/12/13 at 3:50 PM with the DON revealed she did not provide guidance to nursing regarding how to monitor Resident #3 or the frequency for monitoring when a resident made verbalizations threatening suicide. The DON stated she was unaware if the resident had attempted suicide in the past. Review of the MAR indicated [REDACTED]. The documentation on the MAR indicated [REDACTED]. The Behavior Monitoring Flow Sheet dated January 2013 reflected Resident #3 was being monitored for Anxiety, Continuous Screaming and Striking Out/Hitting. According to the documentation, Resident #3 exhibited no episodes of these behaviors for the month of January 2013. Danger to self was not an indicator being monitored. Review of the MAR indicated [REDACTED]. The documentation on the MAR indicated [REDACTED]. The Behavior Monitoring Flow Sheet dated February 2013 reflected Resident #3 was being monitored for Anxiety, Continuous Screaming and Striking Out/Hitting. According to the documentation, Resident #3 exhibited no episodes of these behaviors from 02/01/13 through 02/05/13 during the night shift. There was no documentation of any behavior monitoring during the day shift for this time period. Danger to self was not an indicator being monitored. Review of Resident #3's hospital records (located in the active portion of the facility's clinical record for the resident) revealed the resident was admitted to the hospital on [DATE] from the hospital's emergency room with

Based on interview and record review, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well- being for one (Resident #3) of five residents reviewed for changes in condition. 1. The Director of Social Services failed to notify Resident #3's Clinical Psychologist when the resident made suicidal threats. 2. The Director of Social Services failed to know the facility's policy for suicidal precautions. These failures resulted in an attempt to send Resident #3 to a geriatric psychiatric facility, but the resident was diverted to an acute care hospital due to chest pains. Resident #3 was admitted to the acute care hospital with chest pains and suicidal ideation. 3. The Director of Social Services failed to have a plan in place for Resident #3's verbalizations of suicide when the resident returned from the acute care hospital. 4. The Director of Social Services failed to make arrangements for Resident #3 to be seen by a Psychiatrist, as ordered by the physician, who discharged her from the acute care hospital, after she was readmitted to the facility. She also failed to determine if the resident needed sitter services as ordered by the physician, who discharged the resident from the acute care hospital. 5. The Director of Social Services failed to notify Resident #3's Clinical Psychologist when the resident was readmitted to the facility from the acute care hospital. These failures could affect Resident #3 and the other 75 residents, who resided in the facility, by placing them at risk for inadequate care, attempts of suicide, injuries, anxiety, depression, exacerbation of psychological symptoms, and a decreased quality of life. Findings included: 1. Resident #3, a [AGE] year-old female, was initially admitted to the facility on [DATE] and was re-admitted on [DATE], per the Admission Record Resident Information document dated 12/24/12. Resident #3's MDS assessment dated [DATE] reflected she was most recently admitted to the facility on [DATE] from an acute hospitalization , her hearing was adequate, and she usually understood others and she usually made herself understood by others. The MDS assessment also reflected her long and short-term memory was impaired; her cognitive skills for daily decision-making was moderately impaired; she had little interest or pleasure in doing things; she felt down, depressed or hopeless; she felt tired or had little energy; she had a poor appetite or overeating; she was short-tempered; and was easily annoyed in the last 12 to 14 days. Further review of the MDS assessment revealed Resident #3 experienced hallucinations and delusions, and she was assessed as exhibiting verbal behavior symptoms directed toward others. The MDS assessment reflected she required the extensive assistance of two persons for bed mobility and transfers; limited assistance of one person with locomotion off the unit and used a wheelchair; extensive assistance of one person for dressing and eating; and total assistance of one person for personal hygiene, toileting, and bathing. The MDS assessment included [DIAGNOSES REDACTED]. Resident #3's January 2013 MAR reflected PRN Xanax 0.25 mg was administered a total of seven days and a total of eight times from 01/01/13 through 01/08/13. The documentation on the MAR reflected the reason was for anxiety and the medication was effective. Resident #3's January 2013 Behavior Monitoring Flow Sheet reflected she was monitored for Anxiety, Continuous Screaming and Striking Out/Hitting. According to the Flow Sheet, she exhibited no episodes of these behaviors in January 2013. Danger to self was not an indicator being monitored. Resident #3's Care Plans in her clinical record reflected a computer-generated care plan dated 02/25/13 , which reflected she was cognitively impaired, was impaired with her ability to understand other and was impaired with daily decision-making. Her Care Plans dated 02/25/13 included alteration in continence, risk for falls, nutrition, risks for the development pressure ulcers and psychotropic medications. There were no Care Plans for Resident #3's identified behaviors, mood problems, or psychiatric diagnoses. Resident #3's Nurse's Note dated 01/28/13 reflected she was starting to "hear voices again." Resident #3's Nurse's Note dated 01/29/13 reflected a care plan meeting was held on 01/29/13 and the resident was in attendance. The Note also reflected she continued to exhibit behavioral issues including yelling and anxiety, and "..staff try to redirect as able with psych services following." Resident #3's February 2013 MAR reflected PRN Xanax 0.25 mg was administered a total of two days and a total of three times from 02/03/13 through 02/05/13. The MAR also reflected the reason was for anxiety and the medication was effective. Resident #3's February 2013 Behavior Monitoring Flow Sheet reflected she was monitored for Anxiety, Continuous Screaming and Striking Out/Hitting. According to the Flow Sheet, she exhibited no episodes of these behaviors from 02/01/13 through 02/05/13 during the night shift. There was no documentation of any behavior monitoring during the day shift for this time period. Danger to self was not an indicator being monitored. Resident #3's Social Services Progress Notes, dated 02/04/13, authored by the Director of Social Services and timed at 10:57 AM, reflected, "Resident states very depressed, hearing voices to harm self. She states suicidal ideation, wants to overdose on pills. She states wants to cry all the time, is tearful at this time. She states is lonely...Resident called 911 last night, high anxiety, however was not taken to hospital...." The Note also reflected Resident #3 asked to be sent to a specific geriatric psychiatric facility and the Director of Social Services faxed the resident's records to the requested facility. Interview on 03/12/13 at 3:05 PM with the Director of Social Services revealed Resident #3 ambulated independently via the wheelchair. She stated the resident was seen on a regular basis by psychological services. The Director revealed she did not contact the resident's physician or the psychological services for Resident #3 following the residents verbalizations of suicide on 02/04/13. She stated Resident #3 was seen by psychological services at the facility on 02/05/13 for a routine visit, and it was difficult to find in-patient care for the resident because she required so much physical assistance with ADLs. When asked how she monitored Resident #3 to ensure her safety while attempting to locate an in-patient facility, the she replied the resident was in her office frequently and she and LVN K could see the resident in the hall. She stated she was unaware if the resident had attempted suicide in the past. Further interview with the Director of Social Services on 03/13/13 at 12:15 PM revealed she was unaware of the facility's policy for Suicidal Precautions. Resident #3's Nurse's Note, dated 02/04/13, authored by LVN K, and timed at 12:19 PM, reflected, "As resident was passing in WC she yelled help. I asked her what she needed and if everything was fine. She said she was hearing voices and they were telling her to do it. When I asked her to clarify what she meant she said to take pills. I asked to take pills for what and she said to die. I asked her if she had a plan to do that and she denied it. I asked her to promise me that she wouldn't act on her voices that she was hearing and she agreed. Spoke to SW (Director of Social Services) about episode. will cont to monitor." Resident #3's Psychological session note dated 02/05/13 reflected she was alert and oriented to person, place and time, and the word "Questionable" was hand-written in the space indicating if the resident was suicidal. The Note also reflected her thought processes were illogical and she had poor judgment. The plan/recommendation section reflected, "Pt. awake, repeats she is hearing voices and seeing monsters. Pt. very much wants to go to inpatient (sign for treatment). States she is being told to hurt herself...." The Note further reflected the psychological services provider recommended, to the Director of Social Services, placement for psychological services and treatment. Resident #3's late entry Social Services Progress Note, dated 02/05/13, authored by the Director of Social Services, and timed 4:00 AM, reflected the resident was seen by psychological services "today," and the resident and psychological services agreed the resident required in-patient treatment. The Director of Social Services documented her contact with possible facilities to admit the resident. The Note reflected, "Resident continues to be agitated, suicidal ideation, distressed, staff try to provide support." Resident #3's Nurse's Note, dated 02/05/13, authored by LVN K and timed at 7:20 PM, reflected, "Resident complained of not wanting to live throughout the day and complained of wanting to take pills to die, also to slit her wrists to die. SW notified and she is working on getting her into a psych facility. Resident not at danger to herself currently but being monitored closely...." Interview on 03/12/13 at 3:30 PM with LVN K revealed she determined Resident #3 was not a threat to herself or anyone else and would not act on her threats to harm herself because she did not have a plan and she promised LVN K she would not hurt herself. When asked how she was monitoring Resident #3, she replied she could see the resident in the hall, and she asked the resident if she was okay. LVN K stated she was unaware if the resident had attempted suicide in the past. When asked if the resident's physician was contacted on 02/04/13 regarding Resident #3's suicidal verbalizations, LVN K replied she did not notify the physician, but did not document it. Further interview with LVN K on 03/13/13 at 11:05 AM revealed she was unaware of the facility's policy for Suicidal Precautions. Resident #3's Resident Transfer Form dated 02/05/13 reflected she was transported by non-emergent transportation to a psychiatric facility for "psych - suicidal." Interview on 03/12/13 at 3:50 PM with the DON revealed she did not provide guidance to nursing regarding how to monitor Resident #3 or the frequency for monitoring when a resident made verbalizations threatening suicide. The DON stated she was unaware if the resident had attempted suicide in the past. Resident #3's hospital history and physical examination ...She had been depressed for the last several days, and had voiced suicidal ideation, threatening to kill herself with a bottle of pills. She was evaluated by (name), and being taken to the psych unit in (city). Then she complained of substernal and epigastric chest pain. The patient reports that she has had (sic) this chest pain last night, and it has resolved now...and per the ER records it got better with nigtroglycerin...The patient reported that she does feel very depressed and would like to go into the psych unit as soon as possible, and does not want to return to the nursing home right away. She denied any suicidal ideation at this time, though she reports that she had been suicidal yesterday. ASSESSMENT AND PLAN: 1. Suicidal ideation...5. Depression. PLAN: 1. The patient has been admitted to the ICU with suicide precautions. We will continue with ICU care until she is cleared for medical purposes...." Resident #3's Clinical Assessment, dated 02/13/13 reflected a referral was received from the acute care hospital to evaluate the resident. The Assessment reflected Resident #3 reported a history of two prior suicide attempts by overdose approximately [AGE] years ago. Acute Risk Factors identified for risk of suicide/self harm included the following: Clear intent and high risk for intent/plan to die; lethality of attempt or plan was identified as ideation and low risk; high risk for prior attempts; high risk for hopelessness; some support systems mild risk; no substance abuse; current stressor severity was severe and high risk. The Assessment also reflected she was "High Risk...Pt has current SI (suicidal ideation) & voices telling her to kill herself w/pills. Pt. is in nursing home where meds are monitored, so she has no access...Due to pt's total care needs, no psych facility is willing to accept. Rec (Recommend) pt goes back to nursing home & they provide psych care through their contracted psychiatrist." A hospital physician's orders [REDACTED].#3 was discharged back to the facility on [DATE]. The order also reflected she would need sitter services as necessary and a psychiatry consult. Resident #3's hospital's Extended Care Referral Form and Orders dated 02/14/13 reflected, "Specialist(s) Consultations: Needs PT, sitter services as necessary and psychiatrist consult at NH (Nursing Home." Resident #3's Resident-Data Collection form, dated 02/14/13, timed at 1:30 PM for her re-admission, and signed by LVN C, did not reflect the psychological aspects of the assessment were completed. The first progress note made after Resident #3's re-admission was dated 02/14/13, timed 1:38 AM and authored by LVN L. Review of all available progress notes from Resident #3's re-admission on 02/14/13 did not reveal any documentation of an assessment for sitter services, or the need for a psychiatric evaluation. Interview on 03/13/13 at 10:30 AM with the Staff Development Coordinator/Wound Care Nurse revealed LVN C did not call the physician on 02/14/13 and verify Resident #3's orders on her return to the facility. She stated LVN L was notified by the hospital on [DATE] that Resident #3 would be returning to the facility on [DATE] and LVN L notified her, the DON, ADON and Administrator on 02/13/13 via text messaging. The text message, viewed on the Staff Development Coordinator/Wound Care Nurse's telephone, reflected LVN L sent a text message to her, the DON, ADON, and the Administrator, which reflected Resident #3 would be discharged from the hospital on [DATE], and if the resident needed to go to a psychiatric facility, the nursing home would have to locate placement because the resident was still screaming for help and hearing voices. The text message was sent at 7:07 PM and was acknowledged by the Administrator at 7:53 PM and by the DON at 9:17 PM. Interview on 03/13/13 at 11:30 AM with the DON revealed a pre-admission assessment was not conducted for Resident #3 prior to her return to the facility on [DATE]. She stated there had been no follow-up on the recommendations made by the hospital's physician. Interview on 03/13/13 at 12:15 PM with the Director of Social Services revealed she was aware on 02/14/13 during the facility's morning meeting that Resident #3 was returning to the facility. She stated the facility did not have a psychiatrist, but a clinical psychologist was providing services to the resident. The Director revealed there was not a care conference to address Resident #3's re-admission, and the clinical psychologist was not notified about the resident's return. She stated was aware the resident had a sitter in the hospital, but sitter services were not discussed at the facility, and she did not review care plans to ensure a current plan of care was developed for Resident #3. The Director revealed psychiatric services were not available to residents in the facility seven days a week, 24 hours a day, and she did not know if Resident #3's clinical psychologist was available for emergency or crises situations. Resident #3's Psychological session note dated 02/19/13 reflected she continued to be exceedingly anxious and depressed and "Suicidal - No." Telephone interview on 03/13/13 at 2:30 PM with Resident #3's Clinical Psychologist revealed he evaluated her on 02/19/13 because it was a regularly scheduled visit. He stated he was not contacted by the facility of the resident's re-admission. The Psychologist revealed sitter services was discussed in the past, but not for her most recent hospitalization . He stated he was working with the resident's attending physician regarding medication management/changes. The Clinical Psychologist stated he was not contacted by the facility for crisis intervention on 02/04/13, and he was always available for emergency situations, but the facility had never requested them. He revealed he did not think Resident #3 was a threat to herself or to the safety of others, and he had been working with her to manage her anxiety and build/teach her coping skills. The Clinical Psychologist stated there was not a treatment plan or behavior modification plan developed in conjunction with the facility, but he had developed his own plan, which was not in her clinical record and had not been shared with facility staff. Resident #3's February 2013 Behavior Monitoring Flow Sheet reflected from 02/14/13 through 02/28/13 Resident #3 was monitored for Anxiety, Continuous Screaming and Striking Out/Hitting. Danger to self was not an indicator being monitored. There was no documentation for 02/14/13. The documentation was inconsistent and sporadic for the month of February 2013. 3) The facility's Emergency Procedures Suicide Precautions p/p, dated 05/2007 and identified as current by the Administrator reflected, "1. If a resident verbalizes an intent to attempt suicide or takes any action that could be interpreted as a suicide attempt, the following must occur: a. Do not leave the resident alone. b. Attempt to calm the resident. c. Notify the physician. d. Remove razors and other sharp or potentially dangerous objects from the resident's room...5. Document specific behavior and/or statements of resident, notification of physician and family or responsible party, safety interventions and actions taken." 4) The facility's Census, dated 03/10/13, reflected 76 residents resided in the facility.

Based on observation, interview and record review, it was determined the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical status for three (Residents #1, #2 and #3) of five residents reviewed for a change in condition. 1) Staff failed to consult with Resident #1's physician when the resident heard a "pop" on 02/22/13 and then had increased pain and use of PRN pain medication from from 02/22/13 to 02/28/13. X-rays were ordered on [DATE] after the NP and Pain Management Physician learned of the "pop" and pain during their scheduled visits on 02/27/13. The results of the x-rays indicated a Fractured Right Femur. These failures resulted in delay in treatment for [REDACTED]. These failures could affect the 11 residents who resided on Hall 400 by placing them at risk for inadequate assessments, ineffective pain management, hopelessness and fear, having a negative impact on their health and well-being. 2) Staff failed to consult with Resident #2's physician when the resident's chest x-ray results of Right Lower Lobe Infiltrate and probable Infiltrate of Left Lower Lobe were received on 03/05/13 11:50 PM. The PA was notified on 03/06/13 at 7:10 PM of the results, who ordered breathing treatments. This failure resulted in a delay of treatment for [REDACTED]. This failure could affect all 11 residents who resided on Hall 400 by placing them at risk for delayed care and treatment, exacerbation of medical conditions, decreased physical condition, and decreased quality of life. 3) Staff failed to consult with Resident #3's physician, when she began making suicidal threats on 02/04/13. This failure resulted in the attempt to send Resident #3 to a geriatric psychiatric hospital, but the resident was diverted in route to an acute care hospital due to chest pain. This failure could affect the other 10 residents, who resided on Hall 400, by placing them at risk for suicide attempts, anxiety, depression, and exacerbations of psychological symptoms. Findings included: 1) Resident #1, an [AGE] year-old female, was admitted to the facility on [DATE], per the Admission Record Resident Information document dated 02/08/13. Resident #1's Active/Discontinued/Completed physician's orders [REDACTED]. Review of the Initial MDS assessment dated [DATE] revealed Resident #1 was admitted from the hospital, and her [DIAGNOSES REDACTED]. Resident #1's MDS assessment also reflected her cognition moderately impaired, and she received scheduled pain medication. Resident #2's Care Plan dated 02/04/13 reflected the resident complained of increased pain/discomfort, and the goal was to maintain current ADLs and pain/discomfort will be relieved with in one hour after intervention over next 90 days. The approaches included: monitoring for signs/symptoms of increased pain/discomfort - assessing resident for possible cause, giving medications/treatments, and physical and relaxation modalities and assessing for relief; allowing to verbalize feelings of pain and discomfort; and assessing and documenting pain. The Care Plan did not reflect an approach of consulting with the physician due to increased pain or to determine the cause of increased pain. Review of the Initial History and Physical, dated 01/30/13 and completed by the pain management physician revealed Resident #1's chief complaints included Acute [MEDICAL CONDITIONS] and Bilateral [MEDICAL CONDITION] of the Lower Extremities. The assessment reflected the resident was admitted to the facility to receive rehabilitation following a [DIAGNOSES REDACTED]. The Initial History and Physical reflected, "lower leg & foot pain severe..." Further review of the History and Physical revealed Resident #1 reported sharp pain down from her knees, and her pain was a three on a scale of one to ten with pain medication and without pain medication it was eight out of ten. During an interview on 03/11/13 at 9:00 AM with the Director of Rehabilitation, the Director provided a list of all residents who received PT, OT and ST from 02/01/13 though 03/11/13. The computer-generated list reflected the names of the residents, their admitted s, the start of service dates and the end of service dates for PT, OT and ST services. The List reflected Resident #1 received PT from 01/24/13 through 02/04/13 and OT from 01/24/13 through 02/28/13. The list further reflected there were currently nine residents residing on Hall 400 who were receiving OT. Interview on 03/11/13 at 12:00 PM with OT A revealed Resident #1 received OT for strengthening and mobility, so she could achieve her prior level of functioning which included being able to transfer herself into her electric scooter. OT A also stated Resident #1's primary goal was to return to her home in the community where she lived with her spouse. OT A revealed the resident was weak and her activity tolerance was low. She stated a mechanical sling-type lift was used to transfer Resident #1 from the bed to the scooter in order to increase the resident's tolerance for sitting before attempting transfer training. OT A revealed the mechanical sling-type lift was determined to be the safest mode of transferring the resident. OT A stated on 02/05/13, during a care plan meeting, Resident #1's family member expressed concerns about using the mechanical lift for transfers. OT A stated she informed the family member Resident #1 required maximum assistance for bed mobility and repositioning. OT A revealed the resident was not yet safe to sit on the edge of the bed. OT A also revealed on 02/21/13 Resident #1 demonstrated an improvement with trunk control, pulling herself up in bed, turning from side to side in bed and she was able to scoot to the edge of the bed. OT A stated on 02/22/13 an attempt was made to transfer Resident #1 from the bed to the electric scooter without using the mechanical lift. OT A revealed Resident #1 reached for the arm of the scooter and yelled out in pain stating, "Oh. I felt it pop. What have I done?" OT A stated she went to get LVN B when Resident #1 pointed to her groin area and complained of pain. OT A revealed LVN B examined the resident and administered two pain pills. Interview on 03/11/13 at 2:25 PM with LVN B revealed on 02/22/13 she was summoned to Resident #1's room by OT A. LVN B stated OT A told her Resident #1 heard a pop and her right groin area was hurting. LVN B revealed she removed the resident's adult brief and examined the resident. She stated there was no discoloration, swelling or bruising and she (LVN B) thought it was a muscle spasm. LVN B revealed she did not believe the resident could have fractured anything or that the resident may need to have an x-ray because Resident #1 had not fallen, been dropped or been lifted. LVN B stated she did not notify the physician or initiate an Incident Report. Resident #1's OT daily treatment notes dated 02/22/13 and electronically signed by OT A reflected, "Narrative Comments: While pt (patient) was sitting on side of bed, pt reached for wc arm, feet were not touching the floor, then yelled out in pain. Procedure to set up transfer from bed to wc was stopped. Pt assisted to lie back down on bed. Pt said she heard a pop, and said 'what have I done now, Oh dear.' Once pt was secured in bed, therapist went to report to nurse. Nurse came and checked. Pt did not want to attempt getting into wc again this date. Therapist called daughter and reported event....Tx (Treatment) for transfers and sitting in wc discontinued." Resident #1's Nurse's Notes, dated 02/22/13, authored by LVN B and timed at 11:30 AM, revealed, "OT reported that resident c/o pain at rt (right) groin when OT approached her to get her up in w/c. [MEDICATION NAME] 10/325 mg 1 tab given for pain. @ (at) 1200 verbalized pain relief but resident refused to get up in w/c. Notified family." The facility's 24 Hour Report/Change of Condition Report dated 02/22/13 revealed no documentation of the incident. The 24 Hour Report/Change of Condition Report dated 02/23/13 reflected PRN [MEDICATION NAME] was administered at 11:53 AM and at bedtime for complaints of hip pain. Telephone interview on 03/11/13 at 1:55 PM with OTA I revealed she provided OT to Resident #1 two or three times after 02/22/13. OTA I stated Resident #1 complained of pain to her right hip upon movement. OTA I revealed the resident complained of pain to her lower legs prior to 02/22/13, but after 02/22/13 the resident began complaining of pain to her lower back and hip. Resident #1's Nurse's Notes, dated 02/24/13 authored by LVN C and timed at 11:11 AM, revealed she was alert and oriented times three and complained of pain to her right hip. LVN C administered [MEDICATION NAME] at 9:20 AM, and at 11:00 AM the resident reported the pain was a three on a scale of one to ten. Review of the 24 Hour Report/Change of Condition Report dated 02/24/13 revealed PRN [MEDICATION NAME] was administered to Resident #1 at 9:20 AM, 1:20 PM and 5:00 PM and [MEDICATION NAME] was administered to the resident at 2:00 AM and Tylenol was administered at 5:00 AM. Review of the 24 Hour Report/Change of Condition Report dated 02/25/13 revealed [MEDICATION NAME] was administered to Resident #1 at bedtime and [MEDICATION NAME] was administered to the resident at 4:00 AM for complaints of pain around the hip/waist area. Resident #1's Nurse's Notes, dated 02/26/13 authored by RN F and timed at 12:24 AM, reflected the resident complained of hip pain and [MEDICATION NAME] was administered at 7:45 PM and [MEDICATION NAME] was administered at 12:00 AM. The Note also reflected, "Will cont to assess and monitor for effectiveness." Review of an OT Daily Treatment Note dated 02/26/13 and electronically signed by OTA I revealed, "Pt in bed with c/o R (right) hhip (sic) pain and subjective report that x-ray pending. Therapy provided in bed pending results. Therapeutic Activities: balloon volleyball to increase dynamic balance during sitting in bed, incorporating use of B (Both) arms and crossing midline w/subjective report of hip pain. Activity stopped and moved to static sitting activity to help prevent R hip pain." Interview on 03/12/13 at 10:05 AM with OTA I revealed she provided OT to Resident #1 on 02/26/13, 02/27/13 and 02/28/13. She stated another OTA (OTA J) worked with the resident on 02/25/13. OTA I revealed on 02/26/13 the primary focus of OT was to work on getting Resident #1 out of bed and into the chair. During one of the OT sessions with Resident #1, the resident told OTA I she could not get out bed and stated she was waiting on the results of an x-ray. OTA I stated on 02/26/13 Resident #1 complained of lower back and right hip pain. Resident #1 told OTA I she heard a popping sound during an attempted transfer. OTA I stated she first heard about the popping noise from the resident. OTA I revealed she did not know what the popping noise was about and the resident was complaining of pain during their OT sessions, so OTA I began focusing on the resident's upper body, so as not to compromise her hip. Interview on 03/12/13 at 10:25 AM with OTA J revealed she provided OT to Resident #1 on 02/25/13. OTA J stated on 02/25/13 OT A instructed her (OTA J) to be careful with the resident during treatment because on 02/22/13 during an attempted transfer Resident #1's hip popped. OTA J stated she decided not to get Resident #1 out of bed on 02/25/13 and instead focused on fine motor skills. OTA J stated when she asked Resident #1 how she was feeling the resident told her that her hip was hurting. Resident #1's Pain Management Flow Sheets dated 01/24/13 through 02/28/13 reflected she received 28 doses of [MEDICATION NAME] 50 mg one to two tablets and 15 doses of [MEDICATION NAME] 10/325 mg one to tablets. Interview on 03/12/13 at 11:00 AM with the DON revealed she first learned of the popping noise during the attempted transfer on 02/22/13 of Resident #1 on 02/28/13 at approximately 4:00 PM from OT A. The DON stated at that time she interviewed LVN B, who denied being told by OT A and Resident #1 there had been a popping noise during an attempted transfer on 02/22/13. The DON stated NP H made visits to the facility a minimum of one time weekly. She stated the pain management physician made visits to the facility on ce a week to evaluate residents, including all residents receiving PT and OT therapy, residents who were not achieving therapy goals due to pain and residents who were being administered pain medication more frequently. The DON stated NP H and the pain management physician were at the facility on 02/27/13 for routine visits. She stated Resident #1 described the "pop" to NP H on 02/27/13. The DON stated NP H ordered an x-ray for Resident #1's back on 02/27/13 due to the resident's complaints of pain and the increase in the amount of PRN pain medications being administered. The DON revealed when the pain management physician evaluated Resident #1, the resident complained to him about hip pain. The DON stated the pain management physician utilized Lidocain injections for pain management when indicated. She stated as a standard of practice the pain management physician ordered x-rays prior to giving the injections to rule out other causes of the pain. The pain management physician ordered an x-ray on 02/27/13 of Resident #1's hip. During the interview on 03/12/13 at 11:00 AM with the DON, it was revealed the DON expected the nurses to conduct a thorough assessment and notify the physician when there was an increase in the frequency of pain medication being administered. She stated when PRN pain medications were being used on a routine basis, the physician should be notified. Review of NP H's assessment dated [DATE] revealed, "3 - 4 days ago while transfer from bed to w/c heard a 'pop' in (right) lower back. Since then been having severe LBP (lower back pain) can't sleep." Resident #1's Physician's Telephone Order dated 02/27/13 reflected, "x-ray of Lumbar Spine" Resident #1's follow-up progress note, dated 02/27/13, authored by the pain management physician reflected the resident reported complaints of right hip pain. Exams related to the complaint included, "..tenderness (right) GTB (Greater Trochanteric Bursitis)...." The plan for "Therapy" reflected, "Continue therapy." Resident #1's Physician's Telephone Order dated 02/27/13 reflected, "x-ray (right) hip R/O (Rule Out) dislocation or Fx." Resident #1's Nurse's Note, dated 02/27/13, authored by LVN E and timed at 7:24 PM, reflected a new order was received from the resident's physician to x-ray the resident's right hip to rule out dislocation or fracture. The Note also reflected, "X-ray of lumbar spine, increase [MEDICATION NAME] 19 mg 1 PO QID X 1 wk then 10 mg PO TID, [MEDICATION NAME] 40 mg per 1cc vial, lidocain 1% for joint injection. All orders notified to family. X-ray scheduled. Medicine orders faxed to pharmacy." Resident #1's Radiology Report dated 02/28/13 reflected the lumbar spine x-ray was completed for back pain and an x-ray of bilateral hips was completed for hip pain. The results were "Suspected subcapital [MEDICAL CONDITION] femur." Resident #1's OT Daily Treatment Note, dated 02/27/13 and electronically signed by OTA I, revealed treatment was provided at the bed level due to continuing verbalizations made by the resident of pain. The Note also reflected the resident's right hip pain increased with movement in bed. Resident #1's Nurse's Note, dated 02/28/13, authored by LVN C and timed at 4:05 PM, reflected the resident complained of pain in her left hip area. The resident reported the pain was a seven on a scale of one to ten, and [MEDICATION NAME] was administered. An interview, on 03/11/13 at 3:25 PM with LVN C, revealed Resident #1 complained of pain to her right hip on 02/28/13 and not her left hip. When asked why he documented the pain was to her left hip, LVN C replied it was an error. When asked if he notified the physician about Resident #1's pain, LVN C stated the resident had not fallen, so he administered pain medication which was effective and did not contact the physician. A telephone interview, on 03/12/13 at 11:35 AM with the Radiology Services Director, revealed on 02/28/13 Resident #1 had x-rays for Lumbar Spine and Bilateral Hips taken at the facility prior to 10:15 AM. The Director stated the results of the x-rays were dictated at 11:36 AM, were transcribed at 11:57 AM, and LVN C was notified of the results via a telephone by the x-ray provider at 12:38 PM. The Radiology Services Director revealed, "Anyone (facility staff) can look in computer system for results once dictated." Interview on 03/12/13 at 1:30 PM with the facility's only ADON revealed sometime after 5:00 PM on 02/28/13 she "just happened to see" the radiology report for Resident #1 at the Nurse's Station. The ADON stated LVN C was documenting on another resident and the radiology report was laying on the nurse's desk. The ADON asked LVN C what action had been taken regarding the results of the radiology report, and LVN C told her he left a message for the physician regarding the results of the x-ray and was awaiting a return call from the physician. Resident #1's Nurse's Notes dated 02/28/13, authored by LVN C and timed at 4:27 PM, reflected the x-ray results were "...probable subcapital [MEDICAL CONDITION] femur with mild displacement...Dr called at 1520 (3:20 PM) message left waiting on response. Called Dr at 1635 (4:35 PM) office assistant asked if labs could be faxed. Results faxed...." Interview on 03/12/13 at 11:45 AM with LVN C revealed radiology reports were available on the computer. LVN C stated if the results were critical or reflected a fracture, the radiology provider called the facility and faxed the report. LVN C revealed he received a call from the radiology provider regarding the results of Resident #1's x-rays, and he did not intend to wait so long to notify the physician of the x-ray results Resident #2's Nurse's Note, dated 02/28/13, authored by LVN C and timed at 5:44 PM, reflected an order was received from the resident's physician to send her to the emergency room for further evaluation. 2) Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's care plan dated 02/19/13 reflected, "Resident has DX (diagnosis) of Asthma and is at risk for SOB (shortness of breath), and [MEDICAL CONDITION]." Approaches included monitoring the resident for SOB, administering medications as ordered by the MD, notifying the MD of SOB that was not relieved by medication and administering oxygen for unrelieved SOB. Resident #2's care plans also reflected this was the only care plan regarding her respiratory system. Resident #2's untimed Physician's Telephone Order dated 03/05/13 reflected to obtain a portable chest x-ray. Resident #2's Nurse's Notes, dated 03/05/13 at 7:17 PM, reflected there was an order for [REDACTED]. The facility's "24 HOUR REPORT/CHANGE OF CONDITION REPORT" dated 03/05/13 reflected day and evening shift entries for Resident #2 were blank. The night shift entry reflected it was day number one post antibiotic therapy for a Urinary Tract Infection. Resident #2's Chest X-Ray Report dated 03/05/13 reflected: "CLINICAL HISTORY: Cough. CHEST: Single portable view of the chest was obtained on March 5, 2013 and compared with previous study from March 2, 2013. There is an infiltrate noted in the right lower lobe, new compared to previous study. There is increased density noted in the lower portion of the left hemithorax probably related to fluid and hiatal hernia. An infiltrate in the left lower lobe cannot be excluded. The heart is normal in size. IMPRESSION: 1. Right lower lobe infiltrate. 2. Probable infiltrate in the left lower lobe. 3. Probably hiatal hernia." A telephone interview on 03/12/13 at 2:30 PM with the Radiology Services Receptionist revealed Resident #2's chest x-ray results were called to LVN E on 03/05/13 at 11:50 PM. The Receptionist stated there was no documented fax time of the chest x-ray results. A telephone interview on 03/13/13 at 2:10 PM with LVN E revealed she was looking through Resident #2's clinical record when she saw the order for a chest x-ray on 03/05/13. She stated, "The x-ray company did call me and gave me report." LVN E revealed, "I don't call the doctor until I have the paper report because sometimes they want me to read the report to them. The x-ray company said as soon as the radiologist signed it (report), it would be available on the computer to print because our fax didn't work. I checked many times during the night. I told next nurse (LVN D) to follow up on x-ray report. I showed her (LVN D) how to print it and told her to call the doctor. When I came back the next night I asked her (LVN D) about the x-ray, she said whose x-ray. I wasn't even working on that hall, but I asked, so I printed results and gave them to RN F and she called the doctor." RN F received a new physician's orders [REDACTED]. Resident #2's Nurse's Notes dated 03/06/13 at 1:13 AM did not reflect the the chest x-ray results or that the x-ray was completed on 03/05/13. LVN E signed the entry. An interview on 03/12/13 at 4:06 PM with LVN D revealed she worked on 03/06/13 from 6:00 AM to 6:00 PM and was assigned to care for Resident #2. When asked why Resident #2 did not have any Nurse's notes for her shift, LVN D replied, "If I didn't write anything that means she (Resident #2) was doing good that day." LVN D was asked if she usually charted every day on each of her residents, and she replied, "Yes." When asked if she remembered being told anything during shift change report regarding Resident #2, LVN D responded, "No." Resident #2's Nurse's Note dated 03/06/13 at 7:10 PM reflected, "RESIDENT XRAY REPORT RECEIVED AND NOTED RIGHT LOWER LOBE INFILTRATE. PROBABLY INFILTRATE IN LEFT LOWER LOBE, PRBABLYT (sic). RESULTS CALLED INTO (name of PA). NEW ORDER TO START NEB (Nebulizers) TREATMENTS OF [MEDICATION NAME] QID X 7 DAYS WHILE AWAKE.... " RN F signed the entry. The facility's "24 HOUR REPORT/CHANGE OF CONDITION REPORT" dated 03/06/13 reflected the day and evening shifts were blank for Resident #2. The night shift entry reflected Resident #2 had a chest x-ray and the results were pending. The Report reflected, "CXR (chest x-ray) result please print from computer when it is ready. Fax machine not working." An interview on 03/12/13 at 4:20 PM with LVN D revealed when asked if she read the 24-hour report when she started her shift, she replied, "Yes." The surveyor showed LVN D the 24-hour report entry dated 03/06/13 regarding printing Resident #2's chest x-ray results and LVN D stated, "I remember this. (LVN E) told me she got x-ray results and couldn't print it out in the computer." When asked if LVN E told her what the chest x-ray results were, LVN D replied, "I don't remember. She (LVN E) told me I should print out (x-ray results) when it was available. It wasn't available on my shift at all. I think it was available at 5:00 PM (worked 6 AM to 6 PM)." When asked if she printed it out at 5:00 PM, LVN D responded, "No." LVN D was asked if she read the results on the computer, and she replied, "I think when you look at the computer you only see the picture (x-ray), not the results (written)." An interview on 03/13/13 at 9:00 AM with the ADON revealed the nurses could access and print x-ray results from the facility computers. A telephone interview on 03/13/13 at 2:40 PM with RN F revealed at change of shift on 03/06/13, LVN E asked LVN D if she notified Resident #2's physician of the chest x-ray results. RN F stated LVN D said, "What are you talking about?" RN R revealed, "So (LVN E) printed the chest x-ray results and I called the PA." RN F stated she told the PA the resident just completed antibiotics for a UTI, and the PA gave an order to start nebulizer treatments. Resident #2's March 2013 MARs reflected [MEDICATION NAME] nebulizer treatments were started on 03/06/13 at 8:00 PM. Resident #2's Nurse's Notes dated 03/07/13 at 12:41 AM reflected, "...LUNG SOUNDS WITH CONGESTION...." RN F signed this entry. Resident #2's Nurse's Notes dated 03/07/13 at 1:07 PM reflected, "THIS NURSE WAS INFORMED THAT RESIDENT C/0 FEELING HEAVY TO BREATHE. ASSESSED RESIDENT. LUNG SOUND DIMINISHED AT LOWER BASE BILALERAL (sic). NO SIGN OF RESP DISTRESS AT TIME. 02 SAT 77%. INCREASED 02 TO 4L/MIN viA (sic) N/C. 02 SAT 85% AT 4L. 02 THEN 02 SAT FLUCTUATE FROM 79 TO 82. CALLED NP. ORDER RECEIVED AND CARRIED OUT...." The Note also reflected Resident #2 was sent to the hospital, and it was signed by LVN B. An interview on 03/12/13 at 3:55 PM with LVN B revealed she first saw Resident #2 on 03/07/13. LVN B stated PT informed her to check on the resident because the resident told them she was having difficulty breathing and her chest was heavy. LVN B revealed Resident #2 was not having labored breathing, but she had decreased breath sounds in both lung bases. LVN B stated Resident #2's pulse oxygenation level was 77% on 2 L/min, and she increased the resident's oxygen to 4 L/min. LVN B revealed the resident's oxygenation level increased to 85 % then dropped again. LVN B stated the resident remained alert and was sent to the hospital at approximately 1:35 PM on 03/07/13. An interview on 03/12/13 at 2:50 PM with the DON revealed Resident #2 was sent to the hospital for a possible [MEDICAL CONDITION] Embolism because her oxygenation level dropped and her pulse increased. The DON stated Resident #2 had a history of [REDACTED]. Resident #2's hospital history and physical examination IMPRESSION: A 74-old-female, 1: Dyspnea (air hunger resulting in labored or difficult breathing, sometimes accompanied by pain) with the current workup at this point not showing [MEDICAL CONDITION] or pneumonia. Her recent history of asthmatic [MEDICAL CONDITION] is of concern, and the x-ray findings may suggest recurrence of her asthma in a state of decompensation, further mitigated by atelectasis (collapsed lung)...." 3) Resident #3, a [AGE] year-old female, was initially admitted to the facility on [DATE] and was re-admitted on [DATE], per the Admission Record Resident Information document dated 12/24/12. Resident #3's MDS assessment dated [DATE] reflected she was most recently admitted to the facility on [DATE] from an acute hospitalization , her hearing was adequate, and she usually understood others and she usually made herself understood by others. The MDS assessment also reflected her long and short-term memory was impaired; her cognitive skills for daily decision-making was moderately impaired; she had little interest or pleasure in doing things; she felt down, depressed or hopeless; she felt tired or had little energy; she had a poor appetite or overeating; she was short-tempered; and was easily annoyed in the last 12 to 14 days. Further review of the MDS assessment revealed Resident #3 experienced hallucinations and [MEDICAL CONDITION], and she was assessed as exhibiting verbal behavior symptoms directed toward others. The MDS assessment reflected she required the extensive assistance of two persons for bed mobility and transfers; limited assistance of one person with locomotion off the unit and used a wheelchair; extensive assistance of one person for dressing and eating; and total assistance of one person for personal hygiene, toileting, and bathing. The MDS assessment included [DIAGNOSES REDACTED]. Resident #3's January 2013 MAR indicated [REDACTED]. The documentation on the MAR indicated [REDACTED]. Resident #3's January 2013 Behavior Monitoring Flow Sheet reflected she was monitored for Anxiety, Continuous Screaming and Striking Out/Hitting. According to the Flow Sheet, she exhibited no episodes of these behaviors in January 2013. Danger to self was not an indicator being monitored. Resident #3's Care Plans in her clinical record reflected a computer-generated care plan dated 02/25/13 , which reflected she was cognitively impaired, was impaired with her ability to understand other and was impaired with daily decision-making. Her Care Plans dated 02/25/13 included alteration in continence, risk for falls, nutrition, risks for the development pressure ulcers and [MEDICAL CONDITION] medications. There were no Care Plans for Resident #3's identified behaviors, mood problems, or psychiatric diagnoses. Resident #3's Nurse's Note dated 01/28/13 reflected she was starting to "hear voices again." Resident #3's Nurse's Note dated 01/29/13 reflected a care plan meeting was held on 01/29/13 and the resident was in attendance. The Note also reflected she continued to exhibit behavioral issues including yelling and anxiety, and "..staff try to redirect as able with psych services following." Resident #3's February 2013 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Resident #3's February 2013 Behavior Monitoring Flow Sheet reflected she was monitored for Anxiety, Continuous Screaming and Striking Out/Hitting. According to the Flow Sheet, she exhibited no episodes of these behaviors from 02/01/13 through 02/05/13 during the night shift. There was no documentation of any behavior monitoring during the day shift for this time period. Danger to self was not an indicator being monitored. Resident #3's Social Services Progress Notes, dated 02/04/13, authored by the Director of Social Services and timed at 10:57 AM, reflected, "Resident states very depressed, hearing voices to harm self. She states suicidal ideation, wants to overdose on pills. She states wants to cry all the time, is tearful at this time. She states is lonely...Resident called 911 last night, high anxiety, however was not taken to hospital...." The Note also reflected Resident #3 asked to be sent to a specific geriatric psychiatric facility and the Director of Social Services faxed the resident's records to the requested facility. Interview on 03/12/13 at 3:05 PM with the Director of Social Services revealed Resident #3 ambulated independently via the wheelchair. She stated the resident was seen on a regular basis by psychological services. The Director revealed she did not contact the resident's physician or the psychological services for Resident #3 following the residents verbalizations of suicide on 02/04/13. She stated Resident #3 was seen by psychological services at the facility on 02/05/13 for a routine visit, and it was difficult to find in-patient care for the resident because she required so much physical assistance with ADLs. When asked how she monitored Resident #3 to ensure her safety while attempting to locate an in-patient facility, the she replied the resident was in her office frequently and she and LVN K could see the resident in the hall. She stated she was unaware if the resident had attempted suicide in the past. Further interview with the Director of Social Services on 03/13/13 at 12:15 PM revealed she was unaware of the facility's policy for Suicidal Precautions. Resident #3's Nurse's Note, dated 02/04/13, authored by LVN K, and timed at 12:19 PM, reflected, "As resident was passing in WC she yelled help. I asked her what she needed and