Every finding on record at Heritage Trails Nursing and Rehabilitation Center

Based on interview and record review, the facility failed to provide pharmaceutical services (procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, 1 of 1 facilities reviewed for pharmacy services.The facility failed to identify that LVN A was preparing residents' medications ahead of the scheduled administration time and administering medications through CNAs to residents. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, could result in worsening or exacerbation of chronic medical conditions, and hospitalization.The findings included:In an interview on 08/06/2026 at 2:17 p.m., CNA B stated that LVN A gave the resident's medications to CNAs to pass to the residents. CNA B stated that LVN A did that all the time, and CNA B was pretty sure LVN A did that last week when she was working. CNA B stated that it had probably been going on for more than two years.In an interview on 08/06/2026 at 2:30 p.m., CNA C stated that the nurse was putting medications on the resident's trays during dinner to pass medication. CNA C stated the nurse put those medications in the cup and put it on the tray. CNA C stated that just one nurse did it. CNA C stated that LVN A was the one who placed medication on the resident's tray. In a telephone interview on 08/06/2026 at 3:12 p.m., CNA D stated she worked in the facility from December 2025 to July 2026. CNA D stated she was not terminated but quit because of LVN A. CNA D stated she was not comfortable with LVN A putting medication on trays. CNA D stated LVN A would come to the dining area and hand medications to her to give to the residents. CNA D stated that after handing medications to CNA D, LVN A left without observing whether the resident was taking the medication properly. In an interview on 08/06/2026 at 3:46 p.m., LVN A stated that at no point did she observe any nurses pre-prepping medications or serving medications to residents. LVN A stated she did not see any nurses hand medications to CNAs or other staff for medication administration. LVN A stated that if she saw medication on the tray, CNAs should return it to the nurses and report it to the supervisor. LVN A stated she had been trained on medication administration multiple times. LVN A stated that for medication administration, she would first pull up the computer and the MAR, verify the resident and time, how often to give the medication, and the correct medication, then give it to the resident. LVN A stated that after medications were pulled out (Popped) from the blister package or from the bottle into the small clear cup, they closed the computer and took the medication with water to the resident. LVN A stated she stayed in the resident's room to ensure the resident was swallowing the medication properly, then left the room. In an interview on 08/06/2026 at 4:02 p.m., the ADM stated that she went to check on LVN A and saw LVN A pre-preparing medication in a couple of cups at the nursing station, with her MAR up on the computer. The ADM stated that it was in July 2026 that the ADM received the report that LVN A was preparing medications in advance. The ADM stated that one of the residents reported the situation to her. The ADM stated that she did not remember the resident's name, but the resident was discharged in July 2026. The ADM stated that she did not see any nurses handing medications to the CNAs or other staff for medication administration. The ADM stated she did not see any medication on the resident's tray. The ADM stated she believed all staff members who were passing medication were competent to pass medication. The ADM stated that medication administration in-service was done regularly. The ADM stated that ongoing education, in-service training, and frequent monitoring of medication administration were preventive measures to ensure that nurses do not pass medication to residents through CNAs or other non-licensed staff. In an interview on 08/06/2026 at 4:19 p.m., the DON stated that it was reported to her that LVN A was preparing medication in advance, which was why she conducted an in-service and a one-to-one in-service regarding medication administration with LVN A. The DON stated she did not remember who reported it, but it was reported to her. The DON stated that she did not see any nurses hand medications to CNAs or other non-licensed staff. The DON stated that she did not see any medication on the resident's food tray. The DON stated that she did not see any nurse's pre-preparing medication in advance. The DON stated that she believed all staff members who were passing medication were competent to pass medication and licensed. The DON stated that last medication administration in-service was done on 7/7/2026. The DON stated that a negative outcome would be a medication error if nurses or a medication aide pre-prepared medication in advance, placed it on the food tray, or passed it through CNAs or other unlicensed staff members. The DON stated that ongoing education, in-service training, and frequent monitoring while with the nurses and medication aides were needed to ensure they were administering medication according to policy.Record review on 08/06/2026 of nursing action plan titled Pre-Popping Medications, dated 7/7/2026, identified that LVN A was in-serviced and educated for: All licensed nurses and medication aides, if applicable, will be re-educated on safe medication preparation and administration. Education will include the rights of medication administration, infection prevention, medication identification, proper storage, and preparing medications only for the resident being served. Staff will be instructed that preparing medications for multiple residents in advance is prohibited and will sign an education attendance record.Record review on 08/06/2026 of facility policy titled Administering Medications, revision date April 2019, under Policy Interpretation and Implementation, revealed that2. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions.10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 2 of 6 residents (Resident #1 and #2) reviewed for a clean and homelike environment. The facility failed to ensure Resident #1's bedside commode was emptied appropriately on 05/08/25. The facility failed to ensure Resident #2's urinal was emptied appropriately on 05/08/25. This failure placed residents at risk of decreased feelings of self-worth and a diminished quality of life. Findings included: A record review of Resident #1's face sheet dated 05/08/25 reflected a [AGE] year-old female who was readmitted to the facility on [DATE]. Resident #1's diagnoses included unspecified dementia (a decline in mental abilities), acute on chronic systolic congestive heart failure (heart condition where the heart's left ventricle isn't pumping blood effectively), muscle weakness (loss of muscle strength), and essential primary hypertension (high blood pressure that doesn't have a known secondary cause). A record review of Resident #1's Quarterly MDS assessment, dated 04/09/2025, reflected Resident #1 had a BIMS score of 15, which indicated cognitively intact. Resident #1's Quarterly MDS Section GG Functional Abilities and Goals reflected that Resident #1 required supervision or touch assistance in the areas of toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. A record review of Resident #1's care plan, dated 05/08/2025, reflected Resident #1 was care planned for: Resident #1 has bladder incontinence r/t does not always feel urge to void with an intervention for Resident uses bariatric disposable briefs. During an observation and interview on 05/08/2025 at 9:15am, Resident #1's bedside commode had yellowish liquid in it that appeared to be urine. Resident #1 stated that urine had been there all morning. Resident #1 stated she last used the bedside commode around 6:45am. Resident #1 stated that it's normal for urine to be in her bedside commode due to staff not making rounds. Resident #1 stated the CNA A had been in her room a few times since she last used the bedside commode but did not empty it. During an observation and interview on 05/08/2025 at 11:30am, Resident #1's bedside commode had a brief and yellowish liquid in it that appeared to be urine. Resident #1 stated her bedside commode had not been emptied since I last observed it. A record review of Resident #2's face sheet dated 05/08/25 reflected a [AGE] year-old male who was readmitted to the facility on [DATE]. Resident #1's diagnoses included epilepsy unspecified not intractable without status epilepticus (a seizure disorder where the specific cause of the seizures isn't known), unspecified fracture of right lower leg sequela (a last problem that's a result of a broken right leg), fracture of left lower leg squeal (a long-term condition that develops after the initial break has healed but still affects the leg), and muscle weakness (loss of muscle strength). A record review of Resident #2's Quarterly MDS assessment, dated 02/09/2025, reflected Resident #1 had a BIMS score of 15, which indicated cognitively intact. Resident #2's Quarterly MDS Section GG Functional Abilities and Goals reflected that Resident #2 was dependent in the areas of toileting hygiene, lower body dressing, putting on/taking off footwear. Resident #2 required substantial/maximal assistance in the areas of shower/bathe self, upper body dressing, and personal hygiene. A record review of Resident #2's care plan, dated 05/08/2025, reflected Resident #2 was care planned for: Resident #2 has potential for complications r/t fracture of fracture of unspecified parts of lumbosacral spine and pelvis (lower part of spine that connect to the pelvis, sequela: unspecified fracture of right lower leg, lower leg, sequela; other fracture of left lower leg, sequela. During an observation and interview on 05/08/2025 at 10:50am, Resident #2's urinal had yellowish liquid in it that appeared to be urine. Resident #2 stated that he used his urinal around 9:00am and the CNA had not emptied it. Resident #2 stated that his urinal usually doesn't get emptied until shift change. Resident #2 stated that his CNA for the day was CNA B. During an observation on 05/08/2025 at 11:57am, Resident #2's urinal appeared to have yellowish liquid in it that appeared to be urine. During an observation on 05/08/2025 at 1:09pm, Resident #2's had 1 full urinal and a partially full urinal that appeared to have yellowish liquid in it that appeared to be urine. During an interview on 05/08/2025 at 1:45pm, CNA B stated that he was the CNA working with Resident #2 for the day. CNA B stated that rounds were made at least every two hours. CNA B stated that during rounds CNAs should be checking to see if bed commodes and urinal need emptying. CNA B stated that he had been working assisting other resident and didn't realize that Resident #2 urinals needed to be emptied. CNA B stated that if a resident's urinal or bedside commode was not emptied could cause flies and odors in the resident's room. During an interview on 05/08/2025 at 1:55pm, LVN A stated she emptied Resident #1's bedside commode around 11:45am. LVN A stated when she emptied Resident #1 beside commode there was urine and a brief in it. LVN A stated she was not sure how long the urine and brief had been there. LVN A stated that anyone that enters the resident room could have emptied the bedside commode. LVN A stated that CNAs should make rounds at least every two hours. LVN A stated during the CNAs round they should be checking to see if a resident needs assistance, ensure call lights are within reach, and emptying bedside commodes and urinal. LVN A stated a negative outcome of not emptying a bedside commode or urinal could be odor and flies. During an interview on 05/08/2025 at 2:15pm, CNA A stated that she was the CNA working with Resident #1 for the day. CNA A stated that rounds were made at least every two hours. CNA A stated that during rounds CNAs should be checking to see if bed commodes and urinal need emptying. CNA A stated that Resident #1 urinates frequently so there are times that her bedside commode is not emptied. CNA A stated that if a bedside commode was not emptied timely that could cause odors and the resident may not be able to use the bedside commode if it was full. During an interview on 05/08/2025 at 3:30pm, the DON stated any nursing staff such as CNAs, Medication Aides, or nurses could empty a bedside commode/urinal. The DON stated that CNAs made rounds every two hours or as needed. The DON expected for bedside commodes and urinal to be emptied in a timely manner. The DON stated if bedside commode or urinal was not emptied in a timely manner that could cause odors, and flies. During an interview on 05/08/2025 at 4:00pm, the ADM stated that nursing staff were responsible for ensuring that bedside commodes and urinals are emptied appropriately. The ADM stated that CNAs are to made rounds every two hours or as needed. The ADM stated that a negative outcome of a resident's bedside commode or urinal not being emptied in a timely manner would be odors. The ADM stated she expected for nursing staff to empty bedside commode and urinals in a timely manner to prevent odors. Review of the facility's Bedpan/Urinal, Offering/Removing policy, dated Qrt 3, 2018, reflected, Purpose: The purpose of the procedure is to provide the resident with bedpan and/or a urinal assistance. Preparation 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. General Guidelines 1. Check to see if the resident is on intake and output before discarding the urine and feces. 2. Do not allow the resident to sit on a bedpan for extended periods. This is not only uncomfortable to the resident, it also causes skin breakdown. 3. If the resident prefers to keep a urinal at his bedside, check if frequently. Empty and clean it as necessary.

Based on interviews and record reviews, the facility failed to provide basic life support, including CPR, to a resident requiring emergency care prior to the arrival of emergency medical personnel in accordance with professional standards for one (Resident #1) of four residents reviewed for CPR. The facility failed to update Resident #1's records to reflect he requested a change in his code status on [DATE] from DNR (do not resuscitate) to Full Code. As a result, basic life support measures, including CPR (Cardiopulmonary Resuscitation) were not provided to Resident #1 when Resident #1 was found unresponsive and expired on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ Template was provided to the facility on [DATE] at 4:25 pm. While the IJ was removed on [DATE] at 5:03 pm, the facility remained out of compliance at a level of no actual harm at a scope of isolated because the facility's need to evaluate the effectiveness of the corrective systems. This failure could result in injury, harm, impairment or death to a resident receiving care in this facility. Findings included: Review of Resident #1's face sheet dated [DATE] reflected a [AGE] year-old male admitted [DATE] with diagnoses that included Dementia (progressive memory loss), Heart Disease, Heart Failure, Chronic Obstructive Pulmonary Disease (COPD - a lung disease that blocks airflow and makes it difficult to breathe), Diabetes Mellitus (blood sugar regulation disorder), Hyperlipidemia (high cholesterol levels) and Liver Failure. Review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 6, suggesting severe cognitive impairment. Further review of the MDS reflected Resident #1 could make himself understood and was able to understand verbal content. Review of Resident #1's care plan dated [DATE] reflected the focus: (Resident #1) has an advance Directive as evidenced by: Do not Resuscitate. Review of Resident #1's care plan meeting notes dated [DATE] signed by SW reflected under the Summary of Social Services section: Change to Full Code Status SDPOA provided Review of Resident #1's progress notes dated [DATE] to [DATE] (date of Resident #1's death), reflected no entry from any NF staff correcting Resident #1's care plan meeting notes on [DATE] listing resident's desire to change to code status as a mistake or error and that Resident #1 wanted to remain a code of DNR. Review of Resident #1's progress notes dated [DATE] @ 12:55 pm reflected: PT WAS PROPELLING SELF IN W/C THIS MORNING. NURSE PRACTITIONER (redacted) SAW PT THIS AM DURING ROUNDS. PT HAD NO S/S OF DISTRESS THIS AM. FSBS WAS OBTAINED AT 11:00AM PT WAS ALERT AND ORIENTED X 1WNL. FSBS 107. @ 1230 RESIDENT ROOMMATE REPORTED THAT PT WAS ON FLOOR IN BATHROOM. DON PERFORMED ASSESSMENT AND PRONOUNCED PT DEATH AT 1245. Review of Resident #1's DNR form dated [DATE] reflected a form signed by FM #2 and two witnesses. Review of Resident #1's SDPOA form dated [DATE] reflected Resident #1 had signed a SDPOA appointing FM #2 as his DPOA. During an interview with FM #1 on [DATE] at 1:29 pm, they stated they were at the care plan meeting on [DATE] when Resident #1 verbally expressed a desire to change his code status from DNR to full code. She stated she remembered this distinctly because she did not agree with Resident #1 being a Full Code due to his health issues, but she supported Resident #1's decision. They stated at this meeting they provided the facility staff with a Statutory Durable Power of Attorney (SDPOA) paperwork as well as a marriage certificate. FM #1 stated the facility did not ask Resident #1 to fill out any forms or paperwork redacting his DNR status in this meeting, nor requested Resident #1 put the request in writing. FM #1 stated after Resident #1's death, they went to the NF on [DATE] and DON informed FM #1 that Resident #1 had been found on the floor of the bathroom and that the NF had not provided any lifesaving measures because Resident #1 had a DNR. FM #1 stated they reminded the DON at that time that Resident #1 had changed his mind in the care plan meeting on [DATE] and wanted to be a Full Code and the DON denied that Resident #1 had said that. During an interview with FM #2 on [DATE] at 2:26 pm, they stated they had attended the care plan meeting on [DATE] with Resident #1, FM #1 and facility staff. FM #2 stated in that meeting, Resident #1's code status was reviewed, and Resident #1 stated he wanted to be a Full Code. FM #2 stated they received a call from FM #3 on [DATE] telling her that Resident #1 had been found on the floor at the NF and had passed. FM #2 stated she called the facility on [DATE] and spoke to the SW who informed her that Resident #1 had passed away. FM #2 stated they went to the facility shortly after this call and FM #2 informed her of what the DON had said regarding Resident #1's code status and the NF not doing CPR. FM #2 stated they were very upset and felt the NF lied about Resident #1's code status because they had not done CPR. During an interview with the SW on [DATE] at 2:36 pm, she stated she was at the care plan meeting on [DATE] with Resident #1, his family members and other NF staff. She stated Resident #1's FM #2 was very adamant during that meeting that he change his code status from DNR to Full Code. The SW stated due to FM #2's insistence, Resident #1 initially stated he wanted to change his code status from DNR to Full Code. The SW stated they reminded [FM#2] that it was Resident #1's decision to make and then asked Resident #1 directly and he stated he wanted his code status to stay as DNR. The investigator recited the care plan meeting notes to the SW and the SW confirmed the care plan meeting notes in the EMR were completed by her and that she had signed the notes stating Resident #1 wanted to change his code status from DNR to Full Code. She stated in that meeting on [DATE], there was a period of time that he (Resident #1) was in agreement with (FM #2) and that's probably when I typed in Change to Full Code, and I did not go back in and review that before I finalized the note. The SW stated she made a mistake in her documentation. When informed there were no other progress notes on this care plan meeting in the EMR, the SW stated she does not recall whether she made any additional notes in the EMR, and she was no longer working at the facility so she could not check and does not recall if she went back and correct it. The SW stated that whatever notes were in the EMR was what was documented. During an interview with the DON on [DATE] at 3:48 pm she stated she was in the care plan meeting on [DATE] with Resident #1, [FM#1, FM#2] and SW. The DON stated that the SW reviewed Resident #1's DNR status and [[FM#2] wanted him to be a Full Code. She stated Resident #1 had his head down and was mumbling so the DON asked him if he wanted to be a DNR. The DON stated she explained the Resident #1 what that meant, and Resident # 1 stated he wanted to keep it like it is as a DNR. She stated she did not put in any progress notes related to what was said or happened in the meeting but remembered the [FM#2] pushing him to change it and Resident #1 ultimately saying he wanted to remain a DNR. She stated there were no forms filled out or anything put in writing because Resident #1 was already a DNR, and he stated he did not want to change. During an interview with the AD on [DATE] at 3:29 pm the AD stated he was not aware that Resident #1 had expressed a desire to change his code status from DNR to Full code in the care plan meeting on [DATE] . The AD stated his expectation was that if a resident changes their mind about a code status they can let any staff know and they will direct resident to the SW and make sure the change takes place. The AD stated his expectations were that any request to change code status by a resident would be turned around in less than 72 hours and that if it would be changed - a resident has a right to have advanced directives. The AD was shown the care plan meeting notes from [DATE] showing the SW documented that Resident #1 wanted a change in code status from DNR to Full Code and AD stated he was not aware of those notes and that if the SW had made a mistake in documentation, it should have been corrected. Attempts to reach the MD on [DATE] by phone at 12:36 pm and by text on [DATE] at 12:39 pm, [DATE] at 8:54 am and 9:45 am were unsuccessful, however the MD did leave a return voicemail that they were out of the country traveling and MD responded to texts, but we were unable to connect. Review of facility policy dated [DATE] entitled Charting and Documentation revealed the following policy statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care and additionally: 2. The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. The AD was notified on [DATE] at 4:24 pm, that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on [DATE] at 2:00 pm. On [DATE], an investigation was initiated at [name of facility]. At approximately 4:25 p.m. on [DATE], a surveyor provided verbal notification that Texas Health and Human Services had determined the conditions at [name of facility] constitute immediate jeopardy to resident health and safety. The Immediate Jeopardy findings were identified in the following areas: F-0842 - The facility failed to update Resident #1's records to reflect that Resident #1 requested a change in his code status on [DATE] from DNR (do not resuscitate) to Full Code. As a result, basic life support measures, including CPR were not provided to Resident #1 on [DATE] when Resident #1 was found unresponsive. Corrective Actions and Identification of Others: Immediate Resident Review and Audit: Action: Conduct a comprehensive audit of all current residents' advance directives and code status forms to identify any discrepancies, incomplete documentation, or missing physician signatures. No discrepancies were found. Moving forward, if any discrepancies are found they will be corrected. Responsible party and MD will be notified. Plan of care will be updated to reflect current status if needed. Responsible Party: Director of Nursing (DON), Social Worker. Timeline: Completed on [DATE] Measurement of Success: 100% of residents will have an accurate, up-to-date code status documented in their medical records and reflected in plan of care. Systemic Change: Staff Education and Training: Action: Implement mandatory in-service training for all staff members involved in resident care (nurses, CNAs) to review the policy on DNR vs. Full Code status, including the correct processes for verifying and documenting code status. Our policy for Advance Directives was provided to all staff. Comprehension will be verified by the staff verbalizing and signing the in-service. Focus on key areas: advance directives, communication with families, and identifying/flagging code status on medical records. Responsible Party: DON, ADONs, and Chief of Clinical Services. Timeline: Completed on [DATE], Measurement of Success: Chief of Clinical services provided training to Admin team. From there, the Director of Nursing/Designee will utilize a signed staff roster to track those who have received education and to determine those who still require it. Anyone not in attendance at education sessions, as evidenced by missing signatures on the staff roster sheet, due to vacation, sick leave, or casual work status will be educated upon their return, prior to their first shift worked. Staff Education and Training: Action: Corporate Clinical consultant completed education with IDT team on proper steps to follow upon family or resident requesting to revoke or change current code status. This should include, verifying resident responsible party or POA, notification to all responsible parties, notification to MD, and complete documentation in resident record to reflect what current code status will be. Our policy for Advance Directives was provided to all staff. Comprehension will be verified by the staff verbalizing and signing the in-service. Responsible Party: Corporate Clinical Consultant Timeline: Completed on [DATE], Measurement of Success: 100% of clinical IDT team, including DON, SSW, Nurse managers, Administrator, will complete education on code status Enhanced Documentation Protocol: Action: Implement an improved documentation protocol that includes: A standardized advance directive form that must be completed upon admission. Clear placement of code status (DNR or Full Code) in the resident's chart, electronic health record, and daily care plan. Responsible Party: Nursing Department, Social Worker. Timeline: Documentation protocols will be revised and implemented by [DATE] Measurement of Success: 100% of residents will have complete and correct advance directives documented using the new protocol. Communication with Residents and Families: Action: Establish a clear communication plan with residents and their families regarding the code status decision-making process: At admission, all residents/families will receive education on the differences between DNR and Full Code, and the options for advance directives. Families will be notified immediately of any changes in the residents' condition that may prompt a review of the advance directive. Responsible Party: Social Services Director, Admissions Coordinator. Timeline: Communication plan to be implemented and completed by [DATE] with current and new residents/families. Measurement of Success: 100% of families will be contacted to confirm their understanding of the resident's advance directive and code status within 5 days of admission or change in condition. Monitoring and Quality Improvement: Action: Integrate advance directive and code status accuracy into the facility's ongoing Quality Assurance and Performance Improvement (QAPI) process: Conduct review of all new admissions and 10% of current resident files, weekly, to ensure that code status is documented correctly and that the DNR/Full Code status is being followed. Include code status tracking as part of the quarterly QAPI meetings to review any issues or incidents related to discrepancies. Responsible Party: QAPI Committee, Administrator, Director of Nursing, Social Worker. Timeline: Audits will begin immediately, on [DATE], and results will be reviewed in the next QAPI meeting. Measurement of Success: A 100% compliance rate for correct advance directive documentation in audits, with any errors identified and corrected within 48 hours. QAPI REVIEW Action: Ad hoc QAPI meeting held with IDT team and MD to review policy on CPR, Advanced directives, and Plan of removal/response to Immediate Jeopardy Citation on [DATE] Start Date: [DATE] Completion Date: [DATE] Responsible: Administrator Monitoring for Effectiveness: Any trends or concerns were/will be addressed with Quality Assurance Performance Committee and continue until a lessor frequency deemed appropriate through QAPI review The surveyor monitored the POR on as followed: A comprehensive audit of all current residents an advanced directives and code status forms was completed on [DATE]. In an interview on [DATE] at 1:00pm with the DON, she stated they went down the resident roster on all residents and called families to verify code status on all residents. The staff then ensured all advanced directives and DNRs were signed on the chart, in the red code book at the nurses' station and the order in the computer correlated with the residents wishes. That was completed on [DATE]. The DNR status was correct on all residents the day of audit and day of entry from state. During an interview on [DATE] at 1:00pm with The DON staff education and training was completed on [DATE] including policy review on DNR vs Full Code. This education included verifying documents, location of documents process for verifying and documenting code status. All staff were given a policy for advanced directives. Staff confirmed they had received training and were able to verbalize the process of code status, where it would be located and procedures on what to do if a resident or RP would like to change their code status. The DON stated that the AD and DON were trained first By the Cooperate clinical consultant along with the IDT team. The DON stated the IDT team then instructed all staff, she stated night shift was educated first, we had the policy reviewed it with each employee including where to look for DNR status. The DON reviewed the DNR book at each nurse's station with the staff and informed them that if a resident changes their mind related to code status, they need to inform the DON and ADON so the proper process can be verified and updated. In an interview on [DATE] at 1:00pm with The DON and AD they confirmed an enhanced documentation protocol plan was completed [DATE]. The plan included A standardized advance directive form that must be completed upon admission. Clear placement of code status (DNR or Full Code) in the resident's chart, electronic health record, and daily care plan. The DON explained that the plan would ensure that if a resident wants to make a change to their code status and completing the advanced directive upon admission. She stated the nursing department heads would be responsible for ensuring documentation was correct. The DON stated the IDT would monitor daily with new admission. She stated the Team are reviewing and monitoring this process daily in morning meeting. During an interview on [DATE] at 1:00pm with The DON and AD, The AD stated communication with Residents and Families should start upon admission. Upon admission all residents/families will receive education on the differences between DNR and Full Code, and the options for advance directives. The DON stated that she and the admissions coordinator would be responsible for explaining the differences between full code and DNR educating residents and family on life savings protocols. The DON stated this would include suppling and assisting with the proper paperwork to ensure resident wishes were made clear. The DON stated they do break the explanation down in layman's terms and ensure families understand and give examples of what it means to be Full Code vs DNR. The AD stated the process would be reviewed every day in morning meeting with the internal document system. The DON stated at times the family doesn't always agree and in those cases, we have a meeting with the family and the resident together and again make it as simple as possible in layman's terms. We address it heavily on care plan day always. During an interview on [DATE] at 1:00pm The AD and DON stated Monitoring and Quality Improvement plan was to Conduct review of all new admissions and 10% of current resident files, weekly, to ensure that code status is documented correctly and that the DNR/Full Code status is being followed. The ADON and DON will be responsible for the monitoring and review daily as well as during the QAPI meeting. The AD stated the QAPI will be held monthly. During interviews on [DATE] at 2:30pm Staff interviews were completed on [DATE] with 3 LVNs, 1RN, 2 CNA, 1 MA- reflected that staff were aware of code status policy. The staff were able to verbally demonstrate how to check for code status. They were able to locate the red code book on each hall and verify code status within the EMR. Staff were able to verbalize steps of notification to DON/ADON for resident request in changing code status. Staff stated they were confident they would be able to effectively complete a code blue (full code) if needed. Staff verbalized they had received a copy of full code, DNR policy and education provided by the IDT including the correct processes for verifying and documenting code status. Staff were also able to locate each AED at the nurses station on crash carts readily available. Review of an in-service, dated [DATE] and conducted by the CNO, reflected the AD and the DON were in-serviced on the following: - Review policy on DNR vs. Full Code status - Review process for verifying and documenting code status - Review process on how to change or revoke a resident's current code status - Review policy on advanced directives. Review of in-service dated [DATE], conducted by the AD, reflected all staff from all shifts were being inserviced on the following: - DNR / Advanced Directives Policy - Charting and Documentation Record review of Advanced Directives audit reflected all residents were reviewed for code status on [DATE]. Review of an Ad Hoc QAPI Agenda, dated [DATE], reflected the AD, MD, DON, ADONS, Dietary and Director of Rehabilitation were in attendance. While the IJ was removed on [DATE] at 5:03 pm, the facility remained out of compliance at a level of no actual harm at a scope of isolated because the facility's need to evaluate the effectiveness of the corrective systems.

Based on Interviews and record reviews, the facility failed to ensure that medical records were accurately documented for one (Resident #1) of four residents reviewed for accurate clinical records, in that: The facility failed to update Resident #1's records to reflect he requested a change in his code status on [DATE] from DNR (do not resuscitate) to Full Code. As a result, basic life support measures, including CPR (Cardiopulmonary Resuscitation) were not provided to Resident #1 when Resident #1 was found unresponsive and expired on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ Template was provided to the facility on [DATE] at 4:25 pm. While the IJ was removed on [DATE] at 5:03 pm, the facility remained out of compliance at a level of no actual harm at a scope of isolated because the facility's need to evaluate the effectiveness of the corrective systems. This failure could result in injury, harm, impairment or death to a resident receiving care in this facility. Findings included: Review of Resident #1's face sheet dated [DATE] reflected a [AGE] year-old male admitted [DATE] with diagnoses that included Dementia (progressive memory loss), Heart Disease, Heart Failure, Chronic Obstructive Pulmonary Disease (COPD - a lung disease that blocks airflow and makes it difficult to breathe), Diabetes Mellitus (blood sugar regulation disorder), Hyperlipidemia (high cholesterol levels) and Liver Failure. Review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 6, suggesting severe cognitive impairment. Further review of the MDS reflected Resident #1 could make himself understood and was able to understand verbal content. Review of Resident #1's care plan dated [DATE] reflected the focus: (Resident #1) has an advance Directive as evidenced by: Do not Resuscitate. Review of Resident #1's care plan meeting notes dated [DATE] signed by SW reflected under the Summary of Social Services section: Change to Full Code Status SDPOA provided Review of Resident #1's progress notes dated [DATE] to [DATE] (date of Resident #1's death), reflected no entry from any NF staff correcting Resident #1's care plan meeting notes on [DATE] listing resident's desire to change to code status as a mistake or error and that Resident #1 wanted to remain a code of DNR. Review of Resident #1's progress notes dated [DATE] @ 12:55 pm reflected: PT WAS PROPELLING SELF IN W/C THIS MORNING. NURSE PRACTITIONER (redacted) SAW PT THIS AM DURING ROUNDS. PT HAD NO S/S OF DISTRESS THIS AM. FSBS WAS OBTAINED AT 11:00AM PT WAS ALERT AND ORIENTED X 1WNL. FSBS 107. @ 1230 RESIDENT ROOMMATE REPORTED THAT PT WAS ON FLOOR IN BATHROOM. DON PERFORMED ASSESSMENT AND PRONOUNCED PT DEATH AT 1245. Review of Resident #1's DNR form dated [DATE] reflected a form signed by FM #2 and two witnesses. Review of Resident #1's SDPOA form dated [DATE] reflected Resident #1 had signed a SDPOA appointing FM #2 as his DPOA. During an interview with FM #1 on [DATE] at 1:29 pm, they stated they were at the care plan meeting on [DATE] when Resident #1 verbally expressed a desire to change his code status from DNR to full code. She stated she remembered this distinctly because she did not agree with Resident #1 being a Full Code due to his health issues, but she supported Resident #1's decision. They stated at this meeting they provided the facility staff with a Statutory Durable Power of Attorney (SDPOA) paperwork as well as a marriage certificate. FM #1 stated the facility did not ask Resident #1 to fill out any forms or paperwork redacting his DNR status in this meeting, nor requested Resident #1 put the request in writing. FM #1 stated after Resident #1's death, they went to the NF on [DATE] and DON informed FM #1 that Resident #1 had been found on the floor of the bathroom and that the NF had not provided any lifesaving measures because Resident #1 had a DNR. FM #1 stated they reminded the DON at that time that Resident #1 had changed his mind in the care plan meeting on [DATE] and wanted to be a Full Code and the DON denied that Resident #1 had said that. During an interview with FM #2 on [DATE] at 2:26 pm, they stated they had attended the care plan meeting on [DATE] with Resident #1, FM #1 and facility staff. FM #2 stated in that meeting, Resident #1's code status was reviewed, and Resident #1 stated he wanted to be a Full Code. FM #2 stated they received a call from FM #3 on [DATE] telling her that Resident #1 had been found on the floor at the NF and had passed. FM #2 stated she called the facility on [DATE] and spoke to the SW who informed her that Resident #1 had passed away. FM #2 stated they went to the facility shortly after this call and FM #2 informed her of what the DON had said regarding Resident #1's code status and the NF not doing CPR. FM #2 stated they were very upset and felt the NF lied about Resident #1's code status because they had not done CPR. During an interview with the SW on [DATE] at 2:36 pm, she stated she was at the care plan meeting on [DATE] with Resident #1, his family members and other NF staff. She stated Resident #1's FM #2 was very adamant during that meeting that he change his code status from DNR to Full Code. The SW stated due to FM #2's insistence, Resident #1 initially stated he wanted to change his code status from DNR to Full Code. The SW stated they reminded [FM#2] that it was Resident #1's decision to make and then asked Resident #1 directly and he stated he wanted his code status to stay as DNR. The investigator recited the care plan meeting notes to the SW and the SW confirmed the care plan meeting notes in the EMR were completed by her and that she had signed the notes stating Resident #1 wanted to change his code status from DNR to Full Code. She stated in that meeting on [DATE], there was a period of time that he (Resident #1) was in agreement with (FM #2) and that's probably when I typed in Change to Full Code, and I did not go back in and review that before I finalized the note. The SW stated she made a mistake in her documentation. When informed there were no other progress notes on this care plan meeting in the EMR, the SW stated she does not recall whether she made any additional notes in the EMR, and she was no longer working at the facility so she could not check and does not recall if she went back and correct it. The SW stated that whatever notes were in the EMR was what was documented. During an interview with the DON on [DATE] at 3:48 pm she stated she was in the care plan meeting on [DATE] with Resident #1, [FM#1, FM#2] and SW. The DON stated that the SW reviewed Resident #1's DNR status and [[FM#2] wanted him to be a Full Code. She stated Resident #1 had his head down and was mumbling so the DON asked him if he wanted to be a DNR. The DON stated she explained the Resident #1 what that meant, and Resident # 1 stated he wanted to keep it like it is as a DNR. She stated she did not put in any progress notes related to what was said or happened in the meeting but remembered the [FM#2] pushing him to change it and Resident #1 ultimately saying he wanted to remain a DNR. She stated there were no forms filled out or anything put in writing because Resident #1 was already a DNR, and he stated he did not want to change. During an interview with the AD on [DATE] at 3:29 pm the AD stated he was not aware that Resident #1 had expressed a desire to change his code status from DNR to Full code in the care plan meeting on [DATE] . The AD stated his expectation was that if a resident changes their mind about a code status they can let any staff know and they will direct resident to the SW and make sure the change takes place. The AD stated his expectations were that any request to change code status by a resident would be turned around in less than 72 hours and that if it would be changed - a resident has a right to have advanced directives. The AD was shown the care plan meeting notes from [DATE] showing the SW documented that Resident #1 wanted a change in code status from DNR to Full Code and AD stated he was not aware of those notes and that if the SW had made a mistake in documentation, it should have been corrected. Attempts to reach the MD on [DATE] by phone at 12:36 pm and by text on [DATE] at 12:39 pm, [DATE] at 8:54 am and 9:45 am were unsuccessful, however the MD did leave a return voicemail that they were out of the country traveling and MD responded to texts, but we were unable to connect. Review of facility policy dated [DATE] entitled Charting and Documentation revealed the following policy statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care and additionally: 2. The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. The AD was notified on [DATE] at 4:24 pm, that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on [DATE] at 2:00 pm. On [DATE], an investigation was initiated at [name of facility]. At approximately 4:25 p.m. on [DATE], a surveyor provided verbal notification that Texas Health and Human Services had determined the conditions at [name of facility] constitute immediate jeopardy to resident health and safety. The Immediate Jeopardy findings were identified in the following areas: F-0842 - The facility failed to update Resident #1's records to reflect that Resident #1 requested a change in his code status on [DATE] from DNR (do not resuscitate) to Full Code. As a result, basic life support measures, including CPR were not provided to Resident #1 on [DATE] when Resident #1 was found unresponsive. Corrective Actions and Identification of Others: Immediate Resident Review and Audit: Action: Conduct a comprehensive audit of all current residents' advance directives and code status forms to identify any discrepancies, incomplete documentation, or missing physician signatures. No discrepancies were found. Moving forward, if any discrepancies are found they will be corrected. Responsible party and MD will be notified. Plan of care will be updated to reflect current status if needed. Responsible Party: Director of Nursing (DON), Social Worker. Timeline: Completed on [DATE] Measurement of Success: 100% of residents will have an accurate, up-to-date code status documented in their medical records and reflected in plan of care. Systemic Change: Staff Education and Training: Action: Implement mandatory in-service training for all staff members involved in resident care (nurses, CNAs) to review the policy on DNR vs. Full Code status, including the correct processes for verifying and documenting code status. Our policy for Advance Directives was provided to all staff. Comprehension will be verified by the staff verbalizing and signing the in-service. Focus on key areas: advance directives, communication with families, and identifying/flagging code status on medical records. Responsible Party: DON, ADONs, and Chief of Clinical Services. Timeline: Completed on [DATE], Measurement of Success: Chief of Clinical services provided training to Admin team. From there, the Director of Nursing/Designee will utilize a signed staff roster to track those who have received education and to determine those who still require it. Anyone not in attendance at education sessions, as evidenced by missing signatures on the staff roster sheet, due to vacation, sick leave, or casual work status will be educated upon their return, prior to their first shift worked. Staff Education and Training: Action: Corporate Clinical consultant completed education with IDT team on proper steps to follow upon family or resident requesting to revoke or change current code status. This should include, verifying resident responsible party or POA, notification to all responsible parties, notification to MD, and complete documentation in resident record to reflect what current code status will be. Our policy for Advance Directives was provided to all staff. Comprehension will be verified by the staff verbalizing and signing the in-service. Responsible Party: Corporate Clinical Consultant Timeline: Completed on [DATE], Measurement of Success: 100% of clinical IDT team, including DON, SSW, Nurse managers, Administrator, will complete education on code status Enhanced Documentation Protocol: Action: Implement an improved documentation protocol that includes: A standardized advance directive form that must be completed upon admission. Clear placement of code status (DNR or Full Code) in the resident's chart, electronic health record, and daily care plan. Responsible Party: Nursing Department, Social Worker. Timeline: Documentation protocols will be revised and implemented by [DATE] Measurement of Success: 100% of residents will have complete and correct advance directives documented using the new protocol. Communication with Residents and Families: Action: Establish a clear communication plan with residents and their families regarding the code status decision-making process: At admission, all residents/families will receive education on the differences between DNR and Full Code, and the options for advance directives. Families will be notified immediately of any changes in the residents' condition that may prompt a review of the advance directive. Responsible Party: Social Services Director, Admissions Coordinator. Timeline: Communication plan to be implemented and completed by [DATE] with current and new residents/families. Measurement of Success: 100% of families will be contacted to confirm their understanding of the resident's advance directive and code status within 5 days of admission or change in condition. Monitoring and Quality Improvement: Action: Integrate advance directive and code status accuracy into the facility's ongoing Quality Assurance and Performance Improvement (QAPI) process: Conduct review of all new admissions and 10% of current resident files, weekly, to ensure that code status is documented correctly and that the DNR/Full Code status is being followed. Include code status tracking as part of the quarterly QAPI meetings to review any issues or incidents related to discrepancies. Responsible Party: QAPI Committee, Administrator, Director of Nursing, Social Worker. Timeline: Audits will begin immediately, on [DATE], and results will be reviewed in the next QAPI meeting. Measurement of Success: A 100% compliance rate for correct advance directive documentation in audits, with any errors identified and corrected within 48 hours. QAPI REVIEW Action: Ad hoc QAPI meeting held with IDT team and MD to review policy on CPR, Advanced directives, and Plan of removal/response to Immediate Jeopardy Citation on [DATE] Start Date: [DATE] Completion Date: [DATE] Responsible: Administrator Monitoring for Effectiveness: Any trends or concerns were/will be addressed with Quality Assurance Performance Committee and continue until a lessor frequency deemed appropriate through QAPI review The surveyor monitored the POR on as followed: A comprehensive audit of all current residents an advanced directives and code status forms was completed on [DATE]. In an interview on [DATE] at 1:00pm with the DON, she stated they went down the resident roster on all residents and called families to verify code status on all residents. The staff then ensured all advanced directives and DNRs were signed on the chart, in the red code book at the nurses' station and the order in the computer correlated with the residents wishes. That was completed on [DATE]. The DNR status was correct on all residents the day of audit and day of entry from state. During an interview on [DATE] at 1:00pm with The DON staff education and training was completed on [DATE] including policy review on DNR vs Full Code. This education included verifying documents, location of documents process for verifying and documenting code status. All staff were given a policy for advanced directives. Staff confirmed they had received training and were able to verbalize the process of code status, where it would be located and procedures on what to do if a resident or RP would like to change their code status. The DON stated that the AD and DON were trained first By the Cooperate clinical consultant along with the IDT team. The DON stated the IDT team then instructed all staff, she stated night shift was educated first, we had the policy reviewed it with each employee including where to look for DNR status. The DON reviewed the DNR book at each nurse's station with the staff and informed them that if a resident changes their mind related to code status, they need to inform the DON and ADON so the proper process can be verified and updated. In an interview on [DATE] at 1:00pm with The DON and AD they confirmed an enhanced documentation protocol plan was completed [DATE]. The plan included A standardized advance directive form that must be completed upon admission. Clear placement of code status (DNR or Full Code) in the resident's chart, electronic health record, and daily care plan. The DON explained that the plan would ensure that if a resident wants to make a change to their code status and completing the advanced directive upon admission. She stated the nursing department heads would be responsible for ensuring documentation was correct. The DON stated the IDT would monitor daily with new admission. She stated the Team are reviewing and monitoring this process daily in morning meeting. During an interview on [DATE] at 1:00pm with The DON and AD, The AD stated communication with Residents and Families should start upon admission. Upon admission all residents/families will receive education on the differences between DNR and Full Code, and the options for advance directives. The DON stated that she and the admissions coordinator would be responsible for explaining the differences between full code and DNR educating residents and family on life savings protocols. The DON stated this would include suppling and assisting with the proper paperwork to ensure resident wishes were made clear. The DON stated they do break the explanation down in layman's terms and ensure families understand and give examples of what it means to be Full Code vs DNR. The AD stated the process would be reviewed every day in morning meeting with the internal document system. The DON stated at times the family doesn't always agree and in those cases, we have a meeting with the family and the resident together and again make it as simple as possible in layman's terms. We address it heavily on care plan day always. During an interview on [DATE] at 1:00pm The AD and DON stated Monitoring and Quality Improvement plan was to Conduct review of all new admissions and 10% of current resident files, weekly, to ensure that code status is documented correctly and that the DNR/Full Code status is being followed. The ADON and DON will be responsible for the monitoring and review daily as well as during the QAPI meeting. The AD stated the QAPI will be held monthly. During interviews on [DATE] at 2:30pm Staff interviews were completed on [DATE] with 3 LVNs, 1RN, 2 CNA, 1 MA- reflected that staff were aware of code status policy. The staff were able to verbally demonstrate how to check for code status. They were able to locate the red code book on each hall and verify code status within the EMR. Staff were able to verbalize steps of notification to DON/ADON for resident request in changing code status. Staff stated they were confident they would be able to effectively complete a code blue (full code) if needed. Staff verbalized they had received a copy of full code, DNR policy and education provided by the IDT including the correct processes for verifying and documenting code status. Staff were also able to locate each AED at the nurses station on crash carts readily available. Review of an in-service, dated [DATE] and conducted by the CNO, reflected the AD and the DON were in-serviced on the following: - Review policy on DNR vs. Full Code status - Review process for verifying and documenting code status - Review process on how to change or revoke a resident's current code status - Review policy on advanced directives. Review of in-service dated [DATE], conducted by the AD, reflected all staff from all shifts were being inserviced on the following: - DNR / Advanced Directives Policy - Charting and Documentation Record review of Advanced Directives audit reflected all residents were reviewed for code status on [DATE]. Review of an Ad Hoc QAPI Agenda, dated [DATE], reflected the AD, MD, DON, ADONS, Dietary and Director of Rehabilitation were in attendance. While the IJ was removed on [DATE] at 5:03 pm, the facility remained out of compliance at a level of no actual harm at a scope of isolated because the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 2 of 7 Resident (Resident #64 and Resident #24) reviewed for quality of care. 1. The facility failed to ensure Resident #64 had a clean air filter in his CPCP Machine and the facility towel dried Resident #64's CPAP mask versus allowing to air dry. 2. The facility failed to ensure Resident #24 had an air filter in his CPAP Machine and the facility failed to allow Resident #64's CPAP mask, along with the head strap, to air dry. The failures placed residents who use CPAP treatment at risk of respiratory infection. Findings included: 1. Record review of Resident #64's AR, dated 7/9/2024, reflected a [AGE] year-old-male who admitted to the facility on [DATE]. He was diagnosed with critical illness myopathy (which was a disease having involved muscles of the extremities, trunk, and respiration) and obstructive sleep apnea (which was a medical condition marked by throat muscles having relaxed and having blocked the person's airway while sleeping.) Record review of Resident #64's Admission MDS, dated [DATE], reflected Section C., Cognitive Patterns: Resident #64 had a BIMS Score of 13. A BIMS Score of 13 indicated the resident had no cognitive impairment. Section O., Special Treatments, Procedures, and Programs reflected Resident #64 utilized Non-invasive Mechanical Ventilator while a resident. Record review of Resident #64's CP reflected a focus area for sleep apnea support, initiated 6/27/2024, evidenced by resident having sleep apnea. The goal, initiated on 6/27/2024, was for resident to be free from complications. The intervention, initiated on 6/27/2024, was for the resident to utilize a CPAP machine. Record review of Resident #64's order summary report reflected an order, initiated on 6/25/2024, to cleanse CPAP mask and tubing with soap and water daily after use in the morning. Record review on 7/11/2024 of Resident #64's CPAP Machine manufacturer guidelines , issued June 2021, which was a Resvent Model, reflected the machine required an undamaged filter for proper operation. Dirty inlet filters may have caused high operating temperatures that may have affected the CPAP device's performance. Regular examination was required for the inlet filters as needed for integrity and cleanliness. Interview and observation on 07/09/24 at 10:29 AM with Resident #64's revealed he utilized a CPAP machine for his sleep apnea every night. Interview reflected he was not able to recall the last time his filter was changed in his CPAP machine, when the last time his CPAP mask was washed, or the last time his CPAP tubing was changed. Observations of Resident #64's CPAP machine revealed the filter, utilized to keep contaminates out of his CPAP machine, was dirty. The filter, which was originally white, was approximately 1.5 inches long x .75 inches wide x .125 inches deep. The filter was no longer white. It was grey from dust and the filter had a larger accumulation of dust in a circle. The heavier concentration of dust was in the shape of a circle was where the filter fit directly over the air inlet vent on the back side of the CPAP Machine. There were no date markings to signify the last date the CPAP machine was cleaned or serviced . Interview and observation on 07/10/24 at 9:12 AM Resident #64 stated staff cleaned his CPAP mask today. Observation of the filter in the CPAP machine filter revealed a grey filter with a darker collection of dirt in the shape of a circle where the filter covered the inlet vent. It had not been cleaned or changed since yesterday's observation. The resident's mask was on the resident's lap; he complained that there was water in the mask, left from when staff washed it, and that he needed it to be dry because water leaked into his mouth. Interview and observation on 07/10/24 at 9:14 AM with LVN O revealed she cleaned Resident #64's mask this morning and had done so every morning. The TAR notified the nurse team to clean his mask daily. She stated she cleaned his air inlet filter yesterday and was about to clean it again today. She was observed removing the filter from the CPAP machine and entered the bathroom; she said to wash the filter out. When she emerged from the restroom, she stated she dropped it, the filter, down the drain. She stated she was going to get another filter for Resident #64's CPAP machine. She did not know where to get new filters and said she was going to find out. Observations revealed the CPAP air filter in the drainpipe in Resident #64's bathroom. LVN O was observed returning to Resident #64's room where she was observed having towel-dried Resident #64's CPAP mask. 2. Record review of Resident #24's AR, dated 7/9/2024, reflected a [AGE] year-old male who admitted to the facility on [DATE]. He was diagnosed with a fracture to the thoracic vertebrae (breaks in the discs that composed the spine) and obstructive sleep apnea (which was a medical condition marked by throat muscles having relaxed and having blocked the person's airway while sleeping.) Record review of Resident #24's Quarterly MDS, dated [DATE], reflected Section C., Cognitive Patterns: Resident #24 had a BIMS Score of 12. A BIMS Score of 12 indicated the resident had moderate cognitive impairment. Section O., Special Treatments, Procedures, and Programs reflected Resident #24 utilized Non-invasive Mechanical Ventilator while a resident. Record review of Resident #24's CP reflected a focus area for sleep patterns, initiated 9/29/2023, evidenced by resident having sleep apnea. The goal, initiated on 9/29/2023, was for resident to have adequate sleep. The intervention, initiated on 5/10/2024, was for the resident to utilize a CPAP machine. Record review of Resident #24's order summary report reflected an order, initiated on 5/10/2024, to cleanse mask and tubing with soap and water daily after use in the morning. Record review, on 7/11/2024 of Resident #24's CPAP Machine manufacturer guidelines , undated, which was a ResMed Model, reflected the filter was supposed to be regularly checked for any damage; replaced every 6 months or earlier if there was any sign of holes of blockage. The filter was supposed to be in place at all times to prevent water and dust from entering the device. Interview and observation on 07/09/24 at 10:14 AM with Resident #24 revealed he was diagnosed with sleep apnea and utilized a CPAP machine to help him breathe every night when he slept. He was unable to recall the last time he observed staff clean his CPAP mask, change his filter, or change the tubing. He denied respiratory illnesses. Observation of his CPAP machine revealed his mask was contained in a plastic bag while not in use. The compartment on the CPAP machine, which was supposed to have a filter for clean air intake, was empty. There were no dates on any of the tubing or CPAP machine. Interview and observation on 07/10/24 at 9:33 AM with Resident #24 revealed staff cleaned his CPAP mask this morning. He denied respiratory distress. Observation reflected the mask was tucked away in a closed plastic bag. The CPAP mask and the headband for the mask were damp to the touch. Observation of the chamber for the air filter reflected an empty chamber; there was no filter. Interview and observation on 07/10/24 at 9:34 AM with LVN O revealed she cleaned Resident #24's mask with soap and water this morning under the water in the bathroom sink and the placed the mask back into the plastic bag. She did not clean his filter and did not recall the last time it was changed. She was observed checking the resident's filter and discovered the resident did not have a filter in its machine. LVN O stated she told the ADON B, who got the filters . LVN O stated the TAR prompted masks to be washed daily, but the orders and the TAR did not indicate anything about the filter . Interview on 07/10/24 at 9:44 AM with the DON reflected replacement filters, and parts, for CPAP Machines were not kept at the facility. The facility coordinated with either the resident's family, or with a third-party vendor, for CPAP supplies . Interview on 7/10/24 at 11:15 AM ADON B revealed the facility contacted the third-party vendor for Resident #64's CPAP supplies and a responsible party for Resident #24's CPAP supplies. ADON B stated the facility had initiated contact for the supplies needed. Interview on 7/11/2024 at 10:40 AM with LVN P revealed staff were trained in caring for CPAP machines. LVN P stated staff was trained to wash the CPAP mask with soap and water and let them air dry. She stated the training did not cover filters. She stated a dirty air filter on a CPAP machine, or uncleaned CPAP components, placed the resident at risk for respiratory illness. She stated the failure to have clean filters, or to know to check for dirty ones fell on education, no changes specified as an order, or notifications prompted in the TAR. Interview and record review on 7/11/2024 at 11:21 AM with the DON revealed nursing staff had been trained on how to care for CPCP machines. Training entailed CPAP masks were washed daily and placed on a towel to air dry. The filter was supposed to be checked weekly and changed, as necessary. Per policy, it was the facility's responsibility to provide routine supplies and routine cleaning for residents' CPAP machines. Per policy, the facility was also responsible to follow specific cleaning instruction obtained from the manufacturer of the CPAP device. If a CPCP machine was not maintained per policy and manufacturer recommendations, the resident was placed at risk of respiratory infection. The failure for proper care for the CPAP fell upon general knowledge, not being specified in the orders, or listed on the TAR. Interview on 7/11/2024 at 11:30 AM with the ADM revealed she expected the staff to clean resident's CPAP machines according to the policy and manufacturer guidelines. The failure of staff to maintain the CPAP machines, items such as air filters and air drying the masks, full upon education, vague written orders, and the lack of instructions on the TAR. Residents with poorly maintained CPAP machines were placed at risk for respiratory illnesses. Record review on 7/15/2024 of URL: Sleepfoundation.org (2024); CPAP machines were a form of positive airway pressure therapy, which used compressed air to open and support the upper airway during sleep. A portable machine generated the pressurized air and directed it to the user's airway via a hose and mask system. The machines were humid and often warm, having made them the perfect home for mold, bacteria, viruses, and other harmful microbes. Having cleaned your machine components regularly washed these microbes away and prevented them from reaching dangerous levels, but having neglected your machine's hygiene could have led to both acute and chronic respiratory illnesses. Record review of the Facility's CPAP Support Policy, dated March 2015, reflected CPAP therapy's purpose was to provide spontaneous breathing residents with continuous positive airway pressure to improve obstructive sleep, resident comfort, and resident safety. The policy indicated directed nursing staff to rinse washable filters under running water once a week to remove dust and debris and replace at least once a year. Disposable filters were supposed to be replaced monthly. CPAP masks were supposed to be cleaned by placing them in warm soapy water and soaking/agitating for 5 minutes. Then, rinse with warm water and allowed to air dry between uses. The CPCP mask head strap was supposed to be washed with warm soap and water and allowed to air dry. Per policy, the facility was also responsible to follow specific cleaning instruction obtained from the manufacturer of the CPAP device.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for 1 of 1 laundry. The facility failed to ensure laundry staff handled and transported linens in a manner to ensure cleanliness and protect from dust and soil to prevent cross-contamination and the spread of infections. This failure could place residents at risk for development of communicable diseases and infections that could diminish a residents' quality of life. Findings were: Observation on 07/09/24 at 02:05 pm revealed the LS walking down the hall delivering linens to residents on an uncovered linen cart. Clothing for multiple residents was hanging openly on the cart. There were other residents, staff, and visitors in the hall when she was delivering the linens. In an interview on 07/09/24 at 02:05 pm the LS stated that staff normally covered laundry from the laundry building to the residents building. She stated once inside the residents building, they took= the cover off to deliver the clothes to the resident's room. The LS stated the linen/clothing was not kept covered as it went down the halls. In an interview on 07/10/24 at 11:55 am the LM stated that laundry was taken from the laundry to the residents building covered and left covered as they go down the hall. She stated they moved the cover enough to remove a single resident's clothing then recovered the cart. The LM stated the LS delivered the laundry yesterday and she was kind of new. The LM stated the policy was that laundry should be covered at all times to prevent contamination and cross-contamination. The LM stated the outcome of laundry not being covered could be infections for residents. In an interview on 07/11/24 at 08:57 am the DON stated the policy for transporting clean linens to residents was to bring the linen into the building covered with plastic or a sheet. She stated the purpose of covering the linen is to keep stuff from getting all over the clean linen and that they want it to be as clean as possible for the residents. The DON stated the outcome if the linen is not covered, is that you could introduce bacteria to a resident and make them sick. In an interview done on 07/11/24 at 09:22 am ADM stated the policy for transporting clean linens to residents was to bring the linen from laundry to the linen closet covered and resident clothing should be bagged or covered during transport. She stated the purpose of covering the linen is to prevent cross contamination. The ADM stated if linen was not covered, the staff would need reeducation and the laundry would need to be rewashed. The ADM stated the outcome if linen is not covered is that residents could get germs. In an interview done on 07/11/24 at 09:26 am ADON-A stated the policy for transporting clean linens to residents was to bring the linen from laundry in a bag. She stated the purpose of covering the linen was to prevent the linen from touching our clothing and keep it clean for residents. ADON-A stated the outcome if linen was not covered. is that it could spread infection to residents if it touches something else. On 7/11/24 a Record review of the facility's undated policy titled, Laundry and Bedding, Soiled-Transport Section reflected, Clean linen is protected from dust and soiling during transport and storage to ensure cleanliness. The policy also reflected for storing clean linens that the use of separate rooms, closets, or other designated spaces with a closing door are used to reduce the risk of accidental contamination.

Based on interview and record review, the facility failed to provide advance notice of change in services and charges not covered under Medicare for 1 of 3 residents (Residents #3) reviewed for Medicaid and Medicare Coverage Liability Notices. The facility failed to ensure Resident #3 was provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage Form CMS-10055 (SNF ABN) when she was discharged from Medicare Part A skilled nursing services. This failure placed residents, or their representatives, at risk of not being fully informed about services covered by Medicare Part A. Findings Included: Record review of Resident #3's AR, dated 7/11/2024, reflected a [AGE] year-old woman who admitted to the facility on [DATE]. She was diagnosed with congestive heart failure (which was a long-term condition that happened when the heart could not pump blood well enough to give your body a normal supply.) Record review of Resident #3's Quarterly MDS, dated [DATE], Section C., Cognitive Patterns indicated Resident #3 had a BIMS Score of 14. A BIMS Score of 14 indicated Resident #3 did not have cognitive impairment . Record review of Resident #3's census data, viewed 7-11-2024, indicated Resident #3 admitted to the facility on Medicare Part A on 2/13/2024 and discharged from Medicare Part A to private pay on 3/3/2024. Resident #3 was not taking part in skilled nursing services as of 3/3/2024. Interview on 7/11/2024 at 9:01 AM with MDSC P revealed Resident #3 was admitted to the facility on [DATE] for skilled nursing services having utilized Medicare Part A. The resident initiated a move from skilled nursing services, Medicare Part A, to private pay because she did not want to pay the co-pay for skilled nursing services. Resident #3 stayed at the facility on private pay. Resident #3 did not utilize the full 100 days of Medicare Part A, so she had days remaining. She should have received a SNF ABN. The facility did not have SNF ABN on file with the resident's acknowledgement. Resident #3 did not receive the SNF ABN due to human error. The error did not place the resident in any harm or risk her ability to receive care. The error did not deny the resident the ability to have utilized Medicare Part A later. Interview on 7/11/2024 at 11:21 AM with the DON revealed SNF ABN forms were handled by the MDSC. Staff was supposed to follow the Medicare Part A guidelines for SNF ABN dispersal. The omission in dispersing a SNF ABN to Resident #3 fell upon human error and the unique situation that Resident #3 chose to drop Medicare Part A and stayed at the facility with private pay. Resident #3 was not placed in any harm and her opportunities to participate in Medicare Part A later were not altered. Interview on 7/11/2021 at 11:34 AM with the ADM revealed she expected her staff to follow the rules of Medicare Part A and the Medicare Claims Processing Manual for financial liability protections. The failure for the SNF ABN having not been provided was human error. Resident #3 was never placed in any harm. She was not placed at risk for denial to participate in Medicare Part A moving forward. Record review of the facility's guidelines for determination to issue a SNF ABN was the Medicare Claims Processing Manual, dated 12/20/2023. Section 70.4 of the Medicare Claims Processing Manual indicated : When completing and delivering the SNF ABN, skilled nursing facilities must meet the written notice standards of this chapter, unless otherwise specified. Failure to provide a proper SNF ABN in situations where a physician has ordered the extended care item or service may result in the skilled nursing facilities being held financially liable under the provisions, where such provisions apply. skilled nursing facilities may also be sanctioned for violating the conditions of participation regarding resident (beneficiary) rights.

Based on observation, interview, and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 of 7 Residents (Resident #51) who were reviewed for accuracy of assessments. The facility incorrectly coded Resident #51 with weight loss on the quarterly MDS. This failure placed residents at risk of incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings included: Record review of Resident #51's AR, dated 7/9/2024, reflected an [AGE] year-old woman who admitted to the facility on [DATE]. She was diagnosed with encounter for removal of internal fixation device (which was admittance to remove a medical device post-surgical procedure.) Record review of Resident #51's Quarterly MDS, dated [DATE], reflected Section C., Cognitive Patterns: Resident #51 had a BIMS Score of 12. A BIMS Score of 12 indicated the resident had moderate cognitive impairment. Record review of Resident #51's order summary report reflected an order, initiated on 6/13/2024, to weigh the resident upon admission, then monthly, if gain/loss greater than 3 pounds, reweigh, notify medical doctor. Record review of Resident #51's CP reflected a focus area for nutritional problem, initiated on 6/21/2024, evidenced by potential weight loss. The goal, initiated on 6/21/2024, was for the resident to maintain weight. The intervention, initiated 6/21/2024, was for nursing staff to monitor weight and report significant weight loss: 3 pounds loss in a week; greater than 5% in a month; greater than 7.5% in 3 months; and greater than 10% in 6 months. Record review of Resident #51's documented weights and vitals in PCC (the facility documentation platform,) taken on 6/13/2024, reflected her weight of 174.6 pounds. Weight taken and recorded by LVN M. Record review of Resident #51's documented weights and vitals in PCC, taken on 6/18/2024, reflected her weight of 157 pounds. Weight taken and recorded by the RD. (Having utilized the LTCSP software: On 06/13/2024, the resident weighed 174.6 lbs. On 06/18/2024, the resident weighed 157 pounds which was a -10.08 % loss.) Record review of the facility's monthly weight report (loose paper copy; not in PCC,) dated 7/1/2024, reflected Resident #51 weighed 171 pounds. Weight taken and recorded by the AAD. (Having utilized the LTCSP software: On 06/13/2024, the resident weighed 174.6 lbs . On 07/01/2024, the resident weighed 171 pounds which was a -2.06 % loss.) Record review of Resident #51's documented weights and vitals in PCC, taken on 7/4/2024, reflected her weight of 146 pounds. Weight taken and recorded by LVN N. (Having utilized the LTCSP software: (Having Utilized the LTCSP software: On 06/13/2024, the resident weighed 174.6 lbs . On 07/04/2024, the resident weighed 146 pounds which is a -16.38 % Loss.) Record review of Resident #51's Quarterly MDS, dated [DATE], reflected Section K., Swallowing/Nutritional Status: Resident #51 weighed 146 pounds. Resident #51's weight of 146 pounds reflected a loss of 5% or more in the last month, or more than 10% in the last 6 months, and was not on a physician-prescribed weight loss regimen. Record review of Resident #51's documented weights and vitals in PCC, taken on 7/8/2024, reflected her weight of 157 pounds. Weight taken and recorded by LVN O. (Having Utilized the LTCSP software: (Having Utilized the LTCSP software: On 06/13/2024, the resident weighed 174.6 lbs . On 07/08/2024, the resident weighed 157 pounds which was a -10.08 % Loss.) Interview and record review on 7/10/2024 at 11:10 AM with the KM revealed she was unaware that Resident #51 was flagged for weight loss on her most recent MDS assessment, dated 7/5/2024. The KM stated she and the RD had weights taken on 7/1/2024 and Resident #51 weighed 171 pounds, which did not result in any significant weight loss. The KM produced a loose paper copy of residents' weights of indicated the weights taken on 7/1/2024 was the weight information used for dietary management and the weight of 171 pounds did not reflect the need for weight loss intervention for Resident #51. The weights recorded from 7/1/2024 had not been uploaded in the facility weights and vitals summary in PCC. Interview on 07/10/24 at 11:28 AM with Resident #51 revealed she had been at the facility for a few weeks. She claimed she felt good and that she hoped to go home soon. She was at a healthy body weight and did not feel she had any significant weight loss. Interview on 07/11/24 at 9:01 AM with MDSC P revealed Resident #51's Quarterly MDS, dated [DATE], was documented with the most recent weights on the weights and vitals summary in PCC, which was 146 pounds taken on 7/4/2024. If the weights were incorrect on the weights and vitals summary in PCC, it would have been incorrect on the MDS also. The MDS identifier for weight loss was triggered incorrectly based on inaccurate weights on the weights and vitals summary in PCC. Interview and observation on 7/11/2024 at 9:45 AM with the AAD revealed he was the staff member who weighed residents listed the 7/1/2024 monthly weight report. He, along with other staff who weighed Resident #51, had access to two distinct types of scales at the facility. One was a wheelchair scale, which weighed residents while seated in a wheelchair, and the other was a mechanical chair, which weighed residents from on a cushioned seat (not in a wheelchair.) He stated he wanted to be the only staff member to weigh the residents so they would be weighed using the same scale in the same body position, which would reflect the most accurate weight. He stated sometimes residents rested their foot/feet on a small bar under the seat of the mechanical scale, which resulted in inaccurate weights. If a different staff member weighed the resident on a different scale than before or did not notice the resident having rested their foot on the bar under the seat, the weights would have been inaccurate. Observations reflected the wheelchair scale accurate. Observations reflected the mechanical scale 5 pounds greater. A second weight was taken with the mechanical scale with a foot placed on the bar under the seat. The second weight taken, with a foot on the bar, was 100 pounds lighter and did not reflect an accurate weight. Interview on 7/11/2024 at 11:21 AM with the DON revealed Resident #51 had been coded for weight loss in her most recent Quarterly MDS, dated [DATE]. The DON was not aware of any significant weight loss because she participated in the facility's monthly weight loss meetings, where Resident #51 had not been discussed with the KM or RD. When the DON reviewed Resident #51 weights recorded in the weights and vitals summary in PCC, she remarked how the weights fluctuated and how she would have liked for one person to weight the residents, so the same scales were used and weights more accurate. Interview and record review on 7/11/2024 at 1:00 PM with the ADM revealed she expected her staff to follow the facility policies for Weight Assessment and Interventions as well as Resident Assessments. Record review of Resident #51's documented weights and vitals in PCC, taken on 7/11/2024 at 12:14 PM by LVN O, reflected Resident #51's weight of 169.8 pounds. The inaccurate weights in the weights and vitals summary in PCC was a failure for staff having been consistent with the scale used, the resident's body position at the time of being weighed and making corrections to observable weight errors. The failure of the accurate MDS Assessment fell upon the use of inaccurate weights documented in the weights and vitals summary in PCC. Resident #51 had not suffered any significant weight loss and was never at risk of harm due to weight loss. Record review of the facility's Weight Assessment and Intervention Policy, dated March 2022, reflected weights were supposed to be recorded in each unit's weight record chart and in the individual's medical record. Any weight change of 5% or more since the last weight assessment was supposed to be retaken the next day for confirmation. If the weights were verified, nursing would immediately notify the dietitian in writing. Unless notified of significant weight change, the dietician would review the unit weight record monthly to follow individual weight trends over time. Record review of the facility's Resident Assessment Policy, dated March 2022, reflected the resident assessment coordinator was responsible for ensuring the IDT team conducts timely and appropriate resident assessments.

Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart and ensure infection control measures during implementation of care, handling, cleaning, storage and disposal of equipment, supplies, biohazardous waste and including infection control practices for mechanical ventilation/tracheostomy care including the use of humidifiers were followed by staff for 2 (Residents #1 and #2) of 5 residents reviewed for respiratory care, in that: 1. The facility failed to ensure Resident #1's nasal cannulas and tubing and Resident #1's and 2's CPAP masks and tubing were properly stored when not in use. These failures could place residents at risk of cross-contamination and illness. Findings included: Record review of Resident #1's admission record, dated 04/30/24, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including other specified sepsis (a life-threatening complication of an infection), unspecified dementia, systolic congestive heart failure (a specific type of heart failure that occurs in the heart's left ventricle) and cognitive communication deficit. Record review of Resident #1's comprehensive MDS assessment, dated 04/19/24, revealed a BIMS score of 3, which indicated she had severe cognitive impairment. Resident #1 also required oxygen therapy. Record review of Resident #1's baseline care plan, dated 04/12/24, revealed she required a C-pap machine (a machine that uses mild air pressure to keep breathing airways open while a person sleeps) and oxygen therapy of two liters per minute continuously delivered by a nasal cannula. Record review of Resident #1's order summary report, dated 04/30/24, revealed Resident #1 was ordered, and started on 04/12/24, the following: -Check oxygen saturation levels q shift every shift -Oxygen: Obtain SPO2 >90% at 2-3lpm via nasal cannula every shift -Change CPAP/BIPAP distilled water every night before bed at bedtime -CPAP-Use CPAP QHS at bedtime -CPAP/BIPAP setting 5 at 30% at bedtime Resident #1 was also ordered on 04/12/24 and started on 04/15/24 the following: -Change nebulizer mask and tubing q week every day shift every Monday Record review of Resident #2's admission record, dated 05/01/24, revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including left side orbital floor fracture (when the bones of the rim of your eye socket push back), multiple left rib fractures, unspecified dysphagia (difficulty swallowing), presence of cardiac pacemaker, generalized muscle weakness, other lack of coordination, and cognitive communication deficit. Record review of Resident #2's comprehensive MDS assessment, dated 04/21/24, revealed a BIMS score of 14, which indicated he was cognitively intact . Resident #2 did not require any respiratory treatments. Record review of Resident #2's baseline care plan, dated 04/14/24, revealed he did not require respiratory treatments, had no altered respiratory status, and did not use supplemental oxygen. Record review of Resident #2's order summary report, dated 05/01/24, revealed he was ordered, and started on 04/24/24, the following: -O2 at 2-4 LPM VIA NC TO MAINTAIN SATS >95% PRN every 24 hours as needed for ABN CXR Resident #2 was also ordered on 04/14/24 and started on 04/15/24 the following: -Monitor and record Temperature and O2 sats once daily, Monitor for the following: Fever >99.0, Cough, Chest pain, Runny nose, SOB, Chills, Muscle pain, Headache, Loss of smell or taste, N/V or diarrhea and loss of appetite, or sore throat. If source of symptoms has not yet been determined or treatment implemented, follow up with MD for any positive findings. one time a day An observation on 04/30/24 at 1:05 p.m. in Resident #1's room revealed Resident #1 was sitting in her wheelchair. Resident #1's tubing and nasal cannula for her oxygen tank were hanging over her wheelchair back support. There was no plastic bag attached to the wheelchair to store the tubing and nasal cannula. Resident #1 was not using the oxygen tank at the time of the observation. A C-PAP mask was also sitting on top of a mini refrigerator that was sitting directly on top of Resident #1's night stand next to Resident #1's bed. There was no plastic bag to store the C-PAP mask. Resident #1 was not using the C-PAP machine at the time of the observation. An attempt to interview Resident #1 was made, but Resident #1 was unable to answer the surveyor's questions. During an interview on 04/30/24 at 2:08 p.m., LVN A revealed nurses were responsible for wrapping the oxygen tubing and nasal cannula in a plastic bag and hanging the plastic bag over the oxygen concentrator if a resident was not using it. LVN A did not know why Resident #1's oxygen tubing and nasal cannula were not stored away in a bag when not in use. LVN A also did not know why Resident #1's C-PAP mask was not bagged when not in use. LVN A did not know when she was last trained on oxygen storage. LVN A stated residents' health, safety, and wellbeing could be affected if oxygen tubing, nasal cannula, and C-PAP mask were not properly stored when not in use. During an interview on 04/30/24 at 2:48 p.m., LVN B revealed oxygen tubing and nasal cannula should be bagged, hung on a resident's concentrator, and with the resident's name and date of last tubing and nasal cannula change out, on it, when not in use. LVN B stated a resident's C-PAP mask should also be bagged when not in use. LVN B did not know why Resident #1's oxygen tubing and nasal cannula were not stored away in a bag when not in use. LVN B also did not know why Resident #1's C-PAP mask was not bagged when not in use. LVN B did not indicate when she was last trained on oxygen storage. LVN B stated residents' health, safety, and wellbeing could be affected because residents could pick up germs if staff were not properly storing oxygen supplies away when not in use. During an interview on 04/30/24 at 3:22 p.m., CNA C revealed nurses were responsible for storing oxygen tubing, nasal cannula, and C-PAP masks when not in use. CNA C stated residents' health, safety, and wellbeing could be affected if tubing, nasal cannula, and C-PAP masks were not properly stored when not in use. During an interview on 04/30/24 at 4:03 p.m., LVN D revealed if a resident's oxygen tank or machine was not in use, the oxygen tubing and nasal cannula were stored by rolling it up and placing it on the resident's bedside table or on the oxygen tank or machine. LVN D did not observe residents' oxygen tubing and nasal cannula being bagged when not in use. LVN D also stated resident's C-PAP mask was bagged when not in use. LVN D stated he did not observe Resident #1's oxygen tank and machine and C-PAP machine tubing, nasal cannula, and C-PAP mask storage. LVN D did not indicate if residents' health, safety, and wellbeing could be affected by staff not bagging and storing oxygen tubing, nasal cannula, and C-PAP mask when not in use and when he was last trained on oxygen storage. An observation on 04/30/24 at 4:55 p.m. in Resident #2's room revealed Resident #2's C-PAP mask was sitting on his bedside table. There was no bag. Resident #2 was not using his C-PAP machine at the time of the observation. During an interview on 04/30/24 at 4:55 p.m., Resident #2 revealed he last used his C-PAP machine on 04/29/24. Resident #2 stated he had no concerns or issues with his care. During an interview on 04/30/24 at 4:57 p.m., the DON revealed nurses were responsible for storing resident's oxygen tubing and nasal cannula in drawers and a bag if not in use. The DON also stated resident's C-PAP masks were to be bagged when not in use. The DON stated she last checked on residents' oxygen storage last week. The DON stated she did not document checking residents' oxygen tubing, nasal cannula, and C-PAP masks. The DON also stated residents' health, safety, and wellbeing could not be affected if oxygen tubing, nasal cannula, and C-PAP masks were not properly stored when not in use. Record review of the facility's in-services, from 02/01/24 through 04/30/24, revealed staff were in-serviced on oxygen tank storage and changing out oxygen supplies on 03/12/24 and 04/10/24. Record review of the facility's Departmental (Respiratory Therapy) Prevention of Infection policy and procedure, revised November 2011, revealed staff were required to do the following, 8. Keep the oxygen cannulae and tubing used PRN in a plastic bag when not in use. Record review of an email sent by the DON, dated 05/01/24 at 12:57 p.m., revealed she would apply the same oxygen tubing storage policy for C-PAP storage.

Based on interview and record review the facility failed to establish an infection prevention and control program that must include, at minimum, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 1 of 1 facility reviewed for an antibiotic stewardship program. The facility did not have pharmacist review for antibiotic stewardship. The facility did not have protocols incorporated in the overall infection prevention and control program and had no system of reports related to monitoring antibiotic usage and resistance data such as the rate of new antibiotic starts, types prescribed or days of antibiotic treatment per 1,000 resident days; antibiotic resistance based on laboratory data from, for example the last 18 months; or tracking measures of outcome surveillance related to antibiotic use. This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. Findings include: Record review of Facility Infection Control Log for January 2024 through March 2024 revealed facility maps with color coded rooms and the legend revealed the color to coordinate with the type of infection. There was no tracking form that included if a resident had a lab completed before starting an antibiotic, if they met/did not meet the surveillance criteria in the electronic health record for antibiotic therapy, or if the infections were facility or community acquired. There were no reports that combined all the antibiotic usage. In an interview on 04/17/2024 at 5:20 pm the DON reported she was the infection preventionist. She said the facility was able to monitor the antibiotic use in the facility through the electronic health record. She said the system tracked the number of antibiotics prescribed, the prescriber, the length of time the prescription was utilized, and the diagnosis leading to the prescription for each individual resident. She stated if a resident exhibited symptoms of an infection the nurse completed an assessment for a change of condition and notified the doctor. If an antibiotic was ordered the information was entered on the infection surveillance form in the electronic health record for each individual resident. Information could be located by researching each individual electronic health record, but the facility did not have a list of residents that were on antibiotics. The team, which consisted of the DON, ADON, SW, Admission Nurse, and Therapy evaluated the antibiotic usage daily. She reported they informed the doctor of their evaluation, and the doctor accessed the electronic health record for labs. She stated the facility's antibiotic stewardship documentation was contained in the electronic health record. The facility did not have a licensed pharmacist to assess, monitor and communicate antibiotic use. The DON stated she was unaware that a pharmacist was required to monitor antibiotics. In an interview on 04/17/2024 at 5:40 pm with Administrator he reported the facility tracked infections and antibiotics through the Infection Surveillance form in the electronic health record for each resident. He reported the team discussed the antibiotic therapy in the morning meetings to determine the appropriateness of the antibiotics prescribed and inform the doctor of their findings. He reported the Infection Preventionist, who was the DON, was responsible for maintaining infection control. Review of Infection Control Policy dated Qtr. 3, 2018, reflected in part: 3. Surveillance a. Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infections, and detecting unusual pathogens with infection control implications. 4. Antibiotic Stewardship a. Culture reports, sensitivity data and antibiotic usage reviews are included in surveillance activities. 5. Data Analysis a. Data gathered during surveillance is used to oversee infections and spot trends. b. One method of data analysis is by manually calculating number of infections per 1,000 resident days as follows: 1. The infection preventionist collects data from the nursing units, categorizes each infection by body site (these can also be categorized by organism or according to whether they are facility or community-acquired), and records the absolute number of infections. 2. To adjust for differences in bed capacity or occupancy on each unit, and to provide a uniform basis for comparison, infection rates can be calculated as the number of infections per 1,000 patient days (a patient day refers to one patient in one bed for one day), both for each unit and for the entire facility. 3. Monthly rates can then be plotted graphically or otherwise compared side-by-side to allow for trend comparison; and 4. Finally calculating means and standard deviations (using computer software) allows for screening of potentially clinically significant rates of infections (greater than two standard deviations above the mean). c. The Medical director will help design data collection instruments, such as infection reports and antibiotic usage surveillance forms, used by the Infection Preventionist.

Based on interview and record review, the facility failed to protect a resident's right to be free from abuse for 2 (RES # 1 and RES #2) of 15 residents who were reviewed for abuse. The facility failed to protect RES# 1 and RES # 2 from engaging in a resident-on-resident physical altercation on 10-3-2023 at 8:30 PM in the front lobby of the facility, which resulted in physical harm to both residents. This failure could place all residents at the facility at risk for physical harm. Findings included: Record review of the facility's PIR, dated 10-3-2023 at 8:45 PM, reflected a resident-on-resident altercation occurred on 10-3-2023 at 8:30 PM in the front lobby at the facility. The resident-on-resident altercation was between RES # 1 and RES # 2, which resulted in physical harm to both residents. The PIR Summary, written by the ADM, reflected the facility attempted to send RES # 1 to a psych hospital, but the EMTs refused to transport; instead, sent her, RES # 1, to the local hospital. RES # 1 was tested and proved positive for a UTI, and infection of the urinary system. RES # 1 was treated and prescribed antibiotics for her UTI. When RES # 1 returned to the facility, she, RES # 1, was placed on observation for at least 24 hours after the antibiotics were in place and working. RES # 1 was relocated to the other side of the facility to prevent and further interaction and incidents. In the days following the incident, both residents, RES # 1 and RES # 2, became more cooperative with their communication and began to speak about the incident. RES # 1 was seen by the psych NP, nurse practitioner, and communicated that RES # 2 was the one that initiated the incident. The results of the PIR indicated RES # 1 and RES # 2, were both at fault in the incident. Record review of RES # 1's AR, dated 11/21/2023, indicated RES # 1 was a [AGE] year-old female and was admitted to the facility on [DATE]. RES # 1 was diagnosed with paralysis and muscle weakness to side of her body R/T, related to, disrupted blood flow to her brain; decreased in size and wasting of muscle; loss of ability to understand or express speech; impaired ability to remember, think, or make decisions, difficulty with thought and how to understand language; and an infection of her urinary tract. Record review of RES # 1's Quarterly MDS, dated [DATE], Section C-Cognitive Patterns was not completed and did not indicate a BIMS Score. Section E-Behavior reflected a code of 0, zero, for (A.) Physical behavior symptoms directed towards others, such as kicking, pushing, scratching, grabbing, and abusing others sexually; (B.) Verbal behavioral symptoms directed toward others, such as threatening others, screaming at others, or cursing others; and (C.) Other behavioral symptoms not directed toward others, such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal and vocal symptoms like screaming or making disruptive sounds. A code of 0, zero, indicated that the behavioral symptoms for A., B., and C. were not exhibited by RES # 1. Record review of RES # 1's PN reflected RES # 1 engaged in a physical altercation with RES # 2 in the lobby of the facility on 10/03/2023. The PN, entry dated 10/03/2023 at 8:48 PM by the ADON, reflected she responded to a report from a visitor that two residents were actively involved in an altercation in the lobby of the facility. The ADON wrote that she went to the front of the building immediately and noticed RES # 2 with scratch marks to her face and arms yelling stop it! The ADON wrote that she separated the residents immediately. After the separation, the ADON wrote that RES # 1 denied hitting or scratching RES # 2. The ADON wrote that an examination of RES # 1's hands revealed blood under her fingernails. Upon the examination, RES # 1 stated 'I did do it; furthermore, RES # 1 was sent to the hospital to be evaluated for harm to self and others. Record review of RES # 1's PN reflected an Event Follow-up note for the resident-on-resident altercation. The PN, entry dated 10/04/2023 at 3:15 AM by RN/LPN A, indicated a follow up visit with RES # 1, who expressed no new injury and no complaint of pain. RES # 1 received visual checks every 30 minutes. Record review of RES # 1's PN reflected a Physician's Order Note on 10/04/2023 at 7:56 AM. The PN, entry date 10/04/2023 at 7:56 AM by the ADON, indicated RES # 1 was prescribed an antibiotic, Ciprofloxacin 500 MG by mouth 2 times daily, for a UTI, which was an infection of RES # 1's urinary tract. Record review of RES # 1's PN reflected a Nurses Note on 10/04/2023 at 9:06 AM. The PN, entry date 10/04/2023 at 9:06 AM by LPN A, indicated RES # 1 received consent, from her responsible party, for a psychological evaluation. Record review of RES # 1's PN reflected an Event Follow-up note for the resident altercation. The PN, entry date 10/04/2023 at 12:15 PM by LPN B, reflected RES # 1 complained of no new injury was compliant with separating from RES # 2 by staying in room. Record review of RES # 1's PN reflected an Event Follow-up Note for the resident-on resident altercation. The PN, entry date 10/04/2023 at 5:35 PM by LN C, indicated RES # 1 was prescribed Melatonin 3 MG by mouth at bedtime, as a sleep aid, and Lexapro 10 MG by mouth daily, for depression and anxiety. RES # 1 complained of no new injury and received visual checks every 30 minutes for behavioral monitoring, while RES # 1 and RES # 2 remained separated. Record review of RES # 1's PN reflected an Event Follow-up note for the resident-on resident altercation. The PN, entry date 10/05/2023 at 2:54 AM by RN/LPN B, indicated that RES # 1 had no new injuries and no complaints of pain. RES # 1 was compliant with staying in room and received visual checks every 30 minutes. Record review of RES # 1's PN reflected an Event Follow-up note for the resident-on resident altercation. The PN, entry date 10/05/2023 at 12:19 PM by LPN B, indicated that RES # 1 had no new issues and RES # 1 moved to room [ROOM NUMBER]A, which was on the opposite side of the facility to separate the residents. Record review of RES # 1's PN reflected an Event Follow-up note for the resident-on resident altercation. The PN, entry date 10/06/2023 at 2:38 PM by LN B, indicated that RES # 1 had no new issues. Record review of RES # 1's CP, initiated 8/2/2021, indicated RES # 1 had impaired cognitive function/dementia or impaired thought process related to dementia. The goal, revised on 6/26/2023, indicated RES # 1 would maintain current level of decision-making ability by the target date of 12/26/2023. The interventions for the CNA were to monitor and document any changes in cognitive function, specifically changes in decision making ability, memory, recall, general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mantal status. Record review of RES # 1's CP, initiated 09/29/2023, indicated RES # 1 refused to allow staff to cut her fingernails. The goal, initiated on 9/29/2023, reflected RES # 1's goal was to allow staff to maintain nails short, trimmed, and filed through the target date of 12/26/2023. The interventions on RES # 1's CP indicated RES # 1 refused the ADON to cut her nails on 9/29/2023, so RES # 1 was encouraged to attend an activity called 'pretty nails,' in the activity room. On 10/02/2023, RES # 1 refused to allow the DON to cut her fingernails. An update to RES # 1's CP, initiated on 10/03/2023, reflected RES # 1 agreed to allow staff to cut her fingernails; on 10/04/2023, RES # 1 allowed staff to trim her nails. Record review of RES # 1's CP, initiated 10/2/2023, indicated RES # 2 had an altercation with another resident related to her mood and a UTI, which was an infection of her urinary tract. The goal, initiated on 10/2/2023, was for RES # 1 to be free of altercations through the target date of 12/26/2023. The interventions on RES # 1's CP indicated RES # 1 received antibiotics for her UTI initiated on 10/04/2023; changed rooms on 10/09/2023; has trim nails beginning on 10/9/2023; and was referred for psychological assessment on 10/9/2023. Interview on 11-21-2023 at 10:10 AM with RES # 1 revealed no memory or knowledge of the resident-on-resident altercation, which occurred on 10-3-2023 at 8:30 PM. RES # 1 stated she felt safe at the facility. Record review of RES # 2's AR, dated 11/21/2023, indicated RES # 2 was a [AGE] year-old female and was admitted to the facility on [DATE]. RES # 2 was diagnosed with a disorder that affected her ability to move and maintain balance, a mental disorder marked by extreme changes in mood, thought, energy, and behavior, and limitations with social skill, language, and self-care. Interview and observation on 11-21-2023 at 10:00 AM with RES # 2 revealed some details of the resident-on-resident altercation, which took place on 10-3-2023 at 8:30 PM. RES # 2 recalled that she and RES # 1 engaged in a physical altercation, which occurred by the front door in the lobby of the facility. RES # 2 stated that she struck RES # 1 with her right hand and mimicked her actions when she demonstrated with her right arm. RES # 2 stated that RES # 1 scratched her arm and her face; and RES # 2 pointed to her right arm, where three visible marks to the skin were still present. RES # 2 was unable to explain how the argument happened and was unable to recall who was the first to assault the other. Res # 2 stated that she did not interact with RES # 1 anymore because RES # 1 moved. Record review of RES # 2's Quarterly MDS, dated [DATE], Section C-Cognitive Patterns indicated RES # 2 had a BIMS Score of 8. A BIMS Score of 8 suggested RES # 2 was assessed with moderate cognitive impairment. Section E-Behavior indicated a code of 1, one, for (A.) Physical behavior symptoms directed towards others, such as kicking, pushing, scratching, grabbing, and abusing others sexually. A code of 1, one, indicated that the behavioral symptoms for A. occurred with RES # 2 one to three days since the last MDS assessment. Section E-Behavior indicated a code of 0, zero, for (B.) Verbal behavioral symptoms directed toward others, such as threatening others, screaming at others, or cursing others; and (C.) Other behavioral symptoms not directed toward others, such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal and vocal symptoms like screaming or making disruptive sounds. A code of 0, zero, indicated that the behavioral symptoms for B. and C. were not exhibited by RES # 2 at the time of the assessment. Record review of RES # 2's PN reflected Res # 2 engaged in a physical altercation with RES # 1 in the lobby of the facility on 10/03/2023. The PN, entry dated 10/03/2023 at 8:49 PM by the ADON, reflected she responded to a report from a visitor that two residents were actively involved in an altercation in the lobby of the facility. The ADON wrote that she went to the front of the building immediately and noticed RES # 2 with scratch marks to her face and arms yelling stop it! The ADON wrote that she separated RES # 1 and RES # 2 immediately and brought RES # 2 back to the nurse's station for assessment. RES # 2 stated that RES # 1 'hit me, she hit me, she scratched me.' The ADON wrote vital signs were obtained, head-to-toe assessment was completed, then ADM, the DON, and responsible party were notified. Record review of RES # 2's PN reflected an Event Follow-up note for the resident-on-resident altercation. The PN, entry dated 10/04/2023 at 5:37 AM by LN A, indicated a follow up visit with RES # 2, who expressed no new injury and did not ask for pain medications. RES # 2 received wound care with normal saline and triple antibiotic ointment monitored for infection. Record review of RES # 2's PN reflected an Event Follow-up note for the resident-on-resident. The PN, entry dated 10/04/2023 at 1:04 PM by LPN A, indicated a follow up visit with RES # 2, who expressed no new injury, but discomfort to scratches above mouth. RES # 2 received wound care with normal saline and triple antibiotic ointment. Record review of RES # 2's PN reflected an Event Follow-up note for the resident-on-resident altercation. The PN, entry dated 10/04/2023 at 6:31 PM by SM A, indicated a follow up visit with RES # 2, who expressed no new injury, but complained of scratches that itched and hurt. RES # 2 received PRN Acetaminophen, which was pain reducer, and ointment for the scratches. Record review of RES # 2's PN reflected an Event Follow-up note for the resident-on-resident altercation. The PN, entry dated 10/05/2023 at 2:48 AM by LN A, indicated a follow up visit with RES # 2, who expressed no new injury. RES # 2 was monitored for infections. Record review of RES # 2's PN reflected an Event Follow-up note for the resident-on-resident altercation. The PN, entry dated 10/05/2023 at 3:12 PM by LPN A, indicated a follow up visit with RES # 2, who expressed no new injury. RES # 2 received triple antibiotic ointment and was monitored for infection. Record review of RES # 2's PN reflected an Event Follow-up note for the resident-on-resident altercation. The PN, entry dated 10/06/2023 at 3:18 AM by LN A, indicated a follow up visit with RES # 2, who expressed no new injury. RES # 2 received triple antibiotic ointment. Record review of RES # 2's CP, initiated on 10/02/2023, indicated that RES # 2 had another altercation with another resident, which resulted with scratches to face and right arm R/T, related to, behaviors. The goal, initiated on 10/2/2023, was for RES # 2 to be free of altercations within the next review period with a target date of 1/8/2023. The interventions on RES # 2's CP indicated psychological services initiated on 10/9/2023; avoid altercations to other residents initiated on 10/9/2023; and provided medical care to the scratches on RES # 2's face and right arm. Interview on 11-21-2023 at 11:50 AM with the ADON revealed a family member of a resident at the facility pointed out to the ADON that two residents, RES # 1 and RES # 2, were observed hitting each other in the front of the facility. The ADON immediately went to the front of the facility where RES # 2 was observed with scratches to her face and arms and overheard yelling 'stop it.' The ADON immediately separated the residents. RES # 2 was brought to the nurse's stations for medical assessment and treated for scratches. Next, RES # 1refused medical assessment and denied hitting or scratching RES # 2. When blood was discovered under RES # 1's fingernails on her right hand, RES # 1 admitted she scratched RES # 2. RES # 1 was unable to expressed why she did it. RES # 1 was sent to the local hospital where she was diagnosed with a UTI, an infection to her urinary tract, and returned to the facility with antibiotics. The ADON stated that neither resident have displayed aggression towards each other or other residents Interview on 11-21-2023 at 12:30 PM with the AAD revealed residents involved in a resident-on-resident altercation were to be immediately separated and medically assessed by a member of nursing staff. The next steps were to report the incident to the abuse coordinator, who was the ADM. The AAD stated staff has received training and in-service education on abuse. Interview on 11-21-2023 at 2:45 PM with CNA A revealed how she was trained to immediately separate residents if they engaged in an altercation and let nursing staff know to have the residents medically assessed. CNA A stated that the nursing staff made necessary notifications to the DON and the ADM. CNA A stated she was trained on how to respond to resident-on-resident altercations. Interview on 11-21-2023 at 2:50 PM with MA A revealed to immediately separate residents if they engaged in a resident-on-resident altercation and let the nursing staff know right away. The nursing staff would then medically assess the residents and inform the DON and the ADM. MA A stated she wrote a statement on 10-4-2023, which indicate RES # 2 admitted to hitting RES # 1 first. Interview on 11-21-2023 at 3:00 PM with CNA B revealed that residents involved in an altercation were to be separated immediately and let nursing staff know so that could provide medial assessment. CNA B stated she recently attended an in-service on abuse. Interview on 11-21-2023 at 3:05 PM with RN A revealed that residents were to be immediately separated if involved in an altercation. After the residents were safe from more harm, the nursing staff would medically assess. The DON and the ADM were to be notified immediately. RN A stated she recently attended an in-service class on abuse. Interview and record review on 11-21-2023 at 3:30 PM with the DON revealed RES # 2 was not on a behavior monitoring plan at the time of the resident-on-resident altercation on 10/3/2023 but had been receiving psychological services since her admitted [DATE]. The DON presented RES # 2's psychiatric progress notes for 8/22/2023 and 10/11/2023, which indicated RES # 2 was seen by Physician A for medication review and displayed behaviors. The progress note, dated 8/22/2023, reflected remarks to continue counseling, increase Seroquel (an antipsychotic) to 150 MG by mouth twice a day, and commence Ativan (anti-anxiety) 1 MG by mouth every 12 hours. The progress note, dated 10/11/2023, reflected remarks to continue to monitor mood, behaviors, and potentials side effects of medications; and to increase Seroquel (an antipsychotic) to 170 MG by mouth twice a day. Interview on 11-21-2023 at 4:00 PM with the LPC revealed RES # 2 received counseling services since January 2022. The LPC stated goals were for RES # 2 to keep hands to self and respect boundaries. The LPC stated counseling serviced continued two times a week. Interview on 11-21-2023 at 4:45 PM with the DON revealed staff was instructed to monitor RES # 2 to ensure RES # 2 did not ambulate to the other side of the facility where RES # 1 resided. Both RES # 1 and RES # 2 had updated CP that addressed the resident-on-resident altercation on 10/3/2023 and that all the residents were safe. The DON stated that the resident-on-resident altercation was not the result of staff failure. Interview on 11-21-2023 at 5:00 PM with the ADM revealed RES # 2 received psychological and counseling services and continued to do so. The facility staff were educated and made aware of RES # 1 and RES # 2's behavior and instructed to anticipate similar incidents and provide preemptive redirection. It was important to protect residents from physical altercations because it could cause physical and emotional pain. The facility staff cannot stop a behavior from happening but can only respond to behaviors, and work to correct them moving forward. The ADM stated that the resident-on-resident altercation was not a result of staff failure. Record review of a statement written by MA A, written 10/4/2023, stated RES # 2 admitted she struck RES # 1 first on 10/3/2023 at 8:30 PM and that she continued hitting RES # 1. Record review of a facility in-service education for staff dated 10-10-2023 reflected training on Alzheimer's Disease, Abuse, Neglect, and Trauma Informed Care. Record review of the facility's Abuse Prevention Program, dated 10-3-2018, reflected the facility's policy statement, which stated 'Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The facility policy defined abuse as: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also 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. The facility policy defined willful as: The individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 8 of 12 residents (Residents #74, #48, #26, #47, #61, #71, #59 and #25) reviewed for care plans. The facility failed to address Residents #74, #48, #26, #47, #61, #71, #59 and #25's Code Status on their comprehensive person-centered care plan. This failure could place residents at risk of receiving cardiopulmonary resuscitation (CPR) against their wishes. Findings include: Record review of Residents #74, #48, #26, #47, #61, #71, #59 and #25 revealed no care plan for their code status. Record review of Resident #74's face sheet revealed the Code Status was Full Code. Record review of Resident #48's face sheet revealed the Code Status was DNR. Record review of Resident #26's face sheet revealed the Code status was Full Code. Record review of Resident #47's face sheet revealed a Code Status of DNR. Record review of Resident #61's face sheet revealed a Code status of DNR. Record review of Resident #71's face sheet revealed a Code Status of DNR. Record review of Resident #59's face sheet revealed the Code Status was Full Code. Record review of Resident #25's face sheet revealed the Code Status was Full Code. Interview on [DATE] at 11:24 AM with the R.N., she stated the purpose of a care plan was to ensure all resident needs were being provided and Plan of Care was comprehensive. The R.N. stated physician orders for each resident should be reflected in the plan of care. The R.N. stated Code status should be on each plan of care. The R.N. stated Code status was the residents' final wishes. The R.N. stated if she wanted to know Resident Code Status she would check the plan of care. Interview on [DATE] at 11:44 AM, LVN C stated a Care Plan described the resident needs and everything about the resident was included in the plan of care. LVN C stated her expectation of Physician's orders would be reflected in the residents plan of care. LVN C stated it was very important to include Code Status in the plan of care so staff would know how to treat a resident in an emergency. LVN C stated failure to follow Code status could have legal implications. LVN C stated failure to perform CPR on a resident with Full Code status could cause resident death. Interview on [DATE] at 11:58 AM, ADON A stated all disciplines were involved in individual care plan development. ADON A stated a care plan incorporated all of a residents needs and the plan was used by all disciplines to ensure resident needs were met. ADON A stated Physician Orders should be reflected in a care plan and Code Status should be included in all care plans so all staff would know the resident's wishes. ADON A stated DON, ADON, nurses and the Social Worker were all responsible for checking care plans to ensure plans were a correct reflection of resident needs. ADON A stated all care plans were reviewed quarterly and staff would talk to the family, resident, and doctor to ensure all needs were included. ADON A stated it was very important for code status to be included because staff had to know whether to perform CPR or not; and whether to send a resident to the hospital (even if resident was a DNR). ADON A stated everyone was responsible to obtain a DNR form if that was the residents wishes. ADON A stated failure to follow code orders was failure to follow physician orders and residents last wishes. Interview on [DATE] at 8:00 AM with the Social Worker, she stated she discussed Code Status with family/administration and if she needed to initiate a DNR, she would go over required paperwork with the family/resident. The Social Worker stated after discussion with resident/family, a care plan meeting was held, and she discussed Code Status with the care-plan team and Code Status would become part of the Care Plan. The Social Worker stated Code Status was discussed with resident/family at admission. The Social Worker stated the Care Plan described how the resident was to be cared for and it was important for all staff to know Code Status in the event of an emergency. The Social Worker stated all staff referred to care plans. The Social Worker stated she was not sure why Code Status would not be in the Care Plan. The Social Worker stated she usually obtained Code Status and gave information to the ADON or the charge nurse and they entered the information into the computer and into the care plan. The Social Worker stated failure to follow resident wishes was a failure to follow physician orders, as well. The Social Worker stated a Care Plan should reflect Physician Orders. Interview on [DATE] at 8:24 AM with ADON B, she stated the Admissions Coordinator provided Code Status to ADON B and to the nurses on Side One and she was not sure about how Side Two acquired Code information. ADON B stated she notified the physician of code status, and he initiated an order. ADON B stated she then entered status into the computer. ADON B stated the Code Status was entered into the Care Plan as a Team effort. ADON B stated no one person was responsible for entering Code Status into the Care Plan. ADON B stated the DON was responsible for ensuring Care Plans were complete. ADON B stated a resident plan of care should reflect Physician Orders. ADON B stated all nurses, Social Worker, therapy and dietary staff used information in Care Plans. ADON B stated when care plans were incomplete the resident did not receive all required needs. ADON B stated the impact of not including Code Status in the Care plan would be staff would not know how to treat a resident in an emergency. Interview on [DATE] at 10:35 AM with the DON stated the Admission Coordinator would provide Code Status on some residents and some residents did not have a code status on admission and the SW would discuss with the resident/family and initiate DNR paperwork as needed. The DON stated once Code Status was ascertained, the information would be given to the ADON's to enter into the computer. The DON stated all nursing staff were responsible for ensuring Code Status was included in the Plan of Care. The DON stated each Plan of Care should reflect the physician orders. The DON stated failure to include Code Status in the Plan of Care was a failure to follow the physician orders. Interview on [DATE] at 10:45 AM, the Administrator stated each resident should have a comprehensive care plan. The Administrator stated a resident plan of care should encompass all physician orders and failure to include Code Status in the plan of care was a failure to follow physician orders and could cause harm to the resident. Record review of the facility policy Care Plans, Comprehensive Person-Centered, dated 2001 (Revised [DATE]), reflected Policy Statement: A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including . exercising his or her rights, including the right to refuse treatment.

Based on observation, interview, and record review, the facility failed to assist residents in obtaining routine dental care for one (Resident #194) of 18 residents reviewed for dental services. The facility failed to assist in providing routine dental services for Resident #194 after learning of lost dentures. This failure could place residents at risk for oral complications, dental pain, and a diminished quality of life. Findings included: Record review of Resident #194's face sheet revealed a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #194 had diagnoses which included Metabolic encephalopathy (a problem in the brain, caused by a chemical imbalance in the blood), acute pulmonary edema (an abnormal buildup of fluid in the lungs), bipolar disorder, without psychotic features (Mood is elevated out of keeping with the patient's circumstances and may vary from carefree joviality to almost uncontrollable excitement), and cognitive communication deficit (difficulty with thinking and how someone uses language). Record review of Resident #194's modified MDS, dated [DATE], revealed a BIMS score of 9, which indicated the resident had moderately impaired cognition. Her functional status revealed she required extensive assistance with bed mobility, transfer, and toilet use. She required limited assistance personal hygiene and set up with oral hygiene. Record review of Resident #194's Order Summary Report revealed Resident #194 had a regular diet with a start date of 05/01/2021. Review of Resident #194's care plan, dated 03/10/2023, revealed she had an activities of daily living (ADL) self-care performance deficit related to dementia, fatigue, weakness, and debility. Record review of Resident #194's Certification of no medical contradiction - dental and Attending physician request for services form revealed they were signed by the physician on 02/06/2023. A review of the facility's medical authorization form revealed it was signed by Resident #194 and dated 2/22/2023. An interview on 05/23/2023 at 9:48AM with Resident #194 revealed she was missing her bottom denture for a long time. She said she did not recall how long and was not sure what happened to them. She said she told the social worker but had not heard back. She said her family members also spoke to the administrator about it. She said she did not have trouble eating most food but would like to have them replaced. An interview on 05/24/2023 at 4:19PM with the Social Worker revealed she did not recall when she was informed Resident #194's bottom dentures were missing. She said Resident #194's family member did contact her about it but she did not recall when. She said she had not documented the issue but did recall going to Resident #194's room to have her sign the consents for dental services. She said she did send a referral to the dentist on 02/22/2023 but would have to check her records to see if Resident #194 was ever seen by the dentist. She said she should have followed up with the referral. An interview on 05/25/2023 at 11:22AM with ADON A revealed she was not sure if Resident #194 had seen the dentist recently. She said Resident #194 was sent to the emergency roiagnom on [DATE] and when she returned tested positive for COVID-19 which placed her in quarantine. ADON A stated the physician signed the request on 02/06/2023 so the dental referral should have been sent then. She stated she was not sure why the social worker had not sent the referral until 02/22/2023 but it was the social worker's responsibility to follow up wiht referrals. She said not having dentures could impact Resident #194's self-esteem and her ability to eat certain foods. She stated Resident #194 also had the right to have dental services in a timely manner. An interview on 05/25/2023 at 9:46AM with the Administrator revealed Resident #194's family had spoken to him about her missing dentures, and he informed the Social Worker who then started a referral. He said he did not know why there was no follow up on the dental referral but expected the Social Worker to do that within days of getting the consents signed. He said he hated that Resident #194's referral fell through the cracks, and was not followed up with. An interview on 05/25/2023 at 10:22AM with the DON revealed she had worked in the facility for fourteen months and Resident #194 had not had her bottom dentures the entire time. She stated the missing dentures were brought up during Resident #194's care plan meeting but was not sure about the follow up. She said the Social Worker would follow up with the dental referral to ensure appointments were timely. An interview on 05/25/2023 at 11:45AM with the Social Worker revealed the dental service providers were in the facility on 4/14/2023 and 05/12/2023 to provide services to other residents but Resident ##194 was not seen on either of those dates. She said she followed up with the dentist's office on 05/12/2023 and was informed the physician's printed name was not on the forms sent on 02/22/2023. She stated that was why Resident #194 did not get seen. The SW stated she corrected the form and resent the referral on 05/12/2023. She stated she had not followed up after sending the initial referral on 02/22/2023 and should have. She stated Resident #194 had a right to ensure her dental appointment was timely. An interview on 05/25/2023 at 12:10PM with the Speech Therapist revealed he was not currently working with Resident #194 and no triggers of choking or loss of appetite had been brought to his attention. He said nursing staff had not brought any issue with eating to his attention. He stated regardless of if Resident #194 had any physical issues as a result of not having her lower dentures, she had a right to see a dentist timely. Record review of the facility's policy titled , Dental Services, dated 12/2016, stated .Routine and 24-hour emergency dental services are provided to our residents through: a contract agreement with a dentist that comes to the facility monthly; referral to the dentist . social services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan . if dentures are damaged or lost, residents will be referred for dental services within 3 days Record review of the facility's policy titled, Availability of Services, Dental, stated .Social services will be responsible for making necessary dental appointments . all requests for routine and emergency dental services should be directed to Social Services to assure that appointments can be made in a timely manner . residents with lost or damaged dentures will be promptly referred to a dentist

Based on observation, interview, and record review, the facility failed to properly store, prepare, distribute, and serve food in accordance with the professional standards for food service safety in the facility's only kitchen reviewed for safety requirements. The Dietary Manager failed to wear a hair restraint while in the kitchen. The failure placed residents at risk for food borne illness and cross-contamination. Findings included: Observation on 04/18/22 at 9:07 AM revealed the Dietary Manager not wearing a hairnet. Facility kitchen tour was conducted with Dietary Manager, she was observed proving food items to cook and was observed putting away food items. Interview on 04/18/22 at 9:18 AM with the Dietary Manager revealed she was not aware she did not have a hairnet on. She stated she always wore one and thought it may have fallen off. The Dietary Manager stated her expectation was for everyone to wear a hairnet. She stated the risk of not wearing a hairnet was the potential for hair to fall in the residents' food. Record review of the facility's current Authorized Kitchen Personnel policy, revised September 2017, reflected the following: All authorized personnel must wear appropriate head covering while in the kitchen or production area.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (Residents #236, #27, #17, 20 and #21) of 21 residents observed for infection control. 1. The facility failed to ensure Hospice Nurse donned proper PPE prior to entering Resident #263's room, who was under COVID precautions. 2. The facility failed to ensure re-useable blood pressure cuffs were disinfected between uses on Residents #17, 20 and #21. 3. The PTA failed to appropriately wear his facemask in Resident #27's room. The failure could place residents at risk for the development of infections such as COVID-19 and could cause illness or hospitalization . Findings included: 1. Record review of Resident #263's face sheet, printed on 04/20/22, reflected Resident #263 was an [AGE] year-old female with an admitted [DATE]. Observation on 04/19/22 at 9:34 AM revealed Hospice Nurse entered Resident #263's room (located on the quarantine unit) wearing only a surgical face mask. Hospice Nurse did not have a surgical gown, gloves, or eye protection. Observation revealed a shelf with drawers in front of Resident #263's door. Inside the drawers was PPE which included surgical gowns, N95 facemask, gloves, and face shields. Observation of Resident #263's door revealed a sign which indicated to contact the nurse before entering the room and to properly don PPE which included gown, faces shield, facemask and gloves. Observation of Hospice Nurse inside Resident #263's room revealed Hospice Nurse touching resident hand, shoulder and opening her mouth. Observed Hospice Nurse trying to wake up resident and was closed to resident face. Resident #263 was observed to be laying in her bed sleeping. Observed Regional RN informed Hospice Nurse to wear gown, facemask, and gloves while in room. Interview on 04/19/22 at 09:48 AM with Hospice Nurse revealed she was just informed Resident #263 was on quarantine due to unknown COVID status and for not being fully vaccinated. Hospice Nurse stated this is her second visit with the resident, she stated she was not informed on Sunday (04/17/22) that resident was on quarantine and she did not don PPE. Hospice Nurse stated she has two patients admitted at this facility. She stated as a nurse if she would have known Resident #263 was on quarantine, she would have don PPE. Hospice Nurse stated not wearing the appropriate PPE inside resident rooms could lead to the spread of COVID-19 or other infections. Interview on 4/19/22 at 10:07AM with LVN D stated Resident #263 was in quarantine due to being a new patient and not being fully vaccinated. She stated any staff or visitor entering the quarantine unit should don full PPE which consist of mask, gown, gloves and face shield. She stated nurses are responsible to ensure visitors don proper PPE before entering the rooms, however; they have signs on the door indicating they have to don PPE before entering the rooms. LVN D stated if a visitor is not wearing the appropriate PPE it is the nurse's responsibility to educate the visitor or staff. LVN D stated the risk not wearing the appropriate PPE inside resident rooms could lead to the spread of COVID-19 or other infections. Interview on 04/20/22 at 2:45 PM with the DON revealed staff should wear full PPE which included a gown, gloves, eye protection, and face mask while working with residents on the quarantine unit. The DON stated it is the nurse's responsibility to notify visitors that residents are in isolation/quarantine upon admission. The DON stated Resident #263 is in quarantine due to not being fully vaccinated. She stated residents who are newly admitted and are not vaccinated are placed in quarantine for 10-14 days. She stated the potential risk of not donning appropriate PPE could lead to transmission of respiratory illness, whether is COVID or the flu. 2. Record review of Resident #17's EHR revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #17's care plan, dated 11/03/21, revealed the resident was care planned for falls related to his [CONDITION(S)], shortness of breath related to his [CONDITION(S)], and risk of psychosocial wellbeing related to the risk of exposure to Covid-19. Record review of Resident #17's MDS Assessment, dated 04/09/22, revealed the resident had severe cognitive impairment with a BIMS score of three. Record review of Resident #20's EHR revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #20's care plan, dated 03/09/22, revealed the resident was care planned for alteration in thought processes related to her head injury and dementia, potential for difficulty breathing related to her heart failure, and risk for mood alteration related to risk for exposure to Covid-19. Record review of Resident #20's MDS Assessment, dated 02/15/22, revealed the resident had severe cognitive impairment with a BIMS score of seven. Record review of Resident #21's EHR revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #21's care plan, dated, 03/28/22, revealed the resident was care planned for being at risk for nutritional problems, pressure ulcers related to immobility, impaired cognitive function related to dementia, and risk of contracting Covid-19 related to comorbidities and underlying disease processes. Record review of Resident #21's MDS Assessment, dated 02/15/22, revealed the resident had severe cognitive impairment with a BIMS score of four. Observations on 04/19/22 between 8:00 AM - 9:00 AM revealed MA G, during medication pass, checked the blood pressure on Residents #17, #20, #21 with a reusable blood pressure cuff without disinfecting the cuff between each resident. After checking the blood pressure on Resident #20, she discovered her blood pressure was below the parameters for administering the resident's blood pressure medication. MA G summoned LVN C to notify her of Resident #20's blood pressure. LVN C removed a reusable blood pressure cuff from the pocket of her pants and checked the resident's blood pressure. LVN C returned the cuff to her pocket without sanitizing it. Interview on 04/19/22 at 2:08 PM with MA G revealed she was aware of the need to sanitize her blood pressure cuff between residents but simply forgot to do so. She revealed she had been trained to sanitize reusable items between residents as part of her infection control training and failing to sanitize items between residents could expose them to infections from other residents. Review on 04/20/22 at 1:20 PM of the facility's undated policy on Cleansing and Disinfecting Non-Critical Resident Care Items reflected the following: .(1) Non-critical resident-care items include bedpans, blood pressure cuffs, crutches, and computers. (2) Most non-critical re-useable items can be decontaminated where they are used. Interview on 04/20/22 at 2:00 PM with the DON revealed staff were trained in infection control processes, which included sanitizing re-useable equipment between resident uses. Her expectation was that staff followed the policy and failure to follow the policy could result in transmitting germs and bacteria from one resident to another. The DON stated staff were provided with two different sanitizing wipes that they could use to wipe down equipment, carts, etc. She stated the nursing carts and Medication Aide carts were stocked with disinfecting wipes. Interview on 04/20/22 at 2:15 PM with LVN C, LVN E, and LVN F revealed all re-useable equipment should be decontaminated with a wipe before use between residents to prevent spreading infections from one resident to another. LVN B revealed that she should clean her blood pressure cuff after she takes it out of her pocket and before she puts it back in her pocket. 3. Review of Resident #27's annual MDS assessment dated [DATE] reflected an [AGE] year-old female admitted to the facility on [DATE], diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 04/20/22 at 04:20 PM revealed the PTA was in Resident #27's room standing about a foot away from the resident with his surgical mask under his chin, not covering his nose or mouth. The PTA assisted Resident #27 out of bed and transfer into her wheelchair and at that time the PTA noticed surveyor in the hallway and he pulled his surgical mask over his nose and mouth. Interview on 04/20/22 at 12:30 PM with the PTA revealed he did not recall having his surgical mask under his chin as he was assisting Resident #27 out of her bed. He stated the surgical mask must have fell or slid down under his chin. The PTA further stated he had been trained masks were to be worn snug around the face covering his nose and mouth many times due to the risk of transmitting COVID. Interview on 04/20/22 at 2:30 PM with the DON revealed the facility expectation was that masks were to be always worn around residents, covering the nose and mouth. She said risk of not appropriately wearing masks included spreading bacteria. Record Review of facility policy, COVID-19 Outbreak Standards of Practice , revised 1/13/21, revealed the following; standard precautions shall apply to the care of all residents in all situation regradless of suspected or confirmed presenceof infectiouse diseases. Standard precautions include the following practices; hand hygiene, gloves, mask, eye protection, face shields and gowns.

Based on observation, interview and record review the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one (Resident #43) of seven residents reviewed for contracture management. The facility failed to apply rolled washcloth to Resident #43's right hand for contracture management as ordered by the physician. This failure could place residents at risk for a decline in range of motion, decreased mobility, worsening of contractures and a decline in physical capabilities. Findings include: Review of Resident #43's quarterly MDS assessment, dated 01/30/22, reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS further reflected the resident has unclear speech and required extensive assistance of two staff member for bed mobility and total assistance of one staff member for personal hygiene. Review of Resident #43's care plan revised on 07/29/21, reflected the following: The resident has an ADL self-care performance deficit r/t [CONDITION(S)] Review of Resident #43's April 2022 consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #43's TAR for April 2022 revealed the following: wash cloth to right hand at all times every shift for contracture. Observations on 04/19/22 at 4:22 PM and on 04/20/22 at 8:39 AM of Resident #43 revealed she was in bed and only smiled when she was spoken to. The resident's right hand was contracted and there was not a washcloth in place for the contracture. Interview on 04/20/22 at 1:28 PM with CNA A revealed she believed it was therapy or the nurses' job to put the washcloth in Resident #43's hand. The CNA stated there were some days it was on and some days it was not and she also did not believe the resident was able to remove it herself. CNA A further stated she did not know how often the resident was supposed to have the washcloth in her right hand but was aware the wash cloth was used for moisture protection and help lessen the pressure of the contracture. Interview on 04/20/22 at 1:35 PM with CNA B revealed therapy was responsible for placing a washcloth in Resident #43's right hand and it was the nurse's job to ensure it was being done and never the CNA's responsibility. Interview on 04/20/22 at 2:13 PM with the OT and DOR revealed if residents had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Therapy only handled devices such splints as washcloths were mainly used for hygiene to prevent moisture that could lead to skin breakdown. Interview on 04/20/22 at 9:21 AM with LVN C revealed it was the CNA's responsibility to put a washcloth in Resident #43's right hand contracture and it was her job to oversee and ensure it was being done during her shift. The washcloths are only to be changed if they get wet or damp and stated if the washcloth was not in the resident's hand that could lead to skin breakdown or have the fingernails dig into the resident's skin. Review on 04/20/22 at 2:27 PM with the DON revealed she had only been at the facility for 4 weeks and she was not sure what the policy on resident contractures was but would have the charge nurse ensure the washcloths were in place if a resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's policy and procedure titled Resident Mobility and Range of Motion dated 10/2018, reflected the following: 1. Residents will not experience an avoidable reduction in range of motion (ROM), 2. Resident with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM, 3. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable

Based on observation, interview, and record review, the facility failed to ensure licensed nurses and CNAs were able to demonstrate skills and techniques necessary to care for residents needs for (1) of (1) residents reviewed for wound care (Resident #1) and (2) out of (2) residents reviewed for incontinent care (Resident #2 and Resident #3). A. LVN A failed to wash her hands and change her gloves while performing wound care for Resident #1. B. CNA B failed to wash and or sanitize her hands during incontinent care for Resident #2. C. CNA C and CNA D failed to wash or sanitize their hands during incontinent care for Resident #3. This deficient practice placed residents who require wound care and residents who are occasionally or frequently incontinent of bowel and bladder at risk for cross-contamination and/or spread of infection. Findings Include: A. Review of Resident #1's face sheet dated 10/27/20 reflected Resident #1 was an [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's treatment record reflected the resident had wound care orders for a stage 3 coccyx wound. Review of Resident #1's wound care orders dated 10/27/20 reflected and order to cleanse the coccyx wound with normal saline, apply Santyl cover with calcium alginate secure with adhesive dressing, change daily. Review of Resident #1's MDS dated [DATE] reflected the resident had a BIMS score of seven (7) indicating a moderate impaired ability in daily decision making. Review of Resident #1's care plan dated 9/10/20 reflected that the resident had a high risk for skin breakdown due to incontinence and weakness. The resident required incontinent care every two hours and as needed. Resident #1 was at risk for impaired skin breakdown related to impaired mobility and urinary incontinence. During an observation on 10/27/20 at 1:15pm of LVN A, who performed wound care for Resident #1. LVN A entered the room and placed supplies on a clean barrier, on the resident's bedside table. LVN A washed her hands and applied gloves and cleansed Resident #1's wound bed with moisten gauze, pressing her gloves up against the wound bed, but did not wash her hands afterwards. LVN A applied ointment (which was in a small medicine cup) to a dry dressing and placed it on the resident's coccyx wound wearing the same gloves worn to clean the resident's stage 3 coccyx wound. LVN A took off her gloves, washed her hands, and left the room with a bag of trash. During an interview on 10/27/20 at 1:40pm with LVN A who stated that she knew she did not wash or sanitize her hands after she cleansed Resident #1's coccyx wound. LVN A stated she did not usually perform wound care because the facility has a treatment nurse, whom was pulled to work on the floor. LVN A stated that it was important to wash your hands and change your gloves when going from a contaminated area to a clean area to prevent cross contamination. B. Review of Resident #2's face sheet dated 10/27/20 reflected an [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's MDS dated [DATE] reflected the resident had a BIMS score of six (6) indicating the resident had moderate impairment in daily decision making and rarely participated in decision making. Review of Resident #2's care plan dated 3/30/20 reflected the resident was a risk for skin breakdown related to an incontinence. Resident #2 required incontinent care every two hours and as needed. During an observation on 10/27/20 at 2:15pm of CNA B who performed incontinent care for Resident #2 involving a bowel movement. CNA B washed her hands and applied gloves. The CNA B unfastened the resident's brief and cleaned the perineal area. CNA B turned the resident to the right side and folded the soiled brief under the resident's left side and cleaned the resident's rectum and buttock while touching the outside of the wipes package. CNA B took a clean brief but did not wash her hands or change her gloves and placed it under the resident's rectum and buttock. CNA B then turned the resident to the left side and took the soiled brief placed it in the trash while pulling the clean brief covering the resident's buttock and rectum. CNA B fastened the resident's brief, repositioned the linens but did not wash or sanitize her hands or change her gloves. CNA B took off her gloves but did not wash her hands and left the room touching the doorknob. During an interview on 10/27/20 at 2:30 PM of CNA B who stated that she knew she did not wash her hands after removing Resident #2's soiled brief and before handling a clean brief but was not aware that she needed wash her hands at that time. CNA B stated she knew she did not wash or sanitize her hands before leaving the room but thought it was okay because she took off her gloves and sanitized her hands in the hallway. CNA B agreed it was important to wash or sanitize your hands before going from a contaminated area to a clean area and before leaving the room to prevent cross contamination. Review of Resident #3's face sheet dated 10/27/20 reflected an [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's MDS dated [DATE] reflected the resident had a BIMS score of twelve (12) indicating the resident had mild impairment in daily decision making. Review of Resident #3's care plan dated 9/12/19 reflected the resident had a self-care deficit related to history of wounds, impaired mobility and incontinence. Resident #3 required total assistance for incontinent care. During an observation on 10/27/20 at 3:15pm of CNA C and CNA D who performed incontinent care for Resident #3. CNA C and CNA D sanitized their hands in the hallway and entered the resident's room. CNA C opened the residents nightstand drawer and the resident's closet with her gloved hands. CNA C left the room without washing or sanitizing her hands. CNA C returned to the room with a clean brief and sat it on the resident's bedside table but did not wash or sanitize her hands after entering the resident's room. CNA C unfastened the resident's brief and cleaned the resident's perineal area while CNA D assisted in turning the resident to the right side while CNA C cleansed the residents rectum and buttock, wiping off fecal matter getting fecal matter on her gloves. CNA C placed the soiled brief in the trash and took a clean brief and placed it under the resident but did not wash or sanitize her hands prior to handling the inside of the clean brief. CNA C changed her gloves but did not wash or sanitized her hands. CNA C and CNA D repositioned the resident and the resident's linens. CNA C and CNA D took off their gloves and left the room without washing or sanitizing their hands. During an interview on 10/27/20 at 3:45 PM with CNA C and CNA D, stated they were not aware they had to wash or sanitize their hands before and after resident care. CNA A stated she was not aware she needed to wash her hands after handling Resident #3's soiled brief and before touching the inside of a clean brief. CNA A and CNA B stated they thought they could sanitize their hands after leaving the resident's room. CNA A and CNA B agreed it was important to wash and or sanitize your hands before, after, and when going from a contaminated area to a clean area to prevent cross contamination. During an interview on 10/27/20 at 4 PM with LVN E who stated that she expected the CNAs to wash their hands and change their gloves when going from a contaminated area to clean area during incontinent care. LVN E stated that she expected CNAs to not touch the outside of the wipes package while performing incontinent care. LVN E stated that she thought that when a CNA performs incontinent care involving fecal matter, the CNA should wash their hands with soap and water to prevent cross contamination. LVN E stated it was important for CNAs to sanitize their hands and change their gloves when going from a contaminated area to a clean area to prevent cross-contamination and or the spread of infection. During an interview on 10/27/20 at 5:15 PM with the DON, stated that he expected staff to wash their hands and change their gloves before, after, and when going from a contaminated area to a clean area during incontinent care. The DON stated that he expected staff to wash their hands before leaving the room to prevent cross contamination. The DON stated he expected the nurse to wash her hands after cleaning a resident's wound if they used their gloves hands to press against a resident's wound bed. The DON stated this was important to prevent cross contamination. During an interview on 10/27/20 at 5:20 PM with the Administrator who stated that during incontinent care she expects staff to wash their hands and change their gloves before, after, before leaving the resident's room, and when going from a contaminated area to a clean area. The Administrator stated that this was important to prevent cross contamination and the spread of germs. During a review of the facilities' policy on 10/27/20 titled Hand Washing dated August 2012 reflected staff should wash hands and change gloves when coming into contact a resident's intact skin, after contact with the resident's body fluids, when hands are visible soiled, before and after direct resident contact for which hand hygiene is acceptable practice. During a review of the facilities' policy titled Perineal Care dated March October 2010 reflected, Hand hygiene products and supplies should be readily available including alcohol-based hand rub, Hand washing with soap and water should occur when hands are visible soiled, Staff should wash or sanitize their hands before and after contact with a resident, After contact with body fluids and before moving from a contaminated area to a clean area, After contact with body fluids.

Based on observation, interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for (1) of (1) residents reviewed for wound care (Resident #1) and (2) out of (2) residents reviewed for incontinent care (Resident #2 and Resident #3). A. LVN A failed to wash her hands and change her gloves while performing wound care for Resident #1. B. CNA B failed to wash and or sanitize her hands during incontinent care for Resident #2. C. CNA C and CNA D failed to wash or sanitize their hands during incontinent care for Resident #3. This deficient practice placed residents who require wound care and residents who are occasionally or frequently incontinent of bowel and bladder at risk for cross-contamination and/or spread of infection. Findings Include: A. Review of Resident #1's face sheet dated 10/27/20 reflected Resident #1 was an [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's treatment record reflected the resident had wound care orders for a stage 3 coccyx wound. Review of Resident #1's wound care orders dated 10/27/20 reflected and order to cleanse the coccyx wound with normal saline, apply Santyl cover with calcium alginate secure with adhesive dressing, change daily. Review of Resident #1's MDS dated [DATE] reflected the resident had a BIMS score of seven (7) indicating a moderate impaired ability in daily decision making. Review of Resident #1's care plan dated 9/10/20 reflected that the resident had a high risk for skin breakdown due to incontinence and weakness. The resident required incontinent care every two hours and as needed. Resident #1 was at risk for impaired skin breakdown related to impaired mobility and urinary incontinence. During an observation on 10/27/20 at 1:15pm of LVN A, who performed wound care for Resident #1. LVN A entered the room and placed supplies on a clean barrier, on the resident's bedside table. LVN A washed her hands and applied gloves and cleansed Resident #1's wound bed with moisten gauze, pressing her gloves up against the wound bed, but did not wash her hands afterwards. LVN A applied ointment (which was in a small medicine cup) to a dry dressing and placed it on the resident's coccyx wound wearing the same gloves worn to clean the resident's stage 3 coccyx wound. LVN A took off her gloves, washed her hands, and left the room with a bag of trash. During an interview on 10/27/20 at 1:40pm with LVN A who stated that she knew she did not wash or sanitize her hands after she cleansed Resident #1's coccyx wound. LVN A stated she did not usually perform wound care because the facility has a treatment nurse, whom was pulled to work on the floor. LVN A stated that it was important to wash your hands and change your gloves when going from a contaminated area to a clean area to prevent cross contamination. B. Review of Resident #2's face sheet dated 10/27/20 reflected an [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's MDS dated [DATE] reflected the resident had a BIMS score of six (6) indicating the resident had moderate impairment in daily decision making and rarely participated in decision making. Review of Resident #2's care plan dated 3/30/20 reflected the resident was a risk for skin breakdown related to an incontinence. Resident #2 required incontinent care every two hours and as needed. During an observation on 10/27/20 at 2:15pm of CNA B who performed incontinent care for Resident #2 involving a bowel movement. CNA B washed her hands and applied gloves. The CNA B unfastened the resident's brief and cleaned the perineal area. CNA B turned the resident to the right side and folded the soiled brief under the resident's left side and cleaned the resident's rectum and buttock while touching the outside of the wipes package. CNA B took a clean brief but did not wash her hands or change her gloves and placed it under the resident's rectum and buttock. CNA B then turned the resident to the left side and took the soiled brief placed it in the trash while pulling the clean brief covering the resident's buttock and rectum. CNA B fastened the resident's brief, repositioned the linens but did not wash or sanitize her hands or change her gloves. CNA B took off her gloves but did not wash her hands and left the room touching the doorknob. During an interview on 10/27/20 at 2:30 PM of CNA B who stated that she knew she did not wash her hands after removing Resident #2's soiled brief and before handling a clean brief but was not aware that she needed wash her hands at that time. CNA B stated she knew she did not wash or sanitize her hands before leaving the room but thought it was okay because she took off her gloves and sanitized her hands in the hallway. CNA B agreed it was important to wash or sanitize your hands before going from a contaminated area to a clean area and before leaving the room to prevent cross contamination. Review of Resident #3's face sheet dated 10/27/20 reflected an [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's MDS dated [DATE] reflected the resident had a BIMS score of twelve (12) indicating the resident had mild impairment in daily decision making. Review of Resident #3's care plan dated 9/12/19 reflected the resident had a self-care deficit related to history of wounds, impaired mobility and incontinence. Resident #3 required total assistance for incontinent care. During an observation on 10/27/20 at 3:15pm of CNA C and CNA D who performed incontinent care for Resident #3. CNA C and CNA D sanitized their hands in the hallway and entered the resident's room. CNA C opened the residents nightstand drawer and the resident's closet with her gloved hands. CNA C left the room without washing or sanitizing her hands. CNA C returned to the room with a clean brief and sat it on the resident's bedside table but did not wash or sanitize her hands after entering the resident's room. CNA C unfastened the resident's brief and cleaned the resident's perineal area while CNA D assisted in turning the resident to the right side while CNA C cleansed the residents rectum and buttock, wiping off fecal matter getting fecal matter on her gloves. CNA C placed the soiled brief in the trash and took a clean brief and placed it under the resident but did not wash or sanitize her hands prior to handling the inside of the clean brief. CNA C changed her gloves but did not wash or sanitized her hands. CNA C and CNA D repositioned the resident and the resident's linens. CNA C and CNA D took off their gloves and left the room without washing or sanitizing their hands. During an interview on 10/27/20 at 3:45 PM with CNA C and CNA D, stated they were not aware they had to wash or sanitize their hands before and after resident care. CNA A stated she was not aware she needed to wash her hands after handling Resident #3's soiled brief and before touching the inside of a clean brief. CNA A and CNA B stated they thought they could sanitize their hands after leaving the resident's room. CNA A and CNA B agreed it was important to wash and or sanitize your hands before, after, and when going from a contaminated area to a clean area to prevent cross contamination. During an interview on 10/27/20 at 4 PM with LVN E who stated that she expected the CNAs to wash their hands and change their gloves when going from a contaminated area to clean area during incontinent care. LVN E stated that she expected CNAs to not touch the outside of the wipes package while performing incontinent care. LVN E stated that she thought that when a CNA performs incontinent care involving fecal matter, the CNA should wash their hands with soap and water to prevent cross contamination. LVN E stated it was important for CNAs to sanitize their hands and change their gloves when going from a contaminated area to a clean area to prevent cross-contamination and or the spread of infection. During an interview on 10/27/20 at 5:15 PM with the DON, stated that he expected staff to wash their hands and change their gloves before, after, and when going from a contaminated area to a clean area during incontinent care. The DON stated that he expected staff to wash their hands before leaving the room to prevent cross contamination. The DON stated he expected the nurse to wash her hands after cleaning a resident's wound if they used their gloves hands to press against a resident's wound bed. The DON stated this was important to prevent cross contamination. During an interview on 10/27/20 at 5:20 PM with the Administrator who stated that during incontinent care she expects staff to wash their hands and change their gloves before, after, before leaving the resident's room, and when going from a contaminated area to a clean area. The Administrator stated that this was important to prevent cross contamination and the spread of germs. During a review of the facility's' policy on 10/27/20 titled Hand Washing dated August 2012 reflected staff should wash hands and change gloves when coming into contact a resident's intact skin, after contact with the resident's body fluids, when hands are visible soiled, before and after direct resident contact for which hand hygiene is acceptable practice. During a review of the facility's policy titled Perineal Care dated March October 2010 reflected, Hand hygiene products and supplies should be readily available including alcohol-based hand rub, Hand washing with soap and water should occur when hands are visible soiled, Staff should wash or sanitize their hands before and after contact with a resident, After contact with body fluids and before moving from a contaminated area to a clean area, After contact with body fluids.

Based on observation, interview and record review, the facility failed to ensure it was free of a medication rate of five percent (5%) or greater. There were two medication errors observed out of 33 opportunities resulting in an 6% medication error rate. One (MA A) of two staff observed made two errors during the medication pass for one (Resident #23) of three residents observed. MA A failed to administer Resident #23's [MEDICATION NAME] 100 mg capsule and [MEDICATION NAME] 75 mg tablet correctly when she crushed the two medications. These failures could affect the 50 residents, who MA A administered medications to, by placing them at risk for not receiving therapeutic dosages of their medications as ordered by the physician which could result in a decline in health status. Findings included: Observation of MA A on 07/19/18 at 9:20 a.m. revealed she administered Resident #23's Pheyntoin (medication used to control [MEDICAL CONDITION]) capsules by opening the two capsules and putting them in a small cup of pudding. MA A also crushed Resident #23's film coated [MEDICATION NAME] (medication used to help prevent blood clots) capsule and put it in the small cup of pudding. Review of Resident #23's (MONTH) (YEAR) Physician order [REDACTED]. 07/14/16: [MEDICATION NAME] Sodium Extended Release 100 mg capsule. Take 2 capsules by mouth 2 times daily **DO NOT CRUSH** 07/14/16: [MEDICATION NAME] 75 mg tablet. Take 1 tablet by mouth daily. **DO NOT CRUSH** Interview with MA A on 07/19/18 at 10:59 a.m. revealed she was not aware she was not supposed to open the [MEDICATION NAME] capsules and she did not think by opening the capsules that would constitute as crushing the medication. She stated she must have missed the directions on the MAR (Medication Administration Record) which stated not to crush the [MEDICATION NAME]. She stated she would ensure not to crush or open those capsules in the future. Review of Resident #23's MAR for (MONTH) (YEAR) reflected there were **DO NOT CRUSH** instructions beside the [MEDICATION NAME] order and the [MEDICATION NAME] order. Review of [MEDICATION NAME]'s drug information accessed at https://www.cvs.com/drug/[MEDICATION NAME]/oral-capsule-extended-release on 07/19/18 at 11:23 a.m. reflected the following: If you are taking extended-release capsules, swallow them whole. Do not crush or chew. Review of information of the drug information on [MEDICATION NAME] ([MEDICATION NAME]) accessed at http://stroke.emedtv.com/[MEDICATION NAME]/[MEDICATION NAME]-dosage.html on 07/19/18 at 11:37 a.m. reflected the following: While the [MEDICATION NAME] dosage can be taken with or without food, it's important not to break, chew, or crush the tablets. Review of the facility's Medication Administration Guidelines dated 05/2016 reflected the following: The need for crushing medications is indicated on the resident's orders and the MAR indicated [REDACTED].Long-acting, extended release or [MEDICATION NAME]-coated dosage forms should generally not be crushed; an alternative should be sought . 4. Review of the list of residents provided by the DON on 07/18/18 reflected 50 residents received medications from MA A.

Based on observation, interview and record review the facility failed to ensure residents were free of significant medications errors for one (Resident #23) of three residents observed during medication pass. MA A failed to administer Resident #23's [MEDICATION NAME] 100 mg capsule correctly when she opened the extended release capsule and put it in pudding. These failures could affect the 50 residents, who MA A administered medications to, by placing them at risk for not receiving therapeutic dosages of their medications as ordered by the physician which could result in a decline in health status. Findings included: Observation of MA A on 07/19/18 at 9:20 a.m. revealed she administered Resident #23's Pheyntoin (medication used to control [MEDICAL CONDITION]) capsules by opening the two capsules and putting them in a small cup of pudding and administering it to the resident. Review of Resident #23's (MONTH) (YEAR) Physician order [REDACTED]. 07/14/16: [MEDICATION NAME] Sodium Extended Release 100 mg capsule. Take 2 capsules by mouth 2 times daily **DO NOT CRUSH** Interview with MA A on 07/19/18 at 10:59 a.m. revealed she was not aware she was not supposed to open the [MEDICATION NAME] capsules and she did not think by opening the capsules that would constitute as crushing the medication. She stated she must have missed the directions on the MAR (Medication Administration Record) which stated not to crush. She stated she would ensure not to crush or open those capsules in the future. Review of Resident #23's MAR for (MONTH) (YEAR) reflected there were **DO NOT CRUSH** instructions beside the [MEDICATION NAME] order. Review of [MEDICATION NAME]'s drug information accessed at https://www.rxlist.com/[MEDICATION NAME]-drug/patient-images-side-effects.htm#nottake on 07/30/18 at 10:53 a.m. reflected the following: Do not crush, chew, break, or open an extended-release capsule. Swallow it whole. Breaking or opening the pill may cause too much of the drug to be released at one time .Overdose symptoms may include twitching eye movements, slurred speech, loss of balance, tremor, muscle stiffness or weakness, nausea, vomiting, feeling light-headed, [MEDICAL CONDITION], and slow or shallow breathing. Review of the facility's Medication Administration Guidelines dated 05/2016 reflected the following: The need for crushing medications is indicated on the resident's orders and the MAR indicated [REDACTED].Long-acting, extended release or [MEDICATION NAME]-coated dosage forms should generally not be crushed; an alternative should be sought . Review of the list of residents provided by the DON on 07/18/18 reflected 50 residents received medications from MA A.

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 (Residents #1) of three residents reviewed for accidents. The facility staff failed to have Resident #1's fall mat in place at the time of her fall. The resident sustained [REDACTED]. These failures placed the 22 residents who were a high fall risk and required a fall mat at risk for accidents and injuries. Findings included: Review of Resident #1's MDS assessment dated [DATE] revealed she was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #1 required total assistance of two staff members for bed mobility and transfers due to limited range of motion to upper and lower extremities. Review of the Resident Incident Report for Resident #1 dated 05/25/18, revealed the following: CNA notified charge nurse that resident was on floor beside bed. Observed resident on floor beside bed. Resident stated she fell forward resident unable to explain further details about accident. noted half side rail up on L side of bed and bed in lowest position. Noted cal light within reach. Noted half of res body underneath bed when charge nurse arrived Mild bruising to L hip. Mild bruising 6X4CM with abrasion to L lateral knee ordered stat xray of L knee and L hip. Review of the POS [REDACTED] .Immediate Post-Incident Action: Inservice staff to keep floor mat in place at all times while res is in bed CT scan dated 05/25/18 of Resident #1 reflected: .Impression: Redemonstration of an acute impacted fracture involving the right femoral head/neck region with small joint space effusion. Diffuse osteopenia. Mild osteoarthritic changes to both hip joints Review of Resident #1's care plan with an onset date of 12/12/13 revealed she was at risk for injury related to potential falls related to weakness to bilateral lower ext. Approaches included HI/Low bed with floor mat. Resident #1's monthly physician orders [REDACTED]. Observation of Resident #1 on 06/21/18 at 10:04 am revealed she was in bed lying on a scoop mattress with her eye closed did not arouse to verbal stimuli. Her call light was in place and there was a fall mat next to her bed. An interview on 06/21/18 at 11:37 am with ADON A revealed, the aides were making their last round when she was told Resident #1 was on the floor. When she walked in she noticed the fall mat was standing on the other side of the bed, not in place. Resident #1 was on the floor and part of her legs were under the bed. The resident did not appear to be in any distress at first, but after she was gotten up, she began to complain of pain to her hip, but was not able to say which one. ADON A further stated falls mats were to be in place, next to the beds, while residents are on bed. Review of an undated hand written statement by CNA D reflected the following: Around 5am I went in th resident's room to change roommate and I noticed that Resident #1 was on the floor so I called the nurse to come check her. She was on her side and her legs were halfway under the bed. CNA D was no longer employed with the facility and attempts to contact her were unsuccessful. An interview with the DON on 06/21/18 at 2:53 pm revealed, he was called and told Resident #1 had been found on the floor and believes she might had slid out of the bed. She was sent out for xrays because there was bruising to hip. The resident was in a low bed and the fall mat was not in place at the time of the fall. He further stated the fall mats should be in place when the residents are in bed. The staff were inserviced and a list of residents requiring fall mats was placed at each nursing station for staff to check at each shift. An observation on 06/21/18 revealed the facility had two nurse's station and each station had a list of residents that required a fall mat. Observations on 06/21/18 at 9:45 am revealed Resident #4 was in bed with the bed in the lowest position and there was a fall mat in place. Observation on 06/21/18 at 1:52 pm of Resident #3 revealed she was lying in bed and there was a fall mat in place. An inservice held on 05/25/18 reflected the following Anytime there is a fall mat by bed ensure fall mat is placed by bed after providing ADL care on resident. CNA's from each shift participated and a one on one inservice was held with CNA D. Review of the facility's Incident and Accident Process revised (MONTH) (YEAR) reflected the following Purpose: The purpose of the incident and accident process is to ensure the facility environment is as free from accident hazards over which the facility has control and that each resident receives adequate supervision and assertive devices to prevent avoidable accidents Review of a list provided by the Administrator on 06/21/18 revealed there were 22 residents that required fall mats.

Based on observation, interview and record review, the facility failed to ensure the right of residents to be free from neglect when one (Resident #15) of 23 residents, who had history of elopement, continued to exit the facility due failure to provide an appropriate level of supervision 1. The facility failed to ensure interventions were put in place to keep Resident #15 from eloping from the facility three times (04/01/17, 06/30/17, and 07/16/17) within the past four months. 2. The facility failed to provide adequate supervision to prevent Resident #15 from eloping from the facility. 3. The facility failed to ensure Resident #15's care plan was updated after incidents of elopement with supervision needs and elopement precautions necessary to prevent the resident from eloping from the facility. An Immediate Jeopardy situation was identified on 07/20/17. The Immediate Jeopardy was removed on 07/21/17. The facility remained out of compliance at severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. This failure could affect the five residents assessed as high elopement risks, and place them at risk for elopement, serious injury, and/or death. Findings Included: 1. Review of Resident #15's face sheet revealed he was a [AGE] year old male admitted on [DATE]. Review of Resident #15's MDS assessment, dated 05/09/17, reflected he had moderate cognitive impairment. Review of the functional ability of Resident #15 reflected he required no help or staff oversight with locomotion. Resident #15's active [DIAGNOSES REDACTED]. Review of Resident #15's care plan, dated 10/03/16, reflected the following interventions: Educate resident regarding acceptable alternatives to identified behaviors and document response/understanding Wander Guard as appropriate; verify placement and function per protocol Monitor whereabouts when wandering and redirect as needed Approach in a calm manner When confused or experiencing psychotic disturbances do not attempt to bring to reality Respect personal space with interactions If resident refuses/rejects care/interventions, assure safety and leave immediate area. Reapproach in 5-10 minutes or provide alternate caregiver. Document response. Avoid confrontation when agitated Notify MD, family, responsible party of changes as needed. Attempt gradual dose reduction of psych meds as clinically appropriate Check oxygen sats with changes in level of cognition and/or anxiety; Oxygen as ordered Rule out medical complication with changes in behavior Refer to Psych services as needed with exacerbation or inability to effectively redirect behaviors Meds/labs as ordered Social services visits as needed Set Limits Review of Resident #15's initial elopement assessment, completed on 08/10/16, reflected he had one to two incidents of elopement in the past 6 months, was at risk for elopement, was oriented to person and place, displayed impulsive behaviors, and would be fitted with a Wander Guard (an alarm system which includes a bracelet or anklet the resident wears and when they go too close to the exit doors, an alarm will sound alerting staff.) Subsequent elopement assessments for Resident #15, completed on 11/02/16, 02/02/17, and 05/07/17, reflected no change in Resident #15 elopement risk status. A physician's orders [REDACTED]. A nurse's note on 04/01/17 for Resident #15 reflected on 04/01/17 at 11:30 a.m., Resident #15 eloped out the front door and went to the back of the building. Resident #15 was seen trying to cross a ditch when a staff member saw him and redirected him back inside. Resident #15 stated he had left the facility because he was trying to pray for a dead tree. Resident #15 was put on 30-minute visual checks until a new Wander Guard bracelet was placed on his wrist. 2. Interview with the DON on 07/21/17 at 3:27 p.m. revealed he did not remember the first elopement incident on 04/01/17 after reviewing the nurse's note. He stated he might have been on vacation then. 3. Review of the incident reports for the past six months reflected there was no incident report about the elopement on 04/01/17. 4. Review of Resident #15's care plan, dated 10/03/16, reflected no new interventions after the elopement on 04/01/17. 5. An incident report, dated 07/01/17, revealed Resident #15 was reported to be outside in the field adjacent to the facility by another resident on 06/30/17 at 7:30 p.m. A nurse and two CNAs chased after the resident and returned him to the facility. He was weak and hot, wearing sweat pants and sweat shirt. He stated he was just going for a walk. The time he exited the building was not known. 6. Review of Resident #15's nurse's note reflected an entry on 06/30/17 at 8:11 p.m. for Resident #15 which reflected at 7:30 p.m. another resident alerted the nurses that Resident #15 was walking in a field beside the facility. The nurse and two other CNAs chased after the resident and redirected him to the facility. Resident #15 was red faced, sweaty, and visibly weak. The staff had to stop a few times on the walk back to the facility to let Resident #15 rest. Resident #15 stated he had gone out the window. Resident #15 was assisted back into the facility and was assisted to a couch and given a glass of ice water. Resident #15 drank all of the water and his RP (responsible party) was notified. RP had stated, he just doesn't know his limitations. Nurses' note on 06/30/17 for Resident #15 reflected when the staff guided Resident #15 to the front door to check if the Wander Guard was working, Resident #15 was able to tell the nurse the code to shut off the alarm. Nurse's note by the DON on 07/01/17 for Resident #15 reflected Resident #15 explained that he went out the window because it was easier, and he went out into the field to check on a car that was out there. The DON explained to Resident #15 he could not leave the facility without staff supervision because of safety reasons. Resident #15 promised the DON to request staff to go with him next time he wanted to take a walk. Resident #15's care plan, dated 10/03/16, reflected on 06/30/17 one intervention was put in place which included placing Resident #15 on 15 minute visual checks for 72 hours. 7. Observation of Resident #15's window on 07/20/17 at 2:00 p.m. revealed the window was unsecured and could be opened all the way. The screen was loose and appeared to have been pushed out from the inside. 8. Interview with the DON on 07/21/17 at 12:20 p.m. revealed all the windows in resident's rooms could be raised and the facility, after surveyor intervention, was in the process of securing the windows in all the rooms with elopement risk residents so they would only open about six inches. Interview with the DON on 07/20/17 at 12:17 p.m. revealed Resident #15 was put on 15 minute visual checks for 72 hours after he eloped by going out the window. The DON revealed he discontinued the 15 minute checks because Resident #15 had promised he would not elope again and ask staff if he wanted to go outside. 9. Review of https://www.wunderground.com/history/airport/KCPT/2017/6/30/DailyHistory.html?req_city=Cleburne&req_state=TX&req_statename=Texas&reqdb.zip= &reqdb.magic=1&reqdb.wmo= , accessed on 07/24/17, at 4:11 p.m. reflected the high temperature for the area around the facility on 06/30/17 was 93 degrees Fahrenheit, and the heat index was 100.1 degrees at 7:15 p.m. 10. Review of an incident report, dated 07/17/17, revealed Resident #15 turned off the alarm at the exit door on 600 hall and left the faciity on [DATE]. He walked to the local high school and then got a ride back to the facility from someone there. He returned to the facility at 12:15 p.m. and the exact time he left was not listed. 11. Observation of the area outside the 600 hall emergency exit door on 07/21/17 at 11:30 a.m. revealed the school was on the other side of a large field. The field had a slope about two-feet high covered with rock along the edge. This was the path Resident #15 took on 07/16/17, according to the resident. 12. Review of https://www.google.com/maps/place/Heritage+Trails+Nursing+%26+Rehabilitation/@32XXX 63,-97XXX ,17z/data=!4m5!3m4!1s0x864e47bf3aa21c7f:0xb12d73c5b7b113d2!8m2!3d32XXX 68!4d-97XXX 1, accessed on 07/27/17, at 9:18 a.m. reflected a distance of 2500 feet (0.47 miles) from the facility across the field to the nearest school. 13. Observation of the door alarms in the facility on 07/20/17 at 2:40 p.m. revealed halls 100, 200, 500, and 600 had only a simple door alarm installed about five-feet high, which could be disarmed by moving a sliding switch to one side. The exit doors on 300 and 400 halls, as well as the front door, had Wander Guard alarms and a keypad alarm which required a key or alarm code to disarm. 14. Review of Resident #15's care plan, dated 10/03/16, reflected no new interventions were put in place after the 07/16/17 elopement. 15. Interview with the DON on 07/20/17 at 1:30 p.m. revealed Resident #15 had a Wander Guard on admission. He said four halls (100, 200, 500, and 600) did not have a Wander Guard alarm installed. They had only a door alarm which could be turned off with a toggle switch located on the front of the alarm unit. He said Resident #15 had turned off the alarm on 600 hall on 07/16/17 and exited the facility through this door without alerting anyone. He said no one had ever gone out any of those doors that they were basically not used and, after this incident, new alarms had been ordered which would require a key to disarm. He stated the alarms were only checked once per shift to ensure they were working. 16. Review of https://www.wunderground.com/history/airport/KCPT/2017/7/16/DailyHistory.html?req_city=Cleburne&req_state=TX&req_statename=Texas&reqdb.zip= &reqdb.magic=1&reqdb.wmo= , accessed on 07/24/17, at 4:09 p.m. reflected the high temperature around the facility on 07/16/17 was 95 degrees Fahrenheit, and the heat index high was 101.3. 17. Interview with Resident #15 on 07/20/17 at 1:45 p.m. revealed he had left the facility out his window on 06/30/17 because he thought someone in a car might need help. He said he left the facility out the 600 hall exit door on 07/16/17 because he thought he needed to do something at the school. He said he made it all the way to the school across the field before he got tired and asked for a ride to get back. 18. Interview by phone with a family member of Resident #15 on 07/21/17 at 3:20 p.m. revealed the resident had lived with them except for a short stay at another facility. She stated Resident #15 used to live in a little house behind hers, but they were concerned for his safety because he would go wandering around at night and have to be brought back home. She stated she was concerned for his safety because his behavior was very erratic, had no safety awareness, and was confused. 19. Interview with the DON on 07/20/17 at 12:17 p.m. revealed Resident #15 did not have a Wander Guard when he was admitted and it was not until two weeks later, but neither the DON nor ADON could remember why. The DON stated that the policy was if a resident was assessed as an elopement risk, they were given a Wander Guard. The DON revealed that when Resident #15 lived at home, he would do things that worried the family. Resident #15 went out to the neighbor's car to get cigarettes and that was the only history he knew of eloping prior to his admission to the facility. He stated he was not comfortable with Resident #15 going out of the facility because of safety concerns (the extreme heat) and Resident #15's history of poor judgement. He stated Resident #15 had cardiovascular problems and a history of [MEDICAL CONDITION], and so there were times that he was not as oriented as normal. He stated he was afraid something might happen to Resident #15 if he eloped from the facility because of his poor decisions and judgement. 20. Interview with CNA A on 07/21/17 at 1:20 p.m. revealed she had worked at the facility for four years and was Resident #15's CNA. She stated Resident #15 wanders around all the time and tries to go out the front door. She said they have to redirect him to his room. She stated he tried to exit through the front door often, but he never eloped during her shift. 21. Interview with CNA B on 07/21/17 at 1:25 p.m. revealed Resident #15 tried to go out the front door a few times during her shift (the 6 a.m.-2 p.m. and sometimes the 10 p.m.-6 a.m.), but they just lead him away from the door. She stated they checked his Wander Guard once per shift, along with all the other elopement risk residents. 22. Interview with RN C on 07/21/17 at 1:30 p.m. revealed she was Resident #15's nurse. She stated Resident #15 had a Wander Guard that would set off an alarm if he went near an exit. She stated Resident #15 liked to go outside and check on stuff, and that was probably why he tried to elope. 23. Interview with CNA D on 07/21/17 at 1:40 p.m. revealed she was Resident #15's CNA when he was first admitted to the facility. She stated they would have to keep an eye on Resident #15 because he would try to go out the front door or other exit doors and they would have to stop him and redirect him. 24. Interview with CNA E on 07/21/17 at 1:56 p.m. revealed she had worked with Resident #15 during his stay at the facility. She stated Resident #15 would look and watch the staff to see if he could find a way out of the building, but would go back to his room if he noticed someone was watching him. She stated she knew he was a high elopement risk. CNA E stated she believed Resident #15 would elope if he had a task or mission in mind. 25. Review of Resident #15's nurse's notes from July 2016 to July 2017 reflected Resident #15 had a history of [REDACTED]. staring at them, and waiting near the front door to assist a CNA to her car after following her around the facility and petting her hair. 26. Review of the 'Q 15 Min Checks' dated 07/16/17 through 07/21/17 reflected Resident #15 was being monitored by staff every 15 minutes and various staff initialed and recorded the location of Resident #15. 27. Review of the facility's policies revealed the following: The policy, dated 01/2007, reflected Neglect-failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness . Leaving someone unattended who needs supervision. The elopement policy, dated August 2015, reflected the Definition of Elopement: Elopement is the ability of a resident who is not capable of protecting himself or herself from harm to successfully leave the facility unsupervised and unnoticed and who may enter into harm's way . Protocol: All residents will be assessed on admission; re-admission; quarterly and with changes of condition for risk factors that would place the resident at risk for elopement such as wandering, previous history of elopement or exit seeking behavior . Immediate Interventions For Resident Safety: 1. In the event of elopement or onset of exit seeking behavior .the resident will be put on behavior monitoring for elopement/exit seeking behavior until the behavior subsides . 4. Interventions to reduce the risk of elopement will be updated to the resident's Care Plan and communicated with staff. 28. An Immediate Jeopardy (IJ) was identified on 07/20/17. The Administrator and DON were informed of the IJ on 07/20/17 at 4:15 p.m. and a Plan of Removal was requested at that time. 29. The facility's Plan of Removal reflected: A Plan of Action has been implemented to address the identified issue of Failure to prevent elopement for one resident. (1.) Identified resident was reassessed for elopement on 07/21/17 following return from hospital for an unrelated change in condition. Resident was identified at risk for elopement. A wander guard was immediately placed on the resident. Staff was placed at each nurse's station to monitor the four doors that were identified for risk. Adjustments have been made to window in resident's room by placing screws to prevent window from rising high enough for resident to exit. (2.) New alarms for identified doors at risk were ordered on July 17th and are expected to arrive any day. Alarms have been confirmed to be in transit. (3.) Four doors identified at risk will be continuously monitored via line of sight until alarms are installed and functioning properly. Monitors are currently assigned to each station and scheduled until new alarms are installed. On 07/21/17 maintenance installed covers over the alarm switch to keep residents and visitors from turning the alarm off. (4.) All residents currently at risk for elopement will be re-evaluated, and completed on 7-20-17. All residents that are high risk for elopement will receive a wander guard bracelet (as ordered); their names will be added to a list and a notebook will be placed at each nurse's station to alert staff that these residents are identified for high risk of elopement. The wander guard bracelet will be monitored for functionality, and placement every day. When alarm sounds doors will be checked, head count will be assessed and then grounds will be checked, if a resident is not present at the door. (5.) Re-education by in-servicing staff on the facility Elopement protocol initiated July 20, 2017 and will be completed on 7-21-17 for available staff. Will continue to in-service additional staff upon their return to work prior to scheduled duties. (6.) For all residents that have been identified as Elopement Risk adjustments have been made to windows with screws to prevent window from rising high enough for resident to exit. 30. To verify the facility implemented their Plan of Removal, the following observations, interviews and record reviews were conducted: Interviews on 07/21/17 from 1:20 p.m. to 2:46 p.m. regarding how often Wander Guard bracelets are checked, door monitoring, elopement risk assessments, and the elopement policy revealed staff had been in-serviced and were able to answer all questions correctly. The following staff were in-serviced from each shift: 6:00 a.m. to 2:00 p.m. - CNA H, CNA I, CNA J, RN C, CNA L, CNA M, and MA N. 2:00 p.m. to 10:00 p.m. - CNA F, CNA K, CNA D, and CNA E. 10:00 p.m. to 6:00 a.m. - CNA A, CNA B, and CNA O. Cook P, Cook Q, Housekeeper R, and Housekeeper S were also interviewed. Observation of Resident #15's window on 07/21/17 at 1:45 p.m. revealed the window had been secured with screws so that it would only open about six inches. Observation of alarms on 100, 200, 500, and 600 halls on 07/21/17 at 2:00 p.m. revealed all four alarms had a plastic cover installed over them that would prevent access to the switch. 31. On 07/21/17, the Immediate Jeopardy (IJ) was removed. On 07/21/17 at 4:00 p.m. the Administrator and DON was informed the IJ was removed. While the IJ was removed on 07/21/17, the facility remained out of compliance at severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. 32. Review of the 07/18/17 list of Residents with Wander Guards reflected there were six residents who were elopement risks. One resident passed away on 07/20/17, so there were five residents remaining in the facility who were elopement risks.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent neglect of residents for one (Resident #15) of 23 residents reviewed for neglect. 1. The facility failed to ensure interventions were put in place to keep Resident #15 from eloping from the facility three times (04/01/17, 06/30/17, and 07/16/17) within the past four months. 2. The facility failed to provide adequate supervision to prevent Resident #15 from eloping from the facility. 3. The facility failed to ensure Resident #15's care plan was updated after incidents of elopement with supervision needs and elopement precautions necessary to prevent the resident from eloping from the facility. An Immediate Jeopardy situation was identified on 07/20/17. The Immediate Jeopardy was removed on 07/21/17. The facility remained out of compliance at severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. This failure could affect the five residents assessed as high elopement risks, and place them at risk for elopement, serious injury, and/or death. Findings included: 1. Review of the facility's policy reflected the following: The facility's policy, dated 01/2007, reflected Neglect-failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness . Leaving someone unattended who needs supervision The facility's elopement policy, dated August 2015, reflected the Definition of Elopement: Elopement is the ability of a resident who is not capable of protecting himself or herself from harm to successfully leave the facility unsupervised and unnoticed and who may enter into harm's way . Protocol: All residents will be assessed on admission; re-admission; quarterly and with changes of condition for risk factors that would place the resident at risk for elopement such as wandering, previous history of elopement or exit seeking behavior . Immediate Interventions For Resident Safety: 1. In the event of elopement or onset of exit seeking behavior .the resident will be put on behavior monitoring for elopement/exit seeking behavior until the behavior subsides . 4. Interventions to reduce the risk of elopement will be updated to the resident's Care Plan and communicated with staff. 2. Review of Resident #15's face sheet revealed he was a [AGE] year old male admitted on [DATE]. Review of Resident #15's MDS assessment, dated 05/09/17, reflected he had moderate cognitive impairment. Review of the functional ability of Resident #15 reflected he required no help or staff oversight with locomotion. Resident #15's active [DIAGNOSES REDACTED]. Review of Resident #15's care plan, dated 10/03/16, reflected the following interventions: Educate resident regarding acceptable alternatives to identified behaviors and document response/understanding Wander Guard as appropriate; verify placement and function per protocol Monitor whereabouts when wandering and redirect as needed Approach in a calm manner When confused or experiencing psychotic disturbances do not attempt to bring to reality Respect personal space with interactions If resident refuses/rejects care/interventions, assure safety and leave immediate area. Reapproach in 5-10 minutes or provide alternate caregiver. Document response. Avoid confrontation when agitated Notify MD, family, responsible party of changes as needed. Attempt gradual dose reduction of psych meds as clinically appropriate Check oxygen sats with changes in level of cognition and/or anxiety; Oxygen as ordered Rule out medical complication with changes in behavior Refer to Psych services as needed with exacerbation or inability to effectively redirect behaviors Meds/labs as ordered Social services visits as needed Set Limits Review of Resident #15's initial elopement assessment, completed on 08/10/16, reflected he had one to two incidents of elopement in the past 6 months, was at risk for elopement, was oriented to person and place, displayed impulsive behaviors, and would be fitted with a Wander Guard (an alarm system which includes a bracelet or anklet the resident wears and when they go too close to the exit doors, an alarm will sound alerting staff.) Subsequent elopement assessments for Resident #15, completed on 11/02/16, 02/02/17, and 05/07/17, reflected no change in Resident #15 elopement risk status. A physician's orders [REDACTED]. A nurse's note on 04/01/17 for Resident #15 reflected on 04/01/17 at 11:30 a.m., Resident #15 eloped out the front door and went to the back of the building. Resident #15 was seen trying to cross a ditch when a staff member saw him and redirected him back inside. Resident #15 stated he had left the facility because he was trying to pray for a dead tree. Resident #15 was put on 30-minute visual checks until a new Wander Guard bracelet was placed on his wrist. 3. Interview with the DON on 07/21/17 at 3:27 p.m. revealed he did not remember the first elopement incident on 04/01/17 after reviewing the nurse's note. He stated he might have been on vacation then. 4. Review of the incident reports for the past six months reflected there was no incident report about the elopement on 04/01/17. 5. Review of Resident #15's care plan, dated 10/03/16, reflected no new interventions after the elopement on 04/01/17. 6. An incident report, dated 07/01/17, revealed Resident #15 was reported to be outside in the field adjacent to the facility by another resident on 06/30/17 at 7:30 p.m. A nurse and two CNAs chased after the resident and returned him to the facility. He was weak and hot, wearing sweat pants and sweat shirt. He stated he was just going for a walk. The time he exited the building was not known. 7. Review of Resident #15's nurse's note reflected an entry on 06/30/17 at 8:11 p.m. for Resident #15 which reflected at 7:30 p.m. another resident alerted the nurses that Resident #15 was walking in a field beside the facility. The nurse and two other CNAs chased after the resident and redirected him to the facility. Resident #15 was red faced, sweaty, and visibly weak. The staff had to stop a few times on the walk back to the facility to let Resident #15 rest. Resident #15 stated he had gone out the window. Resident #15 was assisted back into the facility and was assisted to a couch and given a glass of ice water. Resident #15 drank all of the water and his RP (responsible party) was notified. RP had stated, he just doesn't know his limitations. Nurses' note on 06/30/17 for Resident #15 reflected when the staff guided Resident #15 to the front door to check if the Wander Guard was working, Resident #15 was able to tell the nurse the code to shut off the alarm. Nurse's note by the DON on 07/01/17 for Resident #15 reflected Resident #15 explained that he went out the window because it was easier, and he went out into the field to check on a car that was out there. The DON explained to Resident #15 he could not leave the facility without staff supervision because of safety reasons. Resident #15 promised the DON to request staff to go with him next time he wanted to take a walk. Resident #15's care plan, dated 10/03/16, reflected on 06/30/17 one intervention was put in place which included placing Resident #15 on 15 minute visual checks for 72 hours. 8. Observation of Resident #15's window on 07/20/17 at 2:00 p.m. revealed the window was unsecured and could be opened all the way. The screen was loose and appeared to have been pushed out from the inside. 9. Interview with the DON on 07/21/17 at 12:20 p.m. revealed all the windows in resident's rooms could be raised and the facility, after surveyor intervention, was in the process of securing the windows in all the rooms with elopement risk residents so they would only open about six inches. Interview with the DON on 07/20/17 at 12:17 p.m. revealed Resident #15 was put on 15 minute visual checks for 72 hours after he eloped by going out the window. The DON revealed he discontinued the 15 minute checks because Resident #15 had promised he would not elope again and ask staff if he wanted to go outside. 9. Review of https://www.wunderground.com/history/airport/KCPT/2017/6/30/DailyHistory.html?req_city=Cleburne&req_state=TX&req_statename=Texas&reqdb.zip= &reqdb.magic=1&reqdb.wmo= , accessed on 07/24/17, at 4:11 p.m. reflected the high temperature for the area around the facility on 06/30/17 was 93 degrees Fahrenheit, and the heat index was 100.1 degrees at 7:15 p.m. 10. Review of an incident report, dated 07/17/17, revealed Resident #15 turned off the alarm at the exit door on 600 hall and left the faciity on [DATE]. He walked to the local high school and then got a ride back to the facility from someone there. He returned to the facility at 12:15 p.m. and the exact time he left was not listed. 11. Observation of the area outside the 600 hall emergency exit door on 07/21/17 at 11:30 a.m. revealed the school was on the other side of a large field. The field had a slope about two-feet high covered with rock along the edge. This was the path Resident #15 took on 07/16/17, according to the resident. 12. Review of https://www.google.com/maps/place/Heritage+Trails+Nursing+%26+Rehabilitation/@32XXX 63,-97XXX ,17z/data=!4m5!3m4!1s0x864e47bf3aa21c7f:0xb12d73c5b7b113d2!8m2!3d32XXX 68!4d-97XXX 1, accessed on 07/27/17, at 9:18 a.m. reflected a distance of 2500 feet (0.47 miles) from the facility across the field to the nearest school. 13. Observation of the door alarms in the facility on 07/20/17 at 2:40 p.m. revealed halls 100, 200, 500, and 600 had only a simple door alarm installed about five-feet high, which could be disarmed by moving a sliding switch to one side. The exit doors on 300 and 400 halls, as well as the front door, had Wander Guard alarms and a keypad alarm which required a key or alarm code to disarm. 14. Review of Resident #15's care plan, dated 10/03/16, reflected no new interventions were put in place after the 07/16/17 elopement. 15. Interview with the DON on 07/20/17 at 1:30 p.m. revealed Resident #15 had a Wander Guard on admission. He said four halls (100, 200, 500, and 600) did not have a Wander Guard alarm installed. They had only a door alarm which could be turned off with a toggle switch located on the front of the alarm unit. He said Resident #15 had turned off the alarm on 600 hall on 07/16/17 and exited the facility through this door without alerting anyone. He said no one had ever gone out any of those doors that they were basically not used and, after this incident, new alarms had been ordered which would require a key to disarm. He stated the alarms were only checked once per shift to ensure they were working. 16. Review of https://www.wunderground.com/history/airport/KCPT/2017/7/16/DailyHistory.html?req_city=Cleburne&req_state=TX&req_statename=Texas&reqdb.zip= &reqdb.magic=1&reqdb.wmo= , accessed on 07/24/17, at 4:09 p.m. reflected the high temperature around the facility on 07/16/17 was 95 degrees Fahrenheit, and the heat index high was 101.3. 17. Interview with Resident #15 on 07/20/17 at 1:45 p.m. revealed he had left the facility out his window on 06/30/17 because he thought someone in a car might need help. He said he left the facility out the 600 hall exit door on 07/16/17 because he thought he needed to do something at the school. He said he made it all the way to the school across the field before he got tired and asked for a ride to get back. 18. Interview by phone with a family member of Resident #15 on 07/21/17 at 3:20 p.m. revealed the resident had lived with them except for a short stay at another facility. She stated Resident #15 used to live in a little house behind hers, but they were concerned for his safety because he would go wandering around at night and have to be brought back home. She stated she was concerned for his safety because his behavior was very erratic, had no safety awareness, and was confused. 19. Interview with the DON on 07/20/17 at 12:17 p.m. revealed Resident #15 did not have a Wander Guard when he was admitted and it was not until two weeks later, but neither the DON nor ADON could remember why. The DON stated that the policy was if a resident was assessed as an elopement risk, they were given a Wander Guard. The DON revealed that when Resident #15 lived at home, he would do things that worried the family. Resident #15 went out to the neighbor's car to get cigarettes and that was the only history he knew of eloping prior to his admission to the facility. He stated he was not comfortable with Resident #15 going out of the facility because of safety concerns (the extreme heat) and Resident #15's history of poor judgement. He stated Resident #15 had cardiovascular problems and a history of [MEDICAL CONDITION], and so there were times that he was not as oriented as normal. He stated he was afraid something might happen to Resident #15 if he eloped from the facility because of his poor decisions and judgement. 20. Interview with CNA A on 07/21/17 at 1:20 p.m. revealed she had worked at the facility for four years and was Resident #15's CNA. She stated Resident #15 wanders around all the time and tries to go out the front door. She said they have to redirect him to his room. She stated he tried to exit through the front door often, but he never eloped during her shift. 21. Interview with CNA B on 07/21/17 at 1:25 p.m. revealed Resident #15 tried to go out the front door a few times during her shift (the 6 a.m.-2 p.m. and sometimes the 10 p.m.-6 a.m.), but they just lead him away from the door. She stated they checked his Wander Guard once per shift, along with all the other elopement risk residents. 22. Interview with RN C on 07/21/17 at 1:30 p.m. revealed she was Resident #15's nurse. She stated Resident #15 had a Wander Guard that would set off an alarm if he went near an exit. She stated Resident #15 liked to go outside and check on stuff, and that was probably why he tried to elope. 23. Interview with CNA D on 07/21/17 at 1:40 p.m. revealed she was Resident #15's CNA when he was first admitted to the facility. She stated they would have to keep an eye on Resident #15 because he would try to go out the front door or other exit doors and they would have to stop him and redirect him. 24. Interview with CNA E on 07/21/17 at 1:56 p.m. revealed she had worked with Resident #15 during his stay at the facility. She stated Resident #15 would look and watch the staff to see if he could find a way out of the building, but would go back to his room if he noticed someone was watching him. She stated she knew he was a high elopement risk. CNA E stated she believed Resident #15 would elope if he had a task or mission in mind. 25. Review of Resident #15's nurse's notes from July 2016 to July 2017 reflected Resident #15 had a history of [REDACTED]. staring at them, and waiting near the front door to assist a CNA to her car after following her around the facility and petting her hair. 26. Review of the 'Q 15 Min Checks' dated 07/16/17 through 07/21/17 reflected Resident #15 was being monitored by staff every 15 minutes and various staff initialed and recorded the location of Resident #15. 27. An Immediate Jeopardy (IJ) was identified on 07/20/17. The Administrator and DON were informed of the IJ on 07/20/17 at 4:15 p.m. and a Plan of Removal was requested at that time. 28. The facility's Plan of Removal reflected: A Plan of Action has been implemented to address the identified issue of Failure to prevent elopement for one resident. (1.) Identified resident was reassessed for elopement on 07/21/17 following return from hospital for an unrelated change in condition. Resident was identified at risk for elopement. A wander guard was immediately placed on the resident. Staff was placed at each nurse's station to monitor the four doors that were identified for risk. Adjustments have been made to window in resident's room by placing screws to prevent window from rising high enough for resident to exit. (2.) New alarms for identified doors at risk were ordered on July 17th and are expected to arrive any day. Alarms have been confirmed to be in transit. (3.) Four doors identified at risk will be continuously monitored via line of sight until alarms are installed and functioning properly. Monitors are currently assigned to each station and scheduled until new alarms are installed. On 07/21/17 maintenance installed covers over the alarm switch to keep residents and visitors from turning the alarm off. (4.) All residents currently at risk for elopement will be re-evaluated, and completed on 7-20-17. All residents that are high risk for elopement will receive a wander guard bracelet (as ordered); their names will be added to a list and a notebook will be placed at each nurse's station to alert staff that these residents are identified for high risk of elopement. The wander guard bracelet will be monitored for functionality, and placement every day. When alarm sounds doors will be checked, head count will be assessed and then grounds will be checked, if a resident is not present at the door. (5.) Re-education by in-servicing staff on the facility Elopement protocol initiated July 20, 2017 and will be completed on 7-21-17 for available staff. Will continue to in-service additional staff upon their return to work prior to scheduled duties. (6.) For all residents that have been identified as Elopement Risk adjustments have been made to windows with screws to prevent window from rising high enough for resident to exit. 29. To verify the facility implemented their Plan of Removal, the following observations, interviews and record reviews were conducted: Interviews on 07/21/17 from 1:20 p.m. to 2:46 p.m. regarding how often Wander Guard bracelets are checked, door monitoring, elopement risk assessments, and the elopement policy revealed staff had been in-serviced and were able to answer all questions correctly. The following staff were in-serviced from each shift: 6:00 a.m. to 2:00 p.m. - CNA H, CNA I, CNA J, RN C, CNA L, CNA M, and MA N. 2:00 p.m. to 10:00 p.m. - CNA F, CNA K, CNA D, and CNA E. 10:00 p.m. to 6:00 a.m. - CNA A, CNA B, and CNA O. Cook P, Cook Q, Housekeeper R, and Housekeeper S were also interviewed. Observation of Resident #15's window on 07/21/17 at 1:45 p.m. revealed the window had been secured with screws so that it would only open about six inches. Observation of alarms on 100, 200, 500, and 600 halls on 07/21/17 at 2:00 p.m. revealed all four alarms had a plastic cover installed over them that would prevent access to the switch. 30. On 07/21/17, the Immediate Jeopardy (IJ) was removed. On 07/21/17 at 4:00 p.m. the Administrator and DON was informed the IJ was removed. While the IJ was removed on 07/21/17, the facility remained out of compliance at severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. 31. Review of the 07/18/17 list of Residents with Wander Guards reflected there were six residents who were elopement risks. One resident passed away on 07/20/17, so there were five residents remaining in the facility who were elopement risks.

Based on observation, interview, and record review, the facility failed to ensure residents were provided with adequate supervision for one (Resident #15) of 23 residents reviewed for risk of elopement. 1. The facility failed to ensure interventions were put in place to keep Resident #15 from eloping from the facility three times (04/01/17, 06/30/17, and 07/16/17) within the past four months. 2. The facility failed to provide adequate supervision to prevent Resident #15 from eloping from the facility. 3. The facility failed to ensure Resident #15's care plan was updated after incidents of elopement with supervision needs and elopement precautions necessary to prevent the resident from eloping from the facility. An Immediate Jeopardy situation was identified on 07/20/17. The Immediate Jeopardy was removed on 07/21/17. The facility remained out of compliance at severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. This failure could affect the five residents assessed as high elopement risks, and place them at risk for elopement, serious injury, and/or death. Findings Included: 1. Review of Resident #15's face sheet revealed he was a [AGE] year old male admitted on [DATE]. Review of Resident #15's MDS assessment, dated 05/09/17, reflected he had moderate cognitive impairment. Review of the functional ability of Resident #15 reflected he required no help or staff oversight with locomotion. Resident #15's active [DIAGNOSES REDACTED]. Review of Resident #15's care plan, dated 10/03/16, reflected the following interventions: Educate resident regarding acceptable alternatives to identified behaviors and document response/understanding Wander Guard as appropriate; verify placement and function per protocol Monitor whereabouts when wandering and redirect as needed Approach in a calm manner When confused or experiencing psychotic disturbances do not attempt to bring to reality Respect personal space with interactions If resident refuses/rejects care/interventions, assure safety and leave immediate area. Reapproach in 5-10 minutes or provide alternate caregiver. Document response. Avoid confrontation when agitated Notify MD, family, responsible party of changes as needed. Attempt gradual dose reduction of psych meds as clinically appropriate Check oxygen sats with changes in level of cognition and/or anxiety; Oxygen as ordered Rule out medical complication with changes in behavior Refer to Psych services as needed with exacerbation or inability to effectively redirect behaviors Meds/labs as ordered Social services visits as needed Set Limits Review of Resident #15's initial elopement assessment, completed on 08/10/16, reflected he had one to two incidents of elopement in the past 6 months, was at risk for elopement, was oriented to person and place, displayed impulsive behaviors, and would be fitted with a Wander Guard (an alarm system which includes a bracelet or anklet the resident wears and when they go too close to the exit doors, an alarm will sound alerting staff.) Subsequent elopement assessments for Resident #15, completed on 11/02/16, 02/02/17, and 05/07/17, reflected no change in Resident #15 elopement risk status. A physician's orders [REDACTED]. A nurse's note on 04/01/17 for Resident #15 reflected on 04/01/17 at 11:30 a.m., Resident #15 eloped out the front door and went to the back of the building. Resident #15 was seen trying to cross a ditch when a staff member saw him and redirected him back inside. Resident #15 stated he had left the facility because he was trying to pray for a dead tree. Resident #15 was put on 30-minute visual checks until a new Wander Guard bracelet was placed on his wrist. 2. Interview with the DON on 07/21/17 at 3:27 p.m. revealed he did not remember the first elopement incident on 04/01/17 after reviewing the nurse's note. He stated he might have been on vacation then. 3. Review of the incident reports for the past six months reflected there was no incident report about the elopement on 04/01/17. 4. Review of Resident #15's care plan, dated 10/03/16, reflected no new interventions after the elopement on 04/01/17. 5. An incident report, dated 07/01/17, revealed Resident #15 was reported to be outside in the field adjacent to the facility by another resident on 06/30/17 at 7:30 p.m. A nurse and two CNAs chased after the resident and returned him to the facility. He was weak and hot, wearing sweat pants and sweat shirt. He stated he was just going for a walk. The time he exited the building was not known. 6. Review of Resident #15's nurse's note reflected an entry on 06/30/17 at 8:11 p.m. for Resident #15 which reflected at 7:30 p.m. another resident alerted the nurses that Resident #15 was walking in a field beside the facility. The nurse and two other CNAs chased after the resident and redirected him to the facility. Resident #15 was red faced, sweaty, and visibly weak. The staff had to stop a few times on the walk back to the facility to let Resident #15 rest. Resident #15 stated he had gone out the window. Resident #15 was assisted back into the facility and was assisted to a couch and given a glass of ice water. Resident #15 drank all of the water and his RP (responsible party) was notified. RP had stated, he just doesn't know his limitations. Nurses' note on 06/30/17 for Resident #15 reflected when the staff guided Resident #15 to the front door to check if the Wander Guard was working, Resident #15 was able to tell the nurse the code to shut off the alarm. Nurse's note by the DON on 07/01/17 for Resident #15 reflected Resident #15 explained that he went out the window because it was easier, and he went out into the field to check on a car that was out there. The DON explained to Resident #15 he could not leave the facility without staff supervision because of safety reasons. Resident #15 promised the DON to request staff to go with him next time he wanted to take a walk. Resident #15's care plan, dated 10/03/16, reflected on 06/30/17 one intervention was put in place which included placing Resident #15 on 15 minute visual checks for 72 hours. 7. Observation of Resident #15's window on 07/20/17 at 2:00 p.m. revealed the window was unsecured and could be opened all the way. The screen was loose and appeared to have been pushed out from the inside. 8. Interview with the DON on 07/21/17 at 12:20 p.m. revealed all the windows in resident's rooms could be raised and the facility, after surveyor intervention, was in the process of securing the windows in all the rooms with elopement risk residents so they would only open about six inches. Interview with the DON on 07/20/17 at 12:17 p.m. revealed Resident #15 was put on 15 minute visual checks for 72 hours after he eloped by going out the window. The DON revealed he discontinued the 15 minute checks because Resident #15 had promised he would not elope again and ask staff if he wanted to go outside. 9. Review of https://www.wunderground.com/history/airport/KCPT/2017/6/30/DailyHistory.html?req_city=Cleburne&req_state=TX&req_statename=Texas&reqdb.zip= &reqdb.magic=1&reqdb.wmo= , accessed on 07/24/17, at 4:11 p.m. reflected the high temperature for the area around the facility on 06/30/17 was 93 degrees Fahrenheit, and the heat index was 100.1 degrees at 7:15 p.m. 10. Review of an incident report, dated 07/17/17, revealed Resident #15 turned off the alarm at the exit door on 600 hall and left the faciity on [DATE]. He walked to the local high school and then got a ride back to the facility from someone there. He returned to the facility at 12:15 p.m. and the exact time he left was not listed. 11. Observation of the area outside the 600 hall emergency exit door on 07/21/17 at 11:30 a.m. revealed the school was on the other side of a large field. The field had a slope about two-feet high covered with rock along the edge. This was the path Resident #15 took on 07/16/17, according to the resident. 12. Review of https://www.google.com/maps/place/Heritage+Trails+Nursing+%26+Rehabilitation/@32XXX 63,-97XXX ,17z/data=!4m5!3m4!1s0x864e47bf3aa21c7f:0xb12d73c5b7b113d2!8m2!3d32XXX 68!4d-97XXX 1, accessed on 07/27/17, at 9:18 a.m. reflected a distance of 2500 feet (0.47 miles) from the facility across the field to the nearest school. 13. Observation of the door alarms in the facility on 07/20/17 at 2:40 p.m. revealed halls 100, 200, 500, and 600 had only a simple door alarm installed about five-feet high, which could be disarmed by moving a sliding switch to one side. The exit doors on 300 and 400 halls, as well as the front door, had Wander Guard alarms and a keypad alarm which required a key or alarm code to disarm. 14. Review of Resident #15's care plan, dated 10/03/16, reflected no new interventions were put in place after the 07/16/17 elopement. 15. Interview with the DON on 07/20/17 at 1:30 p.m. revealed Resident #15 had a Wander Guard on admission. He said four halls (100, 200, 500, and 600) did not have a Wander Guard alarm installed. They had only a door alarm which could be turned off with a toggle switch located on the front of the alarm unit. He said Resident #15 had turned off the alarm on 600 hall on 07/16/17 and exited the facility through this door without alerting anyone. He said no one had ever gone out any of those doors that they were basically not used and, after this incident, new alarms had been ordered which would require a key to disarm. He stated the alarms were only checked once per shift to ensure they were working. 16. Review of https://www.wunderground.com/history/airport/KCPT/2017/7/16/DailyHistory.html?req_city=Cleburne&req_state=TX&req_statename=Texas&reqdb.zip= &reqdb.magic=1&reqdb.wmo= , accessed on 07/24/17, at 4:09 p.m. reflected the high temperature around the facility on 07/16/17 was 95 degrees Fahrenheit, and the heat index high was 101.3. 17. Interview with Resident #15 on 07/20/17 at 1:45 p.m. revealed he had left the facility out his window on 06/30/17 because he thought someone in a car might need help. He said he left the facility out the 600 hall exit door on 07/16/17 because he thought he needed to do something at the school. He said he made it all the way to the school across the field before he got tired and asked for a ride to get back. 18. Interview by phone with a family member of Resident #15 on 07/21/17 at 3:20 p.m. revealed the resident had lived with them except for a short stay at another facility. She stated Resident #15 used to live in a little house behind hers, but they were concerned for his safety because he would go wandering around at night and have to be brought back home. She stated she was concerned for his safety because his behavior was very erratic, had no safety awareness, and was confused. 19. Interview with the DON on 07/20/17 at 12:17 p.m. revealed Resident #15 did not have a Wander Guard when he was admitted and it was not until two weeks later, but neither the DON nor ADON could remember why. The DON stated that the policy was if a resident was assessed as an elopement risk, they were given a Wander Guard. The DON revealed that when Resident #15 lived at home, he would do things that worried the family. Resident #15 went out to the neighbor's car to get cigarettes and that was the only history he knew of eloping prior to his admission to the facility. He stated he was not comfortable with Resident #15 going out of the facility because of safety concerns (the extreme heat) and Resident #15's history of poor judgement. He stated Resident #15 had cardiovascular problems and a history of strokes, and so there were times that he was not as oriented as normal. He stated he was afraid something might happen to Resident #15 if he eloped from the facility because of his poor decisions and judgement. 20. Interview with CNA A on 07/21/17 at 1:20 p.m. revealed she had worked at the facility for four years and was Resident #15's CNA. She stated Resident #15 wanders around all the time and tries to go out the front door. She said they have to redirect him to his room. She stated he tried to exit through the front door often, but he never eloped during her shift. 21. Interview with CNA B on 07/21/17 at 1:25 p.m. revealed Resident #15 tried to go out the front door a few times during her shift (the 6 a.m.-2 p.m. and sometimes the 10 p.m.-6 a.m.), but they just lead him away from the door. She stated they checked his Wander Guard once per shift, along with all the other elopement risk residents. 22. Interview with RN C on 07/21/17 at 1:30 p.m. revealed she was Resident #15's nurse. She stated Resident #15 had a Wander Guard that would set off an alarm if he went near an exit. She stated Resident #15 liked to go outside and check on stuff, and that was probably why he tried to elope. 23. Interview with CNA D on 07/21/17 at 1:40 p.m. revealed she was Resident #15's CNA when he was first admitted to the facility. She stated they would have to keep an eye on Resident #15 because he would try to go out the front door or other exit doors and they would have to stop him and redirect him. 24. Interview with CNA E on 07/21/17 at 1:56 p.m. revealed she had worked with Resident #15 during his stay at the facility. She stated Resident #15 would look and watch the staff to see if he could find a way out of the building, but would go back to his room if he noticed someone was watching him. She stated she knew he was a high elopement risk. CNA E stated she believed Resident #15 would elope if he had a task or mission in mind. 25. Review of Resident #15's nurse's notes from July 2016 to July 2017 reflected Resident #15 had a history of [REDACTED]. staring at them, and waiting near the front door to assist a CNA to her car after following her around the facility and petting her hair. 26. Review of the 'Q 15 Min Checks' dated 07/16/17 through 07/21/17 reflected Resident #15 was being monitored by staff every 15 minutes and various staff initialed and recorded the location of Resident #15. 27. Review of the facility's elopement policy, dated August 2015, reflected the Definition of Elopement: Elopement is the ability of a resident who is not capable of protecting himself or herself from harm to successfully leave the facility unsupervised and unnoticed and who may enter into harm's way . Protocol: All residents will be assessed on admission; re-admission; quarterly and with changes of condition for risk factors that would place the resident at risk for elopement such as wandering, previous history of elopement or exit seeking behavior . Immediate Interventions For Resident Safety: 1. In the event of elopement or onset of exit seeking behavior .the resident will be put on behavior monitoring for elopement/exit seeking behavior until the behavior subsides . 4. Interventions to reduce the risk of elopement will be updated to the resident's Care Plan and communicated with staff. 28. An Immediate Jeopardy (IJ) was identified on 07/20/17. The Administrator and DON were informed of the IJ on 07/20/17 at 4:15 p.m. and a Plan of Removal was requested at that time. 29. The facility's Plan of Removal reflected: A Plan of Action has been implemented to address the identified issue of Failure to prevent elopement for one resident. (1.) Identified resident was reassessed for elopement on 07/21/17 following return from hospital for an unrelated change in condition. Resident was identified at risk for elopement. A wander guard was immediately placed on the resident. Staff was placed at each nurse's station to monitor the four doors that were identified for risk. Adjustments have been made to window in resident's room by placing screws to prevent window from rising high enough for resident to exit. (2.) New alarms for identified doors at risk were ordered on July 17th and are expected to arrive any day. Alarms have been confirmed to be in transit. (3.) Four doors identified at risk will be continuously monitored via line of sight until alarms are installed and functioning properly. Monitors are currently assigned to each station and scheduled until new alarms are installed. On 07/21/17 maintenance installed covers over the alarm switch to keep residents and visitors from turning the alarm off. (4.) All residents currently at risk for elopement will be re-evaluated, and completed on 7-20-17. All residents that are high risk for elopement will receive a wander guard bracelet (as ordered); their names will be added to a list and a notebook will be placed at each nurse's station to alert staff that these residents are identified for high risk of elopement. The wander guard bracelet will be monitored for functionality, and placement every day. When alarm sounds doors will be checked, head count will be assessed and then grounds will be checked, if a resident is not present at the door. (5.) Re-education by in-servicing staff on the facility Elopement protocol initiated July 20, 2017 and will be completed on 7-21-17 for available staff. Will continue to in-service additional staff upon their return to work prior to scheduled duties. (6.) For all residents that have been identified as Elopement Risk adjustments have been made to windows with screws to prevent window from rising high enough for resident to exit. 30. To verify the facility implemented their Plan of Removal, the following observations, interviews and record reviews were conducted: Interviews on 07/21/17 from 1:20 p.m. to 2:46 p.m. regarding how often Wander Guard bracelets are checked, door monitoring, elopement risk assessments, and the elopement policy revealed staff had been in-serviced and were able to answer all questions correctly. The following staff were in-serviced from each shift: 6:00 a.m. to 2:00 p.m. - CNA H, CNA I, CNA J, RN C, CNA L, CNA M, and MA N. 2:00 p.m. to 10:00 p.m. - CNA F, CNA K, CNA D, and CNA E. 10:00 p.m. to 6:00 a.m. - CNA A, CNA B, and CNA O. Cook P, Cook Q, Housekeeper R, and Housekeeper S were also interviewed. Observation of Resident #15's window on 07/21/17 at 1:45 p.m. revealed the window had been secured with screws so that it would only open about six inches. Observation of alarms on 100, 200, 500, and 600 halls on 07/21/17 at 2:00 p.m. revealed all four alarms had a plastic cover installed over them that would prevent access to the switch. 31. On 07/21/17, the Immediate Jeopardy (IJ) was removed. On 07/21/17 at 4:00 p.m. the Administrator and DON was informed the IJ was removed. While the IJ was removed on 07/21/17, the facility remained out of compliance at severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. 32. Review of the 07/18/17 list of Residents with Wander Guards reflected there were six residents who were elopement risks. One resident passed away on 07/20/17, so there were five residents remaining in the facility who were elopement risks.