Every finding on record at Highland Nursing Center

Based on interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for 1 of 1 facility reviewed for infection prevention. The facility failed to develop and implement a system of infection surveillance program for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents and staff. These failures could result in the spread of illness or infection. Findings included: Record review of the facility documents titled Signs/Symptoms of Urinary Tract Infection (UTI) WITHOUT [sic] an Indwelling Urinary Catheter, Signs/Symptoms of Skin and Soft Tissue Infection (SSTI) or Scabies, and Signs/Symptoms of Respiratory Tract Infections (RTI): Common Cold or Influenza-like Illness dated 12/1/2025 through 3/20/2026 reflected 10 worksheets from the facility pharmacy indicating symptoms of residents that required antibiotic treatment, and the antibiotic prescribed. Record review of an e-mail dated 3/27/2026 at 9:21 AM from the Admin. to the surveyor reflected the 10 worksheets were the entirety of the infection surveillance documentation maintained by the facility. Record review of the facility document titled Anti-Infective Utilization [facility] Units: All, [pharmacy] February 1, 2026, through February 28, 2026 reflected an undated report created by the facility's pharmacy summarizing the antibiotic treatments prescribed for residents during February 2026. The report included names of residents, the medication name, administration directions, and prescriber. Record review did not reveal information regarding the reason for antibiotics, type of infection, or infection rates. In an interview with CRN on 3/27/2026 at 10:39 AM, she said she served as the Infection Preventionist for the facility. She said she does not use a specific method to track infections at the facility. She said she used the antibiotic usage report from the pharmacy to monitor infections. She said she knew what type of infection a resident has based on the antibiotic prescribed, and she knew which residents had frequent infections because she is familiar with their medical history. After deducing the type of infection based on the prescription, she said she would then mentally calculate the current rate of infection based on the census. She was unsure how she uses this report to compare and monitor overall infection rates at the facility for extended time periods. She was unsure what the overall infection rates were for the facility since the prior survey, and she was unsure if there were any trends in infections since the prior survey. In an interview with the DON on 3/27/2026 at 11:05 AM, she said she manages the QAPI meetings and the agendas for the meeting. She said the QAPI team will review residents who have an active infection, but they do not discuss overall infection rates, trends, or other surveillance data. She said the CRN is the Infection Preventionist and manages the surveillance of infections. Policies for infection control and infection surveillance were requested from the facility from the CRN on 3/27/2026 at 10:39 AM and by e-mail to the Admin. on 3/27/2026 at 11:20 AM, but the documents were not provided prior to survey exit.

Based on interview and record review, the facility failed to implement policies and procedures to ensure each staff member is offered the COVID-19 vaccine for 1 of 1 facility reviewed for infection prevention. The facility failed to offer staff members the 2025-2026 COVID-19 vaccination.This failure could result in illness and the spread of infection.Findings included: Records were requested in e-mails dated 3/25/2026 at 10:45 AM and 3/27/2026 at 8:34 AM to the Admin. for evidence of staff acceptance or declination of the COVID-19 vaccination for 2025-2026. These records were not provided by the facility prior to survey exit. In an interview with CRN on 3/27/2026 at 9:26 AM, she said the facility does not offer COVID-19 vaccinations to the staff. She said the staff were able to utilize the services provided to residents by the contracted pharmacy, but the staff must provide payment or insurance information in order to receive the vaccination. She said most staff members elected to obtain the vaccinations privately, outside of the facility. She was unsure if the facility maintained records of staff vaccinations for each year. In an interview with RN A on 3/27/2026 at 11:35 AM, she said the facility does not provide COVID-19 vaccinations to the staff, but she wished that they would so it would be easier to obtain the vaccination every year. She said she received her annual vaccinations at a local pharmacy without assistance from the facility. In a subsequent interview with the CRN on 3/27/2026 at 5:00 PM, she said she felt the facility met the requirement to provide COVID-19 vaccinations to staff because staff were able to obtain the vaccination from the facility pharmacy by providing their own health insurance. She was unsure how staff would obtain the vaccination if they did not have health insurance coverage or the financial ability to pay for the vaccination. She said expecting the facility to provide the vaccination was like going to a restaurant and reading the menu and ordering but expecting somebody else to pay. Record review of the facility policy titled Staff Vaccination dated 2003/revised March 2003, did not reveal guidance or policy related to COVID-19 vaccinations.

Based on observations, interviews and record reviews, the facility failed to ensure Food safety requirements store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 (1 kitchen) in that: The kitchen ice machine had black specks on the ice machine shaft, and the Maintenance Assistance was not wearing a beard guard while in the kitchen. This could affect all residents that eat from the kitchen and could cause gastric problems. The Findings: 1.Observation on 03/24/2026 10:00 AM with the FSM, revealed during initial rounds, the ice machine had black specks on the ice machine shaft, and Maintenance Assistance was not wearing a beard guard, while in the kitchen. Observation of the Maintenance Assistant revealed he had a short beard and was near the microwave area. 2.Observation on 3/25/2026 at 12:20 PM in the kitchen, the Maintenance Assistant was not wearing a beard guard. Interview on 3/25/2026 at 12:21 PM the Maintenance Assistantconfirmed he was not wearing a beard guard while in the kitchen. The Maintenance Assistant stated he forgot and only went into kitchen for a bit. Observation on 3/25/2026 at 12:27 PM the Maintenance Supervisor told Maintenance Assistant to wear a hairnet, while seen in kitchen. Interview on 3/25/2026 3:03 PM with the FSM confirmed the ice machine black specks may be dirt and resident can get sick. The FSM stated that any person that went into kitchen needed to have on, a hair restraint. The FSM stated staff not wearing a hairnet/beard guard could affect the residents by hair going into the food. Interview on 3/25/2026 at 5:23 PM the ADM stated the ice machine needed to be kept maintained and it could cause contamination of the ice and could cause residents to have stomach issues. The ADM stated when the Maintenance Assistant was not wearing a beard guard, because he forgot to put it on. The ADM stated all staff should wear hair restraints in the kitchen. Record review of policy, (no date) revealed Kitchen-.Ice Machine Cleaning and Hairnet policy, the ice machine will be regularly maintained (both the ice bin and the ice making section), and staff will wear hairnets and beard nets in the kitchen at all times.

Based on observations, interviews and record reviews, the facility failed to ensure that the facility must ensure that the residents' environment remains free of accident hazards for 1 of 8 (16) residents in that: 1.Resident #16 had in his room a sink with 3 razors, a bottle of rubbing alcohol and in the medicine cabinet, 2 containers of mouth wash. Resident #16 also kept drinking alcohol in his room that he drank at his leisure. 2. The A hall shower room door was open and the cabinet was unlocked and had razors in the cabinet. The failures could place residents at risk for harm and injuries. The Findings:1.Record review of Resident #16's admission Record dated 4/3/2025 revealed he was [AGE] years old, was admitted on [DATE] with diagnoses of elevated myocardia, (the thick, middle muscular layer of the heart wall responsible for contracting to pump blood throughout the body) weakness, vitamin D deficiency and reduced mobility.Record review of Resident #16's Quarterly MDS dated [DATE] revealed his BIMS was 15/15 (cognitively intact), and no history of falls. Record review of Resident #16s consolidated orders for March 2026 reveaeld his orders included: May have 1 glass of wind daily as needed (12 ounces).Record review of Resident #16's care plan dated 3/13/2026 revealed he was a fall risk, unsteady gait, weakness, impaired mobility, able to transfer self, and visions improved related to cataract surgery. Observation on 3/24/2026 at 11:13 AM in Resident #16's room revealed over the sink were 3 razors, a 16-ounce plastic bottle of rubbing alcohol, and in the medicine cabinet there were 2 containers of mouth wash (8 ounces each). Observation revealed a cabinet in Resident #16's room that was locked. Interview on 3/24/2026 at 11:14 AM with Resident #16, in his room, he stated he shaved himself in the room, that was why he had razors. Resident #16 stated he had bought alcohol and wine from the store and drink and kept it in his locked cabinet in his room. Interview on 3/25/2026 at 11:17 AM Resident #16 stated he got the wine from a convenience store and locked it up in his room. Resident #16 stated the ADM gave him permission to keep the wine in his room. 2. Observation on 3/24/2026 at 11:19 AM of the A hall shower room in A hall revealed the door was open and the cabinet with a lock was wide open and contained 1 razor and the medicine cabinet had 2 razors. Interview on 03/24/2026 at 11:38 AM LVN D charge nurse stated she was not aware Resident #16 had razors in his room, rubbing alcohol, and mouth wash. LVN D stated they were safety hazards and not sure if another resident would enter the room, who was confused. LVN D stated Resident #16 went to the store on his own and did not always tell staff. Interview on 3/25/2026 at 5:40 PM the ADM and the CRN stated Resident #16 bought alcohol when out on pass, and he kept it in his locked cabinet. The ADM and CRN stated Resident #16 was alert and orientated, able to make his own decisions, and no one could get to the alcohol because it was locked. The ADM stated he was allowed to have it in his room as long as it was locked up. No other policies. Interview on 3/27/2026 at 9:10 AM LVN B stated the shower cabinet should be locked, if razors were in it and the razors should be kept at the nurse's station. LVN B stated if a nurse wanted a razor to shave a resident, the CNA would have to ask the nurse. LVN B stated the shower room should be closed and the cabinet in the shower with razors in it should be locked. Interview on 3/27/2026 at 9:30 AM CNA C stated Resident #16 shaved himself and got razors from the shower room. CNA C stated residents were not have sharp objects because they could hurt themselves. CNA C stated the cabinet in the shower room should be locked, and it contains razors. Interview on 3/27/2026 at 10:15 AM CNA E stated with razors/sharp objects residents could cut themselves and cause an accident. Record review of a policy, Razors in resident room and Showers (no date), revealed razors in resident rooms and shower was documented. The facility will maintain razors in a safe manner. All razors will be stored in secure locations so that residents will not be able to access them.

Based on interview and record review, the facility failed to ensure the development and implementation of an effective discharge planning process that focuses on the resident's discharge goals for 4 of 4 residents (Residents #3, #16, #2, #1) reviewed for discharge planning.The facility failed to ensure Resident #3's discharge goals were reviewed and implemented during an attempted facility transfer in December 2025. The facility failed to ensure Resident #16's care plan included discharge plans. The facility failed to ensure Resident #2's care plan included discharge plans.The facility failed to ensure Resident #1's care plan included discharge plans.These failures could result in loss of residents' autonomy and rights to determine care.The Findings: 1.Record review of the facility document titled Resident Master Information dated 4/02/3035 reflected Resident #3 was a [AGE] year-old male admitted to the facility on the 3/02/2022. Relevant diagnoses included bipolar disorder (a mental health disorder characterized by significant mood swings) and dementia (a progressive neurological disorder affecting memory and judgement). Record review of Resident #3's quarterly MDS submitted 2/9/2026 reflected a BIMS score of 06, which indicated severely impaired cognitive status. Record review of the facility document titled Interdisciplinary Team Care Conference for Resident #3 dated 12/12/2025 did not reveal care planning related to discharge planning. Record review of an undated voicemail transcript provided by Resident #3's family member on 3/26/2026 at 7:35 PM reflected a message from the Admin. requesting to speak to Resident #3's family member so that he could sweet talk her into reconsidering the transfer from the facility. He said the facility was accepting a reduced co-pay, and the proposed facility would expect the entire amount. He acknowledged receipt of the records request from the proposed facility. Record review of a text message dated 1/13/2026 reflected a message from the Admin. to Resident #3's family member that read as follows: Good morning [Resident #3's family member], [MR] counted the pages of medical records requested and she counted 224 pages. We charge $25 for the work plus .40 cents a page, which equals $114.60, which we require in advance of making copies. Record review of a facility document titled Authorization to Disclose Protected Health Information dated 12/3/2025 reflected a request signed by Resident #3's family member for medical records from the facility to be sent to the proposed facility for treatment/continuing medical care. Evidence of Resident #3's documented discharge planning was requested from the facility on 3/27/2026 at 8:34 AM but was not provided prior to survey exit. Resident #3 declined to participate in an interview attempted on 3/24/2026 at 11:21 AM. In an interview with Resident #3's family member on 03/27/2026 at 7:30 AM, she said she had not been invited to care plan meetings for Resident #3. She said she had not discussed discharge planning with anyone at the facility for Resident #3. She said she in December 2025, she had attempted to transfer Resident #3 to a different nursing facility because she was unhappy with the service provided by the current facility. She said the receiving facility requested records from the current facility, but the records were never provided, and Resident #3 was not accepted. She said she asked multiple staff members about the records request, and they told her they were not aware of a request from the other facility. She said she asked the Admin. about the records request for transfer of Resident #3, and he discouraged her from transferring Resident #3 because it would result in increased expenses for Resident #3. She said she did not have further communication with the Admin. about the transfer, and she was unsure why the records were not sent. She said she still wanted to transfer Resident #3 to another facility, but she felt discouraged because the facility was creating barriers to prevent transfer and she was worried about the cost. In an interview on 3/27/2026 at 9:45 AM, the LSW said she did not routinely attend care plan meetings. She said she did not review discharge goals with residents unless the staff made a request for a specific resident. She said she had not reviewed discharge or transfer goals with Resident #3 or his family, and she was not aware of a transfer request for the resident. In an interview on 3/27/2026 at 11:00 AM, the DON said Resident #3's family member had not been invited to any care plan meetings for Resident #3. She said she was not aware of any discharge or transfer goals for Resident #3, and she was unaware that Resident #3's family member wanted to transfer him to another facility. She said when records were requested from another facility, they were sent by fax and not duplicated from the paper charting system that was in place at the facility. She said any fees attached to the process were managed by the Admin., and she was unsure of the facility policy or procedure for charging residents for records associated with discharge planning. In an interview on 3/27/2026 at12:47 PM, MR said the Admin. reviewed requests for medical records and determined if there was a fee. She was unsure how the fee was calculated or determined. She said medical records requests made by a physician's office or hospital did not have a fee. She was unsure if record requests for a transfer required payment before processing. In an interview with the Admin. on 3/27/2026 at 12:50, he said requests for medical records that required a lot of time or volume of copies had an associated fee. He was unsure of the specific time or number of pages that constituted an associated fee. He said the fee was applied to any request, including records that were not intended for personal use. He said he was aware of the proposed transfer for Resident #3, but Resident #3's family member failed to pay the fee for the records request, so the documents were not sent. He was unsure of the discharge planning process for residents, and he said the policy for records request fees was in the facility admission packet. Record review of the facility's admission packet (undated) included a document titled Notice of Privacy Practices (undated) reflected the following: You have the right to inspect and copy your health information, such as your medical and billing records that we use to make decisions about your care and services. In order to inspect and/or copy your health information, you must submit a written request to the Administrator of this Facility [sic]. If you request a copy of your medical information, we may charge you a reasonable fee for the paper, labor, mailing, and/or retrieval costs involved in fulfilling your requests. We will provide you with information concerning the cost of copying your health information prior to performing such service . 2. Record review of Resident #16's admission Record dated 4/3/2025 revealed he was [AGE] years old, was admitted on [DATE] with diagnoses of elevated myocardia, (the thick, middle muscular layer of the heart wall responsible for contracting to pump blood throughout the body) weakness, vitamin D deficiency and reduced mobility. Record review of Resident #16's Quarterly MDS dated [DATE] was documented that his BIMS was 15/15 (cognitively intact), and no history of falls. Record review of Resident #16's care plan conference dated 3/13/2026 did not include the residents or representatives. Record review of Resident #16's care plan dated 3/13/2026 revealed it did not include discharge planning. 3. Record review of Resident #2's admission Record (no date) revealed she was [AGE] years old, was admitted on [DATE] and readmitted on [DATE] with diagnoses with depressive disorder, diabetes II, anxiety, and bipolar disorder. Record review of Resident #2's Quarterly MDS dated [DATE] revealed her BIMS score was 15/15 (cognitively intact). Record review of Resident #2's care plan conference dated 2/13/2026 did not include the residents or representatives. Record review of Resident #2's care plan dated 3/27/2026 revealed the care plan did not include discharge planning. 4.Record review of Resident #1's admission Record dated 2/11/2026 revealed she [AGE] years old, and was admitted on [DATE] with diagnosis of anxiety, schizophrenia and depressive disorder. Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMs score of 15/15 (cognitively intact). Record review of Resident #1's care plan conference dated 2/27/2026 did not include the residents or representatives. Record review of Resident #1's care plan dated 2/27/2026 revealed Resident #1's care plan did not include discharge planning. In an interview with the DON on 3/27/2026 at 11:00 AM, she said she stated she did not have discharge care plan for the residents #16, #2 and #1. DON had no other comments. In an interview on 3/27/2026 at 9:45 AM, the LSW said she did not review discharge goals with residents unless the staff make a request for a specific resident, and she did not routinely attend care plan meetings. She said she had not reviewed discharge or transfer planning goals for residents on care plans and the DON was responsible for resident care plans. She said she had not reviewed discharge or transfer goals with Resident #3 or his family, and she was not aware of a transfer request for the resident. Record review of the facility policy titled Discharge Planning dated January 2022, reflected the following: Discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family and will contain, as a minimum: a. A description of the resident's and family's preferences for care: [sic] b. A description of how the resident and family will access such services .

Based on interview and record review, the facility failed to ensure the medical records on each resident were complete and contained physician and other licensed professional's progress notes for 7 of 7 residents (Residents #7, #5, #3, #22, #29, #30, and #33) reviewed for resident records. The facility failed to ensure progress notes from physicians and other licensed professionals were included in the charts of Residents #7, #5, #3, #22, #29, #30, and #33.This failure could result in miscommunication between health care providers and inaccurate care provided to residents. Findings included: Record review of Resident #7's Resident Master Information [face sheet] dated 6/19/2025 reflected a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included dementia (a progressive neurological condition affecting memory and reasoning) and hypertension (high blood pressure). Record review of Resident #7's paper medical chart did not reflect an admission history and physical or any progress notes from subsequent visits by Resident #7's primary care provider. Record review of Resident #5's Resident Master Information [face sheet] dated 4/3/2025 reflected a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included dementia and schizoaffective disorder (a mental health disorder in which a person has difficulty distinguishing reality from delusions).Record review of Resident #5's paper medical chart reflected documentation of the most recent history and physical by Resident #5's primary care provider was dated 4/7/2025. There was no documentation present in the chart of any evaluations from Resident #5's PCP since 4/7/2025. Record review of Resident #3's Resident Master Information [face sheet] dated 4/3/2025 reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included dementia and hypertension.Record review of Resident #3's paper medical chart reflected documentation of the most recent history and physical by Resident #3's primary care provider was dated 4/22/2025. The document included a large watermark of the word draft and reflected THIS NOTE HAS NOT BEEN SIGNED in the footer of the documents. Record review of Resident #22's Physician's Orders for March 2026 dated 2/27/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included cerebral palsy (a neurological condition affecting development, movement, and muscle control). Record review of Resident #22's paper medical chart reflected documentation of the most recent history and physical by Resident #22's primary care provider was dated 4/22/2025. The document included a large watermark of the word draft and reflected THIS NOTE HAS NOT BEEN SIGNED in the footer of the documents. Record review of Resident #29's Resident Master Information [face sheet] dated 7/28/2025 reflected a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included dementia.Record review of Resident #29's paper medical chart reflected documentation of the most recent history and physical by Resident #22's primary care provider was dated 4/22/2025. The document included a large watermark of the word draft and reflected THIS NOTE HAS NOT BEEN SIGNED in the footer of the documents. Record review of Resident #30's Resident Master Information [face sheet] dated 4/03/2025 reflected a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included dementia.Record review of Resident #30's paper medical chart reflected documentation of the most recent history and physical by Resident #30's primary care provider was dated 4/7/2025. There was no documentation present in the chart of any evaluations from Resident #30's PCP since 4/7/2025. Record review of Resident #33's Resident Master Information [face sheet] dated 4/13/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included schizophrenia (a mental health disorder in which a person has difficulty distinguishing reality from delusion).Record review of Resident #33's paper medical chart did not reflect an admission history and physical or any progress notes from subsequent visits by Resident #33's primary care provider. In an interview with the DON on 3/25/2026 at 1:30 PM, she said the progress notes were sent by e-mail to the Admin., and he would print them out and give them to the nursing staff to be filed in the residents' charts. She said she did not have access to the progress notes and had previously requested that she be allowed to receive the documentation in order to maintain accurate and current charts. She said the health care team is made aware of the current status of residents by the nursing notes, conversations with providers, and the physicians' orders. She said she felt the current progress notes were important to include in the charts in order to provide accurate communication of a resident's condition and needs. She was unaware of any circumstances in which residents were harmed due to missing documentation from providers. In an interview with the Admin. on 3/26/2026 at 1:30 PM, he said he received documentation from residents' primary care providers visits by e-mail, and he printed them out to be in the paper medical charts. He said he had requested documentation of the visits for all residents in January 2026 but he had not received a response from the provider group. He said he had not made additional attempts to obtain the documentation. In an interview with the CRN on 3/26/2026 at 1:34 PM, she said the responsibility of maintaining the admission history and physical documentation and documentation of provider's progress notes was of hers and the DON's. She said, the doctor's progress notes are based on what the nurses tell them, so they're not useful. She was unaware the documentation was required to be maintained in residents' charts, and she felt the documents did not need to be maintained in the charts because the Admin. could provide the information to any requesting health care staff quickly. She was unsure how the information would be accessed and provided if the Admin. was unavailable, overnight, or if the Admin. was on vacation/leave. A policy for medical records was requested on 3/25/2026 at 10:45 AM but not provided prior to survey exit.

Based on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 (1 microwave) microwave in the kitchen in that: The microwave in the kitchen had a spot in the corner, rusting and exposing the inner area of the microwave. This deficient practice could affect all residents' foods and could cause illness to residents. The Findings:Observation on 3/24/2026 at 10:00 AM in the kitchen, with the FSM revealed the microwave, in the corner was rusted and exposing the inner area of microwave. Interview on 3/25/2026 at 3:03 PM with FSM confirmed she did not know the microwave, in the corner was rusted, and the stove had to be restrained. The FSM was new to the position and covering for the permanent FSM. The FSM stated the effect would be it could make residents sick. The FSM stated she was not sure how long it had been like that; she was new to the kitchen. FSM stated she would notify the maintenance department to fix the problem. Interview on 3/25/2026 at 5:23 PM with ADM stated he was not aware the kitchen microwave was rusted inside of it. Record review of policy, Kitchen Essential Equipment, (no date), reflected the facility will maintain all kitchen-essential equipment in good repair.

Based on observations, interviews and record reviews, the facility failed to ensure the resident has a right to be treated with respect and dignity for 1 of 8 (Resident #2) residents in that:Resident #2 had facial hair on her upper lip and chin area. The failure placed residents at risk of embarrassment and low self-esteem. The Findings:1.Record review of Resident #2's admission Record (no date) revealed she was admitted on [DATE] and readmitted on [DATE] with diagnoses with depressive disorder, diabetes II, anxiety, and bipolar disorder. Record review of Resident #2's MDS based summary dated 2/9/2026 revealed short-term/long-term memory, and personal hygiene was dependent. The MDS revealed independent eating, impaired vision, and communicated verbally and orientation/memory was good. Record review of Resident #2's Quarterly MDS dated [DATE] revealed her BIMS score was 15/15 (cognitively intact), she had impairment on one side of her upper extremity, impairment on both sides on her lower extremities, mobilized with an electric wheelchair, and was dependent on personal hygiene. Record review of Resident #2's care plan dated 3/27/2026 revealed she required extensive assistance with self-care, had a communication deficit, and poor vision.Observation on 3/25/2026 at 12:01 PM revealed Resident #2 had upper lip and chin hairs. Resident #2 was sitting in her mobilized wheelchair in the dining room. Interview on 3/25/2026 at 12:02 PM Resident #2 stated she was not aware she had upper lip and chin hairs and would like staff to help her and make her aware of facial hair, next time.Observation on 3/25/2026 at 3:55 PM revealed Resident #2 and LVN F revealed Resident #2 had upper lip and chin hairs. Observation of Resident #2 revealed she had facial hair on her upper lip and chin area.Interview on 3/25/2026 at 3:56 PM with Resident #2 and LVN F confirmed facial hair on upper lip and chin. LVN F stated she was not aware and would let a CNA take care of it. LVN F stated the nursing staff should groom residents and offer to assist with grooming facial hair.Interview on 3/25/2026 at 5:50 PM the ADM and CRN stated residents' facial hair was important for resident self-esteem. The ADM stated nursing staff would be responsible for resident facial hair and offering to groom them. Interview on 3/27/2026 at 9:10 AM LVN B stated the aides should offer groom residents' hair, face, nails etc.Interview on 3/27/2026 at 9:30 AM CNA C (that worked with Resident #2) stated they should offer all residents facial grooming.Record review of a policy on Resident Rights/Grooming (no date) revealed, Residents will be groomed on at least a daily basis, including .face/body hair shaven for those women and men who do not want facial/body hair.

Based on interview and record review, the facility failed to ensure residents had the right to participate in the development and implementation of his or her person-centered plan of care for 1 of 7 residents (Resident #3) reviewed for resident rights. The facility failed to ensure Resident #3's family member/POA was included in care plan meetings.This failure could result in loss of independence and decreased quality of life. Findings included:Record review of the facility document titled Resident Master Information dated 4/02/3035 reflected Resident #33 was a [AGE] year-old male admitted to the facility on the 3/02/2022. Relevant diagnoses included bipolar disorder (a mental health disorder characterized by significant mood swings) and dementia (a progressive neurological disorder affecting memory and judgement). Record review of Resident #3's quarterly MDS submitted 2/9/2026 reflected a BIMS score of 06, which indicated severely impaired cognitive status. Record review of the facility document titled Interdisciplinary Team Care Conference dated 12/12/2025 reflected a sign in sheet for Resident #3's quarterly care plan meeting, and it included the signatures of the DON, LSW, Activity Director, and a fourth, illegible signature. Further record review of the care plan did not reveal care planning related to Resident #3's capacity to make decisions or involvement of his family in the care planning process. Resident #3 declined to participate in an interview attempted on 3/24/2026 at 11:21 AM.In an interview with Resident #3's family member on 3/27/2026 at 7:30 AM, she said Resident #33 had mental health issues that made him unable to care for himself or make decisions for himself. She said she was his legal POA for medical and financial decisions. She said she had not been invited to a care plan meeting for Resident #3 since he was admitted to the facility. She said she called the facility or talked to a nurse when she has questions about Resident #3's care, but she felt the process was frustrating because it was difficult to get answers for her questions. In an interview with the DON on 3/27/2026 at 11:00 AM, she said she coordinated care plan meetings for residents, and she did not routinely invite family members to attend or participate in the formulation of the care plan. She said if she had questions about a resident's care, she would call the family members on the telephone. The facility provided a document titled Your Rights in a Nursing Facility published by the State Log-Term Care Ombudsman Program (January 2025) when a policy for resident rights was requested. Record review of the document reflected the following: .You have the right to: make your own choices regarding personal affairs, care, benefits and services .Designate a guardian or representative to ensure quality stewardship of your affairs if protective measures are required .

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including misappropriation of resident property, are reported not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 7 residents (Resident #3) reviewed for abuse, neglect, and exploitation. The facility failed to report an allegation of exploitation of Resident #3 to the SSA when Resident #3's POA alleged the Admin. stole money from Resident #3's bank account in the fall of 2025. This failure could result in lack of oversight of abuse, neglect, or exploitation of residents. Findings included: Findings included: Record review of the facility document titled Resident Master Information dated 4/02/3035 reflected Resident #33 was a [AGE] year-old male admitted to the facility on the 3/02/2022. Relevant diagnoses included bipolar disorder (a mental health disorder characterized by significant mood swings) and dementia (a progressive neurological disorder affecting memory and judgement). Record review of Resident #3's quarterly MDS submitted 2/9/2026 reflected a BIMS score of 06, which indicated severely impaired cognitive status. Resident #3 declined to participate in an interview attempted on 3/24/2026 at 11:21 AM. In an interview with Resident #3's family member on 03/25/2026 at 3:10 PM, she said she was the legal POA for financial and medical issues for Resident #3 due to his inability to care for himself. She said that in the fall of 2025, she became aware that Resident #3's bank account had approximately $500 removed, and she felt it was suspicious because Resident #3 only went to the bank when she took him. She said she was told by the bank that the Admin. had been added to the bank account as a second POA by Resident #3, and the money was removed from the account by the Admin. She said she confronted the Admin. and the DON about the withdrawal of the money without her consent, and she was not given a clear answer what the money was used for and why it was withdrawn from the account. She said she told the Admin. and DON that she felt like the act was theft, and she later wrote her concerns in a letter to the State Attorney General's office. In an interview with the DON on 3/26/2026 at 1:45 PM, she said she was present when Resident #3's family member alleged the Admin. was stealing money from Resident #3. She said she was unsure why the Admin. had taken money out of Resident #3's account, and she was unsure if the Admin. was added to Resident #3's bank account. She was unsure why the Admin. did not report the allegations to the SSA. In an interview with the Admin. on 3/26/2026 at 1:53 PM, he said he was the Abuse and Neglect Coordinator for the facility. He said he recalled the conversation with Resident #3's family member in which she accused him of stealing Resident #3's money. He said Resident #3 had financial issues that led to a lapse in his Medicaid coverage, so he took Resident #3 to the bank and was added as a POA to his account so he could assist Resident #3 with paying his applied income. He said Resident #3's family member declined to assist with Resident #3's financial affairs at the time, so that was the only option. He said he removed $500 from the account in October 2025, but he had not withdrawn any additional funds since Resident #3's family member accused him of stealing, and thus the facility had not been paid the co-payment for Resident #3's care. He said he did not report the allegations to the SSA because the allegations were false, and he felt it did not warrant reporting. He said he thought Resident #3's family member was exploiting Resident #3 financially, but he did not report his concerns to the SSA because he wanted to believe that she was not stealing from the resident. Record review of the facility policy titled Abuse Policy dated 10/2004 revealed the following: .3. Reporting concerns/incidents/grievances by residents providing residents/family/staff with information on reporting and resolving concerns/grievances. Identifying those residents at risk, correcting situations in which abuse/neglect [sic]. Misappropriation may occur. [sic.] .

Based on interview and record review, the facility failed to ensure that all alleged violations of abuse, neglect, and exploitation are thoroughly investigated, and the results of the investigation are reported to the SSA within five working days for 1 of 7 residents (Residents #3) reviewed for abuse, neglect, and exploitation.The facility failed to have evidence of an investigation of alleged exploitation of Resident #3.This failure could result in continued mistreatment of residents or lack of oversight.Findings included: Record review of the facility document titled Resident Master Information dated 4/02/3035 reflected Resident #33 was a [AGE] year-old male admitted to the facility on the 3/02/2022. Relevant diagnoses included bipolar disorder (a mental health disorder characterized by significant mood swings) and dementia (a progressive neurological disorder affecting memory and judgement). Record review of Resident #3's quarterly MDS submitted 2/9/2026 reflected a BIMS score of 06, which indicated severely impaired cognitive status. Resident #3 declined to participate in an interview attempted on 3/24/2026 at 11:21 AM. In an interview with Resident #3's family member on 03/25/2026 at 3:10 PM, she said she confronted the Admin. on or around October 2025 with concerns that he was stealing money from Resident #3's bank account. She said the Admin. admitted to taking the money, but he said the money was for business expenses. She said he did not follow up with the conversation, but no additional funds had been withdrawn from the bank account since then. In an interview with the DON on 3/26/2026 at 1:45 PM, she said she was present when Resident #3's family member alleged the Admin. was stealing money from Resident #3. She was unsure why the Admin. did not report the allegations to the SSA, and she was not aware of any further investigation into the allegations by the Admin.In an interview with the Admin. on 3/26/2026 at 1:53 PM, he said he was the Abuse and Neglect Coordinator for the facility. He said he recalled the conversation with Resident #3's family member in which she accused him of stealing Resident #3's money. He said he did not report the allegations to the SSA because the allegations were false, and he felt it did not warrant reporting. He said that he did not conduct an investigation into the allegations because he already knew the allegation was untrue. Record review of the facility policy titled Abuse Prohibition Regulations (undated, provided by the facility on 3/27/2026), reflected the following: .3. The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress.

Based on interview and record review the facility failed to ensure Comprehensive Care Plans, A comprehensive care plan must be to the extent practicable, the participation of the resident and the resident's representative. An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not to be practicable for the development of the resident's care plan for 2 of 8 (#2,#16) residents in that:Resident #2 and 16 Resident/Families were not offered to attend their care plan meetings. This could affect residents and could cause residents to decrease self-esteem. The Findings: 1. Record review of Resident #2's admission Record (no date) revealed she was admitted on [DATE] and readmitted on [DATE] with diagnoses with depressive disorder, diabetes II, anxiety, and bipolar disorder. Record review of Resident #2's Quarterly MDS dated [DATE] revealed her BIMS score was 15/15 (cognitively intact), impairment on one side of upper extremity, impairment on both sides on lower extremity, mobilized with an electric wheelchair, and was dependent with personal hygiene. Record review of Resident #2's MDS 2/9/2026 revealed she mobilized in an electric wheelchair, independent in eating, impaired vision, and communicates verbally orientation/memory was good. Record review of Resident #2's care plan dated 3/27/2026 revealed she required extensive assistance with self-care, communication deficit, and poor vision. No record of residents or staff signatures documented on the care plan conference sheet. Interview on 3/27/2026 at 1:15 PM with Resident #2 stated she had not been invited to care plan meetings. 2.Record review of Resident #16's admission Record dated 4/3/2025 revealed he was [AGE] years old, was admitted on [DATE] with diagnoses of elevated myocardia, (the thick, middle muscular layer of the heart wall responsible for contracting to pump blood throughout the body) weakness, vitamin D deficiency and reduced mobility.Record review of Resident #16's Quarterly MDS dated [DATE] revealed that his BIMS was 15/15 (cognitively intact), and no history of falls. Record review of Resident #16's care plan dated 3/13/2026 revealed he was a fall risk, unsteady gait, weakness, impaired mobility, able to transfer self, and visions improved related to cataract surgery. In an interview on 3/27/2026 at 9:45 AM, the LSW said she did not routinely attend care plan meetings. In an interview with the DON on 3/27/2026 at 11:00 AM, she said she coordinated care plan meetings for residents, and she did not routinely invite family members to attend or participate in the formulation of the care plan. She said if she had questions about a resident's care, she would call the family members on the telephone. DON had no comments. Interview on 3/27/2026 at 2:15 PM Resident #2 stated she had not been invited to care plan meetings. Record review of policy, Care Plan Comprehensive, (no date) revealed an individualized comprehensive care plan that includes measurable objective and timetables to meet the resident's [NAME], nursing, mental and psychological needs is developed for each resident. 1. Our facility's care planning/interdisciplinary team, in coordination with the resident, his/her family or representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident ay be expected to attain.

Based on observation, interview, and record review, the facility failed to provide routine dental services for 1 of 2 residents (Resident #3) reviewed for dental services. The facility failed to ensure Resident #3 received routine dental care in 2025 and 2026. This failure could result in tooth decay or loss, infection, and decreased quality of life. Findings included: Record review of the facility document titled Resident Master Information dated 4/02/3035 reflected Resident #3 was a [AGE] year-old male admitted to the facility on the 3/02/2022. Relevant diagnoses included bipolar disorder (a mental health disorder characterized by significant mood swings) and dementia (a progressive neurological disorder affecting memory and judgement). Resident #3's insurance was identified as Medicaid.Record review of Resident #3's quarterly MDS submitted 2/9/2026 reflected a BIMS score of 06, which indicated severely impaired cognitive status. Section L of the MDS (oral/dental status) was not assessed. Record review of Resident #3's paper chart did not reveal documentation from a dental provider for routine and/or emergency care. Record review of an e-mail from the facility's contracted dental provider to the Admin. dated 12/13/2023 reflected an e-mail from the Admin. requesting an evaluation for Resident #3 due to dental pain. Record review of the document titled New Patient Registration and Consent dated 3/7/2024 reflected Resident #3 had a non-life threatening urgent dental need of c/o hot/cold sensitivity [and] tooth pain. In an observation and attempted interview on 3/24/2026 at 11:21 AM, Resident #3 was observed to have multiple missing teeth to the upper and lower jaws, and there was brown discoloration to the remaining teeth. Resident #3 declined to be interviewed for the survey. In an interview with the Admin. on 3/27/2026 at 10:33 AM, he said Resident #3 had not received dental care since 2024 because he had not complained of any new dental issues. He said he was not aware that the facility was required to assist residents with obtaining routine dental care, including residents with Medicaid insurance coverage. He said the current contracted dental provider would only provide dental care for several residents during each visit, and the lack of routine care was their fault. He said he had not attempted to find an alternative or additional dental provider. A policy regarding dental care was requested from the Admin. during the interview on 3/27/2026 at 10:33 AM but was not provided prior to survey exit.

Based on observation, interviews and record review the facility failed to dispose of garbage and refuse properly for 1 of 1 (1 dumpster) in that: There was no plug for the garbage dumpster, and the side door was open 1/4 of the way. This deficient practice could increase pests and rodents in the area. The Findings:Observation on 3/24/2026 at 10:00 AM with FSM revealed the dumpster had no dumpster plug and the door was 1/4 open on the side of the dumpster. Observation on 3/25/2026 at 3:30 PM with FSM revealed the dumpster did not have a plug. Interview on 3/25/2026 at 3:31 PM with FSM stated she was not aware the dumpster had to have a plug and was not sure who opened the side door for the dumpster. FSM was not aware of how it would affect the residents. Interview on 3/25/2026 at 5:23 PM with ADM stated the dumpster door should be closed, and the garbage dumpster should have a plug to prevent rodents. No policy on keeping dumpster doors closed. Record review of policy, (no date) Garbage Dumpster policy, reflected The Garbage Dumpster will have a plug in the bottom drain at all times to prevent vermin from entering and liquids waste for escaping.

Based on observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5%, for 27 medication administration opportunities with 15 errors resulting in a 55.56% medication error rate, for 4 of 4 residents (Residents #6, #7, #22, and #30) reviewed for medication administration. 1. LVN D administered Resident #6's medications by her gastronomy tube (often called a G tube, is a surgically placed device used to give direct access to a person's stomach for supplemental feeding, hydration, or medicine), contrary to professional standards by administering all the medications together rather than one by one, and late by 11 minutes. 2. LVN D administered Resident #30's medications by her gastronomy tube contrary to professional standards by administering all the medications together rather than one by one, and late by 50 minutes. 3. Medication Aide I did not administer Amlodipine 5mg to Resident #7 as prescribed by her physician. 4. Medication Aide I did not administer hydrochlorothiazide 25mg to Resident #22 as prescribed by his physician. These deficient practices placed residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: A record review of Resident #6's admission record dated 1/9/2025, revealed an admitted [DATE] with diagnoses which included hypertension (high blood pressure), diabetes (a person's difficulty using blood sugar in their cells) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). A record review of Resident #6's quarterly MDS assessment dated [DATE] revealed Resident #6 was an [AGE] year-old female admitted for long term care and was unable to participate in a BIMS assessment which indicated severe cognitive impairment. Resident #6 was assessed with the need for a feeding tube (also known as a g-tube). A record review of Resident #6's care plan dated 01/09/2025 revealed, potential for weight loss and dehydration r/t CVA, dementia, tube feeding . flush PEG tube (Feeding tubes, or PEG tubes, allow you to receive nutrition through your stomach) with water and post medication administration as ordered per physician for hydration. tube feeding . flush tube as ordered A record review of Resident #6's physicians orders dated 1/9/2025 revealed the physician prescribed Resident #6 to receive medications which included metformin 500mg 1-tab PGT daily diagnoses diabetes mellitus type 2 at 8:00 AM and acetaminophen 500mg 1-tab PGT every 8 hours diagnosis generalized pain at 8:00 AM, 4:00 PM, and at midnight. Further review revealed the physician prescribed for Resident #6 to receive a water flush before and after each medication all shifts. During an observation on 01/09/2025 at 9:11 AM revealed LVN D prepared and administered medications for Resident #6 per Resident #6's g-tube. LVN D crushed and mixed the prescribed acetaminophen, metformin, miralax, and her liquid multivitamin by flushing the medications with an unmeasured amount of water poured from a 9-ounce plastic cup. LVN D began by pouring water into the resident's G-tube, adding water to the medications, and pouring the medications together in to Resident #6's g-tube, and completed the administration by pouring the remainder of the water from the plastic cup without administering the medications individually and with a water flush in between all individual medications. 2. A record review of Resident #30's admission record dated 07/22/2024 revealed an admitted [DATE] with diagnoses which included gastronomy status (presence of a g-tube), dementia, and seizures (electrical storms of the brain). A record review of Resident #30's quarterly MDS assessment dated [DATE] revealed Resident #30 was a [AGE] year-old female admitted for long term care and assessed with severely impaired cognition, could not communicate her needs. Resident #30 was assessed with the need for a feeding tube. A record review of Resident #30's care plan dated 12/13/2024 revealed Resident #30 was quadriplegic (a symptom of paralysis that affects all a person's limbs and body from the neck down), NPO (Latin for nothing by mouth) and required enteral feeding (enteral administration is food or drug administration via the human gastrointestinal tract), Tube feeding . Resident has gastronomy tube . assess feeding tube placement, patency, and residual every shift and before and after administration of any fluids or medications. A record review of Resident #30's physician order summary dated January 2025, revealed the physician prescribed Resident #30 would have her g-tube flushed with 15 ml of water before and after administration of medications. Further review revealed the physician prescribed Resident #30 to have 11 medications administered by her g-tube, at 8:00 AM, as follows: Apixaban 5mg 1-tab PGT 2x daily crush tab and suspend in 60ml water 8:00 AM, 8:00 PM. Escitalopram 5mg 1-tab PGT daily 8:00 AM. Memantine 5mg 1-tab PGT daily 8:00 AM. Tramadol 50mg 1-tab PGT 2x daily 8:00 AM / 8:00 PM. Reglan 5mg/5ml 10mg PGT 3x daily 8:00 AM, 4:00 PM, midnight. Aspirin 81 mg 1-tab PGT daily 8:00 AM. Docusate sodium 100mg 1-tab PGT 2x daily 8 AM and 8 PM. Sodium chloride 1 gram 1-tab PGT 3x daily 8:00 AM, 2:00 PM, 8:00 PM. Simethicone 80mg 1-tab PGT 2x daily (may crush med) 8:00 AM, 8:00 PM. Oxcarbazepine 300mg 1-tab PGT 2x daily 8:00 AM, 8:00 PM. Miralax 17 grams powder 1 capful 2x daily 8 ounces of water. During an observation on 1/9/2025 at 9:50 AM revealed LVN D prepared and administered medications for Resident #30 per Resident #30's g-tube. LVN D crushed, mixed, with water, and administered the following prescribed medications together and not separately - individually: Apixaban 5mg 1-tab PGT 2x daily crush tab and suspend in 60ml water 8:00 AM, 8:00 PM. Escitalopram 5mg 1-tab PGT daily 8:00 AM. Memantine 5mg 1-tab PGT daily 8:00 AM. Tramadol 50mg 1-tab PGT 2x daily 8:00 AM / 8:00 PM. Reglan 5mg/5ml 10mg PGT 3x daily 8:00 AM, 4:00 PM, midnight. Aspirin 81 mg 1-tab PGT daily 8:00 AM. Docusate sodium 100mg 1-tab PGT 2x daily 8 AM and 8 PM. Sodium chloride 1 gram 1-tab PGT 3x daily 8:00 AM, 2:00 PM, 8:00 PM. Simethicone 80mg 1-tab PGT 2x daily (may crush med) 8:00 AM, 8:00 PM. Oxcarbazepine 300mg 1-tab PGT 2x daily 8:00 AM, 8:00 PM. Miralax 17 grams powder 1 capful 2x daily 8 ounces of water. During an interview on 01/09/2025 at 9:40 AM, LVN D stated the physician's order for Resident #30 was for 15 ml of water to be flushed by the g-tube before and after medication administration. LVN D stated the 9-ounce plastic water cup was unmarked for measurement. During an interview on 01/10/2024 at 11:20 AM, LVN D stated she had administered all medications mixed without a water flush in between each individual medication for Residents #6 and #30, on 1/9/2025, and did not have a response for why nor what effect the action could have had for residents. 3. A record review of Resident #7's admission record dated 7/22/2024 revealed an admitted [DATE] with diagnoses which included hypertension (high blood pressure). A record review of Resident #7's quarterly MDS assessment dated [DATE] revealed Resident #7 was an [AGE] year-old female admitted for long term care with the diagnosis of hypertension and assessed with a BIMS score of 8 out of a possible 15 which indicated mild cognitive impairment. Further review revealed Resident #7 was assessed with the ability to usually understand others and could usually make her needs known. A record review of Resident #7's care plan dated 10/18/2024 revealed Resident #7 was a fall risk with the intervention to assess medications for contributing factors. A record review of Resident #7's physician's orders, dated January 2025, revealed the physician prescribed for Resident #7 to receive amlodipine 5 g daily at 8:00 AM with the stipulation hold for systolic blood pressure less than 100 or diastolic blood pressure less than 60. During an observation and interview on 1/9/2025 at 8:54 AM revealed MA I prepared Resident #7's medications and checked Resident #7's blood pressure with a digital electronic blood pressure cuff. MA revealed the result was 102 systolic blood pressure (the pressure in your arteries when your heart beats) over 63 diastolic blood pressure (the pressure of blood in the arteries when the heart is resting between beats). MA I stated I will not give the (name brand for amlodipine) due to (Resident #7's name) low blood pressure. 4. A record review of Resident #22's admission record dated 7/22/2024 reveled an admitted [DATE] with diagnoses which included hypertension (high blood pressure). A record review of Resident #22's quarterly MDS assessment dated [DATE] revealed Resident #22 was a [AGE] year-old male admitted for long term care, diagnosed with high blood pressure, and assessed with a BIMS score of 06 which indicated severe cognitive impairment. A record review of Resident #22's care plan dated 10/11/2024 revealed, evaluate medications and diet for adverse interactions. A record review of Resident #22's physician orders dated January 2025 revealed the physician prescribed for Resident #22 to receive hydrochlorothiazide 25mg daily at 10:00 AM. Further review of the order revealed no stipulations. During an observation and interview on 1/10/2025 at 9:46 AM revealed MA I prepared medications for Resident #22 and prior to medication administration MA I checked Resident #22's blood pressure and stated the result was 99 SBP over 60 DBP with a pulse of 69 beats per minute. MA I stated she would not administer the amlodipine due to a low blood pressure. During an interview on 1/10/2024 at 1:20 PM, LVN E stated she was the charge nurse and had not received a report from MA-I regarding Resident #22's low blood pressure and the resulting MA-I holding the hydrochlorothiazide. LVN E stated Resident #22 did not have stipulations on the hydrochlorothiazide administration and would assess Resident #22. During an interview on 1/10/2025 at 11:23 AM, LVN E stated she did not have any standing physician orders for g-tube medication administration to reference for enteral flushes. LVN E stated Residents #6 and #30 did have orders for each medication to be administered separately with a water flush in between each medication administration. LVN E stated all nurses should know the professional standard for medication administration per g-tube was for each medication to be administered one at a time with a water flush in between each medication. During an interview on 1/10/2025 at 1:30 PM the DON stated Residents #7 and #30 had physician orders for water flushes in between medication administration and the expectation was for all nurses to administer g-tube medications individually, flush the g-tube with 5-10 ml of water in between each medication, and to flush the g-tube with water before and after the whole medication administration. The DON stated medication aides should administer medications as prescribed by the physician and follow the parameters set by the physician. The DON stated if the medication had no stipulations / parameters then the medication should be administered per physicians' orders. The DON stated she had not received a report that Resident #22 had not received his hydrochlorothiazide this morning and stated if Resident #22's hydrochlorothiazide order did not have parameters it should have been administered with a blood pressure of 99 sbp / 63 dbp. The DON stated the risk for residents could be for residents not to receive the therapeutic effects of their medications. During an interview on 01/10/2025 at 4:40 PM, the Administrator stated he agreed with the DON on her expectations for g-tube medication administration and other medication administration practices. A policy for g-tube medication and medication errors was requested on 1/10/2025 and as of 1/16/2025 was not provided. A record review of the United States of America's National Library of Medicine website, titled Preventing Errors When Drugs Are Given Via Enteral Feeding Tubes, https://pmc.ncbi.nlm.nih.gov/articles/PMC3875244/#:~:text=Appropriate%20administration%20techniques%20must%20be,drugs%20through%20enteral%20feeding%20tubes accessed 01/10/2025, revealed, Preventing Errors When Drugs Are Given Via Enteral Feeding Tubes Problem: Giving medications through a feeding tube can be fraught with errors that occur more often than they are reported or recognized. These mistakes are often the result of administering drugs that are incompatible with administration via a tube, of not preparing the medications properly, and of using faulty techniques. These inaccuracies can result in an occluded feeding tube, a reduced drug effect, or drug toxicity. These potential adverse outcomes can lead to patient harm or even death. FAULTY PREPARATION - Oral medications that are intended to be taken by mouth must be prepared for enteral administration. Tablets must be crushed and diluted, capsules must be opened so the contents can be diluted, and even many commercially available liquid forms of drugs should be further diluted before being administered enterally-a practice not well known to all practitioners. WRONG ADMINISTRATION TECHNIQUE - Most nurses rely primarily on their own experience and on that of their coworkers for information about preparing and administering enteral medications. Because few nurses rely on pharmacists, nutritionists, or printed guidelines, a variety of improper techniques and an overall lack of consistency have often been the result. The most common improper administration techniques include mixing multiple drugs together to give at the same time and failing to flush the tube before giving the first drug and between giving subsequent drugs. Safe Practice Recommendation: Within each organization, an interdisciplinary team of nurses, pharmacists, nutritionists, and physicians should work together to develop protocols for administering drugs through enteral feeding tubes. Protocols should address using appropriate dosage forms; preparing the drugs for enteral administration; administering each drug separately; diluting the drugs as appropriate; and flushing the feeding tube before, between, and after drug administration. A record review of the United States of America's National Library of Medicine website, titled, Hydrochlorothiazide https://medlineplus.gov/druginfo/meds/a682571.html Accessed 1/10/2025, revealed Why is this medication prescribed? Hydrochlorothiazide is used alone or in combination with other medications to treat high blood pressure. Hydrochlorothiazide is used to treat edema (fluid retention; excess fluid held in body tissues) caused by various medical problems, including heart, kidney, and liver disease and to treat edema caused by using certain medications including estrogen and corticosteroids. Hydrochlorothiazide is in a class of medications called diuretics ('water pills'). It works by causing the kidneys to get rid of unneeded water and salt from the body into the urine. High blood pressure is a common condition and when not treated, can cause damage to the brain, heart, blood vessels, kidneys, and other parts of the body. Damage to these organs may cause heart disease, a heart attack, heart failure, stroke, kidney failure, loss of vision, and other problems. How should this medicine be used? Hydrochlorothiazide comes as a tablet, capsule, and solution (liquid) to take by mouth. It usually is taken once or twice a day. When used to treat edema, hydrochlorothiazide may be taken daily or only on certain days of the week. Follow the directions on your prescription label carefully and ask your doctor or pharmacist to explain any part you do not understand. Take hydrochlorothiazide exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor. Hydrochlorothiazide controls high blood pressure but does not cure it. Continue to take hydrochlorothiazide even if you feel well. Do not stop taking hydrochlorothiazide without talking to your doctor.

Resident #33 FTag Initiation 01/10/25 10:39 AM Thorazine consent not signed, wrong resident and theo [NAME] res was not on thorazine vns check was not on mar, 50531 Resident #6 FTag Initiation 01/10/25 03:31 PM Initiate F700 & F656 initiated d/t order for abdominal binder and fact that abdominal binder is not identified in the care plan and use of 1/2 side rail for positioning (not appropriate need for this resident).

Based on observation and interviews, the facility failed to ensure the resident received care and services safely and that the physical layout of the facility maximized resident independence and did not pose a safety risk, with housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior and adequate and comfortable lighting levels in all areas; for 2 of 2 shower rooms (A hall shower and B hall shower) reviewed for trip hazards and lighting. 1. The facility failed to have adequate safe lighting for the showers as evidenced by the B Hall shower having a shower stall with no light fixture within the shower stall and the A hall shower stall having no functioning light bulb in the fixture within the shower stall. 2. The facility failed to ensure there was no trip hazard in the A hall shower room as evidenced by the A hall shower stall had an inclined ramp up to the shower stall with a tile bump atop of the ramp. These failures could place residents at risk for injuries by not having adequate lighting and trip hazards. The findings included: Daily observations beginning on 1/7/2025 at 10:45 AM through 1/10/2025 at 3:00 PM revealed the facility had a census of 34 with 2 shower rooms within the facility, located in A hall and B hall. An observation of the B hall shower room revealed a shower stall with an inclined ramp up into the shower stall, the stall appeared dark and was dimly illuminated by the nearby fluorescent ceiling lamp. Further observation revealed no light fixture within the shower stall. Observation of the A hall shower room revealed a shower stall with an inclined ramp which led up into the shower stall. The ramp presented with a tiled and curved bump atop of the ramp. An observation and interview on 1/10/2025 at 11:34 AM revealed the Maintenance Director reviewed the B hall shower room. The Maintenance Director stated the shower stall did not have a light fixture. The Maintenance Director stated the shower stall had an inclined ramp up into the shower stall, the stall appeared dark and was dimly illuminated by the nearby fluorescent ceiling lamp. An observation and interview on 1/10/2025 at 11:41 AM revealed the Maintenance Director reviewed the A hall shower room. The Maintenance Director stated the shower stall did have a light fixture with a burned-out bulb and was not aware when the bulb may have burned-out. The Maintenance Director stated the shower stall had an inclined ramp which led up into the shower stall. The ramp presented with a tiled curved bump atop of the ramp. The Maintenance Director stated the curved bump tile may have been added to the top of the ramp to prevent water from draining down on to the floor when the drain may clog. The Maintenance Director stated he was not aware if this tiled bump would be a safety risk to anyone. An observation and interview on 1/10/2025 at 1:34 PM revealed hospice CNA K prepared linens and clothing for a Resident's shower in the A hall shower room and stated a light within the shower stall would allow her to better serve her residents with their skin assessments and ensure hygiene. CNA K stated the bump atop of the ramp made it difficult to push or pull residents over the bump, into the shower stall, and would often startle residents when the bump was overtaken. An observation and interview on 1/10/2025 at 2:20 PM revealed CNAs A and J reviewed the A hall shower room and stated the bump atop of the ramp had caused near trip hazards for them as they pushed or pulled residents over the bump. CNAs A and J stated there were several residents who used the shower by themselves, and the poor light and the bump could place them at risk for falling. During an interview on 01/10/2024 at 4:00 PM, the DON stated the poor lighting in the shower rooms should be corrected, and the tile curved bump atop of the A hall shower room ramp would be reviewed for safety and necessity. During an interview on 1/10/2025 at 5:00 PM, the Administrator stated he agreed with the DON assessment of the shower rooms. A policy was requested on 1/10/2025 and was not provided to the survey team before exit.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, which must include, at a minimum, the following elements: A. Standard and transmission-based precautions to be followed to prevent spread of infections, and B. The hand hygiene procedures to be followed by staff involved in direct resident contact; for 2 of 2 residents reviewed for incontinent care and medication administration (Residents #6 and #30) reviewed for standard and transmission-based precautions for infection control and prevention. 1. On 1/9/2025, CNA A and CNA J assisted Resident #6 with incontinent care and failed to change gloves with hand hygiene in between glove changes after touching handling Resident #6's soiled linens and supplies prior to touching handling Resident #6's clean linens and supplies. 2. On 1/9/2025, LVN D failed to change gloves with hand hygiene after touching handling Resident #6's clothing and furniture prior to administering Resident #6's medications. 3. LVN D failed to doff a potentially contaminated PPE gown prior to exiting Resident #6's room and wore the potentially soiled PPE gown in the hallway. 4. On 1/9/2025, LVN D failed to change gloves with hand hygiene after touching handling Resident #30's clothing and furniture prior to administering Resident #30's medications. 5. LVN D failed to doff a potentially contaminated PPE gown prior to exiting Resident #30's room and wore the potentially soiled PPE gown in the hallway. 6. The facility failed to store oxygen concentrator equipment in a clean room and stored the oxygen concentrator equipment in a bathroom. These failures could place residents at risk for harm by cross-contamination. The findings included: A record review of Resident #6's admission record dated 1/9/2025, revealed an admitted [DATE] with diagnoses which included hypertension (high blood pressure), diabetes (a person's difficulty using blood sugar in their cells) and dementia (A group of symptoms that affects memory, thinking and interferes with daily life). A record review of Resident #6's quarterly MDS assessment dated [DATE] revealed Resident #6 was an [AGE] year-old female admitted for long term care and was unable to participate in a BIMS assessment which indicated severe cognitive impairment. Resident #6 was assessed with the need for a feeding tube (AKA a g-tube). A record review of Resident #6's care plan dated 01/09/2025 revealed, at risk for covid-19 virus . follow strict CDC guidelines A record review of Resident #6's physicians orders dated 1/9/2025 revealed the physicians' prognosis for Resident #6 was guarded. During an observation on 1/9/2025 at 10:57 AM revealed CNA A and CNA J assisted Resident #6 with incontinent care by donning PPE to include gowns and gloves. CNA A was observed to position and disrobe Resident #6 and continued to dispense cleansing wipes from the clean wipes package, clean Resident #6's genitalia and buttocks with multiple wipes kept atop of Resident #6's soiled under-pad, changed gloves without hand hygiene in between glove changes, and proceeded to remove the soiled linen and under pads, and then provided clean linen and adult briefs with the same soiled contaminated gloves. CNA A then doffed the gloves without performing hand hygiene and exited Resident #6 room. During an observation on 1/9/2025 at 11:17 AM, CNA A stated she changed gloves after every 3 to 4 wipes. CNA A stated she should have sanitized her hands after changing gloves, and improper hand hygiene was a risk for causing infections and cross contaminations or getting stool into Resident #6's vagina. 2. An observation and interview on 1/9/2025 at 9:11 AM revealed LVN D administered medications to Resident #6 via her g-tube. LVN D donned gloves without providing hand hygiene prior to donning, handled medication cart and keys, and entered Resident #6's room and assessed Resident #6's blood pressure, exited Resident #6 room without doffing the gloves and or performing hand hygiene, nor disinfecting the blood pressure cuff, and proceeded to prepared Resident #6's medications with the same gloves. LVN D donned PPE to include a gown and continued with the same gloves. LVN D was observed to handle Resident #6's person, clothing, furniture, and enteral piston syringe and then proceeded to administer Resident #6's medications via her g-tube while not changing gloves with hand hygiene prior to the medication administration. After the medication administration LVN D was observed to exit Resident #6's room without doffing the gown, doffed the gloves without providing hand hygiene, and continued into the hallway and entered a bathroom to wash Resident #6's enteral piston syringe and performed hand hygiene. LVN D continued in the hallway and reentered Resident #6's room to replace the piston syringe in the package, exited Resident #6's room and doffed the gown without performing hand hygiene. LVN D stated she should have changed gloves with hand hygiene before administering Resident #6's g-tube medications and stated the potential harm for residents was infections. 3. A record review of Resident #30's admission record dated 07/22/2024 revealed an admitted [DATE] with diagnoses which included gastronomy status (presence of a g-tube), dementia, and seizures (electrical storms of the brain). A record review of Resident #30's quarterly MDS assessment dated [DATE] revealed Resident #30 was a [AGE] year-old female admitted for long term care and assessed with a severely impaired cognition, could not communicate her needs. Resident #30 was assessed with the need for a feeding tube. A record review of Resident #30's care plan dated 12/13/2024 revealed Resident #30 was quadriplegic (a symptom of paralysis that affects all a person's limbs and body from the neck down), NPO (Latin for nothing by mouth) and required enteral feeding (enteral administration is food or drug administration via the human gastrointestinal tract), Tube feeding . Resident has gastronomy tube . assess feeding tube placement, patency, and residual every shift and before and after administration of any fluids or medications. A record review of Resident #30's physicians orders dated 1/9/2025 revealed the physicians' prognosis for Resident #30 was guarded. During an observation on 1/9/2025 at 9:48 AM revealed LVN D donned gloves without performing hand hygiene, prepared Resident #30's medications, doffed the gloves without hand hygiene, donned new gloves, entered Resident #30's room, recognized she was missing a piston syringe and a PPE gown, exited the room while continuing with the same gloves, walked to the supply cabinet closet in the hallway, donned a gown and returned to Resident #30's bedside with the same gloves. LVN D was observed to administer Resident #30's medications with the same gloves. After LVN D administered Resident #30's medications she was observed to exited Resident #30's room, without doffing the gown and gloves, continued in the hallway to the bathroom where she doffed the gloves provided hand hygiene and washed the piston syringe. LVN D continued with the same gown in the hallway and returned to Resident #30's room to replace the piston syringe and doffed the gown. 4. During daily observations from 1/7/2025 through 1/10/2025 revealed the A Hallway public bathroom for staff and visitors. Further daily observations revealed the bathroom housed 2 clean oxygen concentrators covered with plastic translucent bags. The bags were labeled cleaned 1/6/2025 and 12/2/24. During an interview on 1/8/2025 at 1:20 PM, LVN E stated the clean oxygen concentrators were available for resident-use and were stored in the staff and visitors public restroom due to lack of space with in the facility. During an interview on 01/10/2025 at 2:00, the DON stated the expectation for infection control and prevention was for staff to follow standard precautions for all residents and enhanced barrier precautions for residents with g-tubes. The DON stated standard precautions were for staff to perform glove changes when going from a dirty to clean scenario and to perform hand hygiene in between all glove changes and when gloves are doffed. The DON continued to state all PPE must not be worn in the hallways and should be doffed in the enhanced barrier precautions room. The DON stated the nursing staff were trained per CDC guidelines for standard and enhanced barrier precautions. During an interview on 1/10/2025 at 5:00 PM, the Administrator stated he agreed with the DON's expectations for infection control and prevention. A policy for infection control was requested on 1/10/2025 and was not provided upon exit on 1/10/2025. A record review of the United States of America's Centers for Disease Control and Preventions website titled, CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings. https://www.cdc.gov/infection-control/hcp/core-practices/index.html Accessed 1/10/2025, revealed, Use Standard Precautions to care for all patients in all settings. Standard Precautions include: 5a. Hand hygiene 5b. Environmental cleaning and disinfection . 5f. Reprocessing of reusable medical equipment between each patient or when soiled Standard Precautions are the basic practices that apply to all patient care, regardless of the patient's suspected or confirmed infectious state, and apply to all settings where care is delivered. These practices protect healthcare personnel and prevent healthcare personnel or the environment from transmitting infections to other patients. 5a. Hand Hygiene . Use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient. Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices. Before moving from work on a soiled body site to a clean body site on the same patient. After touching a patient or the patient's immediate environment. After contact with blood, body fluids or contaminated surfaces. Immediately after glove removal. Ensure that healthcare personnel perform hand hygiene with soap and water when hands are visibly soiled. Ensure that supplies necessary for adherence to hand hygiene are readily accessible in all areas where patient care is being delivered. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink. 5d. Risk Assessment with Appropriate Use of Personal Protective Equipment . Ensure proper selection and use of personal protective equipment (PPE) based on the nature of the patient interaction and potential for exposure to blood, body fluids and/or infectious material: Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur. Wear a gown that is appropriate to the task to protect skin and prevent soiling of clothing during procedures and activities that could cause contact with blood, body fluids, secretions, or excretions. . Remove and discard PPE . upon completing a task before leaving the patient's room or care area. Do not use the same gown or pair of gloves for care of more than one patient. Remove and discard disposable gloves upon completion of a task or when soiled during the process of care. Ensure that healthcare personnel have immediate access to and are trained and able to select, put on, remove, and dispose of PPE in a manner that protects themselves, the patient, and others

FACILITY Environment 01/09/25 02:35 PM poor lighting in shower rooms. a and b, resident little stated she used shower and she could use a better light, and could be warmer, the heater in a and b were not working. 01/09/25 05:36 PM pm [NAME] stated laundry door gap ok, ok for concern and no tag for door gap, shower curtain in between dirty and clean, and toilet on pedestal, Resident #19 FTag Initiation 01/10/25 01:31 PM no light in shwr and bump on ramp.

Based on interview, record review and observation, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 12 residents [Resident #6] reviewed for care plans. The facility failed to develop the appropriate care plan intervention of implementing an abdominal binder to prevent Resident #6 from pulling out her feeding-tube per physician's order. This deficient practice could place resident at risk of trauma or injury. The findings include: Record review of Resident #6 face sheet dated 9/20/24 revealed an [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE]. Relevant diagnosis included Dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with behavioral disturbance, bilateral below the knee amputee. Record review of Resident #6 Quarterly MDS dated [DATE] revealed resident unable to complete BIMS assessment due to severe cognitive impairment. Resident #5 had functional limittion in rang of motion with impairment on both sides of upper extremity to include shoulder, elvow, wrist, hand. The MDS reealed resident was dependent. The BIMS assessment was unable to be completed due to Resident#6 severe cognitive impairment. Resident #6 was dependent and helper did all the effort in ADL needs. Resident did none of the effort to complete any of the ADL activities. Record review of Resident #6 Care Plan (last updated 9/24/24) revealed absence of behavioral disturbance reflecting behavior of pulling out feeding tube or potential for injury related to pulling out feeding tube. Record review of Resident #6 physician's orders reflected an order dated 1/20/16 apply abdominal binder to prevent pulling of G-tube all shifts. During observation on 01/07/2025 at 10:55 AM Resident #6 was resting in bed, eyes closed with tube feeding connected and an abdominal binder was not in place. During observation on 01/08/2025 at 11:05 AM Resident #6 was resting in bed, eyes closed with tube feeding connected and abdominal binder was not in place. During an observation on 01/09//2025 at 2:20 PM Resident #6 was resting in bed, eyes were closed, and tube feeding was not running. An abdominal binder was not in place. An interview on 01/09/25 AM with CNA A revealed Resident #6 has a tendency to pull out tube feeding which is why abdominal binder is placed on resident. CNA A stated she worked with resident on 01/08/25 and applied binder. CNA stated abdominal binders were located in the linen closets. An interview on 01/09/25 at 10:25 AM with CNA B revealed staff used a binder to prevent Resident #6 from pulling out tube feeding. CNA B stated she has not worked with Resident #6 this week. An interview on 01/10/25 at 8:00 AM with LVN E confirmed that resident had an order for an abdominal binder. LVN E stated CNA's apply binder daily and reapply after peri-care as needed. LVN confirmed Charge Nurse is responsible to ensure abdominal binder is in place. LVN stated the staff know about the binder and that she will put it on the nursing MAR so it will not be missed. An interview on 01/10/25 at 8:22 AM with the DON confirmed that Resident #6 did have an order for an abdominal binder on at all shifts. DON confirmed that adverse effects to include trauma / injury to stoma site could occur if resident pulled feeding tube out. A request for a policy on Care Plan development and implementation was made on 01/09/2025 at 9:00 AM and was not provided by the facility.

Based on observations, interviews, and record reviews the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and Each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 4 (Res #1) reviewed for elopements in that: Resident #1 had eloped from facility 3 times (7/26/2023, 8/8/2023, 8/26/2023) with a wander guard on. a. staff were not in-serviced following each elopement. b. no elopement assessment was completed for Resident #1 prior to or immediately following the elopements. c.no measurable (dated) care plan for elopement risk. d. an alarm was not in place on Resident #1's window as indicated on care plan. An IJ was identified on 10/07/2023. The IJ template was provided to the facility on [DATE] at 3:28 PM. While the IJ was removed on 10/11/2023, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm because the facility is still monitoring their effectiveness of their plan of removal. This could affect residents who are elopement risks and could place them at risk for injuries. The Findings were: Record review of Resident #1's Admission Record dated 8/8/2023 revealed she was admitted on [DATE] with diagnoses of vascular dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change), severe cognitive impairment, anxiety (a feeling of worry, nervousness, or unease), state and mood disorder (any of a group of mental conditions characterized by persistent disturbance of mood, especially in the form of depression or euphoria or a combination). Record review of Resident #1's Admission MDS dated [DATE] revealed she was Cognitively severely impaired. Resident #1 was independent with bed mobility, transfers, walk in room/corridor, locomotion on unit, eating, toilet use and dressing. Resident #1 required limited assistance with her personal hygiene and bathing with 1-person physical assistance. Resident #1 had no impairments for range of motion. Resident #1 incontinent of urinary continence and always continent for bowels. Resident #1's height was 61 and weight was 98. Resident #1 had a restraint and alarms was for Alarms used daily wander/elopement alarm. Record review of Resident #1's baseline care plan dated 6/15/2023 revealed she was independent with walks, transfers, eating, and toileting. Resident #1 required supervision for dressing and her hearing/vision was normal. Resident #1 can verbally communicate with others, she had frequent disorientation, had a wander guard and was an elopement risk. Care plan dated 6/15/2023 revealed cognitive deficit: decision making was impaired related to Dementia. Resident #1 was severely impaired and never/rarely makes decisions. The interventions were not dated. Record review of Resident #1's Care plan dated 6/28/2023 was documented problem was wandering/elopement risk-evidence of attempts to leave facility unattended, resident wanders aimlessly, impaired safety awareness, disorientation to place. Resident #1's interventions was documented in a list that included to assess the cause and effectiveness of interventions, maintain safety, make sure all staff are aware of elopement risk, bracelet alarm for alarm doors, assess for fall risk, monitor for fatigue, and weight loss, keep picture of resident in medical record. Titled-Modify Environment included outside secure courtyard for safe walking, safe walking path Titled-Structure activities to include structured and supervise walking activity, re-orientation to person, place and time as needed, distract resident from wandering by offering pleasant diversion structured activities food, conversations, television, and book. (No dates for the new interventions). Record review of Resident #1's consent for restraint use dated 6/15/2023 was documented ordered wander guard for alert staff of elopement attempts. Record review of in-service on dementia, unsafe behaviors, exit seeking, wandering into other resident rooms dated on 7/25/2023 for twenty-two staff signed by LVN D (trainer). Record review of progress noted dated 7/26/2023 for Resident #1 revealed the ADON on call over weekend, notified the DON and the Administrator. Record review of progress noted dated 7/26/2023 for Resident #1 revealed LVN B documented resident #1 went out the laundry room gate was brought back into facility. Resident #1 was placed on 15 minutes with CNA and the monitoring. The on-call ADON notified DON, Administrator. Record review of an incident report dated 7/26/2023 at 6 PM documented Resident #1 went out the laundry room gate and was brought back by staff and Resident was placed on 15-minute observations for safety. Resident #1 was observed by staff on a continuous basis after she returned to the facility signed by LVN A. Resident #1 was gone from facility less than 30 minutes. LVN A took Resident #1 vitals and head to toe assessment was done with no injuries noted. LVN A notified the MD, Administrator. The city outside temperature was 105/77 Degrees Fahrenheit. Record review of 24-hour report dated 7/26/2023 to 7/29/2023 was documented Resident #1 back in facility every 15-minute checks elopement risk, MD notified and review medications. Record review of progress notes for 8/8/2023 at 7:25 AM was documented Resident #1 in the dining room for breakfast, not found in room, looked inside and outside the facility, no alarms were sounded, notified the DON, called police and family, APS. Resident #1 was seen in dining room for breakfast at 7:10 AM, Resident #1 stated she wanted to go home, wander guard was on her. The staff sent out to look for Resident #1 in cars. At 7:52 am police called facility that Resident #1 was found and return to facility. Staff called Administrator that Resident #1 was found by police. At 8 AM Resident #1 arrived at the facility and brought in by police, Resident #1 ate breakfast and drank fluids, assessed head to toe with no injury and updated APS, family, DON, Administrator and MD. At 8:20 AM Resident #1 wander guard was on her wrist still and tested the front alarm door and worked properly by LVN B. Record review of an incident report dated 8/8/2023 at 7:25 AM documented Resident #1 eloped from the facility last seen at 7 AM, notified police, APS (adult protective service), family no signs of point of exit. Resident #1 had her wander guard on her wrist and was brought back by police signed LVN B. Resident #1 was gone from facility less than 30 minutes. LVN B notified APS, Administrator, DON, and police. LVN B took Resident #1 vitals and head to toe assessment was done with no injuries noted. (There were other exits. 2 doors had wander alarms. The courtyard had locked fences and a back gate that alarmed. If vendors knew the code, they could have let her out by accident). The city outside temperature was 106/78 Degrees Fahrenheit. Record review of 24-hour report dated 8/8/2023 to 8/11/2023 documented Resident #1 back in facility every 15-minute checks elopement risk. Resident #1 eloped at 7:25 am to 8 AM, every 15-minute check, monitor for behaviors and elopement. Record review of Resident #1's Care Plan updated on 8/8/2023 APS and guardian notified of resident #1's elopement and safety to be in placed in a secure unit. No new intervention dated for the other 2 elopements for Resident #1. Record review of progress noted dated 8/26/2023 for Resident #1 was documented the Cook C called on the 6-2 PM shift, brought Resident #1 back to the facility. The Cook C stated Resident #1 was walking down the street away from the facility. LVN B did the head-to-toe assessment and was stable. LVN B asked Resident #1 how she got out but was too forgetful and confused to remember. LVN B notified Administrator, MD, and guardian. Resident #1's wander guard was on her wrist and the front door worked properly. LVN B noted 2-10 PM sift to state the 15-minute monitoring due to wanderer signed by LVN B. Record review of an incident report dated 8/26/2023 at 2:05 PM documented dietary manager C called the facility by phone saying that she saw Resident #1 walking down the side street away from the facility and brought her back, wander guard was on wrist and was working signed by LVN B. Resident #1 was gone from facility less than 30 minutes. The city outside temperature was 104/76 Degrees Fahrenheit. Record review of 24-hour report dated 8/26/2023 documented Resident #1 back in facility every 15-minute checks elopement risk. Resident #1 eloped at 7:25 am to 8 AM, every 15-minute check, monitor for behaviors and elopement. Record review of Resident #1's Fall risk evaluation dated 9/28/2023 revealed she was oriented x2, had 1-2 falls, was ambulatory, vision adequate, gait normal, administered 1-2 medications, predisposing disease, she scored an 8, documented a high risk would score a 10 or above. Record review of Resident #1's weekly summary dated 9/28/2023 was documented for Cognitive patterns Resident #1 had inattention, disorganized thinking, memory problem short-long-term, and severely impaired. In section for Behaviors Resident #1 wandered. Resident #1's Functional Status she was independent with transfers, bed mobility and toilet use, and did not use a mobility device. Resident #1 for active diagnoses was dementia and had a wander guard bracelet for restraints. The wonder guard bracelet was to alert staff of elopement attempts. Record review of a 30-day notice for Resident #1 dated 9/28/2023 was provided to Resident #1 and temporary guardian. Record review of List of Residents at risk for Elopement (no date) revealed 4 residents to included, Resident #1. The Administrator provided this list. Record review of Resident #1's chart revealed no elopement assessment for each elopement 7/26/2023, 8/8/2023, and 8/26/2023. No prior elopement risk assessments prior to 10/7/2023. Record review of Elopement Risk assessment dated [DATE] for Resident #1 was documented a score of 25, if the score was 5 or greater, they are at risk. (Does resident have a history of elopements/sundowning- scored 5 for both questions). Elopement precautions on care plan - wander guard bracelet in place-yes. Consider placement in a secured unit-yes. Secure unit available-No. Record review of the in-service's booklet did not have in-services that had staff signatures for elopement risk residents after Residents elopements or attempts. Record review of policy (no date) Protocol for wandering residents was attached to every 15-minute checks sheet for the 3 elopements of Resident #1. Record review of the 3 15 - minute checks were completed and signed by staff for 48 hours, per policy. Record review of Protocol for wandering Residents and Elopement reflected Place resident on a fifteen (15)-minute watch for 48 hours . The following rule states assign staff their time period on the watch and prepare the documentation that needs to be filled out. Record review of Resident #1's 15-minute checks revealed on 7/26/2023 15-minute checks began at 6 PM and ended 7/29/2023 at 5:45 PM. On 8/8/2023 resident 15-minute checks began and ended 8/9/2023. On 8/26/2023 the facility began logging 15-minute checks, on 8/27/2023, 2-10 shift began 30-minute checks. At 10 PM, 15-minute checks resumed each shift through 10/10/2023. Record review of in-service on wandering and elopement precaution care to residents and Resident #1. This included 1:1 (staff to be always close to Resident #1) care, create safe space for activities, finding resident in a timely manner, safe space for staff, document on incidents and follow facility protocol. This in-service was dated 10/6/2023 from 6:30 PM to 7 PM. There was a signature page that included all staff. Record review of list of locked units (no date) that the facility was trying to transfer for safety of Resident #1 to a secure unit. The list included 5 different locked units and denied due to lack of money and Medicaid pending. Record review of paper posted across from nurses' station (no date) near staff timecard, was typed, Attention all staff Members -Make sure that you always monitor Resident #1's whereabouts. Inform charge nurse if Resident #1 is exhibiting signs of wanting to leave facility. Observation on 9/19/2023 at 2:30 PM at entrance revealed the front door had an alarm and was locked with a number pad. Staff came to let surveyor in the facility. Observation on 9/19/2023 at 5:13 PM and 9/20/2023 at 10:14 AM of all exits with the Maintenance supervisor during environment rounds. The front door had an alarm, the smoking section had no exit, and the back door leading out to the courtyard was not locked. So, any resident could go outside and walk around the fenced doors in the courtyard had locks on them that were not easily opened. The courtyard had a back gate that vendors or staff used. This back gate was closed and had a code lock on it. The maintenance supervisor showed surveyor if the back gate stayed open for 3 minutes the alarm in the facility sounded. The back gate if opened lead to a street in neighborhood. The courtyard gate near the laundry room was locked and not easily opened. Observation on 9/19/2023 at 5:17 PM revealed Resident #1 was walking around in the halls, she had a wander guard on her wrist, she went to sit down in the dining room for a meal and saw staff was monitoring her. Observation on 9/20/2023 at 10:15 AM with Maintenance supervisor during environment rounds, in Resident #1's room observed window turn knob locked position, screen on window (window blinds difficult for surveyor to open). Resident #1 was not in room at the time. No observation of an alarm placed in the window. The maintenance supervisor turned the knob down position to open Resident #1's window and then turned the knob up position to close the window. Observations of Resident #1's window with the knob lead to the outside in front of the building, too a 4-lane street separated by middle section. The speed limit was 30 mile per hour and was a business road. Observation of Resident #1 was with staff monitoring and engaging with her in dining room sitting with her. Observation on 9/20/2023 at 10:18 AM revealed staff were with Resident #1. Resident #1 was in the dining room during activity with Activity Director. Observation on 9/20/23 at 12:38 PM with RN supervisor in Resident #1's room window had an alarm on it. Observation on 9/20/2023 at 5:32 PM revealed Resident #1 was in the dining area sitting down with staff talking with them. Observation on 9/22/2023 at 11 AM in Resident #1's room revealed she was in her room in bed sleeping and CNA F was sitting in chair in room. Observation in Resident #1's room window had an alarm on it. Observation on 10/8/2023 at 11:28 AM with Resident #1 was sitting in her wheelchair in her room and had a wander guard bracelet. Observation on 10/8/2023 at noon of sheet of paper posted on (no date) across from nurses' station near staff timecard, was typed, Attention all staff Members -Make sure that you always monitor Resident #1's whereabouts. Inform charge nurse if Resident #1 is exhibiting signs of wanting to leave facility. Interview on 9/19/2023 at 5:18 PM with Resident #1 stated she was at school now and will have to go back home near [NAME] Hwy. Resident #1 was confused when asked how she was doing and how she left the facility. Interview on 9/20/2023 at 10:35 AM with CNA E stated she had worked at facility 4 months on the 1st shift and she picks up hours at times. CNA E stated Resident #1 she remembered did leave the building in the mornings and could not recall what else happened. CNA E stated Resident #1 walked around the inside of building down the halls, but she had not seen Resident #1 get out of the building or the courtyard. CNA E stated she had not heard anyone trying to get out of the window. Interview on 9/20/2023 at 11:08 AM with RN supervisor stated the Maintenance supervisor had told her (on 9/20/23 at 10:15 AM) about the window in Resident #1 was in the locked position and the window was hard to open. The RN supervisor stated she had never seen a window to resident rooms open. Interview on 9/20/2023 at 11:12 AM with LVN D stated Resident # 1 had eloped the 1st time by the back gate, the maintenance supervisor found the gate open. The LVN D stated the maintenance supervisor had replaced the lock with a new one. Interview on 9/20/2023 at 12:14 PM with RN supervisor stated she had called the temporary guardian for Resident #1 and had discussed Resident #1 had to leave the facility and she was waiting for the temporary guardian to find placement. RN supervisor stated Resident #1 was on a 1:1 with staff for 24 hours per day, until they can find placement for her. RN supervisor stated staff had always kept an eye on Resident #1, such as on 2-10 PM the ADON keeps her at the nurse's station with her. Typically, the nurses are aware of Resident #1 and always know where she is in the building. Interview on 9/20/2023 at 1:41 PM with LVN B stated she worked the 1st shift for the last 9 years, and stated 1 nurse per shift 1 treatment nurse, 1 medication aide and 3-4 CNAs per shift. LVN B stated Resident #1 let the building two times while she was on duty (2nd and 3rd elopement). The 1st time was during breakfast, and she was in the dining room looking at her, she turned around to get check a tray, then Resident #1 was gone, LVN B said she had staff looking for her around inside and outside of building. LVN B said she notified the Administrator, and police, LVN B said staff drove around to look for Resident #1, an anonymous person from area called the police and brought her back, LVN B said nurse notified the guardian, and she was not gone for longer than 30 minutes. Resident #1 was brought back by the police, and LVN B did a head-to-toe assessment, LVN B said there were no injuries, and she had her elopement bracelet on, LVN B said she was on 15-minute checks for 3 days. LVN B stated one of the interventions were for the physician to review her medications. LVN B stated the 2nd time Resident #1 left the building was between shifts. LVN B said the nurse had received a call from Cook C stating she had found Resident #1 walking down the street away from the facility. Cook C brought Resident #1 back to the facility, LVN B stated she asked Resident #1 how she got out of the building; Resident #1 did not reply. LVN B stated she did a head-to-toe assessment with no injuries. LVN B stated she notified the Administrator, family, did an assessment and placed Resident #1 on every 15-minute check for 3 days. LVN B stated for all incidents the nurses complete an incident report, place resident on a 15-minute check for 3 days and document the monitoring on the progress notes and the 24-hour report. LVN B stated the intervention was for staff to monitor Resident#1 closely and to entertain her. LVN B stated she was not aware of any 1:1 monitoring checks for Resident #1. LVN B stated the Maintenance supervisor checked all the gates, fences, all windows to see how Resident #1 left the building, LVN B said the only assumption was that someone left the door open in the courtyard and she left out that door, or maybe out the room window. LVN B stated she checked Resident #1's room window, and it was not open and there were no signs of anyone tampering with the window. LVN B stated or maybe Resident #1 went out the front door and staff did not hear the alarm. LVN B said she was not sure how she left the building. Interview on 9/20/2023 at 2:33 PM with LVN D stated she had worked at the facility since 2014 and had worked all shifts. LVN D stated Resident #1 left the building two times. LVN D said once she was on the way to work, and staff called her to look for Resident #1 and when she arrived at work Resident #1 was in the building. LVN D stated Resident #1 was on a 1:1 for a while and she remembers documenting the monitoring. LVN D remembers every 2 hours staff would check on Resident #1. LVN D stated Resident #1 was exit seeking, and she had dementia, LVN D said Resident #1 would leave in the afternoon, and she would state she needed to go home to be with cats, LVN D said today she continues to be on 1:1 until they could find a safe place for her. Interview on 9/20/2023 at 4:55 PM with LVN A stated she worked at facility for 7 years on the 1st shift. LVN A stated Resident #1's when she left the building, she was down the road and a resident family member saw her and the nurse was able to bring her back to facility. LVN A stated she was gone about 10-15 minutes, LVN A notified the charge nurse and family. LVN A stated she did head to toe assessment with no injuries. LVN A stated she had her wander guard on, and staff were doing 15-minute checks for Resident #1. Interview on 9/22/2023 at 3:55 PM with the DON stated Resident #1 notified APS about Resident #1's safety concerns being in this non-locked facility and looking for placement. The DON stated Resident #1 meet the medical criteria, but not the financial criteria. The DON stated Resident #1 had eloped from facility 3 times and each time APS and the temporary guardian was called to notify, this was an unsafe place for her. The DON stated staff were monitoring Resident #1 on a 1:1 basis, every 15-minute for 24-hour period, since her last elopement on 8/26/2023. The DON stated Resident #1's interventions were 1:1 staff for 24 hours period, medications reviews, alarm bracelet, alarm on window and staff training. The DON stated they had in-services for dementia, incident protocol, but was not sure about elopement in-services. Interview on 10/11/2023 at 11:24 AM with the Administrator stated Resident #1's interventions of placing an alarm on her window to the outside was on 9/19/2023. The Administrator stated Resident #1 had her alarm bracelet on her every time she was brought back to the facility from an elopement. Interview on 10/11/2023 at 2:11 PM with the AA she stated she would stay and keep Resident #1 busy, and she would give her paperwork to do. AA stated Resident #1 if she was busy would take her to AD) to keep Resident #1 busy to take over the 1:1 monitoring. AA stated it has been working out ok, with alternating staff to be with resident #1 on a 1:1, staff with her for 24 hours a day. AA stated the RN supervisor is trying to find placement for Resident #1 but was having trouble because Resident #1 had no income, and she is Medicaid pending. Interview on 10/11/2023 at 3 PM with the ADON stated she had worked at the facility for [AGE] years. The ADON stated Resident #1 had eloped, was found with wander guard bracelet- (so staff can hear alarm when she exits the facility), had no injuries and staff, family were notified. The ADON stated staff did incidents reports after the incident occurred. The ADON stated the staff had been alternating 1:1 monitoring with Resident #1, Resident #1 wants to leave, and get sundowners (Sundowning is the name for a group of behaviors, feelings and thoughts people who have Alzheimer's or dementia can experience as the sun sets.). The ADON stated they do not usually take resident with elopement risk and the plan was to transfer Resident #1 to a facility with a secure unit. The ADON stated the interventions were medications review for moods and anxiety. This was determined to be an Immediate Jeopardy (IJ) on 10/07/2023 at 3:28 PM. Administrator was notified. Administrator was provided with the IJ template on 10/07/2023. The following Plan of Removal was accepted on 10/11/2023 at 4:30 PM. Plan of Removal Date 10/11/2023 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Summary of details which leads to outcomes. On 9/19/2023 an investigation was initiated at the facility. On 10/07/2023, a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F689 Quality of Care The facility failed to provide Quality of Care for Resident #1 in that it did not in-service staff after each time she eloped, three times, did not have elopement assessment after each elopement and care plans were not measurable for elopement risk. Problem The Facility's Deficient practice revealed facility failed to ensure the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Immediate Corrections Implemented for Removal of Immediate Jeopardy. Facility's Plan of Removal, 10/7/23 Preparation and/or execution of this Plan of Removal does not constitute admission or agreement by the provider of the truth of facts alleged or conclusions set forth in the preliminary finding in the IJ component date 10/7/23. The Plan of Removal is prepared and/or executed solely because the provisions of Federal and State laws require it. Component one: Noncompliance All Staff will be in-serviced immediately on preventing accidents and hazards, namely the risk of Resident #l's elopement from the facility. In-service started 10/7/23 at 5:00 PM. Completed 10/7/23 at 6:20 PM. We have two other residents who are wheelchair bound and even though they have never eloped, we have completed their elopement risk assessments. Resident #l's care plan has been updated with current interventions related to her elopements. The two other residents who are wheelchair bound, and have never eloped, have also had their care plans updated. Component two: Serious injury, serious harm, serious impairment, or death: Resident #1 has been placed on a one-to-one observation by staff on all three shifts (which means one employee was assigned to Resident #1 24 hours a day, seven days a week) since 09/21/2023. Before 09/21/2023, Resident #1 was on a 15-minute watch by staff. No elopement has occurred since 8/26/23 (42 days ago). When the elopements occurred, no injury was sustained by Resident #1. She was not in any danger, she was found nearby, and she was found within an hour. She did not miss any medications and there was no danger from the weather (neither heat nor cold). Resident #1 is alert enough to navigate the neighborhood (walk on sidewalks, cross streets, etc.) without endangering herself. Completed 10/7/23 at 3:28 PM Component three: Need for immediate action: The facility will ensure that all staff were trained on elopement risk patients, in particular Resident #1. The RN Consultant will monitor on a weekly basis. Resident #1 will continue to be on a one-to-one observation by staff on all three shifts (24 hours a day, seven days a week). We have been trying to place Resident #1 in a locked unit. We have been in constant contact with her Guardian about transferring her to another facility, but to no avail. We have contacted at least six facilities with locked units; however, all have refused because Resident #1 does not have any funds and is Medicaid pending. Completed 10/7/23 at 6:20 PM STAFF MEMBERS WHO ARE ON VACATION, SICK OR ARE UNABLE TO BE REACHED, WILL NOT BE ALLOWED TO COME BACK TO WORK UNTIL IN-SERVICED ON ABOVE TOPICS. In-service started 10/7/23 at 5:00 PM. Completed 10/7/23 at 6:20 PM. Plan of removal has been implemented and completed by 10/7/23 at 6:20 PM. Please, accept this plan of removal as our statement of compliance. Plan Of Removal Verification The facility RN supervisor completed a 100% audit of staff in-service and 100% of resident elopement risk assessments and care plans of elopement risk residents were completed. This audit was completed on 10/11/2023. Record review of the staff in-service with signatures by all staff at the facility. The facility RN supervisor provided the one-to-one observations by staff on all three shifts since 9/21/2023. Record review of the 1:1 sheets with staff signatures were provided form 9/21/2023 to current. The facility RN supervisor provided the form she started to monitor staff training on elopement risk residents on weekly basis. Record review of the staff monitoring sheet was started by the RN supervisor. The facility RN supervisor provided the list of facilities contacted with a secure unit but was denied to funding. Record review of a sheet of paper with a list of secure unit facilities were listed and stated denied due to funding. Record review of in-service dated 9/21/2023 from 6-6:30 PM by DON was documented Elopement, educate staff on resident with elopement risk, resident will have letter E placed on the door, Resident #1 was to wear wander guard at all times and battery check weekly, check on 1:1 status. Record review of in-service had the Wandering and Elopement Protocol with each staff person that signed and dated it. Record review of in-service dated 10/7/2023-10/10/2023 for all 3 shifts with staff signatures/phone calls was documented protocol for wandering residents and elopement prevention, Resident #1 must continue to be on 1:1 basis at all times, offer activities she likes, wander guard at all times, and check alarm bracelet. This had 65 staff. (Some staff signed multiple times- staff made sure all 3 shifts signed that they had the in-service). Record review of in-service had the Wandering and Elopement Protocol. Record review of in-service dated 10/9/2023 for 7/26/2023, 8/8/2023, 8/26/2023 by Administrator/Maintenance supervisor was documented check all exits for possible ways Resident #1 could have eloped, in case of elopement place on every 15-minute check or 1:1 status, charge nurse to notify administrator, family, or APS and medical director, and Resident elopement risk wear I badge, and picture in medical record to ID resident. This in-service had 25 staff. Record review of in-service form- meeting with Administrator, RN supervisor, temporary guardian and Ombudsman dated 10/11/2023 regarding Resident #1. They agreed that as soon as the temporary guardian was a permanent guardian. The permanent guardian will place Resident #1's assets for sale. Then Resident 1's assets will not count as a resource for Medicaid, so she can qualify for Medicaid. Temporary guardian and Ombudsman will be looking for placement as soon as possible. Record review of Resident #1's updated care plan completed by RN supervisor stated she updated the care plan with dates. Resident #1's care plan: this was the order the care plan was in. 7/26-8/82023-Staff member to monitor resident #1 every 15 minutes. 8/26/2023-continue a 1:1 intervention (a staff member accompany Resident #1 at all times. 6/16/2023-make sure resident had a wander guard on, with the name at all times. Check wonder guard daily to make sure that it works. 6/16/2023-makes sure the front door alarm is working, and that resident #1 room window was locked, and alarm is on. (This was not on the original care plan). 107/2023-complete an elopements risk assessment, 7/26/2023 document all incidents of elopement and elopement attempts. 6/16/2023-identify pattern of wandering. Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? 6/16/2023-maintain log of interventions that work, offer activities and entertainment she liked: listening to music, walking outside supervised, puzzle, coloring, etc. maintained safety. 6/162023-identification on band on resident, clothing. 6/16/2023 -wander guard for alarm front door. 6/28/2023 Asses for fall risk. 6/16/20223-make staff aware of elopement risk. 7/26/2023-staff to accompany resident wen going to the patio area for activity. 10/7/2023-personalize room with clock, calendar, signs, or pictures. Structured Activates 6/16/2023-structured and supervised walking activities. Reorientation to person. Place and time. 7/26/2023- distract resident form wandering by offering pleasant diversion, structured activities, [TRUNCATED]

Based on interview and record review, the facility failed to implement policies and procedures that prohibit neglect of residents for 1 of 6 residents (#1) whose care was reviewed for neglect in that: -LVN D and LVN E failed to assess and consult with a physician for Resident #1 when she began to complain of not feeling well and being short of breath from approximately 5:15 p.m. to approximately 7:15 p.m. when Resident #1 lost consciousness and LVN D called 911. (Time determination was from interviews and the time verified on LVN D's personal cell phone as to when 911 was called.) -The facility failed to ensure Resident #1's was provided CPR according to the facility policy and The American Red Cross Association. EMS transported Resident #1 to the hospital and was pronounced on [DATE] at 9:20 p.m. as expired. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE] the facility remained out of compliance at pattern, actual harm due to facility was still in-servicing and monitoring the effectiveness of the Plan of Removal. These failures affected one former resident (Resident #1) and could affect 50 residents residing in the facility by being at risk of negative outcomes, including death, due to not receiving medical interventions in a timely manner. The Findings were: Review of Resident #1's Face Sheet dated [DATE] revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Consolidated Orders dated ,[DATE] to [DATE] revealed the area for Orders indicated under ADVANCE DIRECTIVES CODE STAUS: DNR [DATE]. Review of Resident #1's Plan of Care dated [DATE] revealed the resident was a DNR. Review of Resident #1's Directive to Physicians and Family or Surrogates, dated [DATE] under DIRECTIVE, revealed the resident requested that all treatments other than those needed to keep her comfortable be discontinued or withheld and her physician allow her to die as gently as possible. Review of Resident #1's Resident/Family Consent for Cardiopulmonary Resuscitation, signed by Resident #1 on [DATE] and witnessed, stated in part We ask that you mark ONE of the decisions below- accompanied by your signature and date This statement will remain in effect as long as the resident remains a resident of this facility or until we receive a written and signed notice of revocation from you. A check mark was placed in front of the following statement. I understand that CPR constitutes an extraordinary measure and SHOULD NOT be done on this resident. However, I wish that essential life support interventions such as oxygen, nutrition, hydration and certain medications for the relief of pain be administered to maintain the resident ' s comfort. Review of Resident #1' s Texas Department of Health OUT-OF-HOSPITAL DO NOT-RESUSCITATE ORDER revealed on [DATE], Resident #1 signed box A which states Patient ' s Statement: I, the undersigned, am capable of making an informed decision regarding the withholding or withdrawing of CPR, including the treatments listed below, and I direct that none of the following resuscitation measures be initiated or continued. Cardiopulmonary resuscitation (CPR), Transcutaneous Cardiac Pacing, Defibrillation, Advanced Airway Management, Artificial Ventilation. I understand that I will be given comfort measures as needed. I understand that I may revoke this order at any time. Review of Resident #1's Advanced Care Planning Care Plan dated [DATE] revealed in part: RAP/Problem - End of Life Decision, Goals- DNR, Approaches/Interventions 3. Individual and or family choices to be respected. Review of Resident #1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed under section B, B0700, the resident was able to make herself understood and under B0800, the resident was able to understand. Under section C, resident' s BIMS Score was 15 (indicating the resident was cognitively intact). Review of Resident #1's Nurses Notes dated [DATE], (the hour was marked over and 6:00 p.m. was written over 5:00 p.m.) stated in part Resident was in her room sitting on the toilet anxious and asking for water saying she didn't feel good 6:35 p.m. Resident still anxious and saying she wasn't feeling good. I sat with her and told her to deep breath and relax. Resident was making herself anxious. Started showing her pics on phone to distract resident. When I left the room she was starting to calm down. Signed by LVN D. 7:13 p.m. CNA called me to residents room. When I walked in resident was nonresponsive, pale and could not find radial or carotid pulse. Came to cart and grabbed my stethoscope and went back to residents room. I used stethoscope to find a heart beat and could not hear one. CPR was started by nurse. I left room to use phone to call EMS while CNA continued with CPR. While on phone with EMS was advised to lower resident to floor because resident was in recliner. Resident was lowered to floor and continued with CPR by nurse. Was asked by EMS if we had AED to look for and to use on resident. CPR was still being performed by CNA. Returned with AED to room and applied pads to chest while on phone with EMS. While still performing CPR EMS paramedics walkin and take over doing CPR. Signed by LVN D. Interview with the Director of Nurses (DON) on [DATE] at 3:40 p.m. revealed Resident #1's [MEDICAL CONDITION] was sudden and unexpected. The DON stated Resident #1 had just come back from a doctor ' s appointment and was upset. Further interview revealed the DON's investigation into Resident#1's sudden [MEDICAL CONDITION] was verbal only with the nurses and she had not documented anything. The DON stated Resident #1 expired at the hospital on [DATE] at 9:30 p.m. There were 2 nurses (LVN D and LVN E) and 2 CNAs (CNA F and CNA G) on the 2 to 10 shift. Interview with CNA F on [DATE] at 4:00 p.m. revealed Resident #1 came in from a doctor's appointment with a lot of anxiety and hyperventilating and the resident was moaning, moaning and she told Resident #1 to calm down. CNA F and G put Resident #1 in her recliner. Resident #1 asked to have her feet put up. CNA F stated Resident #1's tongue was moving and she just turned pale/white. Her eyes were just a stare. Resident #1 never said she was hurting, but the groans. She was not perspiring her face was flushed a little bit. She stated Resident #1 called/yelled for the nurse. LVN D came in and shook her and shook her and kept tapping her on the chest then LVN D left the room and then came back in andCNA F left the room. CNA F stated LVN D started CPR and then she stopped and went to do something and then she came back. CNA F stated the other nurse LVN E didn't even come into the room, she did nothing. Interview with CNA G on [DATE] at 4:30 p.m. revealed she assisted CNA F to place Resident #1 in her chair (recliner) and then Resident #1 became more heavy and she turned her head and she was pale. She stated LVN D came in with a machine and told them to get out of the room and it was LVN D and LVN E in the room. She could not emember times. Interview with Assistant Director of Nurses (ADON) on [DATE] at 5:08 p.m. to 5:15 p.m. revealed the AED machine was kept in the nurses' station and there were 2 nurses and a medication aide that had keys to the doors of the nurses' station. Interview with Laundry Attendant (LA) H on [DATE] at 6:15 p.m. revealed she was coming with the linen (could not remember time) and heard Resident #1 yelling she could not breathe and the resident did not want her to leave. She stated she went and told the nurse Resident #1 could not breathe and the nurse (LVN D) told her the resident was having anxiety. LA H stated no one could find LVN E and Resident #1 asked the CNA's to put her in her chair. Then, LVN D had them put the resident on the floor. LA H stated she saw LVN D on the floor with some machine and CNA G was looking for LVN E. LA H stated she helped CNA F and CNA G help place Resident #1 on the floor. Interview with a family member of another resident residing in the facility (wished to remain anonymous) on [DATE] at 6:25 p.m. revealed the family member and her brother were visiting their mother and as she was going back to get her mother's medication around 7:14 p.m. she heard the lady (Resident #1) yelling. She said one nurse was outside (LVN D) and the other nurse (LVN E) was in the room next door to Resident #1's room with the curtain pulled. She said she went into the room and told LVN E they (staff) were looking for her and she said she was on break. LVN E was looking at her phone. Interview with the facility Administrator on [DATE] at 9:00 a.m. revealed it was a surprise because it was a sudden death. The Administrator stated because it was a sudden death he did not question the death. He stated the DON called and informed him of Resident #1's death. He continued to say since the surveyor had come in and questioned Resident #1's death, the DON, ADON, Nurse Consultant and himself got together and determined who was on duty at the time of Resident #1's passing and gathered quite a bit of information. He stated he did not know there was a problem with her death until this surveyor came in on [DATE] and started asking questions. He stated they talked to everyone and found out Resident #1 was being transferred from her wheelchair to her recliner. The staff noticed a change and went and got LVN D, which did not take long and LVN D checked if Resident #1 was breathing and LVN D started doing chest compressions while Resident #1 was in her lazyboy (recliner). Then LVN D left the room and asked CNA F to continue chest compressions while she went out to call EMS and get the AED. LVN D came back to the room. He believed EMS told LVN D to place Resident #1 on the floor and place the AED on the Resident #1. He stated EMS arrived quickly and took over CPR. LVN E was checking medical information when EMS arrived and EMS transported the resident to the hospital. He stated we asked LVN E where she was and she claimed she told LVN D she was going on break and she was in room [ROOM NUMBER], next door to Resident #1 taking her break. The Administrator stated when the Medication Aide (MA) I was questioned, she stated staff were looking for LVN E but could not find her. LVN E claimed she was about 10 minutes into her break when the incident with Resident #1 took place. He stated 2 of the CNAs claimed Resident #1 never said she had chest pain. He stated Resident #1 had an elevated respiratory rate and was just having an anxiety attack. Resident #1 had waited 2 hours at her doctor's office to be picked up and had to go to the restroom. He continued to say at the doctor's office they gave her 14 or 15 units of insulin, then she had to wait to be picked up. He also stated he was told Resident #1 was moaning. He stated the charge nurse (LVN E) came down and checked her out and then got her a shake to drink and she noticed Resident #1 had shortness of breath. Resident #1 was having an anxiety attack and she was doing it to herself. LVN D was trying to calm Resident #1 down by showing the resident pictures of her son (LVN D's son). He stated Resident #1 did not have a [DIAGNOSES REDACTED]. He stated both LVN D and LVN E decided Resident #1 had anxiety. He stated LVN E tried to call the Medical Director and the phone kept ringing and ringing. He stated MA I gave Resident #1 her 4:30 p.m. medications at 5:30 p.m. when she got back from her doctor appointment. He stated Resident #1 kept telling the staff she did not want to be left alone and did not want to die. Interview with LVN D on [DATE] at 10:12 a.m. revealed she was the treatment nurse. She said Resident #1 had come in from a doctor's appointment and the resident stated she did not feel good. Resident #1 got back between 5:00 p.m. and 5:30 p.m. and she went to the dining room till about 6:10 or 6:30 p.m. LVN D stated again Resident #1 again told her she did not feel good and she had clocked out, so she went to LVN E, the charge nurse, and told her Resident #1 was not feeling good and asked her if she had anything prn to calm the resident down, something like [MEDICATION NAME] because the resident had gotten real anxious when she went to her doctor's appointment. LVN D said she remembered the laundry lady (LA H) coming to her and telling her Resident #1 could not breathe, but did not say anything about the resident hurting. LVN D said she clocked back in to check on the resident and the resident told her again she did not feel well. LVN D said she told the resident she needed to eat something and gave her V8 juice and jello. LVN D said Resident #1 ask her about her son, so she began showing the resident pictures of her son. Resident #1 asked her for a shake and she was feeling a little better. When she got back Resident #1 was in her wheelchair talking to someone (could not remember who she was talking to), so she went back to the nurses' station and was talking on the phone to a family member when CNA G came to the hall and informed her Resident #1 had passed out while CNA F and CNA G were transferring the resident. LVN D said she ran into the room to check on Resident #1 and check her carotid and there was no heartbeat. LVN D stated I reacted, I started compressions, CPR in the recliner. CNA F was breathing into her mouth. LVN D stated I walked away and was trying to call 911 on the phone next to Resident #1's room, but could not call out, so she went to the locked nurse ' s station and called 911. They wanted to know where she was and she told them she was in her room in her recliner and CNA F, CNA G and LA H were with her. EMS told LVN D to place Resident #1 on the floor. She said she had staff place the resident on the floor. Then EMS asked me if I had an AED machine, I told them yes and went back to the nurse's station to get the AED. LVN D said LVN E, the charge nurse, came into the room and she told her, EMS was on their way. LVN D said when EMS got there, they took over and then one of the EMS guys said they needed someone to declare Resident #1 had expired and she told them they could not do that. So, another EMS guy came into the resident's room and said they needed to leave, so they took her out. LVN D said that was when she found out Resident #1 was a DNR. LVN D said she knew the blue charts were DNR and the red charts were FULL CODE, also the blue dots on the door meant DNR, but Resident #1 had a wreath covering her dot, so she could not tell what Resident #1 was. When asked why didn't she move the wreath LVN D said she did not think about it. LVN D stated When Resident #1 was in the recliner, CNA F helped her with the CPR, LVN D was doing compressions and CNA F was breathing into her mouth. LVN D stated I stopped to call EMS. LVN D said she did not delegate to anyone to call 911, get the crash cart, or get the AED. LVN D said if she had asked someone to get the AED, they could not have gotten it because the AED was locked up behind the locked nurse's station. She stated When I came into Resident #1's room, I told someone to find LVN E. (She did not remember who she told to find LVN E). LVN D stated EMS told me to lower the resident to the floor (from the recliner). We put her on the floor and then EMS asked me if we had an AED so I went back to get it (in the locked nurse's station). LVN D stated It took LVN E a while to respond, she did not come in until I had the AED hooked up and I was doing compressions. LVN D stated I don't know how long it took to get the AED and start compressions before LVN E came in. Interview with LVN E on [DATE] at 3:15 p.m. revealed Resident #1 acted like she was upset about her doctor's appointment. She stated I heard she was still anxious so I asked the medication aide if she had anything. LVN E said when she came back to check on Resident #1, LVN D was in the room showing Resident #1 pictures. LVN E stated I was over by the coke machines (which are next door to Resident #1's room) talking to my husband on the phone. I had clocked out maybe 10 minutes when I heard a CNA (didn't know who the CNA was) say I need a nurse. I came around the corner and saw LVN D with Resident #1, so I went to the nurse's station and then LVN D came up and called 911 then, she got the AED. LVN E said she went back to Resident #1's room and the resident was already on the floor and LVN D was already doing compressions while she was talking to EMS (on her cell phone speaker). LVN E said she heard the alarm going off at the gate so she told the girls to go and make sure the gate was open. LVN E said she ran everybody out of Resident #1's room and told EMS where the resident was then went back to the office (nurse's station) to make copies of everything. LVN E stated I did not help do CPR and the crash cart was not brought in to Resident #1's room. LVN E stated The charts for DNR are green and the red charts are for FULL CODE. LVN E stated I told LVN D Resident #1 was a FULL CODE after EMS got to the facility and took over and the only place to look to see if a resident is a DNR or FULL CODE was on the chart, Advance Directive or Orders and there is nothing placed on a resident's door. LVN E stated no one came and got her when she was on her phone, she said she heard a CNA (CNA F) was doing CPR but she did not see the CNA doing CPR. Review of the American Red Cross <<http://www.redcross.org>>, information on [MEDICAL CONDITION] revealed in part under Step 3, [MEDICAL CONDITION]/AED Steps, the 9th paragraph down stated the following: If, during your check, you find no signs of life, assume that the heart is not functioning properly. Make sure someone has called for help, and use the AED immediately. If an AED is not available right away, give CPR until an AED is at the scene and ready to use. Review of the Facility Do Not Resuscitate Policy (No Date), received on [DATE] revealed the following in part under Policy Statement Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect Policy Interpretation and Implementation .2. Residents with a DNR order will have their medical records placed in a Blue chart. 3. The name plate next to the resident's door will be white other than blue or red and a blue dot will be placed next to the name of a resident who has a DNR order. 4. An updated list of all residents indicating who is a Full Code or who is a DNR has been attached to the Facility's Crash Cart. The name of residents who have a DNR order have been highlighted in blue. 5. A current photo of residents who have a DNR order will be displayed on a Blue paper in front of the clinical chart indicating DNR status. Full Code residents will have their pictures displayed on a Red paper in front of their clinical chart, indicating Full Code status .8. The resident's Care Plan will address whether the resident is a DNR or a Full Code. 9. The interdisciplinary care planning team will review advanced directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes to such directives. Attached to the DNR Policy, was a hand written sheet If resident is found unconscious or unresponsive, follow these steps: (No Date) revealed the following in part, 1) Staff who finds resident, stays with resident yell as loud as you can for help Code Blue press call light if you are in the resident's room or restroom/shower area. 2) First staff member to respond to call must take comfort cart (crash cart) to area where resident was found. Resident's list of names attached to comfort cart will be checked to see if resident is a DNR or a Full Code. 3) 911 must be call by anyone in the facility if resident is a Full Code. 4) CPR will be initiated by qualified person .5) Follow CPR in 3 simple steps. Give 2 breaths and pump continue with 2 breaths and 30 pumps until help arrives. Review of the Facility policy on Automated External Defibrillator (AED), (No Date) presented to the surveyor on [DATE], revealed the following in part paragraph 2: Assess patient for unresponsiveness, assess breathing and assess circulation (pulse). Call 911 and have someone retrieve the AED. Initiate CPR until AED arrives . Follow AED until EMS arrives and takes over . Review of another paper provided by the Administrator to the surveyor on [DATE] states, How to Use an Automated External Defibrillator, 4th paragraph down: Call [DATE] or have someone else call [DATE]. If two rescuers are present, one can provide CPR (cardiopulmonary resuscitation) while the other calls [DATE] and gets the AED If an AED isn't readily available, do 2 minutes of CPR. Then use the AED (if you have one) to check the person after you have the AED, or if you don't have an AED, give CPR until emergency medical help arrives or until the person begins to move . Review of the Facility Abuse Policy, Effective: ,[DATE], provided to the surveyor on [DATE], Page 2, bullets 5., 6.,7. revealed in part the following: The facility will investigate incidents with unknown causes and trend incidents for individual residents to identify possible abuse/neglect The facility will report alleged violations to proper authorities The facility will protect residents from harm during any investigation. Alleged employees/or residents will be removed from the facility . The facility will report all allegations of abuse to the state agency And will take corrective action as determined by the investigation to implement policies and procedures to prevent further occurrences. The facility also incorporates the state and federal regulations on abuse, neglect and misappropriation of resident property into their policy. Another piece of the facility Abuse/Neglect policy had a section which read in part INDICATORS OF NEGLECT , the 4th bullet down says Health problems left untreated . Review of the facility Protocol: When to Call the Doctor with a written date of [DATE] revealed in part The types of conditions which frequently arise are: .13. Shortness of breath . It is the responsibility of the nursing staff to observe the change, make an assessment, and notify the physician as indicated based on the assessment . The nurse will: a. Recognize the Condition Change d. Notify the physician of any change in condition in agreement with the policy .e. Continue to monitor the resident and again notify the physician when the course of the illness changes, especially when it deviates from the anticipated course . Review of the facility Job Description for Charge Nurses, Initialed by LVN E, dated [DATE] had documeneted in part under Responsibitities: . 2. Recognize significant changes in the condition of the resident and take necessary action .4. Insures that the individual health care plan is followed . Review of the facility Job Description for Quality Assurance and Treatment Nurse, no date, had documented in part under Responsibilities: .19. Assesses and reports changes in resident's condition .to physician . and takes follow-up action as necessary . The Administrator and DON were informed of the IJ on [DATE]. The facility submitted an action plan to remove the immediacy dated [DATE] at 3:30 p.m. which was accepted and consisted of: 1) Supervisory staff will be in-serviced immediately on reporting to Administrator any allegation of Neglect or Abuse. In-service started [DATE] at 5:45 p.m. Completed [DATE] at 12:45 p.m. 2) An investigation will be started as soon as an allegation is received by any staff member of the facility. In-service started [DATE] at 5:45 p.m. Alleged staff were suspended on [DATE] at 12:30 p.m. 3) All staff members will be in-serviced by Supervisory staff on immediately reporting to a Nurse if a resident has a change of mental status, change in condition, or acute distress, or is not feeling well. The nurse will then make an immediate assessment. In-service started [DATE] at 5:45 p.m. Completed [DATE] at 12:45 p.m. 4) Nurses will be in-serviced by Nurse Supervisors on Protocol: When to call the Doctor. Nurses will be in-serviced that it is the responsibility of the nursing staff to observe the change, make an assessment, and notify the Physician based on the assessment. In- service started on [DATE] at 5:45 p.m. Completed on [DATE] at 12:45 p.m. 5) All staff members will be in-serviced on facility's Do Not Resuscitate Policy and their individual role in case of an emergency, as well as identifying which resident is a DNR (Do not resuscitate) and which resident is a FULL CODE. Licensed nursing personnel will be in-serviced on providing un-interrupted CPR, once CPR is started, until EMS personnel arrives to facility. In-service started on [DATE] at 1:45 p.m. Completed on [DATE] at12:45 p.m. 6) All staff members will be in-serviced on location of Automated External Defibrillator (AED). A large legible sign will be attached to the crash cart indicating that AED is inside the crash cart. Licensed personnel will be in-serviced on how to use an AED. In-service started [DATE] at 1:45 p.m. Completed [DATE] at 12:45 p.m. 7) Nursing staff will be in-serviced on facility ' s AED protocol. This AED protocol will be inside crash cart ' s check list binder. AED will be checked for proper functioning on a quarterly basis. In-service started [DATE] at 5:15 p.m. Completed [DATE] at 12:45 p.m. STAFF MEMBERS WHO ARE ON VACATION, SICK OR UNABLE TO BE REACHED, WILL NOT BE ALLOWED TO COME BACK TO WORK UNTIL IN- SERVICED ON ABOVE TOPICS. In-service started [DATE] at 5:15 p.m. Plan of removal will be implemented and completed by [DATE] at 4:30 p.m. Please, accept this plan of removal as our statement of compliance. Verification of Plan of Removal: On-site monitoring was conducted on [DATE] from 3:30 p.m. to 5:00 p.m. Interviews conducted randomly during the on-site monitoring included staff from all shifts: The Administrator, DON, CNA J, CNA K, CNA L, LVN M, MA N, LVN O, CNA P, HSKP Q, COOK R, DA S and AD T. All nursing staff interviewed stated they knew about getting help, LVN's knew CPR and to initiate immediately and how and where to place the AED on the resident's chest when available. All stated they knew where the AED was located. All confirmed a Blue Dot indicated the resident was a DNR and the resident's code status was on the crash cart. If they see a change in the resident's condition to yell, turn on the call light and or get the nurse. Nurse's in-serviced on changes in condition and notifying the physician. If they can not get the resident's doctor to call the Medical Director or if not able to get the doctor call the DON. Review of the facility in-services started on [DATE] revealed the in-service consisted of the facility resuscitation policy, Protocol: When to Call the Doctor on certain conditions and information on the facility AED and where the AED and Code Status of each resident can be found (on the comfort/crash cart). The Administrator and the DON were informed the IJ was removed on [DATE] at 5:10 p.m. The facility remained out of compliance at a severity level actual harm with a scope of pattern due to the facility's need to complete in-service training to all nursing staff on response to CPR emergencies, and the AED and evaluate the effectiveness of training. A list was obtained from the Administrator dated [DATE] indicating there were 16 residents with code status of DNR and 34 residents with code status FULL CODE.

Based on record review and interview the facility must develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 6 residents (Resident #1) reviewed for neglect in that: -LVN D started CPR on Resident #1 who was a DNR. -LVN D nor LVN E assess or consult with the physician for Resident #1 when she was moaning, complaining of not feeling well and was short of breath after returning from her doctor's appointment. An Immediate Jeopardy (IJ) situation was identified on [DATE]. The IJ was removed on [DATE]. The facility remained out of compliance at pattern, actual harm due to the facility's need to complete in-service training and monitor the effectiveness of the Plan of Removal. This failure affected 1 resident (Resident #1) could place 50 residents residing in the facility at risk of delayed treatment resulting in a decline in health or even death. The findings were: Review of the Facility Abuse Policy, Effective: ,[DATE], provided to the surveyor on [DATE], Page 2, bullets 5., 6.,7. revealed in part the following: The facility will investigate incidents with unknown causes and trend incidents for individual residents to identify possible abuse/neglect The facility will report alleged violations to proper authorities The facility will protect residents from harm during any investigation. Alleged employees/or residents will be removed from the facility . The facility will report all allegations of abuse to the state agency And will take corrective action as determined by the investigation to implement policies and procedures to prevent further occurrences. The facility also incorporates the state and federal regulations on abuse, neglect and misappropriation of resident property into their policy. Another piece of the facility Abuse/Neglect policy had a section which read in part INDICATORS OF NEGLECT , the 4th bullet down says Health problems left untreated . Review of Resident #1's Face Sheet dated [DATE] revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Consolidated Orders dated ,[DATE] to [DATE] revealed the area for Orders indicated under ADVANCE DIRECTIVES CODE STAUS: DNR [DATE]. Review of Resident #1's Plan of Care dated [DATE] revealed the resident was a DNR. Review of Resident #1's Directive to Physicians and Family or Surrogates, dated [DATE] under DIRECTIVE, revealed the resident requested that all treatments other than those needed to keep her comfortable be discontinued or withheld and her physician allow her to die as gently as possible. Review of Resident #1's Resident/Family Consent for Cardiopulmonary Resuscitation, signed by Resident #1 on [DATE] and witnessed, stated in part We ask that you mark ONE of the decisions below- accompanied by your signature and date This statement will remain in effect as long as the resident remains a resident of this facility or until we receive a written and signed notice of revocation from you. A check mark was placed in front of the following statement. I understand that CPR constitutes an extraordinary measure and SHOULD NOT be done on this resident. However, I wish that essential life support interventions such as oxygen, nutrition, hydration and certain medications for the relief of pain be administered to maintain the resident's comfort. Review of Resident #1's Texas Department of Health OUT-OF-HOSPITAL DO NOT-RESUSCITATE ORDER revealed on [DATE], Resident #1 signed box A which states Patient's Statement: I, the undersigned, am capable of making an informed decision regarding the withholding or withdrawing of CPR, including the treatments listed below, and I direct that none of the following resuscitation measures be initiated or continued. Cardiopulmonary resuscitation (CPR), Transcutaneous Cardiac Pacing, Defibrillation, Advanced Airway Management, Artificial Ventilation. I understand that I will be given comfort measures as needed. I understand that I may revoke this order at any time. Review of Resident #1's Advanced Care Planning Care Plan with start date of [DATE] revealed in part: RAP/Problem - End of Life Decision, Goals- DNR, Approaches/Interventions 3. Individual and or family choices to be respected. Review of Resident #1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed under section B, B0700, the resident was able to make herself understood and under B0800, the resident was able to understand. Under section C, resident' s BIMS Score was 15 (indicating the resident was cognitively intact). Review of Resident #1's Nurses Notes dated [DATE], (the hour was marked over and 6:00 p.m. was written over 5:00 p.m.) stated in part Resident was in her room sitting on the toilet anxious and asking for water saying she didn't feel good 6:35 p.m. Resident still anxious and saying she wasn't feeling good. I sat with her and told her to deep breath and relax. Resident was making herself anxious. Started showing her pics on phone to distract resident. When I left the room she was starting to calm down. Signed by LVN D. 7:13 p.m. CNA called me to residents room. When I walked in resident was nonresponsive, pale and could not find radial or carotid pulse. Came to cart and grabbed my stethoscope and went back to residents room. I used stethoscope to find a heart beat and could not hear one. CPR was started by nurse. I left room to use phone to call EMS while CNA continued with CPR. While on phone with EMS was advised to lower resident to floor because resident was in recliner. Resident was lowered to floor and continued with CPR by nurse. Was asked by EMS if we had AED to look for and to use on resident. CPR was still being performed by CNA. Returned with AED to room and applied pads to chest while on phone with EMS. While still performing CPR EMS paramedics walkin and take over doing CPR. Signed by LVN D. Interview with the Director of Nurses (DON) on [DATE] at 3:40 p.m. revealed Resident #1's [MEDICAL CONDITION] was sudden and unexpected. The DON stated Resident #1 had just come back from a doctor ' s appointment and was upset. Further interview revealed the DON's investigation into Resident#1's sudden [MEDICAL CONDITION] was verbal only with the nurses and she had not documented anything down. The DON stated Resident #1 expired at the hospital on [DATE] at 9:30 p.m. There were 2 nurses (LVN D and LVN E) and 2 CNAs (CNA F and CNA G) on the 2 to 10 shift. Interview with CNA F on [DATE] at 4:00 p.m. revealed Resident #1 came in from a doctor ' s appointment with a lot of anxiety and hyperventilating and the resident was moaning, moaning and she told Resident #1 to calm down. CNA F and G put Resident #1 in her recliner. Resident #1 asked to have her feet put up. CNA F stated Resident #1's tongue was moving and she just turned pale/white. Her eyes were just a stare. Resident #1 never said she was hurting, but the groans. She was not perspiring her face was flushed a little bit. She stated Resident #1 called/yelled for the nurse. LVN D came in and shook her and shook her and kept tapping her on the chest then LVN D left the room and then came back in and CNA F left the room. CNA F stated LVN D started CPR and then she stopped and went to do something and then she came back. CNA F stated the other nurse LVN E didn't even come into the room, she did nothing. Interview with CNA G on [DATE] at 4:30 p.m. revealed she assisted CNA F to place Resident #1 in her chair (recliner) and then Resident #1 became more heavy and she turned her head and she was pale. She stated LVN D came in with a machine and told them to get out of the room and it was LVN D and LVN E in the room. CNA G could not remember times. Interview with Assistant Director of Nurses (ADON) on [DATE] at 5:08 p.m. to 5:15 p.m. revealed the AED machine was kept in the nurses' station and there were 2 nurses and a medication aide that had keys to the doors of the nurses' station. Interview with Laundry Attendant (LA) H on [DATE] at 6:15 p.m. revealed she was coming with the linen (could not remember time) and heard Resident #1 yelling she could not breathe and the resident did not want her to leave. She stated she went and told the nurse Resident #1 could not breathe and the nurse (LVN D) told her the resident was having anxiety. LA H stated no one could find LVN E and Resident #1 asked the CNA's to put her in her chair. Then, LVN D had them put the resident on the floor. LA H stated she saw LVN D on the floor with some machine and CNA G was looking for LVN E. LA H stated she helped CNA F and CNA G help place Resident #1 on the floor. Interview with a family member of another resident residing in the facility (wished to remain anonymous) on [DATE] at 6:25 p.m. revealed the family member and her brother were visiting their mother and as she was going back to get her mother's medication at 7:14 p.m. she heard the lady (Resident #1) yelling. She said one nurse was outside (LVN D) and the other nurse (LVN E) was in the room next door to Resident #1's room with the curtain pulled. She said she went into the room and told LVN E they (staff) were looking for her and she said she was on break. LVN E was looking at her phone. Interview with the facility Administrator on [DATE] at 9:00 a.m. revealed it was a surprise because it was a sudden death. The Administrator stated because it was a sudden death he did not question the death. He stated the DON called and informed him of Resident #1's death. He continued to say since the surveyor had come in and questioned Resident #1's death, the DON, ADON, Nurse Consultant and himself got together and determined who was on duty at the time of Resident #1's passing and gathered quite a bit of information. He stated he did not know there was a problem with her death until this surveyor came in on [DATE] and started asking questions. He stated they talked to everyone and found out Resident #1 was being transferred from her wheelchair to her recliner. The staff noticed a change and went and got LVN D, which did not take long and LVN D checked if Resident #1 was breathing and LVN D started doing chest compressions while Resident #1 was in her lazyboy (recliner). Then LVN D left the room and asked CNA F to continue chest compressions while she went out to call EMS and get the AED. LVN D came back to the room. He believed EMS told LVN D to place Resident #1 on the floor and place the AED on the Resident #1. He stated EMS arrived quickly and took over CPR. LVN E was checking medical information when EMS arrived and EMS transported the resident to the hospital. He stated we asked LVN E where she was and she claimed she told LVN D she was going on break and she was in room [ROOM NUMBER], next door to Resident #1 taking her break. The Administrator stated when the Medication Aide (MA) I was questioned, she stated staff were looking for LVN E but could not find her. LVN E claimed she was about 10 minutes into her break when the incident with Resident #1 took place. He stated 2 of the CNAs claimed Resident #1 never said she had chest pain. He stated Resident #1 had an elevated respiratory rate and was just having an anxiety attack. Resident #1 had waited 2 hours at her doctor's office to be picked up and had to go to the restroom. He continued to say at the doctor's office they gave her 14 or 15 units of insulin, then she had to wait to be picked up. He also stated he was told Resident #1 was moaning. He stated the charge nurse (LVN E) came down and checked her out and then got her a shake to drink and she noticed Resident #1 had shortness of breath. Resident #1 was having an anxiety attack and she was doing it to herself. LVN D was trying to calm Resident #1 down by showing the resident pictures of her son (LVN D's son). He stated Resident #1 did not have a [DIAGNOSES REDACTED]. He stated both LVN D and LVN E decided Resident #1 had anxiety. He stated LVN E tried to call the Medical Director and the phone kept ringing and ringing. He stated MA I gave Resident #1 her 4:30 p.m. medications at 5:30 p.m. when she got back from her doctor appointment. He stated Resident #1 kept telling the staff she did not want to be left alone and did not want to die. Interview with LVN D on [DATE] at 10:12 a.m. revealed she was the treatment nurse. She said Resident #1 had come in from a doctor's appointment and the resident stated she did not feel good. Resident #1 got back between 5:00 p.m. and 5:30 p.m. and she went to the dining room till about 6:10 or 6:30 p.m. LVN D stated again Resident #1 again told her she did not feel good and she had clocked out, so she went to LVN E, the charge nurse, and told her Resident #1 was not feeling good and asked her if she had anything prn to calm the resident down, something like [MEDICATION NAME] because the resident had gotten real anxious when she went to her doctor's appointment. LVN D said she remembered the laundry lady (LA H) coming to her and telling her Resident #1 could not breathe, but did not say anything about the resident hurting. LVN D said she clocked back in to check on the resident and the resident told her again she did not feel well. LVN D said she told the resident she needed to eat something and gave her V8 juice and jello. LVN D said Resident #1 ask her about her son, so she began showing the resident pictures of her son. Resident #1 asked her for a shake and she was feeling a little better. When she got back Resident #1 was in her wheelchair talking to someone (could not remember who she was talking to), so she went back to the nurses' station and was talking on the phone to a family member when CNA G came to the hall and informed her Resident #1 had passed out while CNA F and CNA G were transferring the resident. LVN D said she ran into the room to check on Resident #1 and check her carotid and there was no heartbeat. LVN D stated I reacted, I started compressions, CPR in the recliner. CNA F was breathing into her mouth. LVN D stated I walked away and was trying to call 911 on the phone next to Resident #1's room, but could not call out, so she went to the locked nurse ' s station and called 911. They wanted to know where she was and she told them she was in her room in her recliner and CNA F, CNA G and LA H were with her. EMS told LVN D to place Resident #1 on the floor. She said she had staff place the resident on the floor. Then EMS asked me if I had an AED machine, I told them yes and went back to the nurse's station to get the AED. LVN D said LVN E, the charge nurse, came into the room and she told her, EMS was on their way. LVN D said when EMS got there, they took over and then one of the EMS guys said they needed someone to declare Resident #1 had expired and she told them they could not do that. So, another EMS guy came into the resident's room and said they needed to leave, so they took her out. LVN D said that was when she found out Resident #1 was a DNR. LVN D said she knew the blue charts were DNR and the red charts were FULL CODE, also the blue dots on the door meant DNR, but Resident #1 had a wreath covering her dot, so she could not tell what Resident #1 was. When asked why didn't she move the wreath LVN D said she did not think about it. LVN D stated When Resident #1 was in the recliner, CNA F helped her with the CPR, LVN D was doing compressions and CNA F was breathing into her mouth. LVN D stated I stopped to call EMS. LVN D said she did not delegate to anyone to call 911, get the crash cart, or get the AED. LVN D said if she had asked someone to get the AED, they could not have gotten it because the AED was locked up behind the locked nurse's station. She stated When I came into Resident #1's room, I told someone to find LVN E. (She did not remember who she told to find LVN E). LVN D stated EMS told me to lower the resident to the floor (from the recliner). We put her on the floor and then EMS asked me if we had an AED so I went back to get it (in the locked nurse's station). LVN D stated It took LVN E a while to respond, she did not come in until I had the AED hooked up and I was doing compressions. LVN D stated I don't know how long it took to get the AED and start compressions before LVN E came in. Interview with LVN E on [DATE] at 3:15 p.m. revealed Resident #1 acted like she was upset about her doctor's appointment. She stated I heard she was still anxious so I asked the medication aide if she had anything. LVN E said when she came back to check on Resident #1, LVN D was in the room showing Resident #1 pictures. LVN E stated I was over by the coke machines (which are next door to Resident #1's room) talking to my husband on the phone. I had clocked out maybe 10 minutes when I heard a CNA (didn't know who the CNA was) say I need a nurse. I came around the corner and saw LVN D with Resident #1, so I went to the nurse's station and then LVN D came up and called 911 then, she got the AED. LVN E said she went back to Resident #1's room and the resident was already on the floor and LVN D was already doing compressions while she was talking to EMS (using her personal phone with speaker). LVN E said she heard the alarm going off at the gate so she told the girls to go and make sure the gate was open. LVN E said she ran everybody out of Resident #1's room and told EMS where the resident was then went back to the office (nurse's station) to make copies of everything. LVN E stated I did not help do CPR and the crash cart was not brought in to Resident #1's room. LVN E stated The charts for DNR are green and the red charts are for FULL CODE. LVN E stated I told LVN D Resident #1 was a FULL CODE after EMS got to the facility and took over and the only place to look to see if a resident is a DNR or FULL CODE was on the chart, Advance Directive or Orders and there is nothing placed on a resident's door. LVN E stated no one came and got her when she was on her phone, she said she heard a CNA (CNA F) was doing CPR but she did not see the CNA doing CPR. Review of the American Red Cross <<http://www.redcross.org>>, information on [MEDICAL CONDITION] revealed in part under Step 3, [MEDICAL CONDITION]/AED Steps, the 9th paragraph down stated the following: If, during your check, you find no signs of life, assume that the heart is not functioning properly. Make sure someone has called for help, and use the AED immediately. If an AED is not available right away, give CPR until an AED is at the scene and ready to use. Review of the Facility Do Not Resuscitate Policy (No Date), received on [DATE] revealed the following in part under Policy Statement Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect Policy Interpretation and Implementation .2. Residents with a DNR order will have their medical records placed in a Blue chart. 3. The name plate next to the resident's door will be white other than blue or red and a blue dot will be placed next to the name of a resident who has a DNR order. 4. An updated list of all residents indicating who is a Full Code or who is a DNR has been attached to the Facility's Crash Cart. The name of residents who have a DNR order have been highlighted in blue. 5. A current photo of residents who have a DNR order will be displayed on a Blue paper in front of the clinical chart indicating DNR status. Full Code residents will have their pictures displayed on a Red paper in front of their clinical chart, indicating Full Code status .8. The resident's Care Plan will address whether the resident is a DNR or a Full Code. 9. The interdisciplinary care planning team will review advanced directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes to such directives. Attached to the DNR Policy, was a hand written sheet If resident is found unconscious or unresponsive, follow these steps: (No Date) revealed the following in part, 1) Staff who finds resident, stays with resident yell as loud as you can for help Code Blue press call light if you are in the resident's room or restroom/shower area. 2) First staff member to respond to call must take comfort cart (crash cart) to area where resident was found. Resident's list of names attached to comfort cart will be checked to see if resident is a DNR or a Full Code. 3) 911 must be call by anyone in the facility if resident is a Full Code. 4) CPR will be initiated by qualified person .5) Follow CPR in 3 simple steps. Give 2 breaths and pump continue with 2 breaths and 30 pumps until help arrives. Review of the Facility policy on Automated External Defibrillator (AED), (No Date) presented to the surveyor on [DATE], revealed the following in part paragraph 2: Assess patient for unresponsiveness, assess breathing and assess circulation (pulse). Call 911 and have someone retrieve the AED. Initiate CPR until AED arrives . Follow AED until EMS arrives and takes over . Review of another paper provided by the Administrator to the surveyor on [DATE] states, How to Use an Automated External Defibrillator, 4th paragraph down: Call [DATE] or have someone else call [DATE]. If two rescuers are present, one can provide CPR (cardiopulmonary resuscitation) while the other calls [DATE] and gets the AED If an AED isn't readily available, do 2 minutes of CPR. Then use the AED (if you have one) to check the person after you have the AED, or if you don't have an AED, give CPR until emergency medical help arrives or until the person begins to move . The Administrator and DON were informed of the IJ on [DATE]. The facility submitted an action plan to remove the immediacy dated [DATE] at 3:30 p.m. which was accepted and consisted of: 1) Supervisory staff will be in-serviced immediately on reporting to Administrator any allegation of Neglect or Abuse. In-service started [DATE] at 5:45 p.m. Completed [DATE] at 12:45 p.m. 2) An investigation will be started as soon as an allegation is received by any staff member of the facility. In-service started [DATE] at 5:45 p.m. Alleged staff were suspended on [DATE] at 12:30 p.m. 3) All staff members will be in-serviced by Supervisory staff on immediately reporting to a Nurse if a resident has a change of mental status, change in condition, or acute distress, or is not feeling well. The nurse will then make an immediate assessment. In-service started [DATE] at 5:45 p.m. Completed [DATE] at 12:45 p.m. 4) Nurses will be in-serviced by Nurse Supervisors on Protocol: When to call the Doctor. Nurses will be in-serviced that it is the responsibility of the nursing staff to observe the change, make an assessment, and notify the Physician based on the assessment. In- service started on [DATE] at 5:45 p.m. Completed on [DATE] at 12:45 p.m. 5) All staff members will be in-serviced on facility's Do Not Resuscitate Policy and their individual role in case of an emergency, as well as identifying which resident is a DNR (Do not resuscitate) and which resident is a FULL CODE. Licensed nursing personnel will be in-serviced on providing un-interrupted CPR, once CPR is started, until EMS personnel arrives to facility. In-service started on [DATE] at 1:45 p.m. Completed on [DATE] at12:45 p.m. 6) All staff members will be in-serviced on location of Automated External Defibrillator (AED). A large legible sign will be attached to the crash cart indicating that AED is inside the crash cart. Licensed personnel will be in-serviced on how to use an AED. In-service started [DATE] at 1:45 p.m. Completed [DATE] at 12:45 p.m. 7) Nursing staff will be in-serviced on facility ' s AED protocol. This AED protocol will be inside crash cart ' s check list binder. AED will be checked for proper functioning on a quarterly basis. In-service started [DATE] at 5:15 p.m. Completed [DATE] at 12:45 p.m. STAFF MEMBERS WHO ARE ON VACATION, SICK OR UNABLE TO BE REACHED, WILL NOT BE ALLOWED TO COME BACK TO WORK UNTIL IN- SERVICED ON ABOVE TOPICS. In-service started [DATE] at 5:15 p.m. Plan of removal will be implemented and completed by [DATE] at 4:30 p.m. Please, accept this plan of removal as our statement of compliance. Verification of Plan of Removal: On-site monitoring was conducted on [DATE] from 3:30 p.m. to 5:00 p.m. Interviews conducted randomly during the on-site monitoring included staff from all shifts: The Administrator, DON, CNA J, CNA K, CNA L, LVN M, MA N, LVN O, CNA P, HSKP Q, COOK R, DA S and AD T. All nursing staff interviewed stated they knew about getting help, LVN's knew CPR and to initiate immediately and how and where to place the AED on the resident's chest when available. All stated they knew where the AED was located. All confirmed a Blue Dot indicated the resident was a DNR and the resident's code status was on the crash cart. If they see a change in the resident's condition to yell, turn on the call light and or get the nurse. Nurse's in-serviced on changes in condition and notifying the physician. If they can not get the resident's doctor to call the Medical Director or if not able to get the doctor call the DON. Review of the facility in-services started on [DATE] revealed the in-service consisted of the facility resuscitation policy, Protocol: When to Call the Doctor on certain conditions and information on the facility AED and where the AED and Code Status of each resident can be found (on the comfort/crash cart). The Administrator and the DON were informed the IJ was removed on [DATE] at 5:10 p.m. The facility remained out of compliance at a severity level actual harm with a scope of pattern due to the facility's need to complete in-service training to all nursing staff on response to CPR emergencies, and the AED and evaluate the effectiveness of training. A list was obtained from the Administrator dated [DATE] indicating there were 50 residents residing in the facility.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest, practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 6 residents ( #1) reviewed for changes in condition in that: -LVN D and LVN E failed to assess and consult with the physician for Resident #1 when she began to complain of not feeling well and being short of breath from approximately 5:15 p.m. to approximately 7:15 p.m. when Resident #1 lost consciousness and LVN D called 911. (Time determination was from interviews and the time verified on LVN D's personal cell phone as to when 911 was called.) -The facility failed to ensure Resident #1's was provided CPR according to the facility policy and The American Red Cross Association. EMS transported Resident #1 to the hospital and was pronounced on [DATE] at 9:20 p.m. as expired. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE] the facility remained out of compliance at pattern, actual harm due to facility was still in-servicing and monitoring the effectiveness of the Plan of Removal. These failures affected one former resident (Resident #1) and could affect 50 residents residing in the facility by being at risk of negative outcomes, including death, due to not receiving medical interventions in a timely manner. The findings were: Review of Resident #1's Face Sheet dated [DATE] revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Consolidated Orders dated ,[DATE] to [DATE] revealed the area for Orders indicated under ADVANCE DIRECTIVES CODE STAUS: DNR [DATE]. Review of Resident #1's Plan of Care dated [DATE] revealed the resident was a DNR. Review of Resident #1's Directive to Physicians and Family or Surrogates, dated [DATE] under DIRECTIVE, revealed the resident requested that all treatments other than those needed to keep her comfortable be discontinued or withheld and her physician allow her to die as gently as possible. Review of Resident #1's Resident/Family Consent for Cardiopulmonary Resuscitation, signed by Resident #1 on [DATE] and witnessed, stated in part We ask that you mark ONE of the decisions below- accompanied by your signature and date This statement will remain in effect as long as the resident remains a resident of this facility or until we receive a written and signed notice of revocation from you. A check mark was placed in front of the following statement. I understand that CPR constitutes an extraordinary measure and SHOULD NOT be done on this resident. However, I wish that essential life support interventions such as oxygen, nutrition, hydration and certain medications for the relief of pain be administered to maintain the resident ' s comfort. Review of Resident #1' s Texas Department of Health OUT-OF-HOSPITAL DO NOT-RESUSCITATE ORDER revealed on [DATE], Resident #1 signed box A which states Patient ' s Statement: I, the undersigned, am capable of making an informed decision regarding the withholding or withdrawing of CPR, including the treatments listed below, and I direct that none of the following resuscitation measures be initiated or continued. Cardiopulmonary resuscitation (CPR), Transcutaneous Cardiac Pacing, Defibrillation, Advanced Airway Management, Artificial Ventilation. I understand that I will be given comfort measures as needed. I understand that I may revoke this order at any time. Review of Resident #1's Advanced Care Planning Care Plan dated [DATE] revealed in part: RAP/Problem - End of Life Decision, Goals- DNR, Approaches/Interventions 3. Individual and or family choices to be respected. Review of Resident #1' s Quarterly Minimum Data Set ((MDS) dated [DATE] revealed under section B, B0700, the resident was able to make herself understood and under B0800, the resident was able to understand. Under section C, resident' s BIMS Score was 15 (indicating the resident was cognitively intact). Review of Resident #1's Nurses Notes dated [DATE], (the hour was marked over and 6:00 p.m. was written over 5:00 p.m.) stated in part Resident was in her room sitting on the toilet anxious and asking for water saying she didn't feel good 6:35 p.m. Resident still anxious and saying she wasn't feeling good. I sat with her and told her to deep breath and relax. Resident was making herself anxious. Started showing her pics on phone to distract resident. When I left the room she was starting to calm down. Signed by LVN D. 7:13 p.m. CNA called me to residents room. When I walked in resident was nonresponsive, pale and could not find radial or carotid pulse. Came to cart and grabbed my stethoscope and went back to residents room. I used stethoscope to find a heart beat and could not hear one. CPR was started by nurse. I left room to use phone to call EMS while CNA continued with CPR. While on phone with EMS was advised to lower resident to floor because resident was in recliner. Resident was lowered to floor and continued with CPR by nurse. Was asked by EMS if we had AED to look for and to use on resident. CPR was still being performed by CNA. Returned with AED to room and applied pads to chest while on phone with EMS. While still performing CPR EMS paramedics walkin and take over doing CPR. Signed by LVN D. Interview with the Director of Nurses (DON) on [DATE] at 3:40 p.m. revealed Resident #1's [MEDICAL CONDITION] was sudden and unexpected. The DON stated Resident #1 had just come back from a doctor' s appointment and was upset. Further interview revealed the DON's investigation into Resident#1's sudden [MEDICAL CONDITION] was verbal only with the nurses and she had not documented anything. The DON stated Resident #1 expired at the hospital on [DATE] at 9:30 p.m. There were 2 nurses (LVN D and LVN E) and 2 CNAs (CNA F and CNA G) on the 2 to 10 shift. Interview with CNA F on [DATE] at 4:00 p.m. revealed Resident #1 came in from a doctor's appointment with a lot of anxiety and hyperventilating and the resident was moaning, moaning and she told Resident #1 to calm down. CNA F and G put Resident #1 in her recliner. Resident #1 asked to have her feet put up. CNA F stated Resident #1's tongue was moving and she just turned pale/white. Her eyes were just a stare. Resident #1 never said she was hurting, but the groans. She was not perspiring her face was flushed a little bit. She stated Resident called/yelled for the nurse. LVN D came in and shook her and shook her and kept tapping her on the chest then LVN D left the room and then came back in and CNA F left the room. CNA F stated LVN D started CPR and then she stopped and went to do something and then she came back. CNA F stated the other nurse LVN E didn't even come into the room, she did nothing. Interview with CNA G on [DATE] at 4:30 p.m. revealed she assisted CNA F to place Resident #1 in her chair (recliner) and then Resident #1 became more heavy and she turned her head and she was pale. She stated LVN D came in with a machine and told them to get out of the room and it was LVN D and LVN E in the room. CNA G could not remember times. Interview with Assistant Director of Nurses (ADON) on [DATE] at 5:08 p.m. to 5:15 p.m. revealed the AED machine was kept in the nurses' station and there were 2 nurses and a medication aide that had keys to the doors of the nurses' station. Interview with Laundry Attendant (LA) H on [DATE] at 6:15 p.m. revealed she was coming with the linen (could not remember time) and heard Resident #1 yelling she could not breathe and the resident did not want her to leave. She stated she went and told the nurse Resident #1 could not breathe and the nurse (LVN D) told her the resident was having anxiety. LA H stated no one could find LVN E and Resident #1 asked the CNA's to put her in her chair. Then, LVN D had them put the resident on the floor. LA H stated she saw LVN D on the floor with some machine and CNA G was looking for LVN E. LA H stated she helped CNA F and CNA G help place Resident #1 on the floor. Interview with a family member of another resident residing in the facility (wished to remain anonymous) on [DATE] at 6:25 p.m. revealed the family member and her brother were visiting their mother and as she was going back to get her mother's medication around 7:14 p.m. she heard the lady (Resident #1) yelling. She said one nurse was outside (LVN D) and the other nurse (LVN E) was in the room next door to Resident #1's room with the curtain pulled. She said she went into the room and told LVN E they (staff) were looking for her and she said she was on break. LVN E was looking at her phone. Interview with the facility Administrator on [DATE] at 9:00 a.m. revealed it was a surprise because it was a sudden death. The Administrator stated because it was a sudden death he did not question the death. He stated the DON called and informed him of Resident #1's death. He continued to say since the surveyor had come in and questioned Resident #1's death, the DON, ADON, Nurse Consultant and himself got together and determined who was on duty at the time of Resident #1's passing and gathered quite a bit of information. He stated he did not know there was a problem with her death until this surveyor came in on [DATE] and started asking questions. He stated they talked to everyone and found out Resident #1 was being transferred from her wheelchair to her recliner. The staff noticed a change and went and got LVN D, which did not take long and LVN D checked if Resident #1 was breathing and LVN D started doing chest compressions while Resident #1 was in her lazyboy (recliner). Then LVN D left the room and asked CNA F to continue chest compressions while she went out to call EMS and get the AED. LVN D came back to the room. He believed EMS told LVN D to place Resident #1 on the floor and place the AED on the Resident #1. He stated EMS arrived quickly and took over CPR. LVN E was checking medical information when EMS arrived and EMS transported the resident to the hospital. He stated we asked LVN E where she was and she claimed she told LVN D she was going on break and she was in room [ROOM NUMBER], next door to Resident #1 taking her break. The Administrator stated when the Medication Aide (MA) I was questioned, she stated staff were looking for LVN E but could not find her. LVN E claimed she was about 10 minutes into her break when the incident with Resident #1 took place. He stated 2 of the CNAs claimed Resident #1 never said she had chest pain. He stated Resident #1 had an elevated respiratory rate and was just having an anxiety attack. Resident #1 had waited 2 hours at her doctor's office to be picked up and had to go to the restroom. He continued to say at the doctor's office they gave her 14 or 15 units of insulin, then she had to wait to be picked up. He also stated he was told Resident #1 was moaning. He stated the charge nurse (LVN E) came down and checked her out and then got her a shake to drink and she noticed Resident #1 had shortness of breath. Resident #1 was having an anxiety attack and she was doing it to herself. LVN D was trying to calm Resident #1 down by showing the resident pictures of her son (LVN D's son). He stated Resident #1 did not have a [DIAGNOSES REDACTED]. He stated both LVN D and LVN E decided Resident #1 had anxiety. He stated LVN E tried to call the Medical Director and the phone kept ringing and ringing. He stated MA I gave Resident #1 her 4:30 p.m. medications at 5:30 p.m. when she got back from her doctor appointment. He stated Resident #1 kept telling the staff she did not want to be left alone and did not want to die. Interview with LVN D on [DATE] at 10:12 a.m. revealed she was the treatment nurse. She said Resident #1 had come in from a doctor's appointment and the resident stated she did not feel well. Resident #1 got back between 5:00 p.m. and 5:30 p.m. and she went to the dining room till about 6:10 or 6:30 p.m. LVN D stated again Resident #1 again told her she did not feel good and she had clocked out, so she went to LVN E, the charge nurse, and told her Resident #1 was not feeling good and asked her if she had anything prn to calm the resident down, something like [MEDICATION NAME] because the resident had gotten real anxious when she went to her doctor's appointment. LVN D said she remembered the laundry lady (LA H) coming to her and telling her Resident #1 could not breathe, but did not say anything about the resident hurting. LVN D said she clocked back in to check on the resident and the resident told her again she did not feel well. LVN D said she told the resident she needed to eat something and gave her V8 juice and jello. LVN D said Resident #1 ask her about her son, so she began showing the resident pictures of her son. Resident #1 asked her for a shake and she was feeling a little better. When she got back Resident #1 was in her wheelchair talking to someone (could not remember who she was talking to), so she went back to the nurses' station and was talking on the phone to a family member when CNA G came to the hall and informed her Resident #1 had passed out while CNA F and CNA G were transferring the resident. LVN D said she ran into the room to check on Resident #1 and check her carotid and there was no heartbeat. LVN D stated I reacted, I started compressions, CPR in the recliner. CNA F was breathing into her mouth. LVN D stated I walked away and was trying to call 911 on the phone next to Resident #1's room, but could not call out, so she went to the locked nurse ' s station and called 911. They wanted to know where she was and she told them she was in her room in her recliner and CNA F, CNA G and LA H were with her. EMS told LVN D to place Resident #1 on the floor. She said she had staff place the resident on the floor. Then EMS asked me if I had an AED machine, I told them yes and went back to the nurse's station to get the AED. LVN D said LVN E, the charge nurse, came into the room and she told her, EMS was on their way. LVN D said when EMS got there, they took over and then one of the EMS guys said they needed someone to declare Resident #1 had expired and she told them they could not do that. So, another EMS guy came into the resident's room and said they needed to leave, so they took her out. LVN D said that was when she found out Resident #1 was a DNR. LVN D said she knew the blue charts were DNR and the red charts were FULL CODE, also the blue dots on the door meant DNR, but Resident #1 had a wreath covering her dot, so she could not tell what Resident #1 was. When asked why didn't she move the wreath LVN D said she did not think about it. LVN D stated When Resident #1 was in the recliner, CNA F helped her with the CPR, LVN D was doing compressions and CNA F was breathing into her mouth. LVN D stated I stopped to call EMS. LVN D said she did not delegate to anyone to call 911, get the crash cart, or get the AED. LVN D said if she had asked someone to get the AED, they could not have gotten it because the AED was locked up behind the locked nurse's station. She stated When I came into Resident #1's room, I told someone to find LVN E. (She did not remember who she told to find LVN E). LVN D stated EMS told me to lower the resident to the floor (from the recliner). We put her on the floor and then EMS asked me if we had an AED so I went back to get it (in the locked nurse's station). LVN D stated It took LVN E a while to respond, she did not come in until I had the AED hooked up and I was doing compressions. LVN D stated I don't know how long it took to get the AED and start compressions before LVN E came in. Interview with LVN E on [DATE] at 3:15 p.m. revealed Resident #1 acted like she was upset about her doctor's appointment. She stated I heard she was still anxious so I asked the medication aide if she had anything. LVN E said when she came back to check on Resident #1, LVN D was in the room showing Resident #1 pictures. LVN E stated I was over by the coke machines (which are next door to Resident #1's room) talking to my husband on the phone. I had clocked out maybe 10 minutes when I heard a CNA (didn't know who the CNA was) say I need a nurse. I came around the corner and saw LVN D with Resident #1, so I went to the nurse's station and then LVN D came up and called 911 then, she got the AED. LVN E said she went back to Resident #1's room and the resident was already on the floor and LVN D was already doing compressions while she was talking to EMS on her cell phone. LVN E said she heard the alarm going off at the gate so she told the girls to go and make sure the gate was open. LVN E said she ran everybody out of Resident #1's room and told EMS where the resident was then went back to the office (nurse's station) to make copies of everything. LVN E stated I did not help do CPR and the crash cart was not brought in to Resident #1's room. LVN E stated The charts for DNR are green and the red charts are for FULL CODE. LVN E stated I told LVN D Resident #1 was a FULL CODE after EMS got to the facility and took over and the only place to look to see if a resident is a DNR or FULL CODE was on the chart, Advance Directive or Orders and there is nothing placed on a resident's door. LVN E stated no one came and got her when she was on her phone, she said she heard a CNA (CNA F) was doing CPR but she did not see the CNA doing CPR. Review of the American Red Cross <<http://www.redcross.org>>, information on [MEDICAL CONDITION] revealed in part under Step 3, [MEDICAL CONDITION]/AED Steps, the 9th paragraph down stated the following: If, during your check, you find no signs of life, assume that the heart is not functioning properly. Make sure someone has called for help, and use the AED immediately. If an AED is not available right away, give CPR until an AED is at the scene and ready to use. Review of the Facility Do Not Resuscitate Policy (No Date), revealed the following in part under Policy Statement Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect Policy Interpretation and Implementation .2. Residents with a DNR order will have their medical records placed in a Blue chart. 3. The name plate next to the resident ' s doo will be white other than blue or red and a blue dot will be placed next to the name of a resident who has a DNR order. 4. An updated list of all residents indicating who is a Full Code or who is a DNR has been attached to the Facility ' s Crash Cart. The name of residents who have a DNR order have been highlighted in blue. 5. A current photo of residents who have a DNR order will be displayed on a Blue paper in front of the clinical chart indicating DNR status. Full Code residents will have their pictures displayed on a Red paper in front of their clinical chart, indicating Full Code status .8. The resident ' s Care Plan will address whether the resident is a DNR or a Full Code. 9. The interdisciplinary care planning team will review advanced directives with the resident during quarterly care planning sessions to determine if the resident whishes to make changes to such directives. Review of the Facility Policy if resident is found unconscious or unresponsive (No Date) revealed the following in part, Follow these steps 1. Staff who finds resident, stays with resident yell as loud as you can for help Code Blue press call light if you are in the resident ' s room or restroom/shower area First staff member to respond to call must take comfort cart (crash cart) to area where resident was found. Resident ' s list of names attached to comfort cart will be checked to see if resident is a DNR or a Full Code. 3. 911 must be call by anyone in the facility if resident is a Full Code. 4. CPR will be initiated by qualified person .5. Follow CPR in 3 simple steps . Give 2 breaths and pump continue with 2 breaths and 30 pumps until help arrives. Review of the Facility policy on Automated External Defibrillator (AED), (No Date), the following in part paragraph 2: Assess patient for unresponsiveness, assess breathing and assess circulation (pulse). Call 911 and have someone retrieve the AED. Initiate CPR until AED arrives . Follow AED until EMS arrives and takes over . Review of another paper provided by the Administrator on [DATE] states, How to Use an Automated External Defibrillator, 4th paragraph down: Call [DATE] or have someone else call [DATE]. If two rescuerers are present, one can provide CPR (cardiopulmonary resuscitation) while the others call [DATE] and gets the AED If an AED isn ' t readily available, do 2 minutes of CPR. Then use the AED (if you have one) to check the person after you have the AED, or if you don ' t have an AED, give CPR until emergency medical help arrives or until the person begins to move . Review of the facility Protocol: When to Call the Doctor with a written date of [DATE] revealed in part The types of conditions which frequently arise are: .13. Shortness of breath . It is the responsibility of the nursing staff to observe the change, make an assessment, and notify the physician as indicated based on the assessment . The nurse will: a. Recognize the Condition Change d. Notify the physician of any change in condition in agreement with the policy .e. Continue to monitor the resident and again notify the physician when the course of the illness changes, especially when it deviates from the anticipated course . Review of the facility Job Description for Charge Nurses, Initialed by LVN E, dated [DATE] had documeneted in part under Responsibitities: . 2. Recognize significant changes in the condition of the resident and take necessary action .4. Insures that the individual health care plan is followed . Review of the facility Job Description for Quality Assurance and Treatment Nurse, no date, had documented in part under Responsibilities: .19. Assesses and reports changes in resident's condition .to physician . and takes follow-up action as necessary . The Administrator and DON were informed of the IJ on [DATE]. The facility submitted an action plan to remove the immediacy dated [DATE] at 3:30 p.m. which was accepted and consisted of: 1) Supervisory staff will be in-serviced immediately on reporting to Administrator any allegation of Neglect or Abuse. In-service started [DATE] at 5:45 p.m. Completed [DATE] at 12:45 p.m. 2) An investigation will be started as soon as an allegation is received by any staff member of the facility. In-service started [DATE] at 5:45 p.m. Alleged staff were suspended on [DATE] at 12:30 p.m. 3) All staff members will be in-serviced by Supervisory staff on immediately reporting to a Nurse if A resident has a change of mental status, change in condition, or acute distress, or is not feeling well. The nurse will then make an immediate assessment. In-service started [DATE] at 5:45 p.m. Completed [DATE] at 12:45 p.m. 4) Nurses will be in-serviced by Nurse Supervisors on Protocol: When to call the Doctor . Nurses will be in-serviced that it is the responsibility of the nursing staff to observe the change, make an assessment, and notify the Physician based on the assessment. In-service started on [DATE] at 5:45 p.m. Completed on [DATE] at 12:45 p.m. 5) All staff members will be in-serviced on facility ' s Do Not Resuscitate Policy and their individual role in case of an emergency, as well as identifying which resident is a DNR (Do not resuscitate) and which resident is a FULL CODE. Licensed nursing personnel will be in-serviced on providing un-interrupted CPR, once CPR is started, until EMS personnel arrives to facility. In-service started on [DATE] at 1:45 p.m. Completed 12:45 p.m. [DATE]. 6) All staff members will be in-serviced on location of Automated External Defibrillator (AED). A large legible sign will be attached to the crash cart indicating that AED is inside the crash cart. Licensed personnel will be in-serviced on how to use an AED. In-service started [DATE] at 1:45 p.m. Completed [DATE] at 12:45 p.m. 7) Nursing staff will be in-serviced on facility ' s AED protocol. This AED protocol will be inside crash cart's check list binder. AED will be checked for proper functioning on a quarterly basis. In-service started [DATE] at 5:15 p.m. Completed [DATE] at 12:45 p.m. STAFF MEMBERS WHO ARE ON VACATION, SICK OR UNABLE TO BE REACHED, WILL NOT BE ALLOWED TO COME BACK TO WORK UNTIL IN- SERVICED ON ABOVE TOPICS. In-service started [DATE] at 5:15 p.m. Plan of removal will be implemented and completed by [DATE] at 4:30 p.m. Please, accept this plan of removal as our statement of compliance. Verification of Plan of Removal: On-site monitoring was conducted on [DATE] from 3:30 p.m. to 5:00 p.m. Interviews conducted randomly during the on-site monitoring included staff from all shifts: The Administrator, DON, CNA J, CNA K, CNA L, LVN M, MA N, LVN O, CNA P, HSKP Q, COOK R, DA S and AD T. All nursing staff interviewed stated they knew about getting help, LVN's knew CPR and to initiate immediately and how and where to place the AED on the resident's chest when available. All stated they knew where the AED was located. All confirmed a Blue Dot indicated the resident was a DNR and the resident's code status was on the crash cart. If they see a change in the resident's condition to yell, turn on the call light and or get the nurse. Nurse's in-serviced on changes in condition and notifying the physician. If they can not get the resident's doctor to call the Medical Director or if not able to get the doctor call the DON. Review of the facility in-services started on [DATE] revealed the in-service consisted of the facility resuscitation policy, Protocol: When to Call the Doctor on certain conditions and information on the facility AED and where the AED and Code Status of each resident can be found (on the comfort/crash cart). The Administrator and the DON were informed the IJ was removed on [DATE] at 5:10 p.m. The facility remained out of compliance at a severity level actual harm with a scope of pattern due to the facility's need to complete in-service training to all nursing staff on response to CPR emergencies, and the AED and evaluate the effectiveness of training. A list was obtained from the Administrator dated [DATE] indicating there were 50 residents residing in the facility.